A Cultural Adaptation of Dialectical Behavior Therapy in Nepal

Abstract

Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.

Income inequality and depression: a systematic review and meta‐analysis of the association and a scoping review of mechanisms

“…Third-wave psychological therapies that include components of self-validation may also counter social defeat and worthlessness associated with depression and suicidality 55 . These therapies are currently being adapted for delivery in settings of extreme poverty 56 .…”

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

“…This further supports perspectives that impulsivity is seen to be more closely connected to suicidality than previous attempts or mental illness. Such findings can help inform the adaptation of education and prevention programs, particularly those targeting emotion regulation, which have been culturally adapted for Nepali and Bhutanese populations (Kohrt, et al, 2012; Ramaiya, et al, 2017). …”

“…Such approaches have some demonstrated success elsewhere (Fleischmann, et al, 2016; Rutz, 2001; Mohanraj, et al, 2014; Calear, et al, 2016; Kohrt, et al, 2015; Vijayakumar, et al, 2013; Mann, et al, 2005). Regarding emotion regulation and enabling individuals to better negotiate relationships and conflict, dialectical behavior therapy (DBT) has recently been culturally adapted for use in Nepal and has shown high feasibility and acceptability (Ramaiya, et al, 2017). However, given limited mental health resources, targeting the social situation and how illness experiences are understood by those who are suffering might be more helpful than psychotherapeutic treatment (Marrow and Luhrmann 2012).…”

Guided Act and Feel Indonesia – Internet-based Behavioral Activation Intervention for Depression in Indonesia: A Systematic Cultural Adaptation

“…For example, they used local idioms of important terms and activities during the treatment, and recruited counselors from various ethnic backgrounds, since the patients came from different cultural backgrounds across Kenya (Papas et al, 2010). Another study in Nepal adapted a dialectical behavior therapy intervention using a tri-phasic approach, with qualitative interviews, an adaptation workshop, and a small-scale treatment pilot test with patients (Ramaiya, Fiorillo, Regmi, Robins, & Kohrt, 2017). The adaptation included the use of role play with examples that are consonant with the local culture of Nepal (Ramaiya et al, 2017).…”

“…Another study in Nepal adapted a dialectical behavior therapy intervention using a tri-phasic approach, with qualitative interviews, an adaptation workshop, and a small-scale treatment pilot test with patients (Ramaiya, Fiorillo, Regmi, Robins, & Kohrt, 2017). The adaptation included the use of role play with examples that are consonant with the local culture of Nepal (Ramaiya et al, 2017).…”