Culturally Adapted Cognitive Behavioral Therapy Plus Problem Management (CA‐CBT+) With Afghan Refugees: A Randomized Controlled Pilot Study

Abstract

Culturally adapted cognitive behavioral therapy (CA-CBT) is a well-evaluated, transdiagnostic group intervention for refugees that uses psychoeducation, meditation, and stretching exercises. In the current study, we added problem-solving training to CA-CBT and evaluated this treatment (i.e., CA-CBT+) in a randomized controlled pilot trial with a sample of Farsi-speaking refugees. Participants (N = 24) were male refugees diagnosed with DSM-5 PTSD, major depressive disorder, and anxiety disorders who were randomly assigned to either a treatment or waitlist control (WLC) condition. Treatment components were adapted both to the specific cultural background and the current social problems of asylum seekers. Assessments were performed pretreatment, 12-weeks posttreatment, and 1-year follow-up. The primary treatment outcome was the General Health Questionnaire (GHQ-28); secondary outcome measures included the Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire, Somatic Symptom Scale, World Health Organization Quality of Life, and Emotion Regulation Scale. Eleven of 12 participants were randomized to CA-CBT+ completed treatment. Based on intent-to-treat data, large between-group effect sizes were seen at posttreatment in the GHQ-28, d = 3.0, and for most secondary outcome measures. Improvements for individuals in the treatment group decreased at 1-year follow-up, but effect sizes demonstrated continued large improvements on all measures as compared to pretreatment levels. In summary, CA-CBT+ led to large improvements in general psychopathological distress and quality of life, which were maintained in the long term. In addition, the dropout rate was very low, with delivery in group format. Thus, problem-solving training appears to be a promising addition to CA-CBT. Most refugees and asylum seekers arriving in host countries have faced many traumatic experiences, such as war, armed conflict, kidnapping, the murder of family members, torture, imprisonment, and physical and sexual violence (United Nations High Commissioner for Refugees, 2017). Recent findings (Bogic et al., 2015; Rohlof et al., 2014; Turrini et al., 2017) provide evidence that asylum seekers and refugees who migrate to Western countries suffer not only from posttraumatic stress disorder (PTSD; 21%-54%) but also from a variety of This work was supported by the Vereinigung von Freunden und Förderern der Johann Wolfgang Goethe-Universität Frankfurt am Main and the Stiftung Polytechnische Gesellschaft Frankfurt am Main. The authors have no conflicts of interest to declare. Clinical trial registration number DRKS00016154.

The effectiveness of adapted psychological interventions for people from ethnic minority groups: A systematic review and conceptual typology

“…Training for therapist/provider/facilitator: Thirty-two studies (36%) reported adaptations that involved the specific provision of training for whomever was providing the intervention. Examples include where training was provided to professionals (e.g., Kananian, Soltani, Hinton, & Stangier, 2020 ; Miranda, Azocar, Organista, Dwyer, & Areane, 2003 ) or to lay/community members (e.g., Bonilla-Escobar et al, 2018 ; Leiler, Wasteson, Holmberg, & Bjärtå, 2020 ) for the purpose of providing better care for the target population group.…”

“… Grote et al, 2009 ; Lovell et al, 2014 ) including use of metaphors, or where intentional emphasis was placed on the cultural norms, practices or expectations of the target population (e.g., Gonyea, Lopez, & Velasquez, 2016 ; Knaevelsrud, Brand, Lange, Ruwaard, & Wagner, 2015 ). Explicit cultural adaptations also involved those where the authors reported that the theoretical stance of the intervention was culturally informed including use of existing theoretical models or adaptations frameworks (e.g., Bedoya et al, 2014 ; de Graaff et al, 2020 ; Hinton et al, 2005 ; Kananian et al, 2020 ; Koch, Ehring, & Liedl, 2020 ; Pan, Huey, & Hernandez, 2011 ). Explicitly reported cultural adaptations were considered in the typology with regard to both their inclusion in the common factors model and as a specific type of adaptation (explored in the analyses later).…”

“…Heterogeneity was considerable: I 2 = 89.95%. Six of the studies were observed to have extremely large effect sizes ( Chien, Leung, & Sk Chu, 2012 ; Habib, Dawood, Kingdon, & Naeem, 2015 ; Hinton et al, 2004 ; Hinton et al, 2005 ; Kananian et al, 2020 ; Kruse et al, 2009 ) compared to other similar studies (i.e. greater than 2) and so the authors made a decision to remove these studies from the analysis, leaving 51 RCTs.…”

Interventions and participatory clinical research for the enhancement of health systems interfacing with displaced Afghan women

“…In terms of jigar-e-khun 3 , she likely knows that her liver is not actually bloody, as this is metaphorical, but it points to her grief feeling somehow physically manifest, including physical agitation and aggression. This somatization would be corroborated through articles on chronic pain in displaced and survivor of torture or targeted violence (TTV) populations (Kananian et al, 2020;Kaur, 2020;Rohlof et al, 2014;Rometsch-Ogioun El Sount et al, 2019;Sarajlić Vuković et al, 2014), especially since the physical consequences of TTV can serve as everpresent reminders of the humiliations endured. More importantly, regardless of how her anguish is expressed, she may identify this grief as problematic due to decreased functioning in important life domains or in her ability to fulfill reasonable responsibilities.…”

A Meta-Analysis of Group Interventions for Trauma and Depression Among Immigrant and Refugee Children

“…The most common group works with refugee and immigrant adults include education and psychoeducational groups, support groups, and trauma-informed groups (Sakamoto & Couto, 2017). Empirically tested effective group interventions include eye movement desensitization and reprocessing therapy (Lehnung et al, 2017; Yurtsever et al, 2018), group cognitive behavioral therapy (Hinton et al, 2012; Kananian et al, 2020; Shaw et al, 2019), trauma-focused group therapy (Drožđek & Bolwerk, 2010), and group art therapy (Dieterich-Hartwell & Koch, 2017). A meta-analysis found that both individual and group interventions on PTSD, depression, and anxiety among immigrant and refugee populations were efficacious with no significant difference between the modalities (Turrini et al, 2019).…”