Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)☆

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Highlights

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    We illustrate how CBT can be adapted to a traumatized Egyptian Islamic population

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    We illustrate the concept of cultural grounding

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    We illustrate the concept of explanatory model bridging

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    We discuss a culturally sensitive assessment measure

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    We present a case to illustrate adaptation

Abstract

In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.

Section snippets

Culturally Sensitive Assessment: The Egyptian Symptom and Syndrome Inventory (E-SSI)

To engage the patient in treatment and to create positive expectancy, one should frame the treatment as addressing complaints of concern (Hinton and Jalal, 2014a, Hinton and Jalal, 2014b). This requires culturally sensitive assessment. Research suggests, for example, that many non-Western groups have prominent somatic complaints (Hinton & Lewis-Fernandez, 2011). In addition, as a way of adapting CA-CBT to the cultural group in question, it was important to learn the local ethnopsychology and

Normalizing and Creating Positive Expectancy About Treatment

Data indicate that positive expectancy about treatment is one of the best predictors of positive outcome in both pharmacology and psychological studies (for a review on the placebo effect see, Price, Finniss, & Benedetti, 2008). It has been shown that culturally adapted treatments have increased effect sizes, and this seems to be through framing the treatment in terms of the patient’s own understanding of disorder (Benish, Quintana, & Wampold, 2011). As noted above, framing the treatment as

Culturally Appropriate Education About PTSD: The Example of the “Inner Child”

Educating patients about trauma symptomatology and the trauma state is another key part of CA-CBT. To this end, one metaphor we use to educate about trauma and teach about trauma-recall triggers in an easy and accessible way is that of the “inner child” (an analogy for the brain’s limbic system; for the “inner child” metaphor used in therapy and in self-help literature see, e.g., Bradshaw, 2013, Capacchione, 1991, Chopich and Paul, 1990). This is another form of explanatory model bridging:

Teaching Mindfulness and Attentional Control to an Egyptian Islamic Population

Several aspects of mindfulness were adapted to the cultural group in question, as they are part of CA-CBT. The use of mindfulness meditation techniques has long been an integral part of the third wave of behavior therapies, including Dialectical Behavior Therapy (DBT; Linehan, 1993), Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002), and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). These approaches encourage mindfulness of internal

Modifying Catastrophic Cognitions: A Cultural Example

Modifying culturally generated catastrophic cognitions is an important part of CA-CBT. For example, the therapist reviews with the patient the culture’s ethnophysiology and cultural syndromes and modifies related catastrophic cognitions. The E-SSI helps to address catastrophic cognitions. The patient can be told that all the E-SSI symptoms are caused by anxiety and depression and will improve with treatment. For example, we explain that anxiety and somatic symptoms are not caused by heart

Addressing Sleep-Related Phenomena

CA-CBT devotes one session to addressing sleep and sleep-related phenomena, including nightmares, sleep paralysis, and nocturnal panic. In many cultural contexts, the nightmares are considered the visitation of a deceased person and an indication that the dreamer is in a physically and spiritually vulnerable state (Hinton, Hinton, et al., 2009). In Islamic tradition, nightmares are believed to be caused by evil spirits (shayateen) that take advantage of a person’s vulnerable state during sleep,

Addressing Worry and Generalized Anxiety Disorder

Uncontrollable worry is a central part of the trauma pathology among refugees and in ethnic populations (Hinton, Rivera, et al., 2012). Worry topics include financial stressors, health concerns, housing issues, and living in dangerous localities with socio-political unrest. Trauma victims tend to have difficulty disengaging from worry. CA-CBT involves examining various worry themes that are pronounced. Eliciting such worry themes promotes an empathic bond between patient and client (the patient

Teaching Anger Management

Anger, another disorder of arousal, is also a major treatment focus (Hinton et al., 2009). We have already mentioned loving-kindness meditation, which may be effective in helping to decrease anger (for a review, see Hofmann, Grossman, & Hinton, 2011). There are several ways to frame anger management to make it more culturally consonant in an Egyptian context. For instance, for the Egyptian cultural group one can mention that Islam emphasizes that anger should be avoided and teaches various

Culturally Indicated Transitional Rituals

In CA-CBT we encourage patients to use cultural transitional rites at the end of the treatment if such are existent in the culture in order to increase positive self-imagery, the sense of efficacy, and positive expectancy. For example, among Cambodian refugees, Vietnamese refugees, and certain American Indian groups, there are steam bath rituals (Silver & Wilson, 1988). For the Egyptian population, we use the purification rituals known as wudhu, that is, ritualistic washing of face, arms, and

Case Example

Omar, age 24, is a former administrative program assistant at an NGO in Cairo, Egypt. His trauma resulted from witnessing brutal and horrendous episodes of sexual assault and being physically mugged himself. In addition to severe trauma, Omar had symptoms of depression and anxiety upon presentation; and he complained of draining somatic symptoms such as neck soreness, dizziness and weakness (low energy and lethargy). Omar also suffered from the local cultural syndrome, “escaping reality”: in

Conclusion

In this article we have attempted to illustrate how CBT can be adapted to a traumatized Egyptian Islamic population, giving examples from CA-CBT. We discussed the concept of cultural grounding and explanatory model bridging. We consider this a key part of adaptation. Explanatory model bridging includes framing the treatment in terms of the local conceptualization of mind and body and how it should be cured (the local ethnopsychology and ethnophysiology). It includes finding appropriate

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    ☆

    We thank Salma ElMasry and Karim Abo Bakr for their remarkable contribution to this project.

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