A pilot study has demonstrated the functional feasibility of a culturally adapted Cognitive Behavioral Therapy (CBT) manual in Bengali for treating major depression in Bangladesh. The study, published in BMC Psychiatry, highlights the importance of cultural sensitivity in mental health interventions to improve patient engagement and outcomes.
The research was conducted in three phases: initial development of the CBT protocol, expert evaluation of the translated version, and a pilot study with five participants diagnosed with major depression. The adapted manual incorporates elements specific to Bangladeshi culture, such as local metaphors, religious practices, and respect for hierarchical roles.
Cultural Adaptation Process
The adaptation of the CBT manual followed a framework that included information gathering, professional evaluation, and preliminary testing. The initial phase involved reviewing existing CBT manuals and gathering information from CBT practitioners in Bangladesh. A questionnaire survey of 40 CBT practitioners in Bangladesh revealed various treatment barriers, including practice-oriented, patient-centered factors such as motivation, social system, therapeutic relationship, and specific challenges in implementing CBT for psychological disorders. This information was used to develop a first draft of the Bengali CBT manual, which also included a psychoeducation section and motivational interviewing (MI) techniques.
Expert Evaluation and Refinement
The first draft was then reviewed by seven experts with varying levels of CBT experience. Their recommendations included adding culturally relevant examples, integrating additional techniques such as psychoeducation, enhancing practitioner training on cultural competence, changing negative thoughts, behavioral activation, problem-solving, and communication skills, and establishing detailed documentation and monitoring guidelines. The content validity ratio (CVR) of the Bengali CBT manual was calculated based on professionals’ ratings. The I-CVR values for individual chapters ranged from 0.7 to 1.0, reflecting different levels of perceived relevance among the professionals. The overall scale CVR (S-CVI/Ave) was determined to be 0.85, indicating that, on average, 85% of the judges found the chapters relevant.
Key Adaptations
Several key adaptations were made to the CBT manual to enhance its cultural relevance:
- Psychoeducation: Educational materials were developed in Bengali and incorporated culturally relevant examples to enhance understanding and engagement. For example, depression is explained via familiar concepts, such as ‘kalo megh’ (dark cloud), ‘jibon ei nodir moton’ (life is like a river, with its ups and downs).
- Behavioral Activation: Culturally relevant activities were incorporated, such as participating in local festivals or family traditions.
- Problem-Solving: Culturally familiar problem-solving approaches, such as community-based discussions and collective problem-solving methods, were applied.
- Use of Metaphor: Local folk tales, stories, and proverbs were used to illustrate CBT concepts. A metaphor for depression, such as ‘cholar pothe onek kada’ (heavy mud in the pathway) illustrates how depression creates obstacles and challenges.
- Religious and Spiritual Practices: Local religious and spiritual practices were integrated into the therapy to ensure alignment with clients’ spiritual beliefs. For example, when suicidal thoughts are addressed, a client’s belief that ‘attohotta moha pap’ (suicide is a great sin) is used as alternative thinking.
- Respect for Hierarchical and Gender Roles: Communication styles and therapeutic approaches were adapted to express respect and honor as per traditional age-related hierarchical and gender roles.
- Festivals and Cultural Events: Goals were set or activities were structured around major festivals such as Pohela Boishakh (Bengali New Year) or Eid.
- Use of Bengali Language: Incorporating Bengali terminology and phrases where possible and appropriate, both in general session discussions and in CBT homework forms (e.g., activity schedules, and thought records) were done.
Pilot Study Results
In the pilot study, five participants diagnosed with major depression received the adapted CBT intervention. Participants were assessed at baseline and after three months using the Depression Scale (DS), Anxiety Scale (AS), General Health Questionnaire (GHQ-28), and Beck Scale for Suicidal Ideation (BSS). The mean age was 25.6 years (SD = 9.0). CBT was provided by the first author.
Implications for Mental Health Care
These preliminary findings suggest that culturally adapted CBT can be a feasible and acceptable intervention for major depression in Bangladesh. The researchers emphasize the importance of considering cultural context when developing and implementing mental health treatments. Further research, including randomized controlled trials, is needed to evaluate the effectiveness of the adapted CBT in a larger population.
