Pakistan Association of Cognitive Therapists

Most low- and middle-income countries (LMICs) have poor or non-existent mental healthcare. Many of LMIC countries allocate less than 1% of their health budgets to addressing mental illness, making large-scale public health interventions not a practical option, at least for the foreseeable future. Psychiatric services are limited to large urban centres, and mental health literacy is low. There is increasing international recognition of the need to build capacity to strengthen mental health systems in LMICs.The aim of this paper is to offer a reflective commentary on our research undertaken over 15 years in Pakistan psychiatric services to create a workforce and culturally adapted cognitive behaviour therapy (CBT) model for LMICs that works for diverse communities served. The exemplar of our work discussed in this article can be used as lessons for developing mental health therapies for LMICs and other countries with diverse communities globally. Our discussion is based largely, if not, on all aspects describing the key barriers and facilitators to implementation of a workable culturally adapted CBT model for use in Pakistan or any similar LMICs. We report on the implementation of culturally adapted CBT in Pakistan over the past 15 years to improve the identified gaps in evidence. We also highlight the successful dissemination strategies our group employed for successful adaption and implementation.

Cognitive Behaviour Therapy (CBT) has an established evidence base and is recommended by the national organizations in United Kingdom and the United States. CBT remains under utilized in low and middle income countries. CBT was developed in the west and it has been suggested that it is underpinned by western values. It therefore follows that to make CBT accessible for non western clients, it needs adapting into a given culture. Our aim was to develop guidelines for adapting CBT for psychosis in Pakistan by incorporating the views of the patients, their carers and mental health professionals. We conducted a series of qualitative studies in Pakistan to adapt CBT for psychosis (a total of 92 interviews). The data were analyzed by systematic content and question analysis. Analysis started by identifying emerging themes and categories. Themes emerging from the analyses of interviews by each interviewer were compared and contrasted with others interviewers constantly. Triangulation of themes and concepts was undertaken to further compare and contrast the data from the different participating groups. The results of these studies highlighted the barriers in therapy as well as strengths while working with this patient group. Patients and their carers in Pakistan use a bio-psycho-spiritual-social model of illness. They seek help from various sources. Therapists make minor adjustments in therapy. The findings from this study will help therapists working with this client group using CBT for psychosis in Pakistan. These results need to be tested through controlled trials.