(p. 108) Commentary: International Implementation of CBT: Universal Principles Meet Local Needs
The work of Thastum and his colleagues (this volume) presents exciting new directions for improving the robustness and accessibility of evidence-based services. Their chapter describes efforts to replicate evidence-based cognitive-behavioral therapy (CBT) treatment programs from one country, Australia, to another, Denmark, which contributes to the ever-expanding evidence base for global applicability of CBT for youth anxiety. We comment on the contributions of this replication trial and its implications for further dissemination of evidence-based practice across the globe, in addition to the unique role that mixed methods can play in this effort.
Youth Anxiety on a Global Scale
Globally, mental health and substance use disorders are the leading cause of all of the “nonfatal burden” of disease, that is, in terms of disease that causes years of living with disability (Whiteford et al., 2013). Anxiety disorders are second among mental health disorders in contributing to functional impairment, next to depressive disorders. For both, the height of burden peaks early, prior to the age of 25 years. Specifically in Europe, anxiety disorders rank sixth as a top cause of disability across all ages, and they rank seventh as a leading cause of disability in Denmark (Murray et al., 2013).
CBT has a robust evidence base that supports its efficacy for treating anxiety in youth in controlled research settings (Silverman, Pina, & Viswesvaran, 2008) and has a growing evidence base for its effectiveness in more naturalistic settings (e.g., Southam-Gerow et al., 2010). Yet generally only a minority of those who require services to address psychological impairment actually receive treatment (Alonzo et al., 2004; WHO, 2004) and this is particularly true in children and adolescent populations. In developing countries, common barriers include a lack of well-established mental health care policies and coverage. Moreover, in both higher-income and lower- and middle-income countries, access to care remains a challenge due to lack of skilled treatment providers and acceptability of treatments across cultures (Patel, Chowdhary, Rahman, & Verdeli, 2011).
(p. 109) Using Mixed Methods to Improve Treatment Efficacy
Despite CBT’s established efficacy, approximately 40% of youth retain their anxiety diagnoses following treatment (James, James, Cowdrey, Soler, & Choke, 2013). Thastum et al.’s research offers an important next phase in improving this rate of success. Using a stepped-care approach, the authors employed a follow-up, individualized booster treatment posttrial for nonresponders like Marius. They found that after the originally nonrespondent youth had received these individualized sessions, remission rates went from 0% to 57%, and improved further at 3-month follow-up to 79%. When the results of the total group were combined, the 3-month follow-up remission rate went from 73% after the group therapy to 89% after the individualized therapy.
Thastum et al.’s case study of Marius highlights the authors’ finding that socially phobic youth in the study responded less well to treatment than youth with other anxiety disorders. Marius’s case demonstrates how social phobia can impact treatment in a variety of ways, primarily as it led to his particular resistance to participate in the group treatment. In addition, as Marius exhibited significant, debilitating anxiety preventing him from engaging in the first group session, it is possible that Marius’s therapist did not have enough time to assess and provide coping skills for the particular behavioral patterns and/or cognitive distortions that maintained his distress. Thus, while cognitive restructuring and gradual exposures were introduced to Marius earlier than others in the group, those skills may not have specifically targeted Marius’s unique anxiety response, particularly regarding entering and participating in the group. Subsequently, as merely sitting at the group table was anxiety provoking for Marius, his anxiety may have limited his ability to concentrate on the skills being taught, as well as his willingness to actively engage in the treatment process (e.g., answer questions, provide examples, etc.).
Furthermore, the group format may have been unable to provide Marius with enough dosage of exposure time to habituate to his anxiety, disconfirm his anxious cognitions, and practice all of his coping skills. The stepped-care approach allowed Marius’s clinicians to combine information from the literature with Marius’s unique experience to develop a second individualized case formulation. Marius’s nonresponder treatment was then provided in an individual format and focused more on completing simple “stepladders” to reach exposure goals.
Marius’s case illustrates several ways that his parents’ anxiety may have maintained his anxiety and impacted treatment outcome. For example, in the group therapy phase, the family missed two sessions and failed to complete homework on several occasions, which may indicate parental avoidance of elements of the therapy. Parental avoidance may have been related to his parents’ anxiety in group situations and their difficulty tolerating Marius’s distress during group sessions and between-session exposures. Group therapists attempted to decrease avoidance by scheduling individual sessions to replace group sessions and giving the family additional support in troubleshooting barriers to homework completion.
(p. 110) In the post-group, individual treatment phase for Marius and his family, the individualized case formulation helped to improve treatment by revealing his parents’ histories of social phobia and ways their continued avoidance behaviors may have contributed both to the etiology and the maintenance of Marius’s anxiety. The therapist addressed these maintaining factors by scheduling individual sessions during times at which the family had no scheduling conflicts and providing large amounts of psychoeducation and individual support to decrease homework avoidance.
Individual formulation also revealed that parental beliefs may have maintained Marius’s anxiety. Within the group format, problematic parental beliefs were illustrated when Marius’s mother expressed that he needed a break from therapy and when his father expressed that the therapy was too hard for Marius and his concern that “the cure is worse than the problem.” The sentiments expressed by both parents point to possible overprotectiveness, low belief in Marius’s coping ability, and belief that distress may be threatening. Within the individual work, therapists addressed such beliefs with psychoeducation aimed at increasing his parents’ awareness of the ways in which their behavior may contribute to the maintenance of Marius’s anxiety.
This study provides a compelling example of how group-based controlled research, integrated with a working knowledge of the literature, and merged with individualized case formulation, can improve outcomes for local patients. Successful outcomes can then be used to develop future iterations of the general treatment protocol to maximize success at the start. In addition, by using both RCT and single case design, the authors created a stepped-care approach to managing nonresponse. Stepped-care approaches are seen as critical systemic interventions to increase access to care in a health care environment of continually declining resources (Collins, Westra, Dozois, & Burns, 2004). The authors’ particular approach should be lauded because its initial group format is relatively resource minimal, and the individual case formulation component provides a systematic process of self-correction (Bower & Gilbody, 2005). This kind of systematic feedback that elevates clients for “step-up” care can help conserve resources while protecting individual health outcomes.
Together, individualized case analysis helps to identify cases in need of step-up care when treatment outcomes are unsatisfactory. Over the long run, cumulative reflection on these case formulations can also provide valuable ideas for iterative protocol improvement that can help increase efficacy and reach for already efficacious treatments.
Extending the Reach of CBT Around the Globe
Improving efficacy in CBT is only one battle in the war to improve access and effectiveness of care worldwide. Disseminating evidence-based practice around the globe is essential, but successful generalization to diverse settings cannot be guaranteed. Implementation of any protocol in new geographic regions requires (p. 111) consideration for local cultures, treatment settings, and clientele. Initial efforts have been promising. As a start, CBT for youth anxiety has since been applied in multiple Western countries and demonstrated successful outcomes in Australia (Hudson et al., 2009; Rapee, 2000); Germany (Essau, Conradt, Sasagawa, & Ollendick, 2012); Canada (Rose, Miller, & Martinez, 2009); and Sweden (Ahlen, Breitholtz, Barrett, & Gallegos, 2012). In general, compared to control conditions, CBT in those countries has resulted in greater likelihood of diagnostic remission, fewer symptoms of anxiety and depression, higher self-esteem, and lower perfectionism.
One particular group-based CBT program, similar in content to Thastum et al.’s CK/CA treatment, is the Friends for Life Program (Barrett, Lowry-Webster, & Holmes, 1999), which was initially developed in Australia—like CK/CA—and has since been extensively researched throughout the world. FRIENDS is a 10-week group-based anxiety intervention/prevention program that aims to build resilience in youth and to develop skills in managing anxiety (e.g., problem solving, relaxation, cognitive restructuring, graduated exposure). A closer review of the FRIENDS literature reveals considerable variability regarding the degree to which cultural adaptations have been made or described by researchers. In particular, studies of the use of FRIENDS in Mexico (Gallegos-Guajardo, Ruvalcaba-Romero, Garza-Tamez, & Villegas-Guinea, 2013), Canada (Rose et al., 2009), and Sweden (Ahlen et al., 2012) did not explicitly describe any cultural adaptations or considerations that were made. Other researchers have highlighted small modifications, including a Canadian study that changed the number of sessions to fit within the particular school setting (Mifsud & Rapee, 2005) and a German study that replaced animal images with more culturally relevant pictures (Essau et al., 2012). Only a few studies have thoroughly described significant cultural adaptations.
For example, Miller and colleagues (2011) described extensive modifications of the FRIENDS program for use with Aboriginal youth in Canada. Those authors specified important aspects of the treatment development process, including enlisting help from Aboriginal school board consultants and support workers to develop engaging, meaningful, and attractive materials for Aboriginal students. They also made considerable adaptations to the treatment content, such as writing scripts for the beginning and end of each lesson to encourage the use of storytelling techniques, introducing a new character to serve as a “guide” throughout the treatment, and including additional craft projects, such as a “medicine pouch” and a modified medicine wheel.
In addition, Siu (2007) also described cultural adaptations of the FRIENDS program for use in Hong Kong. Based on their knowledge of the local culture, they changed the treatment structure to be more acceptable and feasible to school settings (e.g., 10 sessions were reduced to 8) and families (e.g., parent sessions reduced from 4 sessions to 2). Adaptations were also made to the treatment content, including giving characters traditional Chinese names, incorporating pictures, examples, and homework assignments that better reflected the experiences of Chinese youth (e.g., increased emphasis on academic pressure), and replacing the original relaxation exercise with a more well-known Chinese relaxation (p. 112) script. Though the latter studies did not compare the original FRIENDS program with their culturally enhanced versions, the authors hoped that youth would be more engaged in treatment that utilized more culturally relevant materials, which would then translate into enhanced learning and greater program effectiveness.
CBT in Denmark
Notably, the study by Thastum and colleagues is the first evaluation of a CBT program for youth anxiety in Denmark, cross-nationally replicating the Cool Kids program that was originally developed by Rapee and colleagues (2000) in Australia. The Thastum et al. study contributes to the literature by continuing to study CBT in different settings, across different countries and continents. The authors’ mixed-methods approach was particularly informative, as supplementing their rigorous RCT design with exemplary case studies provided valuable analyses at both the group and individual level. Specifically, while the quantitative methods help readers to understand the overall effectiveness of this particular international translation, the qualitative discussion helps to explain important treatment processes, which can improve our understanding of mechanisms of change and ways to enhance and/or adapt our treatments.
The Next Generation of Dissemination: Implementing CBT in Non-Western, Developing Countries
To date, most formalized clinical trials of CBT for anxiety have been conducted in higher income, Western countries. However, the loci of greatest unmet need likely exist in developing, lower- and middle-income countries (LMIC), on such continents as in Africa, Asia, and the Middle East (Patel, Flisher, Hetrick, & McGorry, 2007). Key challenges to addressing mental health needs in these countries include the shortage of mental health professionals, the fairly low capacity and motivation of nonspecialist health workers to provide quality mental health services, and the stigma associated with mental disorders. These national health policy barriers are beyond the scope of this commentary, but good recommendations do exist to guide adaptation of CBT across diverse nations and cultures.
Since evidence has supported the use of CBT across cultures, most recommendations focus on adapting specific content or delivery features of the intervention while leaving the core principles and strategies intact (Chowdhary et al., 2014; Patel et al., 2011). In a meta-analysis of 16 studies of adaptations of treatments for depressive disorders, authors noted that most changes occurred with the implementation of the interventions or were efforts to enhance the acceptability of the treatments (Chowdhary et al., 2014). For example, most adaptations were made in respect to language (e.g., replacing technical terms with colloquial expressions), (p. 113) context (e.g., reducing practical barriers to access, scheduling flexibility, etc.), and the therapist delivering the treatment (e.g., therapist–patient matching, cultural competence; Chowdhary et al., 2014). Many changes also involved incorporating local practices into treatment, extending goals of treatment to include family, attention to somatic models of illness, and simplifying treatment or using nonwritten materials (Chowdhary et al., 2014).
It is important to include details about the adaptation process because it aids in the replication of treatment delivery across new groups and facilitates consensus about the optimal methods of adaptation. Traditional reports of efficacy do not provide sufficient guidance in how to implement evidence-based interventions because they often leave out details about culturally responsive methods (Huey & Polo, 2008). In a meta-analysis of evidence-based treatments for ethnic-minority youth, Huey and Polo (2008) recommend that authors include a description of efforts to make a treatment culturally responsive, and, when methods are not explicit, authors should evaluate the extent to which culturally related content emerges as a natural element of the treatment process. It is notable that adaptations may not always be necessary. Despite the popularity and likely importance of cultural adaptation, evidence is mixed as to whether or not culturally responsive treatments are more beneficial than standard treatments (Huey & Polo, 2008; Chowdhary et al., 2014). Nevertheless, it helps scientific and implementation efforts for researchers to explain their decision regarding specific adaptations, even where no adaptations were made or were needed.
One common approach that guides cross-cultural adaptation is the Medical Research Council’s (MRC) framework for complex interventions (Chowdhary et al., 2014; Patel et al., 2011). The MRC’s framework involves four phases: development (identifying the evidence base, identifying and developing a theory, modeling process and outcomes); feasibility and piloting; evaluation; and implementation (Craig et al., 2008). In the Chowdhary et al. study (2014), common elements in adaptation processes tended to be selection of a theory-driven psychological treatment, consultation with a variety of stakeholders in the adaptation process, the use of mixed methods to assess feasibility and acceptability, pilot studies to evaluate barriers to the delivery of the treatment, and, finally, evaluation in a controlled study. In this way, Thastum et al.’s mixed-methods approach could be used to assess formally for feasibility and acceptability issues that may facilitate or impede further implementation across Danish sites and populations.
Using Mixed Methods to Further Cross-Cultural Dissemination and Implementation
Mixed-methods research, making use of some combination of quantitative and qualitative data and analysis, seems to have an essential role to play in dissemination and implementation science and, therefore, in cultural adaptations (p. 114) (Southam-Gerow & Dorsey, 2014). Qualitative methods, deemphasized in recent years with the prominence of behaviorism and empiricism, may be the most appropriate methodological approach for early-stage research, particularly when trying to understand a treatment’s potential uptake in diverse contextual settings with many potentially influencing factors (Southam-Gerow & Dorsey, 2014). Case study is a type of qualitative data that allows a richness of detail about individuals or groups and their context (Palinkas, 2014). Qualitative data can help one understand the process and context of an RCT, including helping to understand ways to better target study participants, account for unexplained findings in quantitative data, and determine reasons for the success or failure of a treatment (Palinkas, 2014; Southam-Gerow & Dorsey, 2014). Qualitative data are very useful in “translational” research when one wants to know how to proceed with the translation optimally (Palinkas, 2014). In cross-cultural adaptations, qualitative data are not only used to assess the experience of direct participants (i.e., clients) as they receive the intervention, but they are also used to assess the opinions of important stakeholders (e.g., health care administrators, policy makers, nonpatient families) through focus groups and interviews (Chowdhary et al., 2014).
Qualitative data are particularly helpful when making cultural adaptations because they allow one to consider context at various levels. Many dissemination and implementation models account for various levels of the ecology, including child, family, therapist, treatment team, and broader system (Southam-Gerow & Dorsey, 2014). Complexity at various levels must be considered in order to implement treatments effectively across diverse settings. Considering cultural differences among countries in their family systems and in their parenting styles is particularly important when conducting clinical work with children, who rely heavily on their parents. Qualitative data may be especially helpful in teasing out cultural differences between families, as such differences may be particularly subtle. Furthermore, relying solely on quantitative approaches to assess a priori constructs may risk missing important differences in treatment implementation (e.g., understanding important cultural differences in intergenerational relations before implementing parenting management and functional assessment techniques).
Client, Context, Treatment, and Community Factors That Maximize Global Dissemination
To maximize efficacy and effectiveness by creating culturally sensitive CBT, Hinton and Jalal (2014) propose parameters that account for context at multiple levels when implementing CBT in global settings. Hinton and Jalal (2014) suggest that several key client, context, treatment, and community features must be specified to facilitate cross-national implementation. Key client factors to consider include the language of the intended client and the treatment (while including (p. 115) degree of language fluency of the client base); key demographic variables (e.g., socioeconomic status, education, literacy); and religious background of the group (including specific denominations of larger religions).
Key culturally specific contextual factors include typical traumas that the intended client population has experienced; typical external stressors; local community problems; pragmatic barriers in how or where treatment is provided; what kinds of case management resources are available to the client outside of the presiding therapist; and how and where the patient was recruited.
Key treatment and treatment-model factors that implementers are encouraged to think about include how and whether DSM/ICD disorders are considered; what underlying biopsychosocial mechanisms maintain the observable problem; and what target problems the client relates to. These factors then help the provider develop a working case conceptualization of how the disorder is maintained and how treatment targets those mechanisms as contextualized by culture.
To make CBT techniques tolerable and credible for diverse cultural groups, Hinton and Jalal further encourage implementers to consider several community issues, including therapist–client matching and how concerns may differ across the individual and community. They also encourage implementers to utilize local sources of resilience and recovery in order to address stigma about the disorder and the seeking of treatment; to address structural barriers to treatment; and to attend to social demand characteristics and economic incentives of the treatment. Any individual dissemination effort may not have the resources to identify or address comprehensively all concerns that derive from such an analysis. However, the degree to which implementers are mindful of the aforementioned factors may very well predict success for local, regional, and national uptake and sustainability of the intervention or program.
Conclusions and Future Directions
This commentary has reviewed the Thastum et al. study and its broader implications vis-à-vis past and current efforts to disseminate and evaluate CBT for youth anxiety across different countries. To date, formal clinical trials have provided substantial evidence for the generalizability of treatment effects across most higher-income Western societies. In this context, we discussed how the study by Thastum et al. provides further evidence that CBT can be implemented in one such country—Denmark—with relatively limited adaptation needed from prior models of the Cool Kids/Chilled Adolescents protocol, originally developed in Australia. We also pointed out how the Thastum et al. study demonstrates the power of a mixed-methods approach integrating the quantitative data of an RCT with the qualitative data of case studies to better understand in depth the process of change in successful cases and the need for and nature of additional, individualized, “stepped-up” therapy for unsuccessful cases.
(p. 116) We then described how the use of mixed methods, more generally, can be applied to the task of extending dissemination efforts to lower- and middle-income developing countries. For example, in successfully disseminating treatments in these countries, qualitative data are required to assess and adapt the treatments to the different, challenging local conditions in these areas, such as the shortage of mental health professionals, the lack of access to formal CBT when it is needed, and the significant cultural differences that lead to stigma for treatment. This individualization deserves special attention as the field tries to increase access to evidence-based care globally. Such efforts present new challenges, but with these come unique opportunities to learn more about how and why evidence-based care works, for whom, in what settings, and under what circumstances. We look forward to the challenge.
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