Mary Gobbi

Developing Culturally Sensitive Cognitive Behaviour Therapy for Psychosis for Ethnic Minority Patients by Exploration and Incorporation of Service Users' and Health Professionals' Views and Opinions

BACKGROUND Studies of cognitive behaviour therapy (CBT) for schizophrenia demonstrate that African-Caribbean and Black African patients have higher dropout rates and poor outcomes from treatment. AIM The main aim of the study was to produce a culturally sensitive adaption of an existing CBT manual for therapists working with patients with psychosis from specified ethinic minority communities (African-Caribbean, Black-African/Black British, and South Asian Muslims). This will be based on gaining meaningful understanding of the way members (lay and service users) of these minority communities typically view psychosis, its origin and management including their cultural influences, values and attitudes. METHOD This two-centre (Hampshire and West London) qualitative study consisted of individual semi-structured interviews with patients with schizophrenia (n = 15); focus groups with lay members from selected ethnic communities (n = 52); focus groups or semi-structured interviews with CBT therapists (n = 22); and mental health practitioners who work with patients from the ethnic communities (n = 25). Data were analyzed thematically using evolving themes and content analysis. NVivo 8 was used to manage and explore data. RESULTS There was consensus from the respondent groups that CBT would be an acceptable treatment if culturally adapted. This would incorporate culturally-based patient health beliefs, attributions concerning psychosis, attention to help seeking pathways, and technical adjustments. CONCLUSION While individualization of therapy is generally accepted as a principle, in practice therapists require an understanding of patient-related factors that are culturally bound and influence the way the patient perceives or responds to therapy. The findings of this study have practical implications for therapists and mental health practitioners using CBT with people with psychosis from BME communities.

Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: findings from Developing Culturally-sensitive CBT Project (DCCP).

BACKGROUND There is sufficient research evidence in favour of cognitive therapy in western world. However, only limited research has been carried out on its effectiveness in other countries. It is suggested that adaptations in content, format and delivery are needed before CBT can be employed in non-western cultures. We describe a preliminary evaluation of culturally adapted CBT for depression in Pakistan. AIMS We aimed to evaluate the efficacy of this culturally adapted CBT using a therapist manual. METHOD In a randomized controlled trial we compared combination of CBT and antidepressants with antidepressants alone (treatment as usual) in primary care. Referred patients with ICD-10 diagnosis of depression were invited to participate and randomized to the intervention and control groups. Hospital Anxiety and Depression Scale (HADS) and Bradford Somatic Inventory (BSI) were used to measure changes in depression, anxiety and somatic symptoms. RESULTS Seventeen patients each were randomized to each arms of the trial. Except for financial status there were no differences between the two groups on various demographic variables. Patients receiving CBT showed statistically significant improvement on measures of depression (p < .001), anxiety (p < .001) and somatic symptoms (p < .000) as compared to antidepressant alone group. 82% patients attended six or more sessions of therapy. CONCLUSIONS A culturally sensitive manualized CBT was effective in reducing symptoms of depression and anxiety in Pakistan.

Adapting health care competencies to a formal competency model

Health professions education has moved away from process-based curricula to competency-based curricula. Machine readable and processable health care competencies are still embryonic, pending the emergence of appropriate standards. The IMS Reusable Definition of Competency or Educational Objective specification and the HR-XML competency standard are introduced, compared, and their problems identified in the implementation of exemplar competencies from the UK Royal College of Nursing. An improved competency model is proposed.

University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal, social and religious values (a study from Pakistan)

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non Western cultures. Differences between Western and non Western cultures have been reported widely. Psychotherapy was developed in the West and is underpinned by many beliefs which might be specific only to the Western culture. However, in order to modify CBT, we need to understand whether the concepts associated with the CBT might cause conflicts among people who receive therapy. This study explored the beliefs of the university students in Pakistan to find out if the concepts underpinning CBT are consistent with the personal, family, socio-cultural and religious values of the university students. Discussions were held with University students in Rahim Yar Khan, Pakistan. Students were given information on various aspects of the CBT and were asked to rate their agreement with these concepts on a visual analogue scale. There was little disagreement for the principles of CBT for personal values, while some disagreement existed for religious values. This study highlights the value of assessing peoples’ beliefs about acceptability of CBT in non Western cultures. Students in Pakistan felt that the principles of CBT are consistent with their belief system in most areas. However, the value system of students might not be representative of the rest of the population.

The Process of Teaching and Learning about Reflection: Research Insights from Professional Nurse Education.

The study aimed to investigate the process of reflection in professional nurse education and the part it played in a teaching and learning context. The research focused on the social construction of reflection within a post-registration, palliative care programme, accessed by nurses, in the United Kingdom (UK). Through an interpretive ethnographic approach, the organisational, contextual and cultural issues impacting upon teaching and learning interactions, and the use of reflection therein were explored with student and nurse educator participants. Data were collected from observations of teaching and learning, interviews, and extracts from programme documentation and reflective learning contracts (RLCs). Findings contribute new empirical knowledge regarding the process of teaching and learning about reflection, including educator and clinical supervisor facilitation, the emotional work involved in reflection and methods of ‘mapping’ and ‘modelling’ to support reflection. The influence of both higher education and practice partner organisations on the use of reflection is also evident and indicates that professional reflective education requires institutional support from both education and practice. Specific findings in this paper are pertinent and transferable to other disciplines, where reflective education is used to develop being critical in order to learn through experience. This research offers valuable insights into the realities of reflective education and has currency for educators committed to developing skills for reflection and learning through experience for students, through the generation of a reflective culture.

Views of Depressed Patients in Pakistan Concerning Their Illness, Its Causes, and Treatments

Although the core symptoms of depression appear uniform across cultures, their presentations might vary from one culture to another. This interview study was part of a project to establish whether cognitive behavior therapy could be effective for the treatment of depression in a developing country. We interviewed outpatients from a university teaching hospital in Pakistan who were diagnosed as having depression. We tried to elicit their knowledge and perceptions of depression, its causes, and treatments, and their views about nonpharmacological treatments. We discovered that patients had very little knowledge of mental illnesses in general, and depression in particular. They believed that mental health problems were the result of stress or trauma, and that only medicines could help them. Patients had no knowledge of the roles of psychologists or psychotherapy. Their model of understanding mental illnesses appeared to represent a psychosocial understanding, with physical symptoms being their main concern.

A Qualitative Study to Explore Patients’, Carers’ and Health Professionals’ Views to Culturally Adapt CBT for Psychosis (CBTp) in Pakistan

BACKGROUND 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. AIMS 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. METHOD 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. RESULTS 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. CONCLUSIONS 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.

Semantic Annotation of Ubiquitous Learning Environments

Skills-based learning environments are used to promote the acquisition of practical skills as well as decision making, communication, and problem solving. It is important to provide feedback to the students from these sessions and observations of their actions may inform the assessment process and help researchers to better understand the learning process. Through a series of prototype demonstrators, we have investigated the use of semantic annotation in the recording and subsequent understanding of such simulation environments. Our Semantic Web approach is outlined and conclusions drawn as to the suitability of different annotation methods and their combination with ubiquitous computing techniques to provide novel mechanisms for both student feedback and increased understanding of the learning environment.

Using cognitive behaviour therapy with South Asian Muslims: Findings from the culturally sensitive CBT project

Abstract It has been suggested that cognitive behaviour therapy (CBT) needs adaptation for it to be effective for patients from collectivistic cultures, as currently CBT is underpinned by individualistic values. In prior studies we have demonstrated that CBT could be adapted for Pakistani patients in Southampton, UK, and for local populations in Pakistan. Findings from these studies suggest that CBT can be adapted for patients from collectivistic cultures using a series of steps. In this paper we focus on these steps, and the process of adapting CBT for specific groups. The adaptation process should focus on three major areas of therapy, rather than simple translation of therapy manuals. These include (1) awareness of relevant cultural issues and preparation for therapy, (2) assessment and engagement, and (3) adjustments in therapy. We also discuss the best practice guidelines that evolved from this work to help therapists working with this population. We reiterate that CBT can be adapted effectively for patients from traditional cultures. This is, however, an emerging area in psychotherapy, and further work is required to refine the methodology and to test adapted CBT.

The challenges of developing and evaluating complex care scenarios using simulation in nursing education

Demonstrating the impact and effectiveness of educational interventions, including medium and high-fidelity simulation, has long been fraught with methodological challenges and ambiguities. This is particularly the case when there are several confounding factors and variables operating in situations where control trials are inappropriate, and investigative costs can be high. Current theoretical and empirical evidence, while emerging, is parsimonious and fails to take account of the characteristics of different modes of simulation, their contested theoretical models of learning and the opportunities presented by cutting edge computer science. Medium and high-fidelity simulations, situated within technology-rich environments, generate new forms of complex data that have the potential to provide insights into ‘real-world’ practices. Drawing on a range of locally based studies, we argue that until the methodological questions and data management systems can be addressed, the evidence to determine the judicious and optimal use of simulation to improve student and practitioner performance and patient outcomes will remain primarily reliant on proxy measures of self-efficacy and competence.