By Robin Lau, CR Therapist and Research Assistant at King’s College London
Cognitive remediation using CIRCuiTS™ is now widely applied across the globe. CIRCuiTS™ has been translated into seven languages and implemented in the eleven countries shown in Figure 1. Additionally, various other forms of cognitive remediation have been developed and are currently in use across multiple countries. The CIRCuiTS™ treatment is tailored to the client's cultural context—a practice known as cultural adaptation.
In our interconnected world, people from different societies have diverse lifestyles, values, and beliefs about mental health. Therefore, it is important to adapt cognitive remediation so it is relevant and significant for individuals from various cultural backgrounds.
So, how is cognitive remediation culturally adapted?
The first form of adaptation involves modifying or excluding content that could be culturally and religiously insensitive. For example, within a shopping task, Muslim clients might encounter a scenario that involves purchasing non-halal items like bacon and white wine. To maintain religious sensitivity, these food items should be substituted with culturally appropriate alternatives. This adjustment extends to other elements such as names, capital cities, recipes, and more. Cognitive remediation programmes and therapists should make these culturally relevant substitutions to create a tailored therapy. CIRCuiTS™ accomplishes this by adjusting names within certain tasks. For instance, in the "reading a bus timetable” task, place names are replaced with local names in the targeted country. Another instance is a study conducted in Egypt that removed content not applicable to Egyptian culture, such as references to social drinking or the ownership of cats or dogs as pets (1).
When translating therapy into different languages words should fit the local cultural norms and vernacular. For example, the term "fiancée" might not apply to certain religions and cultures (1). In such cases, using alternative words such as "girlfriend," "boyfriend," or "partner" would facilitate better understanding. Additionally, providing information sheets and therapy materials in multiple languages can benefit ethnic minorities, allowing them to share information about cognitive remediation with peers and family members who might not be fluent in the predominant language of the country (2).
Family involvement could be a beneficial supplement to cognitive remediation, provided it aligns with the client’s privacy and preference, and follows local guidance. Family structures and dynamics vary significantly across cultures, influencing the approach to cognitive remediation. Some cultures encourage the involvement of family members in therapy, and the family plays an important role in the client’s care. In China, where familial responsibility is of great cultural significance, therapy often incorporates family participation in decision-making and considers the holistic needs of the family (3). Similarly, a study conducted among South Asian clients residing in England highlighted the positive reception of family involvement in cognitive remediation therapy (2). The family members offered valuable insights into the client's cognitive difficulties and how these difficulties affect the individual's daily life.
Various cultures hold unique beliefs about mental health, including spiritual agents, yin-yang forces, and the notion of predestination (3). It is essential to acknowledge these beliefs without dismissing them. Engaging in discussions that challenge these cultural-specific beliefs might create distance and potentially weaken the therapeutic alliance with the client. A key advantage of cognitive remediation is its non-confrontational nature to cultural beliefs, since clients complete tasks that are neutral and within their expectations.
It is encouraging to see how CIRCuiTS™ and other forms of cognitive remediation therapy have been used globally and how mental health professionals have adapted them to fit diverse cultural norms. The adaptability of cognitive remediation proves highly beneficial by avoiding confrontation with the clients’ belief systems. These adaptation efforts have expanded access to cognitive remediation, ensuring that clients find the therapy both relevant and meaningful.
(1) Gohar, S. M., Hamdi, E., Lamis, A., Horan, W. P., & Green, M. F. (2013). Adapting and evaluating a social cognitive remediation program for schizophrenia in Arabic. Schizophrenia Research, 148(1-3), 12-17.
(2) Press, C. J. (2012). Developing culturally adapted cognitive remediation for South Asian first episode psychosis sufferers. The University of Manchester (United Kingdom).
(3) Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., ... & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714-727.
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