CULTURAL ADAPTATION OF AN INTERVENTION MANUAL FOR INDIVIDUALS AT RISK OF FIRST EPISODE PSYCHOSIS: STUDY FROM PAKISTAN

Abstract

Background: Cognitive behavioural therapy (CBT) is an evidence-based intervention for individuals at at-risk of developing First Episode Psychosis (FEP). However, most CBT protocols have been developed in high-income countries and may not be directly transferable to low- and middle-income country (LMIC) contexts such as Pakistan, where cultural explanatory models, family systems, and health service structures differ substantially.

Aim: This study culturally adapted an existing CBT manual for individuals at risk of FEP in Pakistan using structured existing evidence based multi-stage adaptation framework including.

Methods: A qualitative, multi-stage study design was employed, guided by a structured four-stage cultural adaptation framework and prior CBT adaptation work in Pakistan. Stage 1 involved literature review and qualitative exploration through focus groups with individuals at risk, caregivers, mental health professionals, and community/religious stakeholders. Stage 2 focused on developing structured adaptation guidance. Stage 3 involved translation and iterative cultural adaptation of the manual across domains of language, concepts, communication, content, and cultural norms. Stage 4 evaluated the adapted intervention through a feasibility randomised controlled trial (n = 36).

Results: The adaptation process resulted in systematic modifications across five domains: language, conceptual framework, communication style, intervention content, and cultural norms. Key adaptations included simplification of terminology, use of culturally acceptable and non-stigmatising language, integration of psychosocial and spiritual explanatory models, incorporation of family systems into intervention delivery, and development of culturally relevant case vignettes. The intervention structure was streamlined from to 12 core sessions with a booster session to enhance feasibility. Findings from the feasibility trial indicated that the adapted intervention was acceptable and feasible, with good engagement, retention, and positive feedback from participants and therapists.  Conclusion: This study demonstrates that CBT for individuals at risk of psychosis can be systematically and meaningfully adapted for the Pakistani context without compromising core therapeutic principles. The adapted CBT-ARMS manual is culturally relevant, feasible, and acceptable, providing a strong foundation for future fully powered trials and potential implementation in similar LMIC settings