Background
The evidence to support the effectiveness of CBT for psychosis (CBTp) in Low & Middle-Income Countries (LAMIC) is emerging [
1‐
5], but it is rarely available in these countries. One possible barrier to its use might be a lack of adaptation to address local barriers [
6]. Cognitive behaviour therapy was developed in the West. Cultural adaptation of CBTp has been recommended for its application in non-western cultures [
7‐
9].
There has been a noticeable improvement of the mental health system in China since the first National Mental Health Plan issued in April 2002. However, like many other LAMICs, the health system harbours a large service gap in the form of a severe shortage of mental health professionals and resources [
10]. The most underdeveloped area in this aspect is the integration of psychosocial interventions in the mental health system. There is a recent drive to make evidence-based therapies, particularly CBT available instead of developing indigenous treatments, as CBT might be compatible with Chinese culture if appropriately adapted [
11].
Chinese culture is influenced mainly by Confucianism and Taoism, two different philosophies. Confucianism can be considered as a system of social and ethical philosophy and is believed to have had a powerful influence on Chinese behaviour and social structure for the past 2000 years. The central teachings of Confucianism—which include filial piety, respect for familial and social hierarchy, discouragement of self-centeredness, emphasis on academic achievement, and the importance of interpersonal harmony—are considered principles for social interactions and have profound influences on cognitions and behaviors of Chinese individuals [
12]. However, the Taoism advocates a life of complete simplicity, being connected with nature, and of non-interference with the course of natural events. Most Chinese seem to be able to combine these two philosophies with great ease to guide or rationalize their thinking and behaviours.
Most of the literature on the use of CBT for Chinese population comes from the United States of America, Australia, and Hong Kong. It has been suggested that the Chinese cultural norms and philosophy of CBT are in perfect harmony with each other [
12]. It has also been argued that the Chinese culture places special emphasis on logical thinking. A well-known Chinese proverb says, “Originally there is no disturbance in the world, but people make themselves feel worried” [
13] a notion that precisely mirrors the basic concept of CBT. Similarly, Hodges and Oei [
11] suggest a substantial degree of compatibility between the Chinese culture and CBT philosophy. They also argue that instead of developing indigenized therapies it would be better to adapt an evidence-based intervention like CBT for the Chinese people. Authors in this area warrant caution and have advised modifications to improve therapeutic outcomes [
8].
In our previous work we have used mixed methods approach for cultural adaptation of CBT for both depression and psychosis. Numerous adjustemnts were required to improve accesability, acceptability and efficiency of CBT [
1,
4,
14‐
16]. Based on this work we have developed a methodology to culturally adapt CBTp that has been described in details elsewhere [
15,
17,
18]. This paper reports findings from a qualitative study in which we explored the views and opinions of the mental health professionals, patients and their caregivers to inform cultural adaptation of CBT for the Chinese population.
Aims and objectives
The primary aim of this study was to gather information that can be used to adapt CBTp in China through exploring the views of patients with schizophrenia, their carers, and the mental health professionals. To achieve this broad aim, we conducted interviews with (a) the patients with psychosis and their carers; to explore their views about psychosis, its causes, and the treatment; and (b) mental health professionals helping patients with schizophrenia to examine their experience with this group.
Method
Interviewers
Interviews were conducted by one Associate Professor and five residents in their final year training in Psychiatry (average duration of working in psychiatry =8.8 years, range = 4 to 18 years) in Chinese and then transcribed and translated in English as and when they became available. All the interviewers had an MD and had received training in research and psychiatry. Two interviewers were male, with an average age of 31.8 years (range = 26 to 40 years). Interviewers were not directly involved in the care of patients they interviewed, to ensure that the patients are free to express their views. They received training and supervision from the last authors who have vast experience of qualitative research in this area. For example, based on our experience of conducting qualitative research from other countries with a similar background, interviewers tried to assure patients that their disclosure of non-medical treatments will be acceptable, as we noticed medical professionals in these cultures are not accepting of treatments that are not based on a medical model. Regular supervision also addressed other biases, for example, the status gap with patients. Interviewers provided details of the study, gave participants the opportunity to ask any questions they had and sought informed consent before each interview.
Study design
This qualitative work was underpinned by the principles underlying an ethnographic approach [
19,
20]. This approach to data collection allowed us to understand the focus of people participating in the study within their cultural context [
21]. The data were analyzed using content analysis.
Participants and settings
The particpants in the study were recruited by using purposive sampling. Participants were invited by the research team in face to face contacts. They were given information about the study, and those who agreed were invited to the interview. No records were kept of those who refused to participate in the study, as the numbers were too small. All the interviews were conducted in a healthcare facility. The mental health professionals were interviewed at their offices. The interviews with patients and their carers were conducted in the outpatient clinics.
Based on our previous experience we envisaged that we would require between 8 and 12 participants in each group to get a comprehensive picture. We, therefore, decided to recruit 15 participants in each group. We interviewed 15 patients with a diagnosis of schizophrenia/schizoaffective disorder or delusional disorder using ICD-10, RDC (International Classification of Diseases, 10th edition, Diagnostic Criteria for Research) from outpatient clinics of a psychiatry department with illness lasting for a minimum of one year. We excluded patients with severe illness, disruptive behaviour, intellectual disability or serious substance misuse problems from the study. We enlisted 15 caregivers accompanying the patients in the outpatient clinics of participating psychiatry departments, because of the vital role they play in decision making process in this culture. Finally, we interviewed 15 mental health professionals. We wanted to understand their experience of helping patients with schizophrenia and their carers. To help improve access and to adapt CBT, we engaged mental health professionals who practiced CBT or, at least, were aware of the basic concepts of CBT. Table
1 describes characteristics of participants.
Table 1
Characteristics of the participants
Patients (15) |
Age | Mean = 22 years (range = 16–34) |
Gender | Male = 8 (53.3%), female = 7 (46.7%) |
Duration of illness | Mean = 53.6 months (range = 1–180 months) |
Education | Mean = 10.5 years (range = 6–19 years) |
Marital status | Married = 2 (13.3%), single 13(86.7%) |
Diagnoses | Schizophrenia = 15(100%) |
Urban/rural | Urban = 11(73.3%), rural =4(26.7%) |
Carers (15) |
Age | Mean = 43.3 years (range = 29–53) |
Gender | Male = 3(20.0%) female = 12(80.0%) |
Marital status | Married = 15(100%) |
Relation with patient | Spouse =0(0%), parent = 12 (80%) sibling =2 (13.3%) relatives(aunt) =1 (6.7%) |
Urban/rural | Urban = 9(60.0%) rural =6(40.0%) |
Psychiatrists (15) |
Age | Mean = 32.1 years (range = 26-36 years) |
Gender | Gender male 7 (46.7%), females 8 (53.3%) |
Experience in psychiatry | Mean = 7.3 years (range = 3-15 years) |
Collection of data
We had developed and used semi-structured interviews for cultural adaptation of CBT previously [
6,
18]. We found them effective [
18]. The semi-structured interviews with all the three groups were conducted individually in face to face contact. These semi-structured interviews have open-ended questions with prompts (Additional files
1,
2 and
3). These interviews help the researcher explore areas that have already been considered to be vital for cultural adaptation of CBTp. Table
2 summarizes themes explored through interviews. These semi-structured interview guides can be obtained from authors.
Table 2
Summary of themes explored through interviews with stakeholders
Patients | |
Their knowledge of illness, its causes and its treatment | |
Patients perception of effect of the disease on their lives | |
Presenting problems and care pathways | |
Their experience of modern and traditional methods of help. | |
Their understanding of the ideal treatment. Their knowledge of psychotherapy/CBT | |
Carers | |
Their knowledge of the illness | |
Their understanding of cause and treatment of diseases. | |
The reasons for bringing patient to the hospital | |
Their expectations from treatment and their experience of treatment | |
Their knowledge and experience of traditional methods of help | |
Their understanding of psychotherapy/CBT | |
Psychologists & Psychiatrists | |
Their experience of working with schizophrenic patients and their families | |
Their perception of pathways of care | |
Their experience and expectations from psychotherapy for this patient group | |
What are the barriers in providing therapy? | |
What is helpful in providing therapy for this group | |
Which techniques are useful | |
Do they think therapy needs adapting? | |
To explore their opinion on effect of culture and other factors on therapy | |
The interviews were 60 to 90 min in duration and were audio-recorded. Each interviews was transcribed immediately after completion and ten translated by two authors (BL and LX). These transcripts and translations were randomly assessed by two senior authors (WL&YX) for validity. We acquired contact telephone numbers from the participants and asked their consent to contact them for further clarification of any point raised during the interview. Anonymity and confidentiality were assured. Data was not shared beyond the research team. Any non-verbal communication and behaviours were recorded in the field notes by researchers. We used telephone and video conferencing for communication with and supervision and support to the field team during the study. The interviews were conducted between January and June 2015. We sent the interview scripts to a randomly selected sub-sample of the participants for comment (5 participants from each group), verification and to clarify any issues that arose during the analysis stage. Finally, the results once compiled were shared with all participants.
Analysis of data
The data were analyzed by systematic content and question analysis [
22]. The researcher immersed herself in the data by carefully reading the interview scripts multiple times and identifying emerging themes and categories [
20]. Each interviewer started analyzing the interviews as and when they were conducted. We followed the principle of “emergent design” when the issues requiring further exploration were raised by the respondent [
23]. These issues were then tested appropriately in subsequent interviews with the participants. We also contacted participants by telephone for clarification of areas of uncertainty when the data were analyzed.
Each interviewee was assigned a numbers for the purpose of the transcription and reporting. The data were primarily descriptive, with most themes emerging in response to the interviews. As predicted saturation point was reached after 10–12 interviews. However, we completed the total number of interviews (n = 15) to ensure completeness of data. We adopted an elaborate method of coding. Two teams with three members in each team, one located in China and the second based in Canada coded data separately for the Chinese and the English version of the transcripts. This was to improve the reliability of the analysis and to ensure that the translation is working. The last two authors (MA&FN) supervised the two teams. Finally, the data were reorganized into wider themes (for example, barriers to therapy) and categories (for example, financial burden) and written for this article. Themes were identified in advance based on our previous work which had formed the basis of semi-structured interview.
Discussion
Patients and their families in China use a bio-psycho-social model of psychosis for conceptualisation and management, with additional emphasis on spiritual and religious causes. This study confirms our previous findings that people from Non-Western cultures use a bio-psycho-social-spiritual model of illness [
15]. This is the first study to examine views of the patients, carers and the mental health professionals regarding psychosis from China. While there is one report from China that CBT for psychosis works, the therapy was provided by expert therapists, and additional supervision was given to deal with cultural issues. Findings from this study can help both expert and non-expert therapists in addressing cultural barriers.
The mental health professionals we interviewed in this study emphasized the need for adaptation of treatment and the need to be mindful of cultural, spiritual and other related factors while providing therapy. As identified in previous literature, these findings confirm the need for adapting CBT in non-Western cultures [
8,
11,
12,
24]. This study highlights the need for understanding the patient’s cultural and spiritual needs. It also came to fore that the language needs adapting rather than just being translated. It is essential that the therapists in Non-Western countries make adjustments in therapy while keeping the treatment close to its theoretical underpinning. One such example is the involvement of the family. A family member often accompanies patients in China, and mental health professionals insisted on involving the family in decisions regarding the care of patients. Similarly, dealing with stigma in therapy should be an essential part of therapy, as, like the west, it might prevent people from help seeking in LAMIC, but to a greater degree [
6,
15,
18].
In the absence of a well-established referral system, clients come from a variety of sources. Self-referral is common. It was evident that the similar to other Asian countries [
18] as part of their complex journey patients usually seek help from non-medical healers first. Even though none of the carers or patients considered a spiritual or religious cause, almost all the patients had seen traditional healers or faith/spiritual healers before coming to the psychiatric health facility. The health professionals are seen in high esteem in most Asian countries. It is possible that the patients and their carers were not very comfortable in disclosing their beliefs directly regarding spiritual causes. However, the fact that they had contacted non-medical healers and had spent much money means they believed in these causes at least in the past. It highlights the need to understand the complex pathways used by the patients with psychosis in China. The therapists should adopt an open-minded approach so that patients discuss the involvement of other healers. It might also help understand barriers to receiving help from the modern medical system. Both the carers and the patients knew little about the causes of the illness and in general related the illness to psycho-social problems and stress.
Only a few patients or carers had heard of psychotherapy. It is not surprising, as the mental health professionals were not trained in CBT for psychosis. The mental health professionals were aware of and trained in CBT for non-psychotic disorders, but raised concerns regarding its application in psychosis. They also highlighted difficulties in its application in non-psychotic disorders. Most carers and patients expected medical and psychological treatments from the hospital. It is possible that they see hospitals only responsible for treating them with pills, while their system of mental or spiritual healing exists outside the hospital. It is also possible that only those who are educated, have access to information regarding Western therapies through the internet or are from higher socio-economic background might be familiar with the non-pharmacological interventions. It highlights the need to educate patients.
Similar to our previous work with clients from the non-European background [
6] mental health professionals reported a high rate of dropouts from the follow-up. The main problems seem to be with engagement, high drop outs, lack of awareness of disease and therapy, uncooperative family caregivers or conflicts within the family, dissatisfaction with the therapeutic effect and adverse effect of the drugs. Traveling distance and traveling expenses were described to be a major barrier. Surprisingly none of the mental health professionals described homework assignments to be a problem, even on direct questioning. It is possible that clients who see a therapist in a position of authority follow their instructions, as pointed out by Hodges et al. [
11].
Interviews with mental health professionals highlighted the techniques that they find helpful in dealing with patients to our attention. Although most of these relate to non-psychotic disorders, with some adjustments, these might be applicable for CBT for psychosis. Our study confirmed the preferable use of a teacher-student relationship instead of collaborative style [
8,
11,
14]. Commonly used techniques described to be useful include; helping with coping, behavioural techniques, social skills, family counseling and dealing with family conflicts. The Socratic dialogue was considered a difficult technique to use. It has an intuitive appeal as the model of dialogue in this context in Asian cultures might be sermons delivered by a saint and not a questioning style. It has been suggested that a Socratic questioning style might lead to the patient losing confidence in therapists skills [
12,
25].
This study confirms findings from the previous literature, for example, the need for understanding the cultural values, adjustments in techniques to improve assessment and engagement and adjustment in therapy techniques. The lessons learned from this study can be used to deliver culturally sensitive CBT and culturally adapted CBTp.
Implications for therapy and research
We show through this work that with minor adjustments CBT can be used in China. The information gathered in this study can be easily used to inform “culturally sensitive assessment and formulation to engage clients and adjustments in CBT." An understanding and grasp of the cultural factors will enhance the process of patient engagement with therapy and care.
Limitations
The mental health professionals interviewed in this project came from a big city and patients and their carers were also mostly city dwellers. This may put some limits on the generalisability of the findings. Including three different groups of participants in the study would have addressed this issue at least partially. Interviews have been criticized over their validity, but in our experience, these are a useful tool in the process of adaptation of CBT as we have shown in our other work cited in this manuscript. An additional point which gives us confidence in the value of interviews is the similarity in the results to our previous work in Pakistan, Morocco and the Middle East and with ethnic minority clients in the United Kingdom.
Conclusions
This study is part of a bigger body of work focused on adaptation of CBT for non-western countries including China. The information obtained from this study will be used to deliver culturally sensitive CBT for psychosis in a small RCT. We intend to broaden the scope of this work to include patients with other disorders. There is potential to diversify the treatment to wider strata of social and economic sections of population. Finally, there is a need to exploit the full potential of eMedia in this regards.
Acknowledgements
Authors acknowledge the contribution of patients and their carers and the mental health Professionals who participated in this study.
Authors acknowledge the support from “Research on Demonstration and Application of Collaborative Network Construction in Clinical Research among psychiatric disorders (2015BAI13B02).