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Table of Contents
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 61-65

Culturally adapted CBT (CA-CBT) for traumatised indigenous South Africans (Sepedi): a randomised pilot trial comparing CA-CBT to applied muscle relaxation

1 Department of Psychiatry, Behavioural and Clinical Neuroscience Institute, University of Cambridge, UK
2 Clinical Psychology Section, Mokopane Hospital, RSA
3 Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, USA

Date of Submission01-Dec-2018
Date of Decision04-Feb-2020
Date of Acceptance03-Mar-2020
Date of Web Publication29-May-2020

Correspondence Address:
PhD Baland Jalal
Department of Psychiatry, Behavioural and Clinical Neuroscience Institute, University of Cambridge
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_68_18

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In South Africa, there is a high rate of events such as criminal violence, stress and sexual assault, particularly in lower socio-economic status (SES) communities. Problems are particularly acute amongst indigenous groups. In spite of the great need for interventions for those having experienced these events, little information is available to guide treatment choices. The goal of this randomised controlled trial was to test the efficacy and feasibility of culturally adapted CBT (CA-CBT) compared to applied muscle relaxation (AMR) for traumatised South Africans belonging to the Sepedi cultural group. Twenty patients with post-traumatic stress disorder (PTSD) completed the study. In the completer analysis, we found that CA-CBT offered substantial benefits over AMR, as seen in large effect sizes for PTSD (d = 2.11) as well as anxiety symptoms (d = 2.41), depressive symptoms (d = 2.25), and culturally salient somatic symptoms and syndromes (d = 1.41). The intent-to-treat analysis showed smaller but still large effect sizes for all measures: PTSD (d = 1.27), associated anxiety symptoms (d = 1.38), depressive symptoms (d = 1.30), and culturally salient somatic symptoms and syndromes (d = .99). Our study suggests that CBT can be successfully adapted for South African indigenous groups.
Key implications for practice

  • This study shows the efficacy and acceptability of CBT in a randomised controlled pilot trial of an understudied group in great need of treatment compared to an active treatment condition (applied muscle relaxation (AMR)).
  • This is the first study to show efficacy of CBT for PTSD in any South African indigenous group and suggests that CBT may be successfully adapted for that group, with large effect sizes compared to AMR.
  • CA-CBT, which emphasises the treatment of somatic sensations, yoga-like stretching and meditation techniques to promote emotional and psychological flexibility, may be effective in treating indigenous South Africans.

Keywords: cognitive behaviour therapy, cultural adaptation, pilot trial, South Africa

How to cite this article:
Jalal B, Kruger Q, Hinton DE. Culturally adapted CBT (CA-CBT) for traumatised indigenous South Africans (Sepedi): a randomised pilot trial comparing CA-CBT to applied muscle relaxation. Intervention 2020;18:61-5

How to cite this URL:
Jalal B, Kruger Q, Hinton DE. Culturally adapted CBT (CA-CBT) for traumatised indigenous South Africans (Sepedi): a randomised pilot trial comparing CA-CBT to applied muscle relaxation. Intervention [serial online] 2020 [cited 2023 Jun 3];18:61-5. Available from: http://www.interventionjournal.org//text.asp?2020/18/1/61/285315

  Introduction Top

South Africa has a high rate of traumatic events − such as criminal violence, stress, and sexual assault (Human Rights Watch, 1995) − that may lead to posttraumatic stress disorder (PTSD). As a result, PTSD is a significant public health problem, particularly in communities of lower social economic status such as African indigenous groups (Edwards, 2005). Further complicating treatment implementation in a South African indigenous context is the local view of mental illness. For instance, symptoms of trauma are thought to be precipitated by supernatural forces rather than psychobiological factors. Accordingly, these groups tend to rely on ‘faith healers’ as opposed to evidence-based treatment. Unsurprisingly, the cultural expression of trauma is unique in the groups; for example, especially prevalent are fears that symptoms are due to spirit possession, black magic or ancestral curses, sometimes translating into odd depersonalisation-type syndromes and states of disorientation and confusion (for details, see Jalal, Kruger & Hinton, 2018). As such, cognitive behaviour treatment (CBT) made culturally appropriate for and culturally acceptable to these groups is a key research and clinical task. But little information is available to guide treatment choices for South African indigenous groups. Indeed to date no culturally sensitive CBT exists for traumatised South African indigenous groups, and to our knowledge, no outcome study at all for PTSD. In contrast, psychological interventions (e.g. CBT or others) are available for sub-Saharan African populations such as Congolese with PTSD, traumatised Sudanese refugees, Zimbabweans with HIV as well as those with depression and common mental disorders, and depressed Ugandans with HIV (Bass et al., 2013; Bere et al., 2016; Chibanda Mesu, Kajawu, Cowan, Araya, & Abas, 2011; Nakimuli-Mpungu et al., 2015; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). Relatedly, CBT is available for HIV-afflicted South Africans with depression (Andersen et al., 2016).

When adapting standard CBT treatments (Foa & Rothbaum, 1998; Resick & Schnicke, 1996) for traumatised groups in other cultural contexts, there are often numerous challenges such as low education, extensive traumas, prominent somatic symptoms and considerable stigma about mental health. To address these challenges, we developed a treatment, ‘Culturally Adapted CBT’, or ‘CA-CBT for PTSD’, which has proven effective for Cambodian and Vietnamese refugees, and seemingly for an Egyptian population (Hinton, Chean, Pich, Safren, Hofmann, & Pollack, 2005; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011; Hinton, Pham, Tran, Safren, Otto, & Pollack, 2004; Jalal, Samir & Hinton, 2016).

The current study investigates the efficacy of CA-CBT as adapted for a South African indigenous population. Outcome measures include a culturally sensitive assessment measure of local somatic complaints and cultural syndromes (viz., the Sepedi Symptom and Syndrome Addendum, or Sepedi SSA) to better assess culturally specific somatic complaints and syndromes (for details, see Jalal et al., 2018). The current pilot study examines the efficacy and feasibility of CA-CBT compared to applied muscle relaxation (AMR) for traumatised South Africans belonging to the Sepedi indigenous group. AMR is a much more rigorous comparison condition than waitlist or placebo, with AMR having previously been shown to be effective for PTSD and other psychological conditions (e.g. Öst, 1988; Vaughan, Armstrong, Gold, O’Connor, Jenneke, & Tarrier, 1994). AMR can thus be regarded as an active condition rather than a placebo comparison (e.g. Hinton et al., 2011).

  Method Top


The study was conducted at Mokopane Hospital, including the psychiatric unit and outpatient department, in the Limpopo province of South Africa. The study was approved by the departmental ethics committee at Mokopane Hospital. Patients provided written consent. All participants spoke Sepedi (the local language) and had English as a second language. Many Sepedi have English as a second language, learning it in school. Treatment services were provided in English, but with Sepedi expressions used during therapy, for example, when describing local cultural syndromes. Treatment was provided in an individual format.

We aimed to have 10 patients complete the CA-CBT condition and 10 patients the AMR condition. Participants had to meet criteria for current PTSD as determined by the Structural Clinical Interview for DSM-IV. A total of twenty patients completed the study, of which five were male and fifteen female. Patients were randomly assigned to the treatment condition, aiming to balance by gender and PTSD severity. The two groups did not differ with respect to PTSD, anxiety, depressive symptoms, gender and age (Ps ≥ 0.22). Given the unequal number of males and females, one group included three males and seven females and the other two males and eight females. Participants had a mean age of 28.2 years, with one participant in each condition being less than eighteen years of age, viz., fifteen and sixteen years of age, respectively (in the Sepedi culture, persons of this age are considered adults). Patients were either not taking selective serotonin reuptake inhibitors (SSRIs) or had been on an existing SSRI course for at least twelve weeks before enrolling in the study, with medication kept constant during the study. SSRI status was also a basis for randomisation.


Assessment was done pre- and post-treatment, and the assessor was blind to the treatment condition (CA-CBT or AMR). The primary outcome measure was the PTSD Checklist (PCL) (Weathers, Litz, Herman, Huska, & Keane, 1993). Secondary outcomes included the Hamilton Anxiety Rating Scale (HARS), (Hamilton, 1959) and the Beck Depression Inventory II (BDI-II), (Beck, Steer, & Brown, 1996). Because somatic complaints and cultural syndromes are prominent complaints among psychologically distressed South African indigenous groups, we also used the Sepedi SSA, a 21-item instrument to assess somatic symptoms and cultural syndromes in that group (Jalal et al., in review). Examples of SSA somatic symptoms are ‘heat in the head or body’ and ‘shortness of breath’, and of SSA syndromes, ‘thinking a lot’ and ‘fear of amafufunyana’ (spirit possession). The HARS, BDI-II and SSA were self-administered by patients pre- and post-treatment.


CA-CBT consists of fourteen sessions and was delivered across seven weeks (two sessions/week). The treatment was done in an individual format and lasted for about one hour. CA-CBT includes the following elements (for a description, see Hinton & Otto, 2006): (1) education about symptoms and the nature of PTSD from a CBT perspective, taking into account the local conceptualisation of the disorder; (2) exposure to somatic sensations associated with PTSD and anxiety (interoceptive exposure), with an emphasis on the induced dysphoric state as an opportunity to practise emotion regulation; (3) yoga-like stretching and meditation techniques to promote emotional and psychological flexibility; (4) treatment of somatic sensations; (5) treatment of anxiety-type psychopathological processes such as worry and panic attacks; (6) anger reduction; and (7) sleep improvement. The adaptation of CA-CBT included addressing cultural stigma about trauma (e.g. interpreted as a sign of spirit possession) using non-stigmatising local expressions, and relying on culturally appropriate metaphors, analogies and references (e.g. relating to nightmares, sleep paralysis and indeed overall symptom presentation); with a special emphasis on somatic and sensorial experiencing (for detailed discussion of the adaptation for this cultural group, see Jalal et al., 2018). The AMR consisted of instructions in AMR using a manual (Hinton & Safren, 2009). The AMR treatment condition consisted of the same number of sessions as the CA-CBT, likewise lasting one hour each. This AMR manual has been used in previous research (Hinton, 2010; Hinton et al., 2011).

  Results Top

Ten patients completed both the CA-CBT and AMR. Four participants dropped out of the CA-CBT condition and six out of the AMR condition. To achieve these completers, patients were continuously enrolled until there were 10 in each wing. Logistic issues such as commuting to the hospital and arranging daycare while away from home contributed to drop out rates. Though drop out was lower in CA-CBT, given the limited statistical power, differences in dropout rates did not reach significance, χ2 (1) = 0.800, P = 0.37.

Pre-treatment and post-treatment scores for each treatment group are presented in [Table 1] for completers. Effect sizes (Cohen’s d) comparing pre-post values within groups were calculated using the following formula: . Symptom change across treatment are presented in [Table 2] for completers. Effect sizes comparing differences between groups on these change scores were calculated using the following formula: . The effect sizes were indicative of consistent advantages for CA-CBT over AMR, as seen in the large between-group effect sizes. We also did an intent-to-treat analysis (i.e. for non-completers we carried forward the initial evaluation scores and used those as endline scores), which showed large effect sizes in respect to CBT versus AMR: PCL-C (d = 1.27), HARS (d = 1.38), BDI (d = 1.30), SSA (d = 0.99).
Table 1 Mean pre-treatment and post-treatment values for each treatment group

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Table 2 Mean change in symptom severity (baseline-post-treatment) for each treatment group

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  Discussion Top

We found that in a sample of traumatised indigenous South Africans belonging to the Sepedi cultural group that fourteen sessions of CA-CBT provided great symptom relief among completers, and substantial treatment benefit over AMR. The magnitudes of this benefit compared well to other psychosocial treatments (e.g. CBT) of PTSD, for instance for refugees (for a review, see Palic, & Elklit, 2011). Notably we found great improvement across a range of measures. These include PTSD, anxiety symptoms, depressive symptoms and culturally salient somatic symptoms and syndromes. Drop out was also lower for CA-CBT, though not statistically significant owing to the small sample size.

Our pilot study showed efficacy and acceptability of CA-CBT in a randomised controlled trial of an understudied group in great need of treatment, and showed superior efficacy compared to an active treatment comparison. To our knowledge, this is the first study to show efficacy of CBT for PTSD in any South African group. Our study suggests that CBT can be successfully adapted for South African indigenous groups and that our CBT programme, which emphasises exposure to and treatment of somatic sensations as well as yoga-like stretching and meditation techniques to promote emotional and psychological flexibility, may be effective in treating indigenous South Africans.

Some limitations should be mentioned. The effect size estimates based on small samples may be unreliable. Indeed, because of the limited overall sample, inferences about the effectiveness of CA-CBT are not conclusive yet promising. Ideally we would have investigated the reason for drop out. Also, ideally we would have obtained assessment at the time of treatment drop out (anecdotally patients in the CA-CBT condition dropped out because of perceived improvement to the point that treatment was not necessary). Ideally we would have done the treatment in the local language, in which case the treatment effects probably would have been even greater. Also, in the current study the definition of PTSD was based on the DSM-IV; it is possible that the results might have varied slightly had we relied on DSM-5 criteria instead. Moreover, as the AMR technique was not culturally adjusted, we cannot rule out that treatment effects resulted partly from better identification with cultural changes in the CBT treatment; i.e. CA-CBT may have been more consistent with cultural ways to cope with distress. Finally, a future study should use a group version in order to increase public health impact.

Financial support and sponsorship

The study was unfunded.

Conflicts of interest

There are no conflicts of interest.


  References Top

Andersen L. S., Magidson J. F., O’Cleirigh C., Remmert J. E., Kagee A., Leaver M., Joska J. (2016). A pilot study of a nurse-delivered cognitive behavioral therapy intervention (Ziphamandla) for adherence and depression in HIV in South Africa. Journal of Health Psychology, 23(6), 776-787.  Back to cited text no. 1
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Bere T., Nyamayaro P., Magidson J. F., Chibanda D., Chingono A., Munjoma R., Abas M. (2016). Cultural adaptation of a cognitive-behavioural intervention to improve adherence to antiretroviral therapy among people living with HIV/AIDS in Zimbabwe: Nzira Itsva. Journal of Health Psychology, 22(10), 1265-1276.  Back to cited text no. 4
Chibanda D., Mesu P., Kajawu L., Cowan F., Araya R., Abas M. A. (2011). Problem-solving therapy for depression and common mental disorders in Zimbabwe: Piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health, 11, 828.  Back to cited text no. 5
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Foa E. B., Rothbaum B. O. (1998). Treating the trauma of rape: Cognitive-behavioraltherapy for PTSD. New York, NY: Guilford.  Back to cited text no. 7
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Hinton D. E., Chhean D., Pich V., Safren S. A., Hofmann S. G., Pollack M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18(6), 617-629.  Back to cited text no. 13
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Vaughan K., Armstrong M. S., Gold R., O’Connor N., Jenneke W., Tarrier N. (1994). A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25(4), 283-291.  Back to cited text no. 23
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  [Table 1], [Table 2]


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