September 4, 2022 • 44 mins
In this interview, Dr. Farooq Naeem shares his longstanding research interest in CBT and culture. He discusses how CBT concepts can conflict with the beliefs of people in non-Western cultures and then delves into the various ways people can understand and approach depression and schizophrenia from their own worldviews. He also discusses his research on using CBT for psychosis and delivering CBT interventions by e-mail.
GUEST BIO: Farooq Naeem is a Professor of Psychiatry at the University of Toronto and a psychiatrist at the Centre for Addiction & Mental Health. Dr. Naeem pioneered techniques for culturally adapting CBT. These techniques have been used to adapt CBT in South Asia, North Africa, Middle East, Kenya and China. His research areas include CBT, psychosis and culture, with an overall aim to improve access to CBT. He has also published on issues related to health services and quality improvement. He works with a team of IT experts and has developed a CBT-based therapy program called eGuru that can be delivered through web-based and smartphone apps.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
UNKNOWN (00:00):
Thank you.
SPEAKER_00 (00:00):
Welcome to the CBT Dive, a vodcast that goes into
the lives of real people withreal struggles.
Each episode welcomes a newguest who wants to explore a
challenging situation using themost common cognitive behavioral
therapy tool, the ThoughtRecord.
Your host, Rahim Thawar, is asocial worker and
(00:21):
psychotherapist based in Torontoand well-known for his work in
LGBTQ communities.
He's created the CBT Dive todemonstrate What therapy can
look like and share interventionskills for wellness.
We hope that each episode helpsyou along on your own journey
for insight and self-compassion.
SPEAKER_01 (00:47):
Hello, welcome to the CBT Dive.
Today I have a special guest,Dr.
Farouk Naim.
I'm just going to say a littlebit about our guest before we
start asking questions.
So Dr.
Farouk Naim is a professor ofpsychiatry at the University of
Toronto and a psychiatrist atthe Centre for Addiction and
Mental Health.
(01:08):
He completed a Master's ofScience in Research Methods in
Health and later a PhD in CBTand Culture from Southampton
University in England.
He also trained in psychiatry inLiverpool.
Farouk pioneered techniques forculturally adapting CBT.
These techniques have been usedin Thank you so much.
(02:00):
Welcome, Dr.
Naeem.
Thank you so much for beinghere.
SPEAKER_02 (02:04):
Thank you.
Pleasure.
SPEAKER_01 (02:07):
Yeah.
So, Dr.
Naeem, let's start with your PhDtopic.
It seems like early on in yourcareer, or fairly early on, you
knew you were interested incross-cultural approaches to
mental health interventions.
What got you interested in that?
SPEAKER_02 (02:24):
Thank you.
I think that's...
very important question becauseit allowed me to share my
journey or the beginning of thejourney.
Please do.
You see, I was doing my seniorresidency training with David
(02:48):
Kingdon, who's a pioneer in CBTfor psychosis.
And I was looking at data fromdifferent trials.
And one thing I noticed was, andwe're talking about like 2003,
four.
And I realized that even incities like Manchester and
(03:13):
Birmingham, where there's a hugenumber of non-white people.
In these trials, there were notmany non-white people.
So first of all, I thought, youknow, what's going on?
So first thing seemed like thelevel of recruitment.
And when we looked at the data abit closer, we realized that
(03:37):
even those who join or arerecruited into the trials, They
dropped out very quickly.
So then I started looking at theliterature and I realized that,
and actually at that time, therewas not a lot of literature.
There were some from the US, butnothing in Europe or the global
(04:03):
mental health.
So I then became familiar withthe concept that the The modern
therapies which are developed inWestern Europe or North America,
they are underpinned bydifferent cultural values.
(04:24):
And I kind of reflected on it,and I kind of realized, really,
that's true, because you see, inCBT, we have a concept of
dysfunctional beliefs, right,which I'm sure you're aware of.
Yes.
One dysfunctional belief, forexample, is dependence on
others.
or sacrificing your need for theneeds of others.
(04:48):
So these are some of thedysfunctional beliefs in
traditional CBT.
But they're not dysfunctionalbeliefs in many non-Western
societies.
They are actually, you know,you're seen in high esteem if
you actually sacrifice yourneeds for the needs of others.
others in many Asian and Africanand rights cultures.
(05:08):
So I thought there's something,there's something missing here.
And that's the reason I decidedto do my PhD in CBT and culture.
SPEAKER_01 (05:20):
Okay, lovely.
Well, you already startedtalking about what I wanted to
get into, which is, you know,what are some examples of how
like Western cultures approachesto therapy or CBT in particular
don't always fit with othercultures.
I ask this because I think somepeople would say, you know,
(05:43):
therapy altogether is Westernand not for other people.
But I think you and I would bothagree that they can be adapted.
But I guess I'm trying to figureout what is it that doesn't fit
for people?
What needs to change?
SPEAKER_02 (06:02):
It's not just really the Western therapy.
You know, mindfulness is anEastern spiritual tradition.
And I want to make it very clearbecause especially therapists in
the West or people in the Westthink mindfulness is some kind
of psychotherapy that wasinvented in South Asia, which is
(06:23):
not true.
But my point is mindfulness wasadapted by the Western
therapists.
So adaptation of therapy is notsomething new, number one.
Number two, even if you look atthe CBT model, CBT model has
been adapted over the years.
So for example, you know, if youlook at the history of the CBT
(06:45):
model, the initial model by Beckwas for depression.
Then you saw adaptations foranxiety.
Then the CBT model was adaptedfor trauma.
Right?
And then CBT for psychosis isalso an adaptation of the
original model.
(07:06):
So adaptation is not somethingnew.
And in fact, my take onadaptation is that when it comes
to cultural adaptation, youshould not change the
theoretical or you should nottouch the model, but you
(07:27):
should...
You should modify the method ofdelivery to engage people from
other cultures.
SPEAKER_03 (07:36):
Okay.
SPEAKER_02 (07:38):
So you don't change the theory.
But anyway, regardless, my pointis adaptations of CBT or
psychotherapies are not new.
And I mean, even if you thinkabout the history of Western
psychotherapies, you know,therapies have evolved and have
(08:03):
been adapted.
So, for example, we started withbehavioral therapy, then REBT
comes, then it becomes a littlebit more refined, becomes CBT,
and then it becomes third wavetherapies, which have CBT and
mindfulness techniques, right?
So adaptation is not anythingnew.
new.
And in terms of differencesbetween the Eastern and the
(08:25):
Western cultures, there aremultiple kinds of differences.
For example, and I can give youjust one or two examples.
One example I gave already wasdysfunctional beliefs.
Another example would be workingwith the families.
The CBT especially the NorthernAmerican CBT is very much
(08:47):
focused on, and it's beencriticized, right?
You know that the main criticismof CBT was, okay, it was
developed, which I don't agreeor disagree in particular, you
know, people have the right.
But yeah, people say CBT wasdeveloped for the Wall Street
middle-class white men.
(09:09):
Remember, that is the maincriticism of CBT.
So yes, it is underpinned byindividualism, okay?
And so what do you do whenyou're dealing with people who
are not individualistic, wholive in communities, who live in
families, extended families, andthe family wants to know what's
(09:31):
going on in therapy.
And that's something we teachour therapists, you know, to not
share any information or not toengage anyone.
You see, these are importantkind of differences.
Finally, just one hugedifference is the illness belief
model.
(09:52):
Now, the causes of illness arebiopsychosocial in the Western
world.
And in many non-Westerncountries, the causes of mental
health problems are spiritual.
They have a huge...
spiritual component, right?
(10:13):
So in other words, the illness,belief, motel, or cause and
effect relationship aredifferent.
So the formulation that I advisein culturally adapted CBT is a
biopsychosocial spiritualformulation rather than a
(10:34):
biopsychosocial.
SPEAKER_01 (10:37):
Okay, thank you for that.
Look, as you're speaking, it'sreally making me think about...
my own experience with differentcultural formulations of mental
health or mental illness.
And culturally, you know, mycommunity often would say, would
think about nudger, which islike a kind of evil eye, or they
(10:59):
would talk about things like ginpossession, like a spirit
possession.
They might also think aboutmental illness as a result of,
you know, not being piousenough.
It's like a religious kind ofrepercussion.
Things like that.
And so what does it mean toreally adapt CBT to make it
(11:23):
culturally appropriate when, youknow, I think from a certain
perspective, some of thosebeliefs or that ideology of
mental illness would be seen as,I don't know, in itself
delusional or in itself, youknow, like I'm seeing a bit of a
A conflict.
(11:44):
So help me understand, how do weadapt this model?
SPEAKER_02 (11:49):
When you say conflict, what do you mean by
conflict?
SPEAKER_01 (11:53):
Well, if I were to say I'm struggling with
depression, and I think it'sbecause it's the result of evil
eye.
I'm the target of someone else'scontempt.
because I showed too much pride,for example.
(12:15):
You know, something like that.
You know, one might say, okay,my belief itself is delusional
or it's unfounded.
SPEAKER_02 (12:24):
Yeah.
So you see, yeah.
I'll just take...
one example and elaborate onthat.
And you did mention that.
And that is being religiousmeans you can't be depressed.
You touched on that.
(12:45):
Now, that's a very common beliefamong Muslims and Jews.
Because it's based in the holybooks.
But the exact kind of versesare, and I'll just kind of that
if you are a true believer, youwill not be sad.
(13:08):
So you see, my work, because mywork took me, and I'll give you
another couple of examples in asecond.
So there were actually time, ittook me some time to explore a
certain kind of belief, and I'mnot going to say pathological or
normal or whatever, And I had toexplore.
(13:31):
So in this case, I had to talkto a lot of religious scholars,
both Jewish and the Muslims.
And then actually they told meis that the holy books actually
talk about you won't be sad inthe afterlife.
That's very important thing.
(13:51):
Yes.
Yes.
So basically the explanation is,you know, if you are a good
believer, it makes sense, right?
From religious point of view.
But people actually havemisinterpreted that as, okay,
you're going to be depressed orunhappy in this world too.
So a lot of this work isactually helping people or
(14:14):
tracing the belief or the originof the belief and see why.
where it's coming from.
And that's why a big part Iadvise of the culturally adapted
CBT is to work with people, sayspiritual and faith healers, so
(14:36):
to understand the spiritual partof the origin of a certain
mental health problem thatperson believes in.
And when you present this,excuse me, explanation to many
(14:56):
patients, they're absolutelyfine.
And it makes sense to them.
They say, okay, oh, that's whatit means.
So that is about, that's a veryimportant part.
So you see some investigation,working with people from that
kind of background who canexplain these beliefs to you as
(15:19):
a therapist so you can explainto the patient.
And there are other examples.
For example, in my work, when Icompare the differences between,
and I'll take this one group,South Asians in England, because
(15:40):
most work on South Asians comesfrom England.
Unfortunately, North Americadoes not have a lot of research
work on South Asians.
I was a bit surprised when Imoved to Canada a few years ago
to see that even though SouthAsians are the biggest minority
(16:00):
in this country and yet there'snot any research on mental
health of South Asians orgenerally health of people of
South Asians.
Anyway, so one example was whenyou compare, so we were
comparing the results and onething we noticed like, you know,
(16:21):
was biological, psychological,social, and then there was some
kind of very cultural kind ofbeliefs, and it took me some
time to explore where they'recoming from.
For example, one is phlegm,increased phlegm in the body.
Okay.
(16:41):
can be a cause for mental healthproblems.
So I had to explore, I had tolook, and I asked people, and I
obviously looked at theliterature and everything, and
then it turns out, this isactually a Greek concept, old
Greek medicine concept.
(17:03):
And then I'll tell you where itcame from, how did it end up in
South Asia, right?
The second example is oneperson, not one, but many people
believe that increased heat inthe liver can cause mental
(17:24):
health problems.
So again, it took me some time,and I looked, I explored, and
then I found this belief comesfrom the old Chinese medicine.
Heat, cold, different organs.
Right, right.
Third example, some people saidmasturbation can cause mental
(17:54):
health problems.
Then again, I had to explore andI realized that it's actually a
belief that comes from Ayurveda,the Indian medicine.
So you see, okay and myunderstanding is because you see
like greek medicine in the oldtime that was the most advanced
(18:18):
medicine like the currentwestern medicine is these days
right and then plus alsoespecially south asia and uh uh
south asia uh you know thethere's so many innovators and
they all came through there.
And when they came, they camewith their medicines, with their
doctors, right?
Old time, I think of the oldtimes.
(18:39):
Armies used to travel with thephysicians and, you know, it was
very slow.
So that's where these beliefs,kind of that's how they
traveled.
So you can see there are somereally interesting kind of
beliefs when you're dealing withthis population.
(19:00):
And the way to deal with thatis, and obviously you can't
change that because if yourfather's told you that your
depression is because of phlegmin your body, then you're less
likely to change that view untilit presents some solid evidence
(19:20):
for you, number one.
Number two, the belief isreally, really strong and, you
know, it's not kind of, but,okay, important thing to keep in
mind, people in the non-Westerncultures also have multiple
(19:41):
component model of mentalillness.
That's a very important thing.
And it's a good thing.
Because you see, if somebody issaying, okay, yes, there are
biological causes, you know,genetic causes are very common
among South Asians and Asians.
And it was a bit shocking for mewhen I realized this for the
(20:02):
first time.
You know, you might be awarethat Many South Asians hide
mental health problems in thefamily because of the impact it
can have on arranged marriages.
(20:25):
Because the concept of thegenetic transmission of disease
is actually very strong in thesecultures.
It is shocking, isn't it?
You wouldn't think that, right?
Okay.
But they will be, they'll havesuch strong belief in genetics,
but yeah.
So the whole belief, how hiding,you know, there are multiple
(20:45):
causes, obviously.
The genetic component is very,very strong.
So, so yeah, so it's aboutmodifying the beliefs, providing
education, but also because it'smulti-component, so you don't
necessarily have always need tofight against one belief when
you know the person believesthat it's a multifactorial kind
(21:06):
of position.
SPEAKER_01 (21:08):
Okay, so if I'm hearing this right, when we
think about beliefs about thecause of illness, phlegm,
masturbation, these kinds ofthings, it wouldn't be the
clinician's job to change thosebeliefs necessarily, but just to
(21:30):
be aware of that, right?
SPEAKER_02 (21:32):
Yeah.
Yeah.
Okay.
And you see in many, very oftenyou can educate patients.
So it's not like your religiousbelief is so fixed that they
wouldn't change.
So, you know, you can alwayseducate them.
And, and if you feel that that'skind of, they're not changing,
then, you know, then if theperson has a, they use
(21:57):
biopsychosocial factors.
Anyways, you can work on, youcan still work with age.
That's my point.
SPEAKER_01 (22:05):
Okay.
Here's my question.
Have you, so in the researchyou've done, what have the
outcomes been of, in deliveringCBT interventions to people in
different countries anddifferent cultures.
So specifically, I think you'vedone studies in Pakistan with
(22:27):
South Asian Muslims, but feelfree to draw on any study.
I'm just interested to see whatthe uptake and outcomes are
like.
Because when we talk about aNorth American study, you know,
or a study in the UK, we'resaying that, you know, there's a
high attrition of South Asiansor they're not well represented.
So when we go to a South Asiancontext, what does the
(22:49):
intervention look like?
What are the outcomes?
SPEAKER_02 (22:52):
Yeah, so the outcomes in general of
culturally adapted interventionsare better than the standard
CBT.
Wow.
Yeah, yeah.
However, this is still a verykind of new field And there are
(23:16):
not many RCTs, there are notmany fully powered RCTs.
So the jury's still out.
Okay.
Yeah, but the existing evidenceactually indicates that people
(23:36):
are more, you know, likely tobenefit from culturally adaptive
CBT.
And it makes kind of sense,really, even if you don't think
about, you know, because thebasic concept in CBT is to
(23:59):
provide an individualizedtherapy, right?
SPEAKER_01 (24:03):
Right.
UNKNOWN (24:03):
Right.
SPEAKER_02 (24:04):
Even if you don't think about the evidence from
the research, it is the duty ofevery therapist to think about a
client's culture.
Isn't that right?
That's what we teach.
That's where we train ourtherapists.
SPEAKER_01 (24:24):
Dr.
Naeem, I'm really interested intalking a bit further about your
work around CBT forschizophrenia and psychosis.
I think there's, I know a lot ofclinicians who struggle with
clients who have psychoticsymptoms, have been, you know,
are on antipsychotic medication.
(24:46):
Some are functioning very welland others bring out a lot of
hopelessness in theirclinicians.
And so I think there'ssometimes, This idea that people
with schizophrenia are verydifficult to treat.
Can you tell me a bit about whatCBT for psychosis or
(25:07):
schizophrenia looks like?
And perhaps what's the goal ofCBT with people living with
schizophrenia?
SPEAKER_02 (25:18):
Yeah.
Thank you.
Now, CBT for psychosis is aBritish kind of adaptation, so
it's not as popular in NorthAmerica as it should be.
Most of the RCTs come fromEurope.
Okay.
And the last time I looked, Ithink more than 40, 50
(25:41):
randomized controlled trialshave been conducted, and the
evidence overwhelminglyindicates towards the
effectiveness of CBT forpsychosis in reducing delusions,
hallucinations, even negativesymptoms.
(26:01):
So the overall aim is to helpthe person to become more aware
of the symptoms to help themdevelop some insight, some
self-awareness and reduce thedistress.
reduce the intensity of thesymptoms, and therefore improve
(26:25):
the quality of life of patients.
The main kind of techniques weuse for delusions, we use
Socratic dialogue.
Right.
And for hallucinations, copingskills, but also re-attribution
(26:47):
techniques, challenging thevoices or teaching patients to
challenge the voices.
Negative symptoms.
For negative symptoms, we usebehavioral activation.
So all these kind of things areused.
But yeah, the overall idea is toreduce distress and improve
(27:10):
quality of life.
And there's plenty of evidencethat it
SPEAKER_01 (27:16):
was.
Okay.
So it makes me wonder a bitabout like this idea of
adaptation and learning moreabout different cultures,
adapting the original model fordifferent kinds of illnesses.
(27:39):
Do you adapt the medium oftherapy as well?
I've read like in some of yourwork, you've talked about doing
CBT interventions by email.
Can you tell me a bit aboutthat?
How does that work?
How do you structure that work?
SPEAKER_02 (27:55):
So that's really something I realized recently.
seven, eight years ago.
And it was mainly, you know, bythat time, I had conducted a few
RCTs.
I knew adaptive CBT works.
Well, then I actually realizedit doesn't matter how much I
(28:19):
adapt CBT, the issue is ofaccess.
right because right forget aboutadaptive cbt uh we don't have uh
uh cbt therapists or number ofsufficient number of therapists
to provide therapy to thegeneral population in general so
(28:42):
So that's when I became moreinterested in improving access
to therapy.
And not just for the refugees orimmigrants kind of population,
but for everyone.
And then another thing, aroundabout the same time I started
(29:05):
noticing that internet is verycheap in many low middle income
countries.
Okay, mobile phones are right.
So for$50, you can buy a highquality smartphone in India and
Pakistan and Sri Lanka, right?
So these kind of countries, youcan buy a very cheap mobile.
(29:28):
So that's the kind of time Ialso realized that this is the
only kind of way that we canimprove access to CBT.
I see.
So that's why I took thatdirection.
And so eGuru, which was a set ofCBT apps, I stopped working on
(29:49):
that when I moved to Torontofour years ago.
I was in Queens before that forthree years.
And because I got busy.
But now I've started working oneGuru apps again.
But also, you see...
Recently, actually, we publishedthe very first online culturally
(30:13):
adapted CBT.
It's a pilot kind of evaluation.
And we conducted that.
And as a first...
culturally adapted online CBTprogram published from South
Asia.
And it actually happenedyesterday.
(30:34):
And we found that- Wow,congratulations.
Yes, thank you.
And people engage.
you know, with therapy and theresults were fantastic.
So, so, so you see it seemslike, and you know, the other
thing also we need to keep inmind in global mental health,
(30:54):
poor countries are becomingricher.
People are becoming moreeducated.
And in addition to have to, toimprove access to digital
technology.
So all these factors are, Imean, you know, we should focus
on using apps and web apps todeliver therapy.
(31:19):
So that was the whole ideabehind it.
SPEAKER_01 (31:22):
All right.
That's very interesting.
Are there any populations orconditions for which CBT should
not be conducted electronically,like by email or by using an
app?
So,
SPEAKER_02 (31:39):
Manay, I don't know the exact kind of answer to your
question because there's not alot of research in this area.
This is a very new area.
However, the exclusion criteriamost randomized controlled
trials have used are kind ofstraightforward.
(32:03):
So, for example, havingaccidental Technology is number
one.
Number two is digital literacy.
Digital literacy is veryimportant.
And third is not having anyintellectual disability, right?
(32:25):
I see.
So these are the very basic kindof requirements for digital
mental health or delivery of CBTthrough digital technology.
SPEAKER_01 (32:35):
Now, you have this particular interest in doing CBT
for psychosis, and I justwonder, would that be
appropriate to do by email?
I worry that people withpsychosis sometimes may have a
tough time using technology tobe vulnerable.
SPEAKER_02 (32:57):
Not necessarily.
It depends on the stage.
of illness depends on the age ofthe patients.
Many people actually, you see,one thing we need to keep in
mind is modern medication hashelped a lot.
You know, we have this conceptthat people, and it's true, it's
true.
(33:19):
Until 10, 15 years ago, a lot ofpatients used to have cognitive
deficits, which is part of thenormal kind of illness, process,
so chronic schizophrenia andcognitive deficits, you know,
they grew together.
And it still happens,unfortunately.
With the modern medication,improved compliance, I see that
(33:43):
it's becoming less and less of aproblem.
So while we still struggle, andwhile we still have a reasonable
number of patients who aretreatment-resistant, The
important thing to keep in mindis that the majority of our
(34:10):
patients, they actually canengage.
Having said that, I think thatthere are one or two trials cbt
online cbt but that's actuallyface to face through zoom or
webex for schizophrenia and andalso some kind of websites with
mixed results but generally thishas not been used a lot in
(34:37):
people's schizophrenia One areawhere some progress has been
made is use of virtual realityprograms to reduce fear and
phobias in general, but also inpeople with
SPEAKER_01 (34:56):
schizophrenia.
Oh, that's fascinating.
The virtual reality programming.
Okay.
Well, we've been talking a bitabout schizophrenia, and I want
to ask...
what your stance has been onthat diagnostic label in the
clinical and academic community.
I think there's been some debateon whether or not it's a helpful
(35:20):
label, whether the stigma makesit, I don't know, whether the
stigma itself is too much of abarrier.
So I wonder, what is yourstance?
Should it be renamed?
What's its utility?
SPEAKER_02 (35:35):
Yes, no, I actually, when, you know, I was actually
very, very much in favor ofchanging the name of
schizophrenia.
And I and my group, we wrotesome letters and articles as
well 15 years ago.
But you see, then I actually, Idon't think it's going to make
(36:00):
any change if you change thename.
SPEAKER_03 (36:03):
Uh-huh.
SPEAKER_02 (36:04):
And the reason is because I learn and because of
my work, actually I startedthinking more about the cultural
sort of factors and it gave me,you see, it gave me multiple
insights working in many lowmiddle income countries.
(36:26):
So for example, I learned thatPeople believe that epilepsy was
because of evil spirits.
SPEAKER_01 (36:40):
Huh, okay.
SPEAKER_02 (36:42):
In many, many, many low middle income countries,
especially the Middle Easternand the South Asian.
I don't know about othercultures.
Okay.
And you see what happened then.
So this is like 30 years ago, 40years ago, people tell me, my
colleagues in the field.
And then they say, as theanti-epileptics became available
(37:07):
and people could afford themedication and it became obvious
that epilepsy can be treatedwith the help of medication, now
hardly anyone believes that thisis because of evil spirits.
Right?
For me, it was a big lesson.
The reason it was a big lessonwas because it showed you can't
(37:33):
change people's minds or theirconcepts or their misconceptions
about an illness.
And this, I think, also includesstigma, to be honest with you,
(37:53):
until and unless you change theoutcome.
I mean, if you look at thehistory of mental health
problem, wasn't there a timewhen people with dyslexia were
burned in Europe because peoplethought they are witches, right?
(38:13):
So it's not really that changinga name is going to make any
difference.
And even just psychoeducationalone is not going to make a
difference.
I now believe that until wechange the outcome of
schizophrenia, I don't thinkjust changing the name is going
(38:38):
to make
SPEAKER_01 (38:39):
a difference.
Okay.
To that end, do you think, andwe're getting towards the end,
so I hope I'm not tiring you
SPEAKER_03 (38:50):
out.
UNKNOWN (38:52):
Okay.
SPEAKER_01 (38:53):
I've heard some people argue that what we call
symptoms of psychosis can beexplained better through other
cultural lenses.
And so shouldn't be in thecategory of psychosis.
So for example, you know, aftera loved one dies, lots of people
(39:16):
report that they will get, likethat loved one will show show up
in their dream, you know, andsomebody would be inclined to
call that a visit and they wouldsee it as something affirming.
But if we stick to a certainkind of model, we might call
that, we might say that it'snormative, but we might also
(39:39):
call it a kind of psychosis.
And I wonder how, if thatlanguage could be challenged a
bit.
What are your thoughts on that?
SPEAKER_02 (39:47):
I think any clinician who does that is a
terrible condition.
I'm serious.
I've seen this happening.
Yeah.
I've seen this happening, peoplebeing diagnosed with
schizophrenia because they had atrauma, they see things at
(40:08):
night, in the dark, et cetera,et cetera, or other kind of
visions.
you know, and being diagnosed orsomeone who hears the kind of
voice of a dead relative orthings like that.
So to somebody who, a clinicianwho diagnoses this kind of
(40:31):
picture, you see, schizophreniashould, people should be careful
with diagnosing
SPEAKER_03 (40:39):
schizophrenia
SPEAKER_02 (40:41):
because you are giving someone a lifelong label.
Right.
And we need to be careful withthis kind of experiences which
are mainly expressions ofdistress.
I mean, you can even talk aboutthe religious or spiritual
experiences people see or hearthings, you know, religious
(41:03):
experiences.
But the distinction betweenschizophrenia and this kind of
experiences is that of duration,and then the exclusion and most
importantly, it's also aboutbeing careful in judging the
(41:26):
symptom.
You know, for schizophreniadiagnosis of schizophrenia, we
first have to think about theduration, right?
Symptoms should be there.
Number two is you know, thecollection of symptoms.
So generally we have, and thisis like every disorder in reason
(41:47):
five.
Number three is exclusion.
That person shouldn't be using,you know, drugs, alcohol,
stimulants, that kind of stuff.
My point is many psychiatrists,unfortunately, do not think
about these things generalcriteria when they diagnose
someone.
And the biggest example is I seeso many patients, you know,
(42:10):
being misdiagnosed with bipolar.
And when I actually asked them,they say they had mood swings,
but the mood swing was nevermore than a day or two.
Now, in order to diagnosebipolar, the person should have
experienced manic episode for atleast one week, right?
So my point is, I think that'smore a kind of problem
(42:33):
misdiagnosis because the MertonDSM ICD-11 systems are freely
kind of advanced.
And if psychiatrists use themcarefully, they shouldn't be
misdiagnosing people.
But the simple answer is that'sa terrible thing, you know, if
(42:54):
it's happening even in this dayand
SPEAKER_01 (42:58):
age.
UNKNOWN (42:59):
Yes.
SPEAKER_01 (42:59):
Dr.
Naim, my last question, ifclinicians want to get training
in being not just culturallycompetent, but being able to
deliver culturally adapted CBTfor specific communities and
populations, how might they getthat training?
SPEAKER_02 (43:21):
Yeah.
So, In Canada, I'm currentlyleading a large randomized
controlled trial.
And it was actually a mixedstudy, but currently we are on
the RCT phase.
SPEAKER_03 (43:34):
And
SPEAKER_02 (43:36):
we are running the trial in Vancouver, Toronto, and
Ottawa.
And at the end of this RCTphase, we'll develop a training
specifically for the trial isfor South Asians there.
And we'll develop the trainingpackage and that will be
(44:01):
available freely.
So just.
Look out for that.
SPEAKER_03 (44:10):
Yes.
SPEAKER_02 (44:11):
Yes.
SPEAKER_01 (44:11):
Okay.
Lovely.
Thank you so much, Dr.
Naim for.
My pleasure.
For being with us.
And when I'm back in Toronto,maybe our paths will cross
again.
SPEAKER_02 (44:22):
Absolutely.
Lovely.
You take care.
It was a pleasure talking withyou.
Thank you.
Bye.
UNKNOWN (44:29):
Bye.
SPEAKER_00 (44:30):
Thanks for tuning in to the CBT Dive.
Don't miss an episode.
Subscribe to our YouTube channelat thecbtdive.ca.
You can also listen on the gowherever you get your podcasts.
To follow Rahim on social media,check out ladyativan.com.
See you soon.
Thank you.
SPEAKER_00 (00:00):
Welcome to the CBT Dive, a vodcast that goes into
the lives of real people withreal struggles.
Each episode welcomes a newguest who wants to explore a
challenging situation using themost common cognitive behavioral
therapy tool, the ThoughtRecord.
Your host, Rahim Thawar, is asocial worker and
(00:21):
psychotherapist based in Torontoand well-known for his work in
LGBTQ communities.
He's created the CBT Dive todemonstrate What therapy can
look like and share interventionskills for wellness.
We hope that each episode helpsyou along on your own journey
for insight and self-compassion.
SPEAKER_01 (00:47):
Hello, welcome to the CBT Dive.
Today I have a special guest,Dr.
Farouk Naim.
I'm just going to say a littlebit about our guest before we
start asking questions.
So Dr.
Farouk Naim is a professor ofpsychiatry at the University of
Toronto and a psychiatrist atthe Centre for Addiction and
Mental Health.
(01:08):
He completed a Master's ofScience in Research Methods in
Health and later a PhD in CBTand Culture from Southampton
University in England.
He also trained in psychiatry inLiverpool.
Farouk pioneered techniques forculturally adapting CBT.
These techniques have been usedin Thank you so much.
(02:00):
Welcome, Dr.
Naeem.
Thank you so much for beinghere.
SPEAKER_02 (02:04):
Thank you.
Pleasure.
SPEAKER_01 (02:07):
Yeah.
So, Dr.
Naeem, let's start with your PhDtopic.
It seems like early on in yourcareer, or fairly early on, you
knew you were interested incross-cultural approaches to
mental health interventions.
What got you interested in that?
SPEAKER_02 (02:24):
Thank you.
I think that's...
very important question becauseit allowed me to share my
journey or the beginning of thejourney.
Please do.
You see, I was doing my seniorresidency training with David
(02:48):
Kingdon, who's a pioneer in CBTfor psychosis.
And I was looking at data fromdifferent trials.
And one thing I noticed was, andwe're talking about like 2003,
four.
And I realized that even incities like Manchester and
(03:13):
Birmingham, where there's a hugenumber of non-white people.
In these trials, there were notmany non-white people.
So first of all, I thought, youknow, what's going on?
So first thing seemed like thelevel of recruitment.
And when we looked at the data abit closer, we realized that
(03:37):
even those who join or arerecruited into the trials, They
dropped out very quickly.
So then I started looking at theliterature and I realized that,
and actually at that time, therewas not a lot of literature.
There were some from the US, butnothing in Europe or the global
(04:03):
mental health.
So I then became familiar withthe concept that the The modern
therapies which are developed inWestern Europe or North America,
they are underpinned bydifferent cultural values.
(04:24):
And I kind of reflected on it,and I kind of realized, really,
that's true, because you see, inCBT, we have a concept of
dysfunctional beliefs, right,which I'm sure you're aware of.
Yes.
One dysfunctional belief, forexample, is dependence on
others.
or sacrificing your need for theneeds of others.
(04:48):
So these are some of thedysfunctional beliefs in
traditional CBT.
But they're not dysfunctionalbeliefs in many non-Western
societies.
They are actually, you know,you're seen in high esteem if
you actually sacrifice yourneeds for the needs of others.
others in many Asian and Africanand rights cultures.
(05:08):
So I thought there's something,there's something missing here.
And that's the reason I decidedto do my PhD in CBT and culture.
SPEAKER_01 (05:20):
Okay, lovely.
Well, you already startedtalking about what I wanted to
get into, which is, you know,what are some examples of how
like Western cultures approachesto therapy or CBT in particular
don't always fit with othercultures.
I ask this because I think somepeople would say, you know,
(05:43):
therapy altogether is Westernand not for other people.
But I think you and I would bothagree that they can be adapted.
But I guess I'm trying to figureout what is it that doesn't fit
for people?
What needs to change?
SPEAKER_02 (06:02):
It's not just really the Western therapy.
You know, mindfulness is anEastern spiritual tradition.
And I want to make it very clearbecause especially therapists in
the West or people in the Westthink mindfulness is some kind
of psychotherapy that wasinvented in South Asia, which is
(06:23):
not true.
But my point is mindfulness wasadapted by the Western
therapists.
So adaptation of therapy is notsomething new, number one.
Number two, even if you look atthe CBT model, CBT model has
been adapted over the years.
So for example, you know, if youlook at the history of the CBT
(06:45):
model, the initial model by Beckwas for depression.
Then you saw adaptations foranxiety.
Then the CBT model was adaptedfor trauma.
Right?
And then CBT for psychosis isalso an adaptation of the
original model.
(07:06):
So adaptation is not somethingnew.
And in fact, my take onadaptation is that when it comes
to cultural adaptation, youshould not change the
theoretical or you should nottouch the model, but you
(07:27):
should...
You should modify the method ofdelivery to engage people from
other cultures.
SPEAKER_03 (07:36):
Okay.
SPEAKER_02 (07:38):
So you don't change the theory.
But anyway, regardless, my pointis adaptations of CBT or
psychotherapies are not new.
And I mean, even if you thinkabout the history of Western
psychotherapies, you know,therapies have evolved and have
(08:03):
been adapted.
So, for example, we started withbehavioral therapy, then REBT
comes, then it becomes a littlebit more refined, becomes CBT,
and then it becomes third wavetherapies, which have CBT and
mindfulness techniques, right?
So adaptation is not anythingnew.
new.
And in terms of differencesbetween the Eastern and the
(08:25):
Western cultures, there aremultiple kinds of differences.
For example, and I can give youjust one or two examples.
One example I gave already wasdysfunctional beliefs.
Another example would be workingwith the families.
The CBT especially the NorthernAmerican CBT is very much
(08:47):
focused on, and it's beencriticized, right?
You know that the main criticismof CBT was, okay, it was
developed, which I don't agreeor disagree in particular, you
know, people have the right.
But yeah, people say CBT wasdeveloped for the Wall Street
middle-class white men.
(09:09):
Remember, that is the maincriticism of CBT.
So yes, it is underpinned byindividualism, okay?
And so what do you do whenyou're dealing with people who
are not individualistic, wholive in communities, who live in
families, extended families, andthe family wants to know what's
(09:31):
going on in therapy.
And that's something we teachour therapists, you know, to not
share any information or not toengage anyone.
You see, these are importantkind of differences.
Finally, just one hugedifference is the illness belief
model.
(09:52):
Now, the causes of illness arebiopsychosocial in the Western
world.
And in many non-Westerncountries, the causes of mental
health problems are spiritual.
They have a huge...
spiritual component, right?
(10:13):
So in other words, the illness,belief, motel, or cause and
effect relationship aredifferent.
So the formulation that I advisein culturally adapted CBT is a
biopsychosocial spiritualformulation rather than a
(10:34):
biopsychosocial.
SPEAKER_01 (10:37):
Okay, thank you for that.
Look, as you're speaking, it'sreally making me think about...
my own experience with differentcultural formulations of mental
health or mental illness.
And culturally, you know, mycommunity often would say, would
think about nudger, which islike a kind of evil eye, or they
(10:59):
would talk about things like ginpossession, like a spirit
possession.
They might also think aboutmental illness as a result of,
you know, not being piousenough.
It's like a religious kind ofrepercussion.
Things like that.
And so what does it mean toreally adapt CBT to make it
(11:23):
culturally appropriate when, youknow, I think from a certain
perspective, some of thosebeliefs or that ideology of
mental illness would be seen as,I don't know, in itself
delusional or in itself, youknow, like I'm seeing a bit of a
A conflict.
(11:44):
So help me understand, how do weadapt this model?
SPEAKER_02 (11:49):
When you say conflict, what do you mean by
conflict?
SPEAKER_01 (11:53):
Well, if I were to say I'm struggling with
depression, and I think it'sbecause it's the result of evil
eye.
I'm the target of someone else'scontempt.
because I showed too much pride,for example.
(12:15):
You know, something like that.
You know, one might say, okay,my belief itself is delusional
or it's unfounded.
SPEAKER_02 (12:24):
Yeah.
So you see, yeah.
I'll just take...
one example and elaborate onthat.
And you did mention that.
And that is being religiousmeans you can't be depressed.
You touched on that.
(12:45):
Now, that's a very common beliefamong Muslims and Jews.
Because it's based in the holybooks.
But the exact kind of versesare, and I'll just kind of that
if you are a true believer, youwill not be sad.
(13:08):
So you see, my work, because mywork took me, and I'll give you
another couple of examples in asecond.
So there were actually time, ittook me some time to explore a
certain kind of belief, and I'mnot going to say pathological or
normal or whatever, And I had toexplore.
(13:31):
So in this case, I had to talkto a lot of religious scholars,
both Jewish and the Muslims.
And then actually they told meis that the holy books actually
talk about you won't be sad inthe afterlife.
That's very important thing.
(13:51):
Yes.
Yes.
So basically the explanation is,you know, if you are a good
believer, it makes sense, right?
From religious point of view.
But people actually havemisinterpreted that as, okay,
you're going to be depressed orunhappy in this world too.
So a lot of this work isactually helping people or
(14:14):
tracing the belief or the originof the belief and see why.
where it's coming from.
And that's why a big part Iadvise of the culturally adapted
CBT is to work with people, sayspiritual and faith healers, so
(14:36):
to understand the spiritual partof the origin of a certain
mental health problem thatperson believes in.
And when you present this,excuse me, explanation to many
(14:56):
patients, they're absolutelyfine.
And it makes sense to them.
They say, okay, oh, that's whatit means.
So that is about, that's a veryimportant part.
So you see some investigation,working with people from that
kind of background who canexplain these beliefs to you as
(15:19):
a therapist so you can explainto the patient.
And there are other examples.
For example, in my work, when Icompare the differences between,
and I'll take this one group,South Asians in England, because
(15:40):
most work on South Asians comesfrom England.
Unfortunately, North Americadoes not have a lot of research
work on South Asians.
I was a bit surprised when Imoved to Canada a few years ago
to see that even though SouthAsians are the biggest minority
(16:00):
in this country and yet there'snot any research on mental
health of South Asians orgenerally health of people of
South Asians.
Anyway, so one example was whenyou compare, so we were
comparing the results and onething we noticed like, you know,
(16:21):
was biological, psychological,social, and then there was some
kind of very cultural kind ofbeliefs, and it took me some
time to explore where they'recoming from.
For example, one is phlegm,increased phlegm in the body.
Okay.
(16:41):
can be a cause for mental healthproblems.
So I had to explore, I had tolook, and I asked people, and I
obviously looked at theliterature and everything, and
then it turns out, this isactually a Greek concept, old
Greek medicine concept.
(17:03):
And then I'll tell you where itcame from, how did it end up in
South Asia, right?
The second example is oneperson, not one, but many people
believe that increased heat inthe liver can cause mental
(17:24):
health problems.
So again, it took me some time,and I looked, I explored, and
then I found this belief comesfrom the old Chinese medicine.
Heat, cold, different organs.
Right, right.
Third example, some people saidmasturbation can cause mental
(17:54):
health problems.
Then again, I had to explore andI realized that it's actually a
belief that comes from Ayurveda,the Indian medicine.
So you see, okay and myunderstanding is because you see
like greek medicine in the oldtime that was the most advanced
(18:18):
medicine like the currentwestern medicine is these days
right and then plus alsoespecially south asia and uh uh
south asia uh you know thethere's so many innovators and
they all came through there.
And when they came, they camewith their medicines, with their
doctors, right?
Old time, I think of the oldtimes.
(18:39):
Armies used to travel with thephysicians and, you know, it was
very slow.
So that's where these beliefs,kind of that's how they
traveled.
So you can see there are somereally interesting kind of
beliefs when you're dealing withthis population.
(19:00):
And the way to deal with thatis, and obviously you can't
change that because if yourfather's told you that your
depression is because of phlegmin your body, then you're less
likely to change that view untilit presents some solid evidence
(19:20):
for you, number one.
Number two, the belief isreally, really strong and, you
know, it's not kind of, but,okay, important thing to keep in
mind, people in the non-Westerncultures also have multiple
(19:41):
component model of mentalillness.
That's a very important thing.
And it's a good thing.
Because you see, if somebody issaying, okay, yes, there are
biological causes, you know,genetic causes are very common
among South Asians and Asians.
And it was a bit shocking for mewhen I realized this for the
(20:02):
first time.
You know, you might be awarethat Many South Asians hide
mental health problems in thefamily because of the impact it
can have on arranged marriages.
(20:25):
Because the concept of thegenetic transmission of disease
is actually very strong in thesecultures.
It is shocking, isn't it?
You wouldn't think that, right?
Okay.
But they will be, they'll havesuch strong belief in genetics,
but yeah.
So the whole belief, how hiding,you know, there are multiple
(20:45):
causes, obviously.
The genetic component is very,very strong.
So, so yeah, so it's aboutmodifying the beliefs, providing
education, but also because it'smulti-component, so you don't
necessarily have always need tofight against one belief when
you know the person believesthat it's a multifactorial kind
(21:06):
of position.
SPEAKER_01 (21:08):
Okay, so if I'm hearing this right, when we
think about beliefs about thecause of illness, phlegm,
masturbation, these kinds ofthings, it wouldn't be the
clinician's job to change thosebeliefs necessarily, but just to
(21:30):
be aware of that, right?
SPEAKER_02 (21:32):
Yeah.
Yeah.
Okay.
And you see in many, very oftenyou can educate patients.
So it's not like your religiousbelief is so fixed that they
wouldn't change.
So, you know, you can alwayseducate them.
And, and if you feel that that'skind of, they're not changing,
then, you know, then if theperson has a, they use
(21:57):
biopsychosocial factors.
Anyways, you can work on, youcan still work with age.
That's my point.
SPEAKER_01 (22:05):
Okay.
Here's my question.
Have you, so in the researchyou've done, what have the
outcomes been of, in deliveringCBT interventions to people in
different countries anddifferent cultures.
So specifically, I think you'vedone studies in Pakistan with
(22:27):
South Asian Muslims, but feelfree to draw on any study.
I'm just interested to see whatthe uptake and outcomes are
like.
Because when we talk about aNorth American study, you know,
or a study in the UK, we'resaying that, you know, there's a
high attrition of South Asiansor they're not well represented.
So when we go to a South Asiancontext, what does the
(22:49):
intervention look like?
What are the outcomes?
SPEAKER_02 (22:52):
Yeah, so the outcomes in general of
culturally adapted interventionsare better than the standard
CBT.
Wow.
Yeah, yeah.
However, this is still a verykind of new field And there are
(23:16):
not many RCTs, there are notmany fully powered RCTs.
So the jury's still out.
Okay.
Yeah, but the existing evidenceactually indicates that people
(23:36):
are more, you know, likely tobenefit from culturally adaptive
CBT.
And it makes kind of sense,really, even if you don't think
about, you know, because thebasic concept in CBT is to
(23:59):
provide an individualizedtherapy, right?
SPEAKER_01 (24:03):
Right.
UNKNOWN (24:03):
Right.
SPEAKER_02 (24:04):
Even if you don't think about the evidence from
the research, it is the duty ofevery therapist to think about a
client's culture.
Isn't that right?
That's what we teach.
That's where we train ourtherapists.
SPEAKER_01 (24:24):
Dr.
Naeem, I'm really interested intalking a bit further about your
work around CBT forschizophrenia and psychosis.
I think there's, I know a lot ofclinicians who struggle with
clients who have psychoticsymptoms, have been, you know,
are on antipsychotic medication.
(24:46):
Some are functioning very welland others bring out a lot of
hopelessness in theirclinicians.
And so I think there'ssometimes, This idea that people
with schizophrenia are verydifficult to treat.
Can you tell me a bit about whatCBT for psychosis or
(25:07):
schizophrenia looks like?
And perhaps what's the goal ofCBT with people living with
schizophrenia?
SPEAKER_02 (25:18):
Yeah.
Thank you.
Now, CBT for psychosis is aBritish kind of adaptation, so
it's not as popular in NorthAmerica as it should be.
Most of the RCTs come fromEurope.
Okay.
And the last time I looked, Ithink more than 40, 50
(25:41):
randomized controlled trialshave been conducted, and the
evidence overwhelminglyindicates towards the
effectiveness of CBT forpsychosis in reducing delusions,
hallucinations, even negativesymptoms.
(26:01):
So the overall aim is to helpthe person to become more aware
of the symptoms to help themdevelop some insight, some
self-awareness and reduce thedistress.
reduce the intensity of thesymptoms, and therefore improve
(26:25):
the quality of life of patients.
The main kind of techniques weuse for delusions, we use
Socratic dialogue.
Right.
And for hallucinations, copingskills, but also re-attribution
(26:47):
techniques, challenging thevoices or teaching patients to
challenge the voices.
Negative symptoms.
For negative symptoms, we usebehavioral activation.
So all these kind of things areused.
But yeah, the overall idea is toreduce distress and improve
(27:10):
quality of life.
And there's plenty of evidencethat it
SPEAKER_01 (27:16):
was.
Okay.
So it makes me wonder a bitabout like this idea of
adaptation and learning moreabout different cultures,
adapting the original model fordifferent kinds of illnesses.
(27:39):
Do you adapt the medium oftherapy as well?
I've read like in some of yourwork, you've talked about doing
CBT interventions by email.
Can you tell me a bit aboutthat?
How does that work?
How do you structure that work?
SPEAKER_02 (27:55):
So that's really something I realized recently.
seven, eight years ago.
And it was mainly, you know, bythat time, I had conducted a few
RCTs.
I knew adaptive CBT works.
Well, then I actually realizedit doesn't matter how much I
(28:19):
adapt CBT, the issue is ofaccess.
right because right forget aboutadaptive cbt uh we don't have uh
uh cbt therapists or number ofsufficient number of therapists
to provide therapy to thegeneral population in general so
(28:42):
So that's when I became moreinterested in improving access
to therapy.
And not just for the refugees orimmigrants kind of population,
but for everyone.
And then another thing, aroundabout the same time I started
(29:05):
noticing that internet is verycheap in many low middle income
countries.
Okay, mobile phones are right.
So for$50, you can buy a highquality smartphone in India and
Pakistan and Sri Lanka, right?
So these kind of countries, youcan buy a very cheap mobile.
(29:28):
So that's the kind of time Ialso realized that this is the
only kind of way that we canimprove access to CBT.
I see.
So that's why I took thatdirection.
And so eGuru, which was a set ofCBT apps, I stopped working on
(29:49):
that when I moved to Torontofour years ago.
I was in Queens before that forthree years.
And because I got busy.
But now I've started working oneGuru apps again.
But also, you see...
Recently, actually, we publishedthe very first online culturally
(30:13):
adapted CBT.
It's a pilot kind of evaluation.
And we conducted that.
And as a first...
culturally adapted online CBTprogram published from South
Asia.
And it actually happenedyesterday.
(30:34):
And we found that- Wow,congratulations.
Yes, thank you.
And people engage.
you know, with therapy and theresults were fantastic.
So, so, so you see it seemslike, and you know, the other
thing also we need to keep inmind in global mental health,
(30:54):
poor countries are becomingricher.
People are becoming moreeducated.
And in addition to have to, toimprove access to digital
technology.
So all these factors are, Imean, you know, we should focus
on using apps and web apps todeliver therapy.
(31:19):
So that was the whole ideabehind it.
SPEAKER_01 (31:22):
All right.
That's very interesting.
Are there any populations orconditions for which CBT should
not be conducted electronically,like by email or by using an
app?
So,
SPEAKER_02 (31:39):
Manay, I don't know the exact kind of answer to your
question because there's not alot of research in this area.
This is a very new area.
However, the exclusion criteriamost randomized controlled
trials have used are kind ofstraightforward.
(32:03):
So, for example, havingaccidental Technology is number
one.
Number two is digital literacy.
Digital literacy is veryimportant.
And third is not having anyintellectual disability, right?
(32:25):
I see.
So these are the very basic kindof requirements for digital
mental health or delivery of CBTthrough digital technology.
SPEAKER_01 (32:35):
Now, you have this particular interest in doing CBT
for psychosis, and I justwonder, would that be
appropriate to do by email?
I worry that people withpsychosis sometimes may have a
tough time using technology tobe vulnerable.
SPEAKER_02 (32:57):
Not necessarily.
It depends on the stage.
of illness depends on the age ofthe patients.
Many people actually, you see,one thing we need to keep in
mind is modern medication hashelped a lot.
You know, we have this conceptthat people, and it's true, it's
true.
(33:19):
Until 10, 15 years ago, a lot ofpatients used to have cognitive
deficits, which is part of thenormal kind of illness, process,
so chronic schizophrenia andcognitive deficits, you know,
they grew together.
And it still happens,unfortunately.
With the modern medication,improved compliance, I see that
(33:43):
it's becoming less and less of aproblem.
So while we still struggle, andwhile we still have a reasonable
number of patients who aretreatment-resistant, The
important thing to keep in mindis that the majority of our
(34:10):
patients, they actually canengage.
Having said that, I think thatthere are one or two trials cbt
online cbt but that's actuallyface to face through zoom or
webex for schizophrenia and andalso some kind of websites with
mixed results but generally thishas not been used a lot in
(34:37):
people's schizophrenia One areawhere some progress has been
made is use of virtual realityprograms to reduce fear and
phobias in general, but also inpeople with
SPEAKER_01 (34:56):
schizophrenia.
Oh, that's fascinating.
The virtual reality programming.
Okay.
Well, we've been talking a bitabout schizophrenia, and I want
to ask...
what your stance has been onthat diagnostic label in the
clinical and academic community.
I think there's been some debateon whether or not it's a helpful
(35:20):
label, whether the stigma makesit, I don't know, whether the
stigma itself is too much of abarrier.
So I wonder, what is yourstance?
Should it be renamed?
What's its utility?
SPEAKER_02 (35:35):
Yes, no, I actually, when, you know, I was actually
very, very much in favor ofchanging the name of
schizophrenia.
And I and my group, we wrotesome letters and articles as
well 15 years ago.
But you see, then I actually, Idon't think it's going to make
(36:00):
any change if you change thename.
SPEAKER_03 (36:03):
Uh-huh.
SPEAKER_02 (36:04):
And the reason is because I learn and because of
my work, actually I startedthinking more about the cultural
sort of factors and it gave me,you see, it gave me multiple
insights working in many lowmiddle income countries.
(36:26):
So for example, I learned thatPeople believe that epilepsy was
because of evil spirits.
SPEAKER_01 (36:40):
Huh, okay.
SPEAKER_02 (36:42):
In many, many, many low middle income countries,
especially the Middle Easternand the South Asian.
I don't know about othercultures.
Okay.
And you see what happened then.
So this is like 30 years ago, 40years ago, people tell me, my
colleagues in the field.
And then they say, as theanti-epileptics became available
(37:07):
and people could afford themedication and it became obvious
that epilepsy can be treatedwith the help of medication, now
hardly anyone believes that thisis because of evil spirits.
Right?
For me, it was a big lesson.
The reason it was a big lessonwas because it showed you can't
(37:33):
change people's minds or theirconcepts or their misconceptions
about an illness.
And this, I think, also includesstigma, to be honest with you,
(37:53):
until and unless you change theoutcome.
I mean, if you look at thehistory of mental health
problem, wasn't there a timewhen people with dyslexia were
burned in Europe because peoplethought they are witches, right?
(38:13):
So it's not really that changinga name is going to make any
difference.
And even just psychoeducationalone is not going to make a
difference.
I now believe that until wechange the outcome of
schizophrenia, I don't thinkjust changing the name is going
(38:38):
to make
SPEAKER_01 (38:39):
a difference.
Okay.
To that end, do you think, andwe're getting towards the end,
so I hope I'm not tiring you
SPEAKER_03 (38:50):
out.
UNKNOWN (38:52):
Okay.
SPEAKER_01 (38:53):
I've heard some people argue that what we call
symptoms of psychosis can beexplained better through other
cultural lenses.
And so shouldn't be in thecategory of psychosis.
So for example, you know, aftera loved one dies, lots of people
(39:16):
report that they will get, likethat loved one will show show up
in their dream, you know, andsomebody would be inclined to
call that a visit and they wouldsee it as something affirming.
But if we stick to a certainkind of model, we might call
that, we might say that it'snormative, but we might also
(39:39):
call it a kind of psychosis.
And I wonder how, if thatlanguage could be challenged a
bit.
What are your thoughts on that?
SPEAKER_02 (39:47):
I think any clinician who does that is a
terrible condition.
I'm serious.
I've seen this happening.
Yeah.
I've seen this happening, peoplebeing diagnosed with
schizophrenia because they had atrauma, they see things at
(40:08):
night, in the dark, et cetera,et cetera, or other kind of
visions.
you know, and being diagnosed orsomeone who hears the kind of
voice of a dead relative orthings like that.
So to somebody who, a clinicianwho diagnoses this kind of
(40:31):
picture, you see, schizophreniashould, people should be careful
with diagnosing
SPEAKER_03 (40:39):
schizophrenia
SPEAKER_02 (40:41):
because you are giving someone a lifelong label.
Right.
And we need to be careful withthis kind of experiences which
are mainly expressions ofdistress.
I mean, you can even talk aboutthe religious or spiritual
experiences people see or hearthings, you know, religious
(41:03):
experiences.
But the distinction betweenschizophrenia and this kind of
experiences is that of duration,and then the exclusion and most
importantly, it's also aboutbeing careful in judging the
(41:26):
symptom.
You know, for schizophreniadiagnosis of schizophrenia, we
first have to think about theduration, right?
Symptoms should be there.
Number two is you know, thecollection of symptoms.
So generally we have, and thisis like every disorder in reason
(41:47):
five.
Number three is exclusion.
That person shouldn't be using,you know, drugs, alcohol,
stimulants, that kind of stuff.
My point is many psychiatrists,unfortunately, do not think
about these things generalcriteria when they diagnose
someone.
And the biggest example is I seeso many patients, you know,
(42:10):
being misdiagnosed with bipolar.
And when I actually asked them,they say they had mood swings,
but the mood swing was nevermore than a day or two.
Now, in order to diagnosebipolar, the person should have
experienced manic episode for atleast one week, right?
So my point is, I think that'smore a kind of problem
(42:33):
misdiagnosis because the MertonDSM ICD-11 systems are freely
kind of advanced.
And if psychiatrists use themcarefully, they shouldn't be
misdiagnosing people.
But the simple answer is that'sa terrible thing, you know, if
(42:54):
it's happening even in this dayand
SPEAKER_01 (42:58):
age.
UNKNOWN (42:59):
Yes.
SPEAKER_01 (42:59):
Dr.
Naim, my last question, ifclinicians want to get training
in being not just culturallycompetent, but being able to
deliver culturally adapted CBTfor specific communities and
populations, how might they getthat training?
SPEAKER_02 (43:21):
Yeah.
So, In Canada, I'm currentlyleading a large randomized
controlled trial.
And it was actually a mixedstudy, but currently we are on
the RCT phase.
SPEAKER_03 (43:34):
And
SPEAKER_02 (43:36):
we are running the trial in Vancouver, Toronto, and
Ottawa.
And at the end of this RCTphase, we'll develop a training
specifically for the trial isfor South Asians there.
And we'll develop the trainingpackage and that will be
(44:01):
available freely.
So just.
Look out for that.
SPEAKER_03 (44:10):
Yes.
SPEAKER_02 (44:11):
Yes.
SPEAKER_01 (44:11):
Okay.
Lovely.
Thank you so much, Dr.
Naim for.
My pleasure.
For being with us.
And when I'm back in Toronto,maybe our paths will cross
again.
SPEAKER_02 (44:22):
Absolutely.
Lovely.
You take care.
It was a pleasure talking withyou.
Thank you.
Bye.
UNKNOWN (44:29):
Bye.
SPEAKER_00 (44:30):
Thanks for tuning in to the CBT Dive.
Don't miss an episode.
Subscribe to our YouTube channelat thecbtdive.ca.
You can also listen on the gowherever you get your podcasts.
To follow Rahim on social media,check out ladyativan.com.
See you soon.
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