Evaluation of a culturally adapted cognitive behavior therapy-based, third-wave therapy manual

Table 1 Comprehend, Cope, and Connect schedule of sessions

Session no	Activity
1-4	Listening; introducing the states of mind; introducing mindfulness and/or breathing
	Collaboratively creating the formulation diagram
	Negotiating goals for therapy based on what is needed to break the vicious circles
	Sharing the draft compassionate summing up letter and looking forward to what to work on through the group programme
5-12	Goals based interventions aimed at breaking the cycles. Mindfulness is the core intervention, and the following are employed as indicated by the formulation
	Arousal management, including relaxation breathing and lifestyle adjustment to reduce chronic stress
	Behavioural activation
	Emotion management includes facing, expressing and letting go of emotion self-compassion
	Aspects of self; mindfulness managed subpersonality work. Relationship management including assertiveness building a new relationship with the past
	Follow-up at 12 wk post-therapy

Table 2 Principal interventions post formulation

Intervention
Mindfulness is the core intervention; it informs the application of the others
Arousal management (relaxation breathing etc.)
Behavioral activation
Facing, expressing and letting go of emotion
Self-compassion
Positive anger work
Aspects of self (mindfulness managed subpersonality work)
Relationship management including assertiveness
Building a new relationship with the past

Table 3 Demographic characteristics

Characteristics	Total sample, (n = 32)
Gender (n, %)
Male	5 (16)
Female	27 (84)
Age in years range (mean)	20-53 (34.8)
Ethnicity (n, %)
Black African	2 (6)
Black Caribbean	4 (12)
Black Other	3 (9)
Indian	7 (21)
Bangladeshi	1 (3)
Chinese	3 (9)
Other Asian	2 (6)
Other/mixed	10 (32)
Diagnosis (n, %)
F32: Depressive episode	12 (38)
F20: Schizophrenia	1 (3)
F41.1: Generalised anxiety disorder	9 (28)
F40.1: Social phobia	2 (6)
F43.1: Post traumatic stress disorder	2 (6)
F42: Obsessive compulsive disorder	2 (6)
F41.8: Mixed depression and anxiety	4 (13)
Setting (n, %)
Community Mental Health Team	6 (19)
Improving Access to Psychological Therapies	26 (81)
Therapist delivering intervention (n, %)
1	2 (6)
2	19 (60)
3	9 (28)
4	2 (6)
Number of sessions completed (n, %)
12 (maximum)	19 (60)
6-11	9 (28)
Under 6	2 (6)
Unrecorded	2 (6)

Table 4 Presentation information and strategies used

Participant	Earlier life experiences (traumatic context)	Presenting problem and impact of past	Specific CCC coping, strategies in addition to mindfulness
1	Childhood abuse (by a close family member), age 4 yr, and neglect; judgmental mother - unrealistic academic expectations	Acquiring physical disability (fibromyalgia and chronic pain), triggers sadness, anger, shame and anxiety, and feeling useless	Building a new relationship with the past: Self compassion
2	Childhood abuse. Domestic violence from partners	Anger and cannot cope when feeling unsupported, let down in the present. Unassertiveness	Building a new relationship with the past: Self-compassion; positive; anger work
3	Over-looked academically as a girl; sense of injustice. Sexual abuse by older brother told not to tell (approx 7 years old) told mother, who blamed and chastised her for the act	Unacknowledged in current family leading to disproportionate depression and anger	Emotion management; selfcompassion
4	Punishing and neglectful mother. Anxious childhood	Inability to deal with emotions. Avoidant of relationships	Self-compassion; emotion management
5	Childhood trauma. Father nearly died in car crash when 9 years old. Family preoccupied with impact on sibling	Obsessional thoughts regarding harm to daughter. Avoidance	Arousal management; aspects of self1; self compassion
6	Extreme childhood fear engendered by tales of black magic	Post-natal fears for safety of son. High anxiety. Compensates with controlling pre-emptive and perfectionist behaviors	Arousal management; building a new relationship with the past; emotion management
7	Neglectful and chaotic childhood. Alcoholic father	Avoidance of emotion leading to constant activity and chronic stress. Alcohol	Arousal management; emotion management
8	Multiple deaths of family members coming close together	Obsessive health anxiety	Arousal management; self-compassion; relationship management2
9	Shamed within family as teen for (culturally unacceptable) homosexuality. Physical and emotional abuse by mother. Father left when 3 years old	Envy, anger, relationship and career difficulties. Loneliness copes with perfectionist ideas but behavioral inactivity (fear of failure)	Emotion management; relationship management2
10	Sister preferred. Sexual abuse by ex-partner. Experienced racism at work	Low self-esteem. Perfectionism leading to high stress	Positive anger work; aspects of self; relationship management
11	Childhood trauma - mother left. Sex abuse by a parent at 12 yr. Abusive childhood. Adult trauma - loss of daughter in a road traffic accident. Impact of road traffic accident - reduced memory, increased emotionality and impulse control	Flashbacks. Dissociation. Low self-esteem. Problems with emotions and relationships	Building a new relationship with the past; emotion management; relationship management2
12	Childhood trauma - loving family, experienced war conflict while in Turkey during Kurdish and Turkish conflict - witnessed village members being tortured by soldiers. ‘Reported seeing ‘Jinns’, dead bodies and evil spirits’ - hallucinations? Adult trauma - illegal immigrant for 14 yr - experienced extreme anxiety and feeling under attack from others	Panic, hypervigilance, avoidance of crowds and exercise	Arousal management; emotion management
13	Mental, physical and sexual abuse	Avoidance of emotion. Avoidance of intimacy	Building a new relationship with the past; relationship management2; emotion management; aspects of self1
14	Childhood sexual abuse by a parent between 5 to 12 yr. Experienced 13 yr of mental and physical abuse from husband	Emotionally overwhelmed. Withdrawal and unmotivated, or dysregulated anger	Arousal management; relationship management; self-compassion
15	Emotionally abusing and criticising childhood	Dissociation. Emotional overwhelm and relationship difficulties	Positive anger work; emotion management;self-compassion
16	Migration age 19 yr of age; hostile in-laws. Major health difficulties severely impact marriage	Suicidal and self-harm. Low mood	Arousal management; relationship management; self compassion2
17	Unhappy childhood; migration distress. Breast cancer	Obsessive anger at neighbours leading to conflict	Arousal management positive anger work; emotion management
18	Diagnosed with Autism. Early childhood developmental problems	Social avoidance	Arousal management; behavioral activation; relationship management2
19	Ran away from home age 11 yr. ‘Kicked out’ of family home at the age of 19 yr. Loss of young sibling and felt excluded	Suicidal. Avoidant of emotion	Building a new relationship with the past; self compassion; emotion management
20	Long exploitative and abusive marriage plus racial bullying at work	Stress, chronic hypertension. Relationship difficulties	Arousal management; emotion management; positive anger work; aspects of self1

¹Aspects of self is mindfulness managed subpersonality work.

²Relationship management includes assertiveness.

Mindfulness is the core intervention; it informs the application of the others. Arousal management includes relaxation breathing and lifestyle adjustment emotion management includes facing, expressing and letting go of emotion. CCC: Comprehend, Cope, and Connect.

Table 5 Results of repeated measures analysis of variance for outcome variables

Dependent variable	Independent variable	Degrees of freedom	F value	P value	Partial eta squared (variance explained; i.e., effect size)	Bonferroni adjusted pairwise comparisons
HADS depression	Timepoint (within subjects)	2, 36	12.81	< 0.001	0.42	Baseline (mean 11.21 SD 4.28) vs post-treatment (mean 7.11, SD 3.99), P = 0.004	Baseline vs follow-up (mean 7.21, SD 4.99), P = 0.001	Post treatment vs follow-up, P = 1.0
	Employment (between subjects)	1, 17	9.73	0.006	0.36	Employed vs unemployed mean difference1 -4.55 (95%CI: -7.62 to -1.47); employed have lower mean score at all three time points
	Employment X time point (within subjects)	2, 34	0.06	0.94	0.004	NA	NA	NA
HADS Anxiety	Timepoint (within subjects)	2, 36	9.93	< 0.001	0.36	Baseline (mean 14.53 SD 4.01) vs post-treatment (mean 11.05, SD 3.40), P = 0.003	Baseline vs follow-up (mean 11.21, SD 4.05), P = 0.001	Post treatment vs follow-up, P = 0.831
WHO disability scale total	Timepoint (within subjects)	1.29, 14.182	6.732	0.016	0.382	Baseline (mean 66.58 SD 40.13) vs post-treatment (mean 44.42, SD 32.35), P = 0.034	Baseline vs follow-up (mean 38.75, SD 26.499), P = 0.014	Post treatment vs follow-up, P = 0.194
	Living alone (between subjects)	1, 10	8.99	0.013	0.47	Living alone vs with someone mean difference1 51.9 (95%CI: 13.33 to 90.47); living alone have higher score at all three timepoints
	Living alone X timepoint (within subjects)	1.21, 12.072	0.392	0.581	0.042	NA	NA	NA
	Employment (between subjects)	1, 10	8.68	0.015	0.47	Employed vs unemployed mean difference1 -44.26 (95%CI: -77.62 to -10.79); employed have lower mean score at all three time points
	Employment X Time point (within subjects)	1.32, 13.182	2.992	0.1	0.232	NA	NA	NA
CORE total	Timepoint	1.25, 18.722	14.982	0.001	0.52	Baseline (mean 76.81, SD 23.26) vs post-treatment (mean 49.25, SD 27.00), P = 0.002	Baseline vs follow-up (mean 52.19, SD 25.72), P < 0.001	Post treatment vs follow-up, P = 0.404
CORE total mean with risk	Timepoint	1.25, 18.722	14.982	0.001	0.52	Baseline (mean 2.26, SD 0.68) vs post-treatment (mean 1.45, SD 0.79), P = 0.002	Baseline vs follow-up (mean 1.53, SD 0.76), P < 0.001	Post treatment vs follow-up, P = 0.404
CORE Total mean without risk	Timepoint	1.24, 18.662	16.58	< 0.001	0.532	Baseline (mean 2.62, SD 0.71) vs post-treatment (mean 1, SD 0.87), P = 0.001	Baseline vs follow-up (mean 1.77, SD 0.79), P < 0.001	Post treatment vs follow-up, P = 0.523
CORE risk mean	Timepoint	2, 36	1.83	0.175	0.09	Baseline (mean 0.48, SD 0.75) vs post-treatment (mean 0.26, SD 0.55), P = 0.109	Baseline vs follow-up (mean 0.39, SD 0.77), P = 0.418	Post treatment vs follow-up, P = 0.096
CORE symptoms mean	Timepoint	2, 32	91.10	< 0.001	0.54	Baseline (mean 2.81, SD 0.77) vs post-treatment (mean 1.76, SD 1.03), P < 0.001	Baseline vs follow-up (mean 1.91, SD 0.89), P < 0.001	Post treatment vs follow-up, P = 0.317
CORE functioning mean	Timepoint	1.25, 19.922	7.26	0.01	0.31	Baseline (mean 2.25, SD 0.88) vs post-treatment (mean 1.61, SD 0.86), P = 0.016	Baseline vs follow-up (mean 1.65, SD 0.83), P = 0.009	Post treatment vs follow-up, P = 0.692
CORE well being mean	Timepoint	2, 36	20.41	< 0.001	0.53	Baseline (mean 2.82, SD 0.67) vs post-treatment (mean 1.68, SD 0.68), P < 0.001	Baseline vs follow-up (mean 1.76, SD 0.87), P < 0.001	Post treatment vs follow-up, P = 0.61
BSI total	Timepoint	2, 36	6.50	0.008	0.26	Baseline (mean 22.11, SD 11.40) vs post-treatment (mean 19.05, SD 10.23), P < 0.066	Baseline vs follow-up (mean 16.47, SD 11.10), P < 0.008	Post treatment vs follow-up, P = 0.041

¹This is the difference in average means across all three time-points.

²Greenhouse-Geisser value given due to significant Mauchly’s test of sphericity.

CI: Confidence interval; NA: Not available; WHO: World Health Organization; CORE: Clinical Outcomes in Routine Evaluation; HADS: Hospital Anxiety and Depression Scale; BSI: Bradford Somatic Inventory.

Table 6 Results of repeated measures analysis of covariance for outcome variables

Dependent variable	Covariate	Independent variable	Degrees of freedom	F value	P value	Bonferroni adjusted pairwise comparisons
HADS depression	Gender	Timepoint (within subjects)	2, 42	0.158	0.855	Baseline (mean 11.77 SD 0.78) vs post-treatment (mean 7.75, SD 0.73), P = 0.003	Baseline vs follow-up (mean 7.55, SD 0.89), P < 0.001	Post treatment vs follow-up, P = 1.0
		Employment (between subjects)	1, 21	9.788	0.005	Employed vs unemployed mean difference1 -3.96 (95%CI: -6.60 to -1.33); employed have lower mean score at all three time points
	Age	Timepoint (within subjects)	2, 42	0.595	0.556	Baseline (mean 11.85 SD 0.77) vs post-treatment (mean 7.78, SD 0.74), P = 0.002	Baseline vs follow-up (mean 7.62, SD 0.89), P < 0.001	Post treatment vs follow-up, P = 1.0
		Employment (between subjects)	1, 21	11.266	0.003	Employed vs unemployed mean difference1 -4.33 (95% CI: -7.02 to -1.65); employed have lower mean score at all three time points
HADS Anxiety	Gender	Timepoint (within subjects)	2, 44	0.014	0.986	Baseline (mean 14.54 SD 0.77) vs post-treatment (mean 10.33, SD 0.75), P < 0.001	Baseline vs follow-up (mean 10.38, SD 0.86), P < 0.001	Post treatment vs follow-up, P = 1.0
WHO disability scale total	Gender	Timepoint (within subjects)	1.24, 22.382	0.3542	0.7042	Baseline (mean 85.32 SD 8.72) vs post-treatment (mean 65.83, SD 7.42), P = 0.143	Baseline vs follow-up (mean 53.59, SD 8.26), P = 0.014	Post treatment vs follow-up, P = 0.016
		Living alone (between subjects)	1, 18	8.288	0.010	Living alone vs with someone mean difference1 37.82 (95%CI: 10.22 to 65.42); living alone have higher score at all three timepoints
		Employment (between subjects)	1, 18	10.674	0.004	Employed vs unemployed mean difference1 -30.52 (95%CI: -50.14 to -10.89); employed have lower mean score at all three time points
	Age	Timepoint (within subjects)	1.25, 22.412	3.6312	0.0622	Baseline (mean 84.69 SD 8.62) vs post-treatment (mean 65.47, SD 6.89), P = 0.138	Baseline vs follow-up (mean 53.30 SD 7.41), P = 0.011	Post treatment vs follow-up, P = 0.013
		Living alone (between subjects)	1, 18	8.167	0.010	Living alone vs with someone mean difference1 34.92 (95%CI: 9.25 to 60.59); living alone have higher score at all three timepoints
		Employment (between subjects)	1, 18	14.555	0.001	Employed vs unemployed mean difference1 -35.13 (95%CI: -54.47 to -15.78); employed have lower mean score at all three time points
	Higher Education	Timepoint (within subjects)	1.22, 20.782	3.5062	0.0682	Baseline (mean 84.60 SD 8.89) vs post-treatment (mean 65.38, SD 7.64), P = 0.165	Baseline vs follow-up (mean 52.48, SD 8.31), P = 0.014	Post treatment vs follow-up, P = 0.008
		Living alone (between subjects)	1, 17	7.318	0.015	Living alone vs with someone mean difference1 36.75 (95%CI: 8.09 to 65.41); living alone have higher score at all three timepoints
		Employment (between subjects)	1, 17	10.370	0.005	Employed vs unemployed mean difference1 -31.02 (95%CI: -51.34 to -10.70); employed have lower mean score at all three time points
CORE total	Gender	Timepoint	1.47, 32.302	0.0282	0.9382	Baseline (mean 73.88, SD 4.56) vs post-treatment (mean 47.42, SD 5.11), P < 0.001	Baseline vs follow-up (mean 48.04, SD 5.25), P < 0.001	Post treatment vs follow-up, P = 1.0
	Age	Timepoint	1.47, 32.232	0.9752	0.3642	Baseline (mean 73.88, SD 4.48) vs post-treatment (mean 47.42, SD 4.95), P < 0.001	Baseline vs follow-up (mean 48.04, SD 5.15), P < 0.001	Post treatment vs follow-up, P = 1.0
BSI total	Age	Timepoint	2, 46	0.285	0.753	Baseline (mean 22.64, SD 2.06) vs post-treatment (mean 18.60, SD 2.06), P = 0.041	Baseline vs follow-up (mean 16.60, SD 2.09), P = 0.001	Post treatment vs follow-up, P = 0.406
	Gender	Timepoint	2, 46	1.027	0.366	Baseline (mean 22.64, SD 2.03) vs post-treatment (mean 18.60, SD 2.09), P = 0.026	Baseline vs follow-up (mean 16.60, SD 2.07), P = 0.001	Post treatment vs follow-up, P = 0.411
	Higher education	Timepoint	2, 44	2.811	0.071	Baseline (mean 22.58, SD 2.19) vs post-treatment (mean 18.21, SD 2.15), P = 0.028	Baseline vs follow-up (mean 16.75, SD 2.11), P = 0.003	Post treatment vs follow-up, P = 0.661
	Marital status	Timepoint	2, 46	3.146	0.052	Baseline (mean 22.64, SD 2.05) vs post-treatment (mean 18.60, SD 2.08), P = 0.040	Baseline vs follow-up (mean 16.60, SD 2.08), P = 0.002	Post treatment vs follow-up, P = 0.434

¹This is the difference in average means across all three time-points.

²Greenhouse-Geisser value given due to significant Mauchly’s test of sphericity.

CI: Confidence interval; NA: Not available; WHO: World Health Organization; CORE: Clinical Outcomes in Routine Evaluation; HADS: Hospital Anxiety and Depression Scale; BSI: Bradford Somatic Inventory.