**2. Comprehend, cope and connect (CCC)**

#### **2.1 Rationale for culturally sensitive psychological interventions**

The Western cultural bias of commonly available psychological therapies, including CBT has been identified as a barrier to both engagement and effective treatment of people from diverse ethnicities, and the development of culturally adapted and culturally sensitive forms of therapy is a response to this issue [37–46].

The current study seeks to address some challenges that have emerged during the course of this endeavour. Specifically, where adaptation relies on aligning to a particular culture, this limits applicability in a situation, such as that found in urban areas of the UK, where people from multiple ethnic groups co-exist. Further, mental health challenges are more likely to be viewed in spiritual and religious terms by non-Western societies and therapies such as conventional CBT tend to favour a diagnostic conceptualisation that can feel alienating to these cultures if not culturally responsive.

Third wave CBT approaches are built around the use of mindfulness in order to create distance from patterns of thought and behaviour leading to malfunction. These therapies are normally applied trans-diagnostically, and because of the spiritual origins of mindfulness, sit more easily with the non-Western mind-set. CCC, founded as it is in basic cognitive science, discards much of the complexity of other approaches and works with the universal human need to establish a tolerable internal state. Where this state is hard to reach, malfunctions that get labelled as 'symptoms' within the illness paradigm result, and can become established. The role of trauma in complicating the achievement of a good enough internal state, or sense of self, is given pride of place within the CCC formulation, and CCC has a distinctive approach to trauma which will be explored below.

#### **2.2 The intervention**

CCC was first evaluated within Acute Mental Health services [47–50], and developed for delivery in a primary care, Increasing Access to Psychological Therapies (IAPT) service, for complex cases [51]. Within primary care, the programme consisted of four individual, collaboratively arrived at, emotion and trauma-focused formulation sessions, followed by a 12 week group, skills based, intervention, targeting emotion management and behaviour change. One or two review sessions concluded the programme. The manual for this primary care programme [51] was adapted for the CCC Culture Free manual by the authors IC, LB, PP & FN.

### **2.3 The manual**

The adaptation welcomed inclusion of family members, carers, into the therapy, added somatic elements, made more space for spirituality and religion and added teaching stories.

The Culture Free therapy was briefer than the primary care version because it was targeted more widely. Within the IAPT service, the approach was reserved for complex presentations predicted or proved to be unresponsive to routine protocols. However, the participant group for the current study also included a high proportion of people with complex trauma and relationship issues. It was further hypothesised that involvement of the wider system might assist skills utilisation in the natural environment, so allowing for a briefer therapy, as noted in earlier studies (Naeem, personal communication).

The first four sessions covered open-minded listening to the individual's story and collaboratively drawing this together into an emotion-focused diagrammatic formulation. This incorporated the effect of trauma on current presentation and explained it to the client as covered in Section 3.2 below. Maintaining cycles are identified, along with skills needed to break them. Breaking these cycles informs the choice of goals. This formulation is also summed up in a compassionate letter discussed with and sent to the client. The subsequent four to eight sessions cover skills and behaviour change needed to break the vicious cycles.

#### **2.4 Modifications to the manual**

Refining the manual was a major aim of the study and the manual was revised in the light of new learning arising from the particular challenges that emerged during therapy delivery. Model adherent procedures to meet them were discussed in clinical supervision (with investigators IC, LB & PP), implemented and evaluated accordingly. Successful solutions were added to the manual, below.

Specific modifications included:


The pilot aimed to explore the feasibility, acceptability and effectiveness of CCC a novel third wave CBT integrative approach as a trans-cultural therapy intervention. The objectives included reduction in symptoms of emotional health problems and disability.

## **2.5 Participants**

A total of (n = 32) participants with mental health problems were recruited into the study from Improved Access to Psychological (IAPT) Services and secondary adult mental health services, in a Hampshire NHS Foundation Trust.

Outcome measures were administered at baseline, end of therapy and at eight week follow-up period.

These included:


The final results of this pilot have been prepared for submission. Repeated measures analysis of variance (ANOVAs) for outcome variables: HADS –depression scores indicated a significant effect when all three time points were compared simultaneously; F (2,36) = 12.81, p < .001, partial η<sup>2</sup> = .42. Bonferroni adjusted pairwise comparisons indicated significant reductions from baseline vs. post-treatment 11.21 (SD =4.28) to 7.11 (SD = 3.99) on the HDAS –depression p < .004 and baseline vs. follow-up 7.21 (SD = 4.99), p < .001. However, there was no significant difference between post-treatment and follow-up, p < 1.0.

HADS –anxiety scores was significantly different when all three time-points were compared simultaneously, F(2,26) = 9.93, p < .001, partial η<sup>2</sup> = .36. Bonferroni adjusted pairwise comparisons indicated significant reductions from baseline vs. post-treatment 14.53 (SD =4.01) to 11.05 (SD = 3.40) on the HDAS –anxiety p < .003 and baseline vs. follow-up 11.21 (SD = 4.05), p < .001. However, there was no significant difference between post-treatment and follow-up, p < .831.

WHODAS was significantly different when all three time points where compared simultaneously, F(1.29, 14.18) = 6.73, p < .001, partial η<sup>2</sup> = .38. Bonferroni adjusted pairwise comparisons significantly reduced from baseline to post-treatment 66.58(SD = 40.13) to 44.42(SD = 44.42 (SD = 32.35), p < .034 and baseline to follow-up 38.75(SD = 26.499), p < .014.

CORE Total score was significantly different at three time points, F(1.25, 18.72) = 14.98, p < .001, partial η<sup>2</sup> = .5. Bonferroni adjusted pairwise comparisons indicated significant reductions from baseline to post –treatment 76.81 (SD = 23.26) to 49.25 (SD =27.00), p < .002, and baseline to follow-up, 52.19 (SD = 25.72), p < .001.
