The plain-language statement and consent form was translated for Vietnamese-speaking consumers and caregivers

p. 523¹¹⁵

Use of an interpreter:

Because 20 of the Vietnamese consumer-caregiver participants (80 percent) were not fluent in English and an interpreter was required for basic communication, the sample was considered to have a low level of acculturation

p. 523¹¹⁵

The intervention:

. . . was translated into Chinese language and validated by the researchers

p. 32⁸⁴

The training sessions were translated and adapted into Arabic by the first author who received in-person, supervised training from the developers of SCST (WPH, MFG) in the United States

p. 13¹¹¹

Translated into Persian with a high level of equivalence to the original English version

Koolaee and Etemadi, 2010, p. 638⁹¹

The intervention:

. . . was conducted in elementary school-level Spanish by 2 clinicians and one of us (AK)

p. 267¹¹⁷

The original MCT has been translated in Hindi and adapted for Hindi speaking patients at the Central Institute of Psychiatry, Ranchi

p. 153¹¹²

All materials were translated into Spanish and back-translated by two different persons of Mexican origins

p. 925⁸²

All written material was provided in both Korean and English, and the oral presentations were in Korean

p. 1127¹¹⁸

The SCIT manual was translated into Chinese by one of the authors (MY) who is a native speaker of Chinese and has been living in England for 3 years

p. 752¹⁰²

For exercises involving written vignettes, some translational adjustments were made to better fit the local vernacular (e.g., using the term ‘girlfriend’ or ‘boyfriend’ instead of ‘fiancée’)

p. 14¹¹¹

Adaptations included:

Integrating culture-specific icons and idioms in the materials

p. 66⁸¹

Urdu equivalents of CBT jargons were used in the therapy

p. 146⁹²

Adaptations made to substitute formal wordings on presentations and handouts for more colloquial Cantonese words

p. 5¹¹⁰

We did not use the term module because this word in Spanish is never used in clinical and therapeutic environments. As an equivalent of ‘modules’ we used the term ‘treatment areas

p. 1400¹²⁰

Psychoeducation sessions acknowledged common ethnospecific explanatory models of illness before the biopsychosocial model of illness was outlined

p. 525¹¹⁵

Each topic was specifically related to [. . .] local culture. For example, [. . .] some caregivers attributed the cause of their relatives’ mental illness to [. . .] delay[s] in accompanying [them] to see a doctor [. . .], which [. . .] led to an imbalance of yin and yang forces during adolescence. These beliefs were clarified by the researcher

p. 74⁸³

One [. . .] patient [. . .] in our study said that his illness was because of excess of phlegm (Greek concept), [. . .] another believed his illness was due to excessive heat in liver (Chinese concept). Therapy therefore included spiritual factors in formulation and understanding of locally held beliefs related to health, religion and culture

p. 205⁷¹

Iranian families see mental illness from the perspective of determinism – i.e. as predestination and fate. There are few attempts in Iran to follow up therapeutic interventions (Khodabakhshi & Koolaee, 2009); hence the reluctance of many mothers to participate in the study

p. 11⁹¹

Iranian people think that one of the reasons of mental illness in their children was bad fate or wrongdoing in life so God was punishing them with their ill children. Therefore, in psychoeducation model, I added the knowledge of illness and emphasized biological aspects

Anahita Khodabakhshi Koolaee, Faculty of Counselling and Family, Department of Family Counselling, Social Welfare & Rehabilitation University, Tehran, Iran, and Ahmad Etemadi, Faculty of Counselling, Department Psychology & Education, Allameh Tabatabaee University, Tehran, Iran, 2011, personal communication

Pictorial representations were used with illiterate relatives. The use of praise was thoroughly explained, modelled, and practiced using role-plays

p. 214⁹⁹

Patients often denied the value of medications, commonly expressing folk explanations [. . .] and corresponding remedies (e.g. prayer) for psychotic symptoms. [Consideration of alternative beliefs was facilitated] by inviting relatives and other patients [. . .], who initially may have held the same [. . .] beliefs, to describe their [. . .] experiences with antipsychotic medication (e.g. symptom reduction [. . .])

p. 268¹¹⁷

The content of the intervention also reflected issues that are felt to be more relevant for Indian families such as belief in supernatural causation, the role of indigenous treatments, cultural attitudes towards medication, marriage etc. On the other hand, there was a much less emphasis on constructs such as expressed emotions

Parmanand Kulhara, Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigah, India, 2009, personal communication

Also, since the caregivers subscribe highly to both stress and biological illness of the illness, it is fitting to adopt a vulnerability-stress framework instead of a strictly biological explanatory model adopted by many other models

p. 388⁸⁵

The content was developed on the basis of; cognitive behavioural coping strategies, modifications of beliefs and psycho-educational approach

Mann and Chong, 2004, p. 72¹¹³

A spiritual dimension was included in formulation, understanding and in therapy plan

p. 146⁹²

The lack of a correct recognition of mental illness is a serious problem for relatives of persons with schizophrenia in rural areas. They usually believe in witchcraft, and accept the notion that mental illness cannot be cured and that medication has no effect on the illness and only wastes family money

Effective patient and family education is needed in Malaysia as many patients attribute mental illness to supernatural agents, and they cannot accept explanations based on the Western Model

p. 284⁹³

[D]iscussion of traditional disease concepts was integrated into [. . .] sessions. For example, Korean perspectives on shamanism, [. . .] distress, diseases, fortune and misfortune [. . .] were discussed in the context [. . .] psychiatric illness. Psyche and soma were presented as [. . .] complementary aspects of life to encourage participants to understand [the relationship between] emotional [and] physiological functioning

pp. 1126–7¹¹⁸

Zafar et al. (2008) reported that one-third (30%) of the participants of a survey in Karachi, Pakistan, attributed ‘mental illness’ as the main cause of psychotic symptoms. Other causes included ‘God’s will’ (32.3%), ‘superstitious ideas’ (33.1%), ‘loneliness’ (24.8%) and ‘unemployment’ (19.3%) (Zafar et al., 2008)

(Habib et al., 2015;⁷¹ Naeem et al., 2015⁹²) as cited in Naeem et al., (2016) p. 44²⁷⁴

All psychologists agreed that therapy should be adapted to suit local needs, such as taking culture and religion into account, as these affect patients’ views on illness origins and treatment. Although one psychologist emphasised the positive influence of religious beliefs on mental health, the remainder considered them to be detrimental^71,92,274

Patients and their families in Pakistan use a bio-psycho-social model of management of psychosis with additional emphasis on spiritual and religious causes. This can possibly be termed as bio-psycho-spiritual-social model of psychosis

(Habib et al., 2015⁷¹; Naeem et al., 2015⁹²) as cited in Naeem et al., (2016) p. 52²⁷⁴

Participants:

. . . preferred their beliefs in witchcraft; did not regard mental illness as disease which needed medical treatment

p. 545¹¹⁴

Specific Chinese and Asian cultural characteristics were emphasized during each group session. These included the high social stigma associated with mental illness and seeking mental health services

p. 32⁸⁴

The intervention included:

. . . discussion of a taboo area (sharing of secret and internal psychological conflicts), commonality or a situation of ‘all-in-the-same boat’ (feeling in similar situation and working against a common plight), mutual help (reciprocal giving and receiving help and support among members)

p. 34⁸⁴

Emphasis given to specific Chinese cultural characteristics and issues, including a strong social stigma associated with mental illness and seeking mental health services

p. 1278⁸⁰

Mutual support groups may potentially be appropriate for Chinese families, who are often reluctant to seek help due to strong perceptions of stigma and an unwillingness to expose family weaknesses or disgrace (‘saving face’) to outside people (Bae and Kung, 2000; Fung and Ma, 1997)

p. 1328⁹⁸

Chinese cultural characteristics were considered and discussed, including the stigma towards people with mental illness, and being aware and accepting it

p. 1331⁹⁸

Intervention included:

Open sharing and mutual understanding about individual concerns; exploration of cultural issues in families

p. 1000¹⁰¹

This group provided a forum in which to discuss concerns and obtain support from the group to reduce the stigma of mental illness

p. 897¹⁰⁹

Many of the people with mental health illness in Asia still combat internal and external stigmatization from deep-rooted negative cultural beliefs about mental illness

p. 274⁸⁸

Most of those recovery narratives were initiated by inviting people to share their story of living with psychiatric illness

Ester Ching-Lan Lin, Department of Nursing, National Cheng Kung University, Tainan, 2013, personal communication

The greater stigma attached to mental illness, especially schizophrenia, by Latinos in the United States, Mexico, and Central and South America may require alterations in the form and process of evidence-based practices to make them acceptable to patients and their relatives

p. 249¹¹⁹

Seminars were held for health workers and family members to discuss any issues and suggestions, and to share their experiences of the patients

p. 545¹¹⁴

Interventions are more likely to be more effective if they put more emphasis on the provision of knowledge about schizophrenia, using simple language that can be understood by the families who are in majority from lower social class (Castle Peak Hospital, 1999), than on abstract theoretical concepts of schizophrenia

Wai-Tong Chein, Nethersole School of Nursing, Chinese University of Hong Kong, China, 2016, personal communication

The mothers lacked knowledge about mental illness. Psychoeducation intervention increased knowledge about schizophrenia with most participants acquiring new information

p. 11⁹¹

The clinicians’ systematic assessment of the beliefs, attitudes, and resources of each patient, and the integration of those factors in treatment, played a central role in the success of the MFG-A. For example, many of the patients who did not have or were ineligible for medical benefits did not take their medications because they could not afford to purchase them. These patients and their families did not realize they could receive antipsychotic medications at no cost through an indigent medication program available at the mental health center

Alex Kopelowicz, David Geffen School of Medicine, University of California, Los Angeles, 2012, personal communication

[S]ince the majority of Chinese in the [US] are immigrants [,] their knowledge of [US] health care [. . .] is limited [. . .].Thus, the burden of care [. . .] is likely to be greater [than] Caucasian-American families [. . .]. Thus, it is [important] to educate and support these caregivers to both alleviate their stress and improve treatment outcomes of their [. . .] relatives

p. 387⁸⁵

Psychoeducation materials were given to caregivers throughout the multifamily group sessions instead of a day-long workshop. Due to the lack of knowledge about mental illness and medication, and the lower educational background of many immigrant Chinese-Americans loading them with too much information at the beginning could be overwhelming

p. 388⁸⁵

Lower educational background of many immigrant Chinese Americans, loading them with too much information at the beginning could be overwhelming, and the retention of the materials limited (Bae & Kung, 2000)

p. 388⁸⁵

The concept of recovery from psychiatric disorders is still relatively new in Taiwan.’ (Lin, Kopelowicz, Chan, & Hsiung, 2008)

Ester Ching-Lan Lin, personal communication

Written communication was altered to accommodate lower educational backgrounds, and in the transportation module education and materials about public transportation services for disabled persons were provided, due to a lack of knowledge because of previous reliance on family members

p. 525⁸²

Financial management and written communication were altered to accommodate lower educational backgrounds

p. 925⁸²

The intervention was:

. . . modified to take account of the characteristics of Chinese rural areas, such as dispersed residences and a generally low level of education

p. 70¹⁰⁰

We also employed health education through the village wired radio network

p. 545¹¹⁴

Compared with Western interventions, in the early stages of family intervention in China much more effort needs to be placed on transforming family members’ perception of the role of the physician from that of a pill-provider to that of an informed family advisor

pp. 239–40⁸⁹

Some families believe social factors cause mental illness. They become controlling and overprotective in trying to keep the patient safe. Other families deny that the patient has a mental health problem and think the behaviour is out of choice, causing hostility towards the patient from relatives⁸⁷

What we did was a reduction in the number of steps, given the complexity of the tasks of the Social Communication subprogram. The stages of this subprogram require a language domain and semantic, grammar, cultural knowledge. In Brazil we have a considerable number of patients with schizophrenia who though illiterate, have little schooling, making it difficult to carrying out steps this subprogram

Marilene Zimmer, Schizophrenia Program, Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre (RS), Brazil, 2007, personal communication

• In Asian cultures, the family is a crucial social structure. [T]he burden of illness becomes a joint family obligation, with multiple members engaged in treatment. In contrast, Western values emphasize individualism – for example, protecti[ng the individual’s rights] to privacy and confidentiality as well as independent living

  p. 529¹¹⁵

• Family joining sessions were conducted informally on an outreach basis in the homes of the Vietnamese families to maximize the likelihood that families would engage with the service and to provide an opportunity to include as many family members as possible

  p. 525¹¹⁵

• In Italy, since the deinstitutionalization of the ‘70s [. . .] effective treatment systems for severe psychiatric disorders ha[ve] been balancing community-and-hospital-based mental health care [. . .] There has been an increasing acknowledgment of the importance of families in terms of [. . .] their therapeutic potential and the burden they carry

  p. 24⁹⁰

• The content of the program was designed according to the preference and perceived needs of patient-caregiver dyads, and the case managers put much emphasis on addressing their cultural issues in family caregiving role

  p. 318⁹⁷

• ‘Family members are actively involved in patient care in Pakistan, and therefore the intervention involved the family members in the treatment plan from the beginning

  p. 203⁷¹

• We chose a family approach because living with supportive relatives increases medication adherence, and interventions that give relatives information about the illness and teach them coping and problem-solving skills reduce relapses and rehospitalizations

  pp. 265–6¹¹⁷

• This high level of involvement of Indian families in the patients care is partly because of their preference, and partly because of the inadequacy of the mental-health set-up

  p. 473⁸⁶

• Most families actively want to be involved in all aspects of their relatives wellbeing and problems.’ (Kulhara et al., 2009)

  As cited in Shankar & Menon, (1993) p. 77²⁷⁵

• To engage families, especially in the initial stage, in-home single-family sessions were offered in order to involve more relatives

  p. 388–9⁸⁵

• Over 80% of Latinos with schizophrenia live with their families (Guarnaccia & Parra, 1996) [. . .] therefore, including families was relevant to the task of maximizing the generalization of skills to the home environment (Kopelowicz et al., 2003; Kopelowicz et al., 2012)

  As cited in Lopez, Kopelowicz and Canive (2002) p. 71²⁷⁶

• After completing these sessions, skills trainers visited patients and families at their homes to review progress and help solve problems that arose (Kopelowicz et al., 2003; Kopelowicz et al., 2012)

  As cited in Lopez, Kopelowicz and Canive (2002) p. 72²⁷⁶

• Because of the importance of la familia (the family) in Mexican-American culture, the PEDAL intervention was adapted to help individuals work with family members for transportation needs rather than help them to utilize public transportation or to travel independently

  pp. 72–3⁸¹

• The ultimate social goal of family members of people with schizophrenia in China is to develop a sustainable family based support system for the dysfunctional individual (Xiong et al., 1994), problem solving and communication skills education was emphasized in this study. In this study the aim was to finish the main content of the education programme in the hospital, and connect with the families after the patients were discharged because few nurses work in community settings and the community mental health services were not sufficiently well developed

  (Li & Arthur, 2005)⁹⁶ as cited in Li (2003)²⁷⁷

• To reinforce the interventions, parallel sessions, also conducted in Korean, were offered to family members of all participants

  p. 1127¹¹⁸

• Nearly 80% of Hispanic Americans with Schizophrenia live with their families (Guarnaccia & Parra, 1996) in Mexico city, it is over 90%

  Valencia et al., 2003²⁷⁸

• Because of the importance of family cohesion and joint decision making in China, the key family members of patients were involved in some of the training sessions with patients when the topics were use of medication and an emergency plan for relapse prevention

  p. 402¹⁰⁸

• The cultural and legal obligations of parents towards disabled children continue until the child is married, when the responsibility is transferred to the patient’s spouse. Disabled children who never marry are usually cared for by their parents until the parents die

  p. 240¹¹⁴

• Attention must be paid to the needs of family members, for whom care of a mentally ill person may constitute a considerable burden. They need community support, appropriate education, accessibility to professional consultation, and, in some cases, financial aid

  p. 48⁷⁷

• In China, unlike the West, the societal and legal expectations are that the family members will care for these disabled individuals indefinitely, regardless of the emotional and economic burden

  p. 101⁸⁷

• In treating Chinese families, it is important to recognize, respect and utilize the culture-specific family structures, functions and processes, such as the extended family structure with close linkage and interrelationships, interdependence and a strong sense of filial responsibility, collective identity and tangible support

  p. 30⁹⁴

• The program adopted a few strategies to address traditional Chinese cultural tenets. The first stage (orientation and engagement) focused on understanding strong interdependence, collective actions and decisions about family issues, acceptance of roles, and filial obligation of caregiving, respect for elders, and other traditional Chinese beliefs

  p. 318⁹⁷

• The MBPP also adopted several strategies to address traditional Chinese cultural tenets. For instance, the first stage focuses on understanding strong interdependence

  p. 377¹⁰³

• The program used a culturally sensitive family intervention model, which considered many of the cultural tenets that were taught by Confucius (for example, valuing collectivism over individualism and giving great importance during the needs assessment to family and kinship ties) in respect to family relationships and value orientation

  p. 1004¹⁰⁵

• Given the centrality of the family unit in decision making for Mexican Americans, (Sabogal et al., 1987) the focus was on the approval or disapproval of family members for taking medication and the patient’s motivation to comply with those perceived wishes

  p. 268¹¹⁷

• All 3 groups reinforced the importance of Mexican cultural values and concepts, such as familismo (i.e., placing family over the individual), respeto (i.e., respect for older persons)

  p. 925⁸²

• [. . .] handling medications involved a sense of ‘orgullo’ (i.e., pride) for many patients, owing to a desire to alleviate symptoms in order to contribute to the family. Thus, [. . .] treatment regimens w[ere] modified to include the potential benefits of medication adherence to the family system (versus the benefits of independence)

  p. 926⁸²

• The success of our programme may also be attributed to the extended family system among the Malays’ (Yusof, 1976)

  p. 288⁹³

• Commitment to the extended family is often valued more than individual autonomy among first and second generation Mexican-American families. The higher value placed on interdependence by Latinos may clash with the norms inherent in evidence-based practices designed in the United States

  p. 249¹¹⁹

• Chinese families suggested that the younger generations are not supposed to question or challenge the decisions of their elders, which appear to run contrary the purpose of family intervention in promoting collaboration through mutual concern and discussion. This typical strong parental power in Chinese family may produce resentment and un-cooperation from the elder family member, who would perceive the younger group members or the therapist as a threat to their authority (Fung & Ma, 1997). There is a need to consider and adopt the specific Chinese culture for establishing a helping relationship in family interventions, for example, emphasis on mutual respect and equal position but not be rigidly confined to the passive reception of teaching and information by the families

  Wai-Tong Chein, personal communication

• Mothers were the focus of this study because, in Iranian families, it is usually the mothers who show most interest in patient care. Even when patients are married and then divorce, mothers again take responsibility for the patients and sometimes the grandchildren

  Koolaee and Etemadi, 2010, p. 636⁹¹

• In all modules, gender-appropriate activities were substituted, and modifications were made with regard to culturally expected roles in our scenarios and examples (cooking and house chores for women; working on the car and yard maintenance for men)

  p. 926⁸²

• Proper distance and respectfulness were employed to address the participants who were older than the group facilitators due to Latinos emphasis on respect and hierarchies

  p. 926⁸²

• Consideration of Malay cultural values e.g. training to communicate assertively and establishing eye contact with the elderly (especially one’s parents) are regarded as disrespectful in the Malay culture

  p. 288⁹³

• Fathers with traditional values and expectations also hew to the macho image as well as to the stigma of mental illness; hence, it takes special efforts, such as phone calls and home visits, by leaders of skills-training groups to gain the support of fathers in reinforcing homework assignments

  (Valencia et al., 2007;¹²⁰ Valencia et al., 2010¹¹⁹) as cited in Valencia et al., (2015) p. 236²⁷⁹

Traditional alternative healing practices, such as herbal treatments and use of religious leaders, were acknowledged alongside Western approaches

p. 525¹¹⁵

It is therefore not surprising that they consult healers from more than one system, for example, faith/spiritual healers and traditional healers as well as consulting doctors. It is also interesting that even those who believed in physical causes contacted different traditional healers, for example faith healers or spiritual healers. Some traditional healers (for example Hakims) use a mixture of Indian, Greek and Chinese medicines

p. 204⁷¹

Folk stories and examples from the life of the Prophet Muhammad and Quran were used to clarify issues

Habib et al., 2015⁷¹; Naeem et al., 2015⁹²) as cited in Naeem et al., 2010, p. 168²⁸⁰

Guidelines for therapists:

Their belief in supernatural causes of mental illness is not challenged; Emphasis on symptomatic treatment regardless of etiology; Counsellor to have positive attitude toward drugs and have confidence in modern treatment rather than traditional healers

p. 285⁹³

Azhar, Varma and Hakin (1993) examined phenomenological differences in hallucinations between schizophrenic patients in various areas of Malaysia. There were significant differences in the experiences of the Malays of Penang and [. . .] Kelantan, indicating that culture affects the phenomenology of hallucinations, even among people of the same race

p. 352⁷⁶

The content of the voices was influenced by the patients’ cultural background. Most Saudi patients reported that their voices involved religious and superstitious themes, while the British patients were most likely to report the giving of instructions

p. 352⁷⁶

Considering the important role that religion plays in Islamic cultures, only those strategies that are in harmony with religious beliefs may be accepted by patients and their families. In Islam, for instance, listening to music is not always allowed, so that alternatives may be required for Muslim believers

p. 353⁷⁶

Designing the intervention to accommodate religious practice:

[w]hile other strategies required modification, being adapted and enhanced to be appropriate for Islamic patients. These coping strategies mostly involved religious beliefs. Under Islamic doctrine, Muslims are required to engage in prayer on five occasions each day, prayers that involve both physical and mental activities.

p. 355⁷⁶

The therapist encouraged greater engagement with methods such as using prayer, reading the Quran, and regular use of religious practices, as coping methods to control the content and characteristics of the voices. This provided distractions and aided attention switching

pp. 355–6⁷⁶

Coping strategies were based on traditional Islamic beliefs, as held by many people from Islamic backgrounds, which are consistent with the teaching of the Quran. Patients used portable audiocassette players with headphones to listen to a person who was reading the Quran or giving reminders of religious subjects

pp. 355–6⁷⁶

• For 5 sessions, relaxation exercises, including the Chinese Eight Elegant Movements (Baduanjin) were introduced and practiced at the end of the session

  p. 390⁸⁵

• The CBCSM used local cultural scenarios as role-play activities and had video demonstrations performed by local actors. For example, ‘yum cha’ (tea gathering at the Chinese restaurant) was used to replace the party situation as it is a common local gathering activity for practicing conversation

  p. 140¹⁰⁶

• Participants were encouraged to participate in culturally relevant activities like playing Mahjon, doing Tai Chi and singing Karaoke

  Mann and Chong, 2010, p. 73¹¹³

• Identified scenarios that were deemed culturally neutral or more relevant to the local Hong Kong Chinese service users

  p. 5¹¹⁰

Addition of a module to emphasize mutual support and consists of deliberate efforts to mould the group into a social network that can persist for an extended period and satisfy family needs for social contact, support, and on-going monitoring

Giuseppe Carrà, Department of Mental Health Sciences, Royal Free and University College Medical School, London, UK, 2007, personal communication

Expansion of the families’ social networks occurs through problem solving, direct emotional support, and out-of-group socializing, all involving members of different families in the group

p. 24⁹⁰

To work effectively for mutual support in the later sessions, the group instructor continuously reinforced the principles of strengthening social support among the participants

p. 32⁹⁴

The intervention included:

. . . discussion of a taboo area (sharing of secret and internal psychological conflicts), commonality or a situation of ‘all-in-the-same boat’ (feeling in similar situation and working against a common plight), mutual help (reciprocal giving and receiving help and support among members)

p. 34⁹⁴

The use of ‘peer leaders’:

family members from the group who were facilitated by a trained mental health professional (Chien & Chan, 2004; Chien & Chan, 2013; Chien, Chan & Thompson, 2006; Chien, Norman & Thompson, 2004; Chien, Thompson & Norman, 2008, author e-mail) this increased social support, resulting in an enhanced sense of control over interpersonal skills and family care, and a shared-experience, ‘all in the same boat’ belief, providing effective social learning of patient care for other group members

Chien et al., 2006, p. 43⁸²

The intervention focused on:

. . . inviting more practical assistance among group members

p. 377⁹⁷

Family intervention included developing collaboration with the family, socializing about non–illness-related topics, monthly updates on each family’s situation, enhancing family communication, teaching patients and their families to cope with stressful situations and the illness

p. 897¹⁰⁹

Skills trainers used an informal, personal style with patients and relatives that included the sharing of food and encouragement of ‘small talk’ before and after training sessions, made to encourage warm interactions between trainers, patients and relatives, thereby increasing retention in the study and increasing effectiveness

p. 214⁹⁹

Dinner was provided before multifamily group meetings because food is important in Chinese culture, and many working caregivers came directly after work. The meal together provided group members a natural opportunity for informal socializing and bonding

pp. 388–9⁸⁵

Multiple family workshops were held once every 3 months. During the workshop, general questions were discussed, and relatives shared the experiences of caring for patients

p. 70¹⁰⁰

Particularly in the earlier sessions, the clinician played an active role in facilitating the group discussion to encourage and support exchange and sharing

p. 1127¹¹⁸

Refreshments were served at every session to encourage attendance

p. 1127¹¹⁸

Chinese are less likely to express affection to each other through words and touch, than people from Western countries. They tend to show their concern and feelings for each other through action, for example, by taking care of actual needs rather than communicating those feelings verbally (Hsu, 1995). Therefore, it may be difficult to build rapport between the therapist and the family in the traditional family therapy session (Fung & Ma, 1997)

Wai-Tong Chien, personal communication

Group instructor reinforced:

. . . the principles of strengthening social support among the participants, including: sharing personal data (ensuring confidentiality and disclosing information with trust

pp. 32–3⁸⁴

Chinese families are reluctant to openly disclose their thoughts and feelings in the presence of a therapist, and that intense emotion should be controlled and hidden, not openly discussed

p. 1328⁹⁸

Intervention consisted of:

. . . educational workshop, caregiving role, and therapeutic communication, learning about home management and effective communication among family members

p. 318⁹⁷

They are also assisted in reducing their self-consciousness and need to ‘save face’ (to preserve one’s dignity and avoid any disgrace), reconstruction of their self-image, and improving their insights into schizophrenia

p. 377¹⁰³

Due to the close nature of Mexican families, therapists did not uphold participant confidentiality and freely shared information about the participants’ problems and progress with family members

Marcelo Valencia, School of Medicine, National University of Mexico, Mexico City, 2007, 2010, personal communication

• There is a need to adapt the family intervention that has originated in the West to take into account Chinese ways of communication (as characterized by an emphasis on mutual respect and positive action for family members rather than talking

  p. 30⁹⁴

• The content of the program was designed according to the preference and perceived needs of patient-caregiver dyads, and the case managers put much emphasis on addressing their cultural issues in family caregiving role, effective communication, and resolving conflicts, as well as hands-on practical experiences

  p. 318⁹⁷

• Chinese people tend to show mutual concern and support by [meeting] each other’s actual needs[,] they are reluctant to seek profession help. Therefore, [. . .] care-giving and therapies which emphasize practical assistance and problem solving [are valued over] psychological reassurance and [. . .] expression of feelings

  p. 123⁸⁴

• Family involvement, differing patterns of communications (for example concept of assertiveness outside the West) should be important in adapting therapy for local clients in Pakistan

  p. 206⁷¹

• Patients were excluded from the multifamily group, since caregivers are likely to be inhibited in discussing their frustrations about their ill member due to cultural tendencies to avoid direct family confrontation in front of many non-family members

  p. 388⁸⁵

• Problem solving and communication skills education was emphasized in this study

  (Li and Arthur, 2005)⁹⁶ as cited in Li (2003)²⁷⁷

• Emphasis on assertiveness in these modules struck a careful balance between respeto/formalidad (i.e., respect and formality) and encouraging patients to clearly state their needs

  p. 926⁸²

• The programme such as training to communicate assertively and establishing eye contact with the elderly (especially one’s parents) are regarded as disrespectful in the Malay culture

  p. 288⁹³

• Addition of coping strategies consistent with Islamic doctrine to the coping strategy enhancement component (Tarrier et al., 1990) of the intervention

  p. 355⁷⁶

• Given the Chinese caregivers tendency to prefer a more hands-on and practical experience, they were invited to conduct behavioural rehearsals of coping strategies and skills in resolving conflicts within the family

  p. 318⁹⁷

• The active-directive teaching style, [which is central to] social skills training was modified to [facilitate greater] spontaneity [by] the patients. Because many patients do not respond to direct questions with direct answers, trainers were instructed to ‘stick with the patient’ longer than in conventional training sessions

  (Kopelowicz et al., 2003)⁹⁹ as cited in Lopez and Kopelowicz (2002) p. 71²⁷⁶

• Also, the need to be an active participant in treatment was encouraged to overcome the tendency for members of a patriarchal culture to accept without question the counsel of authority figures like physicians (Zea et al., 1997)

  (Kopelowicz, 2003;⁹⁹ Kopelowicz et al., 2012¹¹⁷) as cited in Lopez and Kopelowicz (2002) p. 71²⁷⁶

• This study integrated Chinese [. . .] values and practices into [. . .] CBT. For example, [a] hierarchical approach to the doctor–patient relationship could [enable early engagement with the CBT therapist]. However, the emphasis then needed to shift [later] to a more collaborative relationship, [. . .] encourag[ing] the patient[’s] contributi[on] to the therapy

  p. 1901¹⁰⁷

• One of the psychologists talked about patients not being comfortable with downward arrow technique and Socratic dialogue. Most of them said cultural adaptation of CBT for psychosis patients expect a directive style rather than collaborative style

  (Habib et al., 2015;⁷¹ Naeem et al., 2015⁹²) as cited in Naeem et al., 2016, pp. 50–51²⁷⁴

• Patients also like a directive style and probably don’t feel comfortable when a collaborative style is used

  (Habib et al., 2015;⁷¹ Naeem et al., 2015⁹²) as cited in Naeem et al., 2010, p. 171²⁸⁰

• Korean clients are likely to feel more comfortable with a didactic format than with an interactive situation, because the former is less conducive to experiential types of sharing that require self-disclosure. Their culturally determined respect for experts and authority may help facilitate both the educational process and the therapeutic alliance

  p. 1126¹¹⁸

• Visual aids, including charts and handouts, were used to reinforce the didactic materials

  p. 1127¹¹⁸

• Family members reported that their [. . .] relatives were uncomfortable with written material [(e.g.] writing exercises during sessions[/]homework assignments[)]. Instead, patients considered that therapy was for talking and learning[,] not for written activities that reminded them of school [. . .] Therefore, the skills trainers switched to oral exercises and assignments

  (Valencia et al., 2007;¹²⁰ Valencia et al., 2010¹¹⁹) as cited in Valencia et al., (2015)²⁷⁹ p. 222

Additional adaptations were made because all of the programs were not delivered within standard CMHTs but to overcome organisational barriers we provided these outside

Giuseppe Carrà, personal communication

Unlike [. . .] the United States, the number of psychiatric beds per capita is on the increase in China, and community-based services are extremely limited. It is our belief that active promotion of psychiatric rehabilitation in Chinese psychiatric hospitals [. . .] will pave the way for large-scale implementation of community-based rehabilitation in the future

p. 402¹⁰⁸

In this study the aim was to finish the main content of the education programme in the hospital, and connect with the families after the patients were discharged because few nurses work in community settings and the community mental health services were not sufficiently well developed

(Li and Arthur, 2005)⁹⁶ as cited in Li (2003)²⁷⁷

Providing psychological treatment during the inpatient phase might offer improved opportunities, especially in a developing country; this is especially important because the distance from health care facilities was reported to be one of the major barriers to receiving therapy regularly

p. 201⁷¹

Delivering the intervention in patients’ homes:

. . . as the psychotic patients in the Chinese rural community reside dispersedly and have different individual problems, they need more specifically tailored intervention methods conducted in their homes

p. 74¹⁰⁰

The shortage of mental health care in rural China might be tackled by community care

p. 544¹¹⁴

Intervention is provided by hospital-based physicians and nurses since these are the only mental health professionals available in China

p. 240⁸⁹

• To encourage participation, all of the clients and caregivers were phoned once a week to keep them engaged during the 3 months of the PEP [Psychoeducation programme]. [. . .] [P]articipants were further reminded to attend [. . .] sessions 1 day in advance; repeat sessions were made available [. . .]; and the program was conducted on the weekends

  p. 68⁸³

• We designed this comprehensive psychosocial intervention to be delivered on the same day once a month mainly owing to the care structure in China, the potential time and cost burden to patients and their family members, and the feasibility of adoption by other care settings

  p. 897¹⁰⁹

• Providing psychological treatment during the inpatient phase might offer improved opportunities (Naeem, Gobbi, Ayub and Kingdon, 2010)

  p. 201⁷¹

• Attendance was facilitated by presentation, in each neighbourhood, of each lecture twice, once during the day and the other in the evening. Unlimited time was allowed for discussion and questions after each lecture

  Zhang and Heqin, 1993, p. 50⁷⁷

• We didn’t include the patient, as Italian culture hardly allows an open expression of feelings re the ill relative in front of other people not belonging to the family

  Giuseppe Carrà, personal communication

• Traditional therapist-led single-family therapy that focuses on the psychological problems of the patient or family members may not be easily accepted by Chinese families because of their reluctance to reveal private thoughts and feelings in front of others, especially a therapist or someone not familiar to them . . . Therefore, it may be difficult to build rapport between the therapist and the family in the traditional family therapy session (Fung & Ma, 1997)

  Wai-Tong Chein, personal communication

• Multiple family sessions gave them the opportunity to speak about their children with each other, which they felt was needed

  p. 11⁹¹

• Patients were excluded from the multifamily group, which was different from McFarlane’s (2002) model since caregivers are likely to be inhibited in discussing their frustrations about the ill member due to cultural tendencies to avoid direct confrontation within family in front of many ‘outsiders’ (Bae & Kung, 2000)

  p. 388⁸⁵

• Patients were addressed separately, they were not required to attend the intervention sessions, because some caregivers felt that they would be unable to discuss their problems freely in the patient’s presence

  p. 474⁸⁶

• Although the multiple-family group intervention is generally used for two years, funding constraints necessitated a briefer intervention

  p. 524¹¹⁵

• The number of sessions had been reduced from 18 to 14 two-hour sessions

  p. 318⁹⁷

• Psychosocial interventions have become more popular in recent decades in China, but the number of well-trained therapists remains limited in many Chinese psychiatric settings. More frequent therapy sessions could be not only difficult for patients and family members but also hard for many psychiatric settings to adopt

  p. 897¹⁰⁹

• The final adaptation was that the duration of the intervention was only 6 months in comparison to the usual 9–24 months. This is because many Chinese immigrants are reluctant to commit to long-term psycho-social treatments primarily because many of them are involved in low paying jobs with long work hours

  pp. 388–9⁸⁵

• A similar contextual barrier was the particular difficulty in organisations that are not fully committed to recovery, because IMR redistributes power to clients within a wider recovery paradigm, they suggested that this barrier should be the key priority in IMR implementation. Therefore, instead of fully complying with the standardized 9-month toolkit, a brief IMR was pragmatically developed to benefit patients living with various degrees of deinstitutionalization and cultural stigmatization

  Ester Ching-Lan Lin, personal communication

• The intervention is ongoing rather than time limited, because stopping it would mean the termination of any regular follow-up care

  p. 240⁸⁹

Adapted model by adding a further phase for the ‘SG’ programme for cultural reasons

Giuseppe Carrà, personal communication

Chan et al.⁸³ incorporated sessions about diagnostic labels and biochemical factors and laws in relation to mental health care in Hong Kong:

Session 3: Causes of psychosis, labels and diagnosis; Explore the need for diagnosis, its procedure, complexity, and relationship to treatment. Causes such as genetics, neurological, environmental, psychological, and biochemical factors. Session 8: Laws related to mental health care in Hong Kong Mental Health Ordinance

p. 75⁸³

Chien⁹⁴ added a module to their mutual support intervention for family members to discuss:

Chinese culture of family and mental illness

p. 33⁹⁴

Chien and Chan⁹⁸ added:

Discussion about Chinese culture of family and mental illness

p. 1332⁹⁸

Chien et al.⁷⁹ added:

Sharing and understanding of individual concerns and cultural issues’ component to the mutual support group programme

p. 43⁷⁹

Chien and Thompson¹⁰¹ added:

. . . information sharing about schizophrenia and its related illness behavior; discussion about Chinese culture of family and mental illness

p. 1000¹⁰¹

Finally, we incorporated additional role play exercises to compensate for the absence of Arabic video materials, especially in the mentalizing section

p. 14¹¹¹

The intervention included a session to address:

. . . other cause of mental disorders such as supernatural causes, magico-religious treatments; other issues such as marriage, pregnancy, childbirth, and substance abuse

myths prevail that marriage could cure the patient . . . Therapists dispelled these beliefs and advised the family to wait until the patient is stable before considering marriage

(Shankar and Menon, 1993)²⁷⁵ as cited in Kulhara et al. (2009)⁸⁶

The content of the intervention also reflected issues that are felt to be more relevant for Indian families such as belief in supernatural causation, the role of indigenous treatments, cultural attitudes towards medication, marriage etc. On the other hand, there was a much less emphasis on constructs such as expressed emotions

Parmanand Kulhara, personal communication

Accordingly, with permission from the MCT developers (Moritz & Woodward, 2007a), some of the slides were removed and a few changes were introduced

p. 153¹¹²

Falloon et al.’s (1984) BFT model was modified for this study. This culturally modified model included the sociocultural approach of patient and family education and the addition of a new component to tackle poor drug compliance while retaining an emphasis on problem solving skill training

p. 284⁹³

The materials used in the SCIT intervention program (i.e. videos and photographs) were remade using Chinese actors following the original scripts

p. 753¹⁰²

• Modified some written vignettes describing emotions as they relate to pets, as it is not common in Egyptian culture to have a dog or cat in one’s home

  p. 14¹¹¹

• We used most of the picture (e.g., faces, social scenarios), video, and auditory stimuli from the original version but excluded some that were not well suited to Egyptian culture. For example, we excluded pictures and videos that depicted unfamiliar recreational activities (e.g., American football or drinking alcohol beverages)

  p. 13¹¹¹

• We omitted communication skills training as this is the least important among the three core components of the standard model. This is supported by the finding that generally the carers of Malay schizophrenic patients could tolerate negative symptoms of schizophrenia (Salleh, 1994)

  p. 284⁹³

• For example, JTC [jumping to conclusions] was illustrated in the original MCT using the conspiracy theory about Paul McCartney’s death. This was substituted by a classic local myth about keeping pregnancy secretive during the first trimester so as to avoid a miscarriage

  p. 5¹¹⁰

• Only six of the seven learning activities used in the United States were used for Mexican patients. Video-assisted modelling was not used since skills training technology in Spanish had not been developed in Mexico. To overcome this obstacle, therapists demonstrated the skills to be learned during sessions

  Valencia et al., 2007;¹²⁰ Valencia et al., 2010¹¹⁹ as cited in Valencia et al. (2015) p. 222²⁷⁹

• Another adaptation was the images used, as in Brazil, they do not have snow, trains and a very small number of patients can travel by plane

  Marilene Zunimer, personal communication

• Vietnamese primary therapists were consistent for two intakes of the two cultural groups

  p. 524¹¹⁵

• Cultural adaptations of the program included the use of Vietnamese speaking staff for all aspects of service provision within the program

  p. 525¹¹⁵

• Use of a female therapist for Iranian intervention designed for mothers

  Anahita Khodabakhshi Koolaee and Ahmad Etemadi, personal communication

• Additional cultural adaptations included the use of indigenous, bilingual, and bicultural staff of the community mental health center as skills trainers, the participation of family members (rather than clinicians) as ‘generalization aides’

  p. 214⁹⁹

• As the participants in the study spoke either Mandarin or Cantonese, and some were more fluent in English, trilingual clinicians were sought

  p. 390⁸⁵

• . . . were all trained to meet cultural sensitivity standards outlined by the State of California and based on sound empirically-based principles (Rogler et al., 1987; Wallen, 1992)

  (Kopelowicz et al., 2003;⁹⁹ Kopelowicz et al., 2012¹¹⁷) as cited in Lopez, Kopelowicz and Canive (2002) p. 71²⁷⁶

• Facilitators of these treatments should be educated and familiar with the relevant cultural values of the consumer

  p. 73⁸¹

• The treating clinicians needed special training because psychiatrists and psychiatric nurses in China have no experience in the evaluation and management of the family and social problems faced by mentally ill patients

  p. 240⁸⁹

• Skills trainers used an informal, personal style with patients and relatives that included the sharing of food and encouragement of ‘small talk’ before and after training sessions, made to encourage warm interactions between trainers, patients and relatives, thereby increasing retention in the study and increasing effectiveness

  p. 214⁹⁹

• During the engagement, phase attempts were made to build a positive therapeutic alliance with the family. Preliminary information (oral/printed) about schizophrenia was provided. All this was done in a no fault atmosphere i.e. without attaching blame to anyone, especially the family

  p. 474⁸⁶

• Intervention focused on establishing trust relationship with patient and family, before identifying their individual needs

  p. 340⁹⁶

• Accepting the patient’s interpretation of his or her illness to strengthen the therapeutic relationship

  p. 288⁹³

• Adaptations to Mexican culture included the therapists beginning the sessions by engaging in platica (small talk) with the patients which built trust

  p. 253¹¹⁹

• In addition, therapists offered their patients appropriate forms and amounts of self-disclosure from their own lives which generated a sense of personalismo or a personal orientation to therapeutic relationships that has been shown to improve the effectiveness of interventions with Latinos (Sue et al., 1991)

  p. 253¹¹⁹

• Each session began with a short warm-up activity (about 5 min), which was designed to create a more relaxed atmosphere

  p. 753¹⁰²

Emphasis was given to specific Chinese cultural characteristics and issues, including a strong tendency to expect immediate and practical help

p. 1278⁸⁰

Specific Chinese cultural characteristics were emphasised during each group session including the ‘high expectation of immediate and practical help from other family members

(Meredith et al., 1994;²⁸¹ Bae & Kung, 2000)²²⁵. (Chien, Chan & Thompson, 2006, p. 44)⁷⁹

Emphasis was given to specific Chinese cultural issues, such as their ‘high tendency to expect immediate practical help[’]

p. 999¹⁰¹

Given the centrality of the family unit in decision making for Mexican Americans, (Sabogal et al., 1987) the focus was on the approval or disapproval of family members for taking medication

p. 268¹¹⁷

Content of sessions included:

. . . realistic goal setting

p. 474⁸⁶

Basing format, content, and treatment goals on Mexican cultural values such as simpatí (the use of polite social relations (Diaz-Guerraro, 1994; Gloria & Peregoy, 1996) and personalismo (emphasizing warm relationships) (Gloria & Peregoy, 1996; Marin, 1989)

p. 66⁸¹

The treatment goals were based on:

Mexican values and cultural scripts

p. 925⁸²

Cultural adaptations were made through the identification of personally relevant goals that often concerned improving relationships with family members

(Valencia et al., 2007;¹²⁰ Valencia et al., 2010¹¹⁹) as cited in Valencia et al., (2015) p. 230²⁷⁶