The Effectiveness of Culturally Adapted CBT for PTSD in East Jerusalem: A Clinical Analysis
DOI:
https://doi.org/10.59680/medika.v3i4.2238Keywords:
Cultural Adaptation, Cultural CBT, East Jerusalem, PTSD, Therapeutic EffectivenessAbstract
This study evaluates the effectiveness of culturally grounded Cognitive Behavioral Therapy (CBT) in the treatment of Post-Traumatic Stress Disorder (PTSD) in East Jerusalem through a systematic meta-analysis of 47 clinical studies involving a total of 2,845 participants published during the period 2010–2023. Quantitative synthesis indicates a statistically significant reduction in PTSD symptoms among groups receiving culturally adapted CBT compared with control groups, with a large effect size (d = 0.89, 95% CI [0.76, 1.02], p < .001). Meta-regression analysis confirms that cultural dimensions function as meaningful moderators, strengthening intervention effectiveness , particularly through the internalization of collectivist values (r = 0.67), religiosity (r = 0.58), and family connectedness (r = 0.71). Further subgroup analyses indicate that therapeutic effects are more pronounced in adolescents (d = 0.94) than in adults (d = 0.82). These findings extend beyond the studies by Arora et al. (2021) and Thomas et al. (2022), which focused on conventional CBT, underscoring the importance of cultural adaptation in enhancing clinical outcomes. In contrast to the meta-analysis by Behrouzan (2015), which was limited to general clinical contexts, this study specifically examines the effectiveness of culturally grounded CBT within the landscape of protracted conflict in East Jerusalem, thereby providing a robust empirical foundation for the development of trauma interventions that are sensitive to cultural context and the realities of conflict.
References
Abu-Kaf, S., & Braun-Lewensohn, O. (2019). Coping resources and stress reactions among Bedouin Arab adolescents during three military operations. Psychiatry Research, 273, 559–566. https://doi.org/10.1016/j.psychres.2019.01.088
Agaibi, C. E., & Wilson, J. P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, & Abuse, 6(3), 195–216. https://doi.org/10.1177/1524838005277438
Alozkan-Sever, C., Uppendahl, J. R., Cuijpers, P., de Vries, R., Rahman, A., Mittendorfer-Rutz, E., & Sijbrandij, M. (2023). Research review: Psychological and psychosocial interventions for children and adolescents with depression, anxiety, and post-traumatic stress disorder in low- and middle-income countries—A systematic review and meta-analysis. Journal of Child Psychology and Psychiatry, 64(12), 1776–1788. https://doi.org/10.1111/jcpp.13891
Arora, P. G., Parr, K. M., Khoo, O., Lim, K., Coriano, V., & Baker, C. N. (2021). Cultural adaptations to youth mental health interventions: A systematic review. Journal of Child and Family Studies, 30(10), 2539–2562. https://doi.org/10.1007/s10826-021-02058-3
Barron, I. G., Abdallah, G., & Smith, P. (2013). Randomized control trial of a CBT trauma recovery program in Palestinian schools. Journal of Loss and Trauma, 18(4), 306–321. https://doi.org/10.1080/15325024.2012.688712
Batniji, R., Khatib, L., Cammett, M., Sweet, J., Basu, S., Jamal, A., & Giacaman, R. (2014). Governance and health in the Arab world. The Lancet, 383(9914), 343–355. https://doi.org/10.1016/S0140-6736(13)62185-6
Behrouzan, O. (2015). Beyond ‘trauma’: Notes on mental health in the Middle East. Medicine Anthropology Theory, 2(3), 1–6. https://doi.org/10.17157/mat.2.3.296
Berger, R., Gelkopf, M., & Heineberg, Y. (2012). A teacher-delivered intervention for adolescents exposed to ongoing and intense traumatic war-related stress: A quasi-randomized controlled study. Journal of Adolescent Health, 51(5), 453–461. https://doi.org/10.1016/j.jadohealth.2012.02.011
Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003
Cohen, F., & Yaeger, L. (2021). Task-shifting for refugee mental health and psychosocial support: A scoping review of services in humanitarian settings through the lens of RE-AIM. Implementation Research and Practice, 2, 2633489521998790. https://doi.org/10.1177/2633489521998790
Common, R. K. (2011). Barriers to developing ‘leadership’ in the Sultanate of Oman. International Journal of Leadership Studies, 6(2), 215–228. https://doi.org/10.4337/9780857938114.00016
Crepet, A., Rita, F., Reid, A., Van den Boogaard, W., Deiana, P., Quaranta, G., & Di Carlo, S. (2017). Mental health and trauma in asylum seekers landing in Sicily in 2015: A descriptive study of neglected invisible wounds. Conflict and Health, 11(1), 1. https://doi.org/10.1186/s13031-017-0103-3
DerSimonian, R., & Laird, N. (1986). Meta-analysis in clinical trials. Controlled Clinical Trials, 7(3), 177–188. https://doi.org/10.1016/0197-2456(86)90046-2
Dimitry, L. (2012). A systematic review on the mental health of children and adolescents in areas of armed conflict in the Middle East. Child: Care, Health and Development, 38(2), 153–161. https://doi.org/10.1111/j.1365-2214.2011.01246.x
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634. https://doi.org/10.1136/bmj.315.7109.629
Ennis, N., Shorer-Zuckerman, Y., Freedman, S., Monson, C. M., & Dekel, R. (2020). Treating posttraumatic stress disorder across cultures: A systematic review of cultural adaptations of trauma-focused cognitive behavioral therapies. Journal of Clinical Psychology, 76(4), 587–611. https://doi.org/10.1002/jclp.22909
Eskici, H. S., Hinton, D. E., Jalal, B., Yurtbakan, T., & Acarturk, C. (2023). Culturally adapted cognitive behavioral therapy for Syrian refugee women in Turkey: A randomized controlled trial. Psychological Trauma: Theory, Research, Practice, and Policy, 15(2), 189–198. https://doi.org/10.1037/tra0001138
Fakhr El-Islam, M. (2008). Arab culture and mental health care. Transcultural Psychiatry, 45(4), 671–682. https://doi.org/10.1177/1363461508100788
Fayaz, I. (2023). Role of religion in posttraumatic growth among population exposed to armed conflict: A systematic review. Mental Health, Religion & Culture, 26(5), 455–469. https://doi.org/10.1080/13674676.2023.2237909
Gearing, R. E., Schwalbe, C. S., MacKenzie, M. J., Brewer, K. B., Ibrahim, R. W., Olimat, H. S., & Al-Krenawi, A. (2013). Adaptation and translation of mental health interventions in Middle Eastern Arab countries: A systematic review of barriers to and strategies for effective treatment implementation. International Journal of Social Psychiatry, 59(7), 671–681. https://doi.org/10.1177/0020764012452349
Hammoudeh, W., Mitwalli, S., Kafri, R., Lin, T. K., Giacaman, R., & Leone, T. (2022). The mental health impact of multiple deprivations under protracted conflict: A multilevel study in the occupied Palestinian territory. PLOS Global Public Health, 2(12), e0001239. https://doi.org/10.1371/journal.pgph.0001239
Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414), 557–560. https://doi.org/10.1136/bmj.327.7414.557
Ibrahim, H., & Hassan, C. Q. (2017). Post-traumatic stress disorder symptoms resulting from torture and other traumatic events among Syrian Kurdish refugees in Kurdistan Region, Iraq. Frontiers in Psychology, 8, 241. https://doi.org/10.3389/fpsyg.2017.00241
Jabr, S., Morse, M., El Sarraj, W., & Awidi, B. (2013). Mental health in Palestine: Country report. Arab Journal of Psychiatry, 24(2), 174–178. https://doi.org/10.12816/0001376
Karam, E. G., Mneimneh, Z. N., Dimassi, H., Fayyad, J. A., Karam, A. N., Nasser, S. C., & Kessler, R. C. (2008). Lifetime prevalence of mental disorders in Lebanon: First onset, treatment, and exposure to war. PLOS Medicine, 5(4), e61. https://doi.org/10.1371/journal.pmed.0050061
Khamis, V. (2012). Impact of war, religiosity and ideology on PTSD and psychiatric disorders in adolescents from Gaza Strip and South Lebanon. Social Science & Medicine, 74(12), 2005–2011. https://doi.org/10.1016/j.socscimed.2012.02.025
Khamis, V. (2019). Post-traumatic stress disorder among Palestinian children and adolescents exposed to political violence: A systematic review. Child Abuse & Neglect, 89, 1–10. https://doi.org/10.1016/j.chiabu.2018.12.024
Lambert, J. E., & Alhassoon, O. M. (2015). Trauma-focused therapy for refugees: Meta-analytic findings. Journal of Counseling Psychology, 62(1), 28–37. https://doi.org/10.1037/cou0000048
Li, J., Li, J., Yuan, L., Zhou, Y., Zhang, W., & Qu, Z. (2023). Cultural adaptation of trauma-focused cognitive behavioral therapy for trauma-affected children in China. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. https://doi.org/10.1037/tra0001523
Maglione, M. A., Chen, C., Bialas, A., Motala, A., Chang, J., Akinniranye, O., & Hempel, S. (2022). Combat and operational stress control interventions and PTSD: A systematic review and meta-analysis. Military Medicine, 187(7-8), e846–e855. https://doi.org/10.1093/milmed/usab310
Marie, M., Hannigan, B., & Jones, A. (2016). Mental health needs and services in the West Bank, Palestine. International Journal of Mental Health Systems, 10(1), 23. https://doi.org/10.1186/s13033-016-0056-8
Meis, L. A., Griffin, J. M., Greer, N., Jensen, A. C., MacDonald, R., Carlyle, M., ... & Wilt, T. J. (2013). Couple and family involvement in adult mental health treatment: A systematic review. Clinical Psychology Review, 33(2), 275–286. https://doi.org/10.1016/j.cpr.2012.12.003
Miller, K. E., & Rasco, L. M. (Eds.). (2004). The mental health of refugees: Ecological approaches to healing and adaptation. Taylor & Francis. https://doi.org/10.4324/9781410610263
Naeem, F., Tuck, A., Mutta, B., Dhillon, P., Thandi, G., Kassam, A., ... & McKenzie, K. (2021). Protocol for a multi-phase, mixed methods study to develop and evaluate culturally adapted CBT to improve community mental health services for Canadians of South Asian origin. Trials, 22(1), 600. https://doi.org/10.1186/s13063-021-05547-4
Nasif, J., Din, N. C., Al-Khawaja, M., Alawi, A. F., Al-Khatib, N., Ayash, A., ... & Sze, A. C. S. (2024). Scoping review for the adaptation of cognitive behavioral therapy to the Arab culture. International Journal of Cognitive Therapy, 17(4), 919–945. https://doi.org/10.1007/s41811-024-00227-y
Nasution, H., Rahmadi, M. A., Mawar, L., & Sihombing, N. (2025). Analysis of the role of social media in the collective trauma of Middle Eastern societies: A digital analysis. Medical Laboratory Journal, 3(3), 26–46. https://doi.org/10.57213/caloryjournal.v1i3.793
Neria, Y., Nandi, A., & Galea, S. (2008). Post-traumatic stress disorder following disasters: A systematic review. Psychological Medicine, 38(4), 467–480. https://doi.org/10.1017/S0033291707001353
Nocon, A., Eberle-Sejari, R., Unterhitzenberger, J., & Rosner, R. (2017). The effectiveness of psychosocial interventions in war-traumatized refugee and internally displaced minors: Systematic review and meta-analysis. European Journal of Psychotraumatology, 8(sup2), 1388709. https://doi.org/10.1080/20008198.2017.1388709
Opoku, M. P., Mustafa, A., Abdullah, E. M., Alsheikh, N., & Elhoweris, H. (2025). Building trauma-informed schools in non-Western contexts: Teachers' perceived competence in identification and trauma-informed practices in schools. Journal of Human Behaviour in the Social Environment, 35(1), 108–129. https://doi.org/10.1080/10911359.2024.2330454
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
Punamäki, R. L., Komproe, I. H., Qouta, S., El-Masri, M., & de Jong, J. T. V. M. (2005). The role of peritraumatic dissociation and posttraumatic stress in the occurrence of mental health problems among Palestinian youth. International Journal of Psychology, 40(5), 358–369. https://doi.org/10.1080/00207590500184604
Ryan, D., Dooley, B., & Benson, C. (2008). Theoretical perspectives on post-migration adaptation and psychological well-being among refugees: Towards a resource-based model. Journal of Refugee Studies, 21(1), 1–18. https://doi.org/10.1093/jrs/fem047
Schulz, P. M., Huber, L. C., & Resick, P. A. (2006). Practical adaptations of cognitive processing therapy with Bosnian refugees: Implications for adapting practice to a multicultural clientele. Cognitive and Behavioural Practice, 13(4), 310–321. https://doi.org/10.1016/j.cbpra.2006.04.019
Stang, A. (2010). Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. European Journal of Epidemiology, 25(9), 603–605. https://doi.org/10.1007/s10654-010-9491-z
Sunderji, N., Ion, A., Ghavam-Rassoul, A., & Abate, A. (2017). Evaluating the implementation of integrated mental health care: A systematic review to guide the development of quality measures. Psychiatric Services, 68(9), 891–898. https://doi.org/10.1176/appi.ps.201600464
Thabet, A. A. M., Abu Tawahina, A., El Sarraj, E., & Vostanis, P. (2013). Exposure to war trauma and PTSD among parents and children in the Gaza Strip. European Child & Adolescent Psychiatry, 22, 283–290. https://doi.org/10.1007/s00787-012-0347-4
Thomas, F. C., Puente-Duran, S., Mutschler, C., & Monson, C. M. (2022). Trauma-focused cognitive behavioural therapy for children and youth in low and middle-income countries: A systematic review. Child and Adolescent Mental Health, 27(2), 146–160. https://doi.org/10.1111/camh.12435
Thompson, S. G., & Higgins, J. P. T. (2002). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine, 21(11), 1559–1573. https://doi.org/10.1002/sim.1187
Tol, W. A., Song, S., & Jordans, M. J. (2013). Annual research review: Resilience and mental health in children and adolescents living in areas of armed conflict—a systematic review of findings in low- and middle-income countries. Journal of Child Psychology and Psychiatry, 54(4), 445–460. https://doi.org/10.1111/jcpp.12053
Veronese, G., & Pepe, A. (2017). Psychological distress in Palestinian adolescents: The role of trauma, stress, and coping. Child Abuse & Neglect, 73, 1–10. https://doi.org/10.1016/j.chiabu.2017.09.013
Williams, A. C. D. C., & Amris, K. (2017). Treatment of persistent pain from torture: Review and commentary. Medicine, Conflict and Survival, 33(1), 60–81. https://doi.org/10.1080/13623699.2016.1242050
Zaghrout-Hodali, M., Alissa, F., & Dodgson, P. W. (2008). Building resilience and dismantling fear: EMDR group protocol with children in an area of ongoing trauma. Journal of EMDR Practice and Research, 2(2), 106–113. https://doi.org/10.1891/1933-3196.2.2.106
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