Introduction
Egypt is located in North Africa and bordered by the Mediterranean Sea to the north, the Gaza Strip and Israel to the northeast, the Red Sea to the east, Sudan to the south, and Libya to the west. Egypt is a country with an approximate area of 1001 thousand square kilometres, divided into 27 governorates, with Cairo as the capital. The official language of Egypt is Arabic, and the currency is the Egyptian pound (CIA, 2018). Established over 5000 years ago, Egypt is one of the oldest civilizations in the world (United Nations, 2008).
The total population of Egypt is 96,411,904. With this estimate, Egypt ranks 13th among the world population and has 7.6% of the total population in Africa and 1.3% of the total world population. Among the Arab world, Egypt ranks first in population (CAPMS, 2018).
Egypt lies within the lower to middle income group and the total health expenditure is $151 per person. Government is by far the most commonly cited source of funds for treatment of mental health disorders (Mental Health Atlas Country Profile, 2014). The World Health Organization estimates the burden of mental disorders in Egypt to be 2567 disability-adjusted life years (DALYs) per 100,000 of population. Major depression ranks seventh, anxiety disorders 18th and substance use disorders 24th of the top 25 causes of DALYs (Global Burden of Diseases, Injuries, and Risk Factors Study, 2010).
Egypt has come a long way in developing and regulating mental health services. Law 71, developed in 2009 for mental health, regulates the doctor–patient relationship and superseded previous legislation. Law 198, established in 1956, regulates psychotherapy provision (AIMS Report on Mental Health System in Egypt, 2006). Mental health services in Egypt include both governmental and non-governmental facilities. The governmental mental health facilities include 18 mental health in-patient units and seven psychiatric units in general hospitals. The mental health teams consist of psychiatrists, nurses, social workers, psychologists and other practitioners, representing a rate of 0.68, 3.10, 0.29, 0.12 and 2.56 per 100,000 of population, respectively (Mental Health Atlas Country Profile, 2014).
A national survey that identifies rates of different psychiatric disorders in Egypt concluded that the overall prevalence of mental disorders is 16.9%. The most common disorders were depression (6.43%) and anxiety disorders (4.75%). The least common were alcohol dependence/abuse and adjustment disorder. Women had significantly higher odds of having a mental disorder (Ghanem etal., Reference Ghanem, Gadallah, Meky, Mourad and El-Kholy2009). Another cross-sectional study conducted to estimate rates of psychiatric disorders among adolescents in Cairo concluded that depression was present in 18.5% and anxiety in 9.5% of the surveyed sample (Ahmed etal., Reference Ahmed, Refaee, Fadaa and Elsayed2008).
The aim of this review is to describe the journey of CBT in Egypt, highlighting the local CBT education and training opportunities available for professionals in the field. Specific adaptations applied to the theory and practice of CBT with patients will be discussed, followed by a review of the national CBT efficacy and adaptability studies conducted over the last decade.
CBT education and training in Egypt
Egypt has 27 state universities, four non-governmental, 20 private universities and 12 academies. Psychotherapy is taught in the undergraduate psychology curriculum, Faculty of Arts (both Bachelor’s degree and graduate studies) and for medical postgraduate studies (MSc and PhD programmes). Aside from medical students who receive their education in English, Arabic is the official language used in teaching (Supreme Council of Universities, 2017).
Undergraduate education
Only 12 state universities offer Bachelor’s, Master’s and Doctoral degrees in psychology. Curricular courses on psychotherapy tend to emphasize theory rather than research and practice. These courses are relatively general and basic (Soliman and Ibrahim, Reference Soliman and Ibrahim1998). Courses offered at the undergraduate level and the qualifying years for the Master’s and Doctoral degrees are mandatory. Undergraduate psychology programmes cover areas such as cognitive, learning, personality, pathology, assessment, clinical and counseling (Abdelfattah etal., Reference Abdelfattah, Abdelazeim, Osama and Elgammal2010). Despite the psychoanalytic and cognitive behavioural inclination of the two psychology departments in the Faculty of Arts (University of Ain-Shams and Cairo), no specific course on cognitive behavioural therapy is included in any of the undergraduate level studies in either.
Graduate education and training
For all mental health professionals in Egypt, further training in psychotherapy can be pursued through the Master’s and Doctoral programmes (Abou-Hatab, Reference Abou-Hatab1997). For psychology graduates pursuing further training, a diploma in applied psychology is mandated initially. These diplomas are considered to be professional rather than academic degrees. Nevertheless, the emphasis of this training programme is mainly in psychological assessment. Upon successful completion of the diploma, the psychology graduate gains admission to a Master’s (MSc) or Doctoral (PhD) programme. Successful completion of an MSc or PhD includes a thesis (study design) to be submitted. The MSc and PhD programmes might take 2–4 or 3–6 years to complete, respectively (Ahmed, Reference Ahmed, Wedding and Stevens2004).
Therefore, candidates who wish to pursue further specific training on CBT can now agree (in co-operation with their supervisors) to work on a relevant subject. Although theses are conducted through postgraduate studies, very few centres provide an opportunity to conduct research and studies (Abou-Hatab, Reference Abou-Hatab1997).
For psychiatrists in Egypt, the case remains the same. Egypt has 17 medical schools, all with psychiatric departments. Medical schools have offered a diploma in neuropsychiatry for more than 60 years, a Master’s degree in psychiatry (MSc) for the past 25 years and a doctorate (PhD) for the past 20 years. Residency and postgraduate training years are typically spent at psychiatric hospitals, where junior psychiatrists develop competencies in medication management, and, depending on the focus and expertise of their supervisors, learn counselling and psychotherapy skills (Okasha, Reference Okasha2004). As with postgraduate studies for psychology graduates, psychiatrists do not receive any structured psychotherapy training in their residency programmes. For those who seek further training in psychotherapy or CBT specifically, the thesis as part of a Master’s or PhD is their only option. The choice of such topics is generally guided by the supervising department orientation and occasionally by individual preferences.
Extra-curricular education and training
Continuing professional development through conferences and workshops is important to Egyptian psychotherapists seeking further training. However, due to the limited budget and funding for such activities, as well as language barriers, the number of Egyptian psychologists who attend international and regional conferences and workshops is quite small (Ahmed, Reference Ahmed, Wedding and Stevens2004).
In response to the absence of systematic counselling and psychotherapy skills training, many universities, private clinics and professional associations arrange workshops and training courses. These may be facilitated by a visiting psychotherapist ‘school master’, particularly from the USA and UK, or by a local professional. Theoretical courses in counselling and CBT are offered by different Egyptian Associations, especially the Egyptian Association of Psychotherapists and the Egyptian Association of Cognitive Behavior Therapy (Alnabolsey, Reference Alnabolsey1999). Nevertheless, practical skills of psychotherapy require in-depth training and direct supervision.
The Cognitive Behavioural Therapist Certificate
The Cognitive Behavioural Therapist Certificate programme was initiated in 2016, organized and supervised by the Egyptian Association of Cognitive Behavior Therapy in collaboration with the Egyptian Medical Syndicate. The programme provides postgraduate quality systematized training in CBT. Eligible candidates include graduates of medicine, psychiatrists, psychologists, social workers, occupational workers, educational staff and counsellors. The programme parallels international standards of CBT training (EACBT, 2013).
The Certificate consists of four modules. The first is a direct teaching module (four courses: basic, advanced and two specific CBT courses for depression and anxiety). This module provides approximately 96 hours of direct teaching and learning. The second module is a required reading module (12 seminal texts on CBT, approximately 200 hours). The third module is direct supervision on practice training (eight clinical cases minimum). The fourth and final module requires a case write-up and an audiotape of a session. Upon completion of all training and documents, candidates are awarded the certificate of a cognitive behavioural accredited therapist. The Cognitive Behavioural Therapist Certificate is a 2-year continuing education programme. To date, a total of 100 candidates have completed the Certificate and were awarded Certified Therapist by the EACBT (EACBT, 2013).
Provision and adaptation of CBT
Egypt has 38 mental health hospitals (state, private and others), serving a total of 96,411,904 population with a rate of 0.045 per 100,000 of population. The total number of mental health out-patient facilities in Egypt is 96, with a rate of 0.114 per 100,000 of population. There are only two day treatment facilities with a rate of 0.002 per 100,000 of population. Patients who receive treatment in these out-patient facilities represent 46.27 per 100,000 of population; 23% are females and 29% are children and adolescents. The Ministry of Health & Population runs 17 hospitals for mental health located around the country. These hospitals represent 84% of the total bed capacity in Egypt (Mental Health Atlas, 2011).
Psychotherapists in Egypt are typically either psychiatrists or psychologists, although some social workers may also provide supportive family counselling. In clinical settings there is generally a congenial relationship between psychologists and psychiatrists, physicians, social workers and nurses (Amer and Jalal, Reference Amer and Jalal2012). Currently, the total number of psychiatrists registered in the Egyptian Medical Syndicate is estimated to be approximately 3082, which corresponds to a rate of 3.08 per 100,000 of population (Egyptian Medical Syndicate, 2018). A recent review of the Psychotherapy Licence Committee revealed that since its activation in 1958 to date, a very limited number of candidates have passed the licensing exam successfully, with a maximum of 20 candidates per year and a minimum of 0 candidates. Today, the number of licensed non-medical psychotherapists in Egypt is 282 (Committee of Psychotherapy Licensure, 2018). As a result, cognitive behaviour therapies remain inaccessible for the majority of Egyptian patients.
Besides the obvious limitations of availability of service providers in the field of psychotherapy in general and also in CBT, there are other challenges. By law, in order to engage in the professional practice of psychotherapy in Egypt, a doctorate in psychology is required in addition to a licence. Yet only one psychology department (Cairo University) places a major emphasis on cognitive therapy in their curriculum, while no psychiatry residency programmes provide such training (Amer and Jalal, Reference Amer and Jalal2012). Moreover, in practice, psychologists’ roles are limited to psychological assessment as directed by other professionals, such as physicians and psychiatrists.
Furthermore, Egyptian patients’ attitudes and preferences remain an important cornerstone in psychiatric treatment. A study of Egyptian patients’ preferences and trends with regard to psychiatric treatment found that pharmacotherapy is mostly preferred, followed by psychotherapy and hospitalization. There are further challenges in the provision of CBT in Egypt. Challenges include the particular social contexts, the limited and under-resourced mental health services, the language barrier and finally, the cultural differences between the western world and Egypt (Falah etal., Reference Falah, Elmahalawy, Zaki and Sultan2011).
Even assuming that most psychiatric diagnoses, and therefore the interventions designed to treat them, are more or less universal (Canino and Alegría, Reference Canino and Alegría2008), the beliefs implicated in the development and maintenance of these disorders, and beliefs about health and illness generally, are shaped by culture, with implications for clinical practice (Swartz, Reference Swartz1998).
Cross-cultural applicability of cognitive behavior therapy
CBT has been endorsed as a culturally adaptable form of psychotherapy and its efficacy in adult populations has been explored in culturally diverse and non-Western settings (Rathod etal., Reference Rathod, Kingdon, Phiri and Gobbi2010). While there are studies demonstrating the effectiveness of cognitive therapy in a range of cultural contexts, these constitute only a fraction of the outcome studies that have been published (Hayes, Reference Hayes2004). Recently, evidence-based frameworks for adaptation of therapy to cultural contexts have been developed and published. Therefore, CBT appears to be well suited to work with diverse clients as it adopts an emphasis on individual conceptualizations that guide the treatment interventions (Rathod etal., Reference Rathod, Phiri and Naeem2019).
However, further support to the multi-cultural applicability of CBT requires a strong body of evidence in local settings and clear recommendations if required to maintain the international rates of effectiveness.
CBT research in Egypt
The majority of research and studies in Egypt have been conducted as a part of postgraduate studies (MSc or PhD). In this context, a broad range of effectiveness studies on CBT in Egypt have already been conducted. The studies cover a wide variety of topics for different populations. Due to the language barrier and the absence of adequate funding, most of these studies have not been published. Yet they remain a platform for the further development of CBT research among Egyptian patients. We identified these studies and reviewed their inclusion criteria, methods and conclusions. We chose not to do a systematic review because the search was restricted to studies conducted in Egypt and the aim was to highlight the journey of CBT.
We conducted computerized searches on an aggregator service including the Egyptian Universities Libraries Consortium (The Egyptian Universities Libraries Consortium, 2018), the Egyptian Knowledge Bank (The Egyptian Knowledge Bank, 2018) and PubMed databases. The search terms included combinations of CBT, cognitive, behaviour/behavior, behavioural/behavioral, therapy, Egypt, and Arab. The review identified several studies conducted in various domains of CBT in Egypt. Reviewing the Egyptian Universities Libraries Consortium included all studies of psychotherapy conducted in Egypt between 1988 and 2017. One hundred and forty-one psychotherapy studies in Egypt were identified; of these, 118 studies focus on CBT representing 83.6% of the total. Studies included case-based research, cohort studies and randomized controlled trials (RCTs). These studies were in English and others in Arabic. Of the total 118 CBT studies, 47 studies investigated CBT for children and adolescents, and 67 studied CBT in adults, representing 39.8 and 56.7%, respectively. The remaining four publications reviewed current status of theory and practice considering international and local settings. The majority of studies of CBT in adults in Egypt focused on anxiety disorders (31.3%) addiction (17.9%), depression (10.44%), psychosis (9%) and aggression (6%). Among the child and adolescent CBT studies, 27.6% were studies on anxiety disorders, followed by aggression and disruptive behaviour (25.5%), depression (10.6%), attention deficit hyperactivity disorder (ADHD) (8.5%), autistic disorders (6.3%), addiction and smoking (6.3%) and eating disorders (4.2%). The affiliation of these studies (including those for MSc and PhD) were: Faculty of Education (33%), Faculty of Arts (26%), Faculty of Medicine (14%), Faculty of Social Service (14%), Faculty of Nursing (6%) and a remaining 6% designated to various research institutes and centres.
Another 30 relevant CBT studies were identified from an electronic literature search in the Knowledge Egyptian Bank. These studies were published in local journals in Arabic. Eleven out of 30 (36.6%) published studies were CBT for children and adolescents. The remaining studies were CBT for adults (The Egyptian Knowledge Bank, 2018). The search on PubMed revealed only three studies (Alhaggar etal., Reference Alhaggar, Al-Naggar and Abdel-salam2006; Habib and Seif El-Din, Reference Habib and Seif El-Din2007; Elkady etal., Reference Elkady, Ibrahim and Mohamed2012).
This might be due to the fact that international databases such as PubMed do not take into account numerous articles published in languages other than English. Therefore, local research activity in Egypt (being mostly in Arabic) is not internationally visible. As a result, some potentially relevant information suggestive of the effectiveness and applicability of CBT for Egyptian adults, children and adolescents could have been excluded. However, a detailed review of these studies highlights that the majority of researchers have used a modified therapy programme, hence the importance of cultural adaptation of CBT programmes to the Egyptian culture. In that way, Egyptian researchers have attempted to replicate studies cross-culturally including investigations of attitudes, childhood development, creativity, oral development, personality and psychopathology since 1990s (Eissoy, Reference Eissoy1989).
Psychiatry diagnoses most frequently worked with using CBT
The review of Egyptian CBT thesis and studies concludes that CBT for anxiety disorders is by far the most frequently studied, followed by CBT for addiction and CBT for depression.
Anxiety disorders
Earlier studies of psychiatric morbidity among university students in Egypt showed that anxiety is prevalent in 36% of the study sample. In 1993, anxiety states represented about 22.6% of diagnoses made in a psychiatric out-patient clinic in a selective Egyptian sample. Given the high prevalence of anxiety disorders and the obvious need to make CBT more readily available for patients, the study recommended further examination of the efficacy of CBT for anxiety disorders compared with other countries (Okasha, Reference Okasha2004).
Nevertheless, studies examining the effectiveness of CBT in treating anxiety disorders in Egypt are particularly significant in demonstrating adaptability of CBT. Several studies provide data indicating that cognitively oriented therapy resulted in the reduction of anxiety symptoms amongst a sample of the Egyptian population. One study aimed to investigate efficacy of CBT in the treatment of generalized anxiety disorder (GAD) in a sample of faculty students. The study sample involved 180 faculty students (102 female and 78 male). Results of the study revealed significant changes (pre–post and on follow-up) following the CBT programme in treatment of GAD (Elmoktry etal., Reference Elmoktry, Aly and Goeas2005). Several further studies in different locations and settings in Egypt support the cultural generalizability of the results. Outcomes obtained in these studies were supported by results of several Egyptian RCTs (Ahmed, Reference Ahmed, Wedding and Stevens2004; Eldok etal., Reference Eldok, Elsabowa and Ismaeil2011; Ismaeil etal., Reference Ismaeil, Elsabwa and Elnabegha2016; Mahmoud etal., Reference Mahmoud, Abdel-Hay, Essa, Badawy and Abdel-Kareem2015; Soliman and Ibrahim, Reference Soliman and Ibrahim1998).
In 2010, the role of the internet and computers as an alternative route of delivering CBT to patients with anxiety disorders was investigated. A randomized controlled study was conducted with a sample of 40 patients suffering with different types of anxiety disorders. The control sample received a CBT therapy programme as usual and the study sample received CBT assisted by computer and internet. The study concluded that both routes of delivering CBT were effective. This study was among the very few studies that included computerized CBT for anxiety disorders and recommended replicating the results for further evidence (Aly etal., Reference Aly, Ghanem, Mansour and Fekry2010).
Addiction
Egypt’s growing addiction problem draws attention to further studies on prevalence and service provision. One study (44,000 subjects) aiming to determine the prevalence of substance use and addiction in Egypt and its socio-demographic correlates concluded that the lifetime prevalence of any substance use in Egypt varies between 7.25 and 14.5%. The study added that the true population prevalence is probably higher due to under-reporting (Hamdi etal., Reference Hamdi, Gawad, Khoweiled, Sidrak, Amer, Mamdouh, Fathi and Loza2013).
In 2000, a study aimed to assess the effectiveness of a CBT programme on coping with craving and compared the progress through stages of change in patients receiving CBT vs a control group who did not receive the programme. Study results indicated that craving scores significantly declined for patients receiving CBT, and those patients were moving effectively through the stages of change (Elgamil etal., Reference Elgamil, Moussa, Wasfi and Goueli2010). Another study in 2006 augmented a CBT programme for the management of a relapsed sample of patients suffering from substance use with environmental changes. The study indicated efficacy using both CBT augmented by environmental changes in the management of relapsed addicts (Hany etal., Reference Hany, Elotaik and Bahary2006). Further evidence continued to support the effectiveness of CBT in the management of substance use disorders and addiction in Egypt (Abdelrahman etal., Reference Abdelrahman, Aboughazala and Kafafy2017; Abdelsamie etal., Reference Abdelsamie, Metwaly, Mohamed and Elbaih2017).
Another study has identified impulsivity as an important factor in the development of substance use disorders in a sample of patients suffering with adult ADHD comorbid with addiction. The study modified a treatment programme for the study group and examined its efficacy in comparison with another group who did not receive the treatment programme. Statistically significant changes were noted in the study group. The study recommended a special focus on impulsivity as a significant factor in development of addiction especially in patients with ADHD (Helal and Dewedar, Reference Helal and Dewedar2016).
Depression
Despite the high estimated prevalence and incidence of depression in the Egyptian population, fewer studies examined CBT for depression. Nevertheless, these studies provided significant evidence of the efficacy of CBT in the treatment of depression in Egyptian patients (Nemr etal., Reference Nemr, Gabr and Elhamrawy2008).
In 2012 and 2014, two studies were conducted on a sample of patients suffering from depression secondary to general medical condition. Studies aimed to identify efficacy of a CBT programme in reducing symptoms of depression in this population. Both studies documented a positive outcome (Abdelhalim etal., Reference Abdelhalim, Hafez and Shehata2016; Fouad etal., Reference Fouad, Elsafy, Abu-Hendy and Abouhashim2012).
Serrag and colleagues have examined CBT for depression complicated with substance use. A programme based on CBT techniques was adapted and modified to meet the needs of this population. The study concluded positive outcomes in management of patients suffering from depression associated with substance use disorders (Serrag etal., Reference Serrag, Elhousainy and Younes2014).
CBT with special populations
CBT with children and adolescents in Egypt
In Egypt, children constitute almost 40% of the Egyptian population. The number of Egyptian children below the age of 18 years has reached 33.3 million, representing 36.6% of the total population. The highest number of children was between 5 and 9 years old, representing 28.7% of children, while the lowest number was for those below 1 year of age, representing 6% of children (CAPMS, 2018).
A study conducted in 2009 attempting to estimate the prevalence of psychiatric disorders in a sample of Egyptian children concluded that the prevalence of probable psychiatric diagnoses was 8.5% for any psychiatric diagnosis, 2% for emotional disorder, 6.6% for conduct disorder and 0.7% for ADHD (Abdelhamid etal., Reference Abdelhamid, Howe and Reading2009). However, the general public does not favour the inclusion of disorders of children and adolescents within the province of psychiatrists (Okasha, Reference Okasha2004), hence the importance of cognitive behaviuoral psychotherapeutic interventions for children and adolescents. Gendy and colleagues reviewed the advantages of using CBT as an evidence-based psychotherapeutic intervention for children and adolescents in Egypt. The study concluded the suitability of CBT for children and adolescents being goal oriented, symptom focused, and providing the child or adolescent with skills and techniques to master their difficulties (Gendy etal., Reference Gendy, Abdo, Awaad and El Missiry2016). A second study also confirmed suitability of CBT for children. The study implied that the briefer CBT, associated with specific measurable and achievable target goals, is particularly effective with children. In addition, the therapist’s active and directive stance plays a critical role in making CBT time efficient. (Mohamed etal., Reference Mohamed, Ibrahim and Ibrahim2016). Another study recommended CBT for children and adolescents for decreasing adjustment reactions in children and adolescents suffering from domestic troubles (Abdelsamie etal., Reference Abdelsamie, Ghazal and Morsy2016).
Other studies were conducted to examine efficacy of CBT for management of different psychiatric disorders in children and adolescents. A study was carried out on a sample of children and adolescents aged from 8 to 18 years suffering from depression. The study concluded that CBT is at least as effective as fluoxetine in the treatment of childhood and adolescent depression (Haikal etal., Reference Haikal, Khater, El-Naggar and Salama2008). Another study conducted in 2016 applied CBT to adolescents suffering from anxiety comorbid with addiction and concluded that application of CBT for this population reduced incidence of future relapses on follow-up (Hegazy etal., Reference Hegazy, Eldesouky and Ebrahim2016). For children and adolescents suffering from ADHD, CBT was concluded to increase their attention span and improve executive skills, as well as decreasing disruptive behaviour and aggression (Abdelfattah etal., Reference Abdelfattah, Abdelazeim, Osama and Elgammal2010; Hendy etal., Reference Hendy, Sherbet and Kheder2017). Another study looked at anxiety symptoms and disruptive behaviours in autistic disorders. The study sample consisted of three autistic children, 5–7 years old, with simple autism ranging between 31 and 34 degrees on the Childhood Autism Rating Scale (2 males and 1 female). The study revealed significant differences between the pre- and post-measurement for the growth of the language and for the children’s communication skills. The study recommended further investigation of the topic in a larger sample (Salama etal., Reference Salama, Ibrahim and Abdelhady2017). Another study considered enhancing parenting skills for autistic patients. A cognitive behaviour programme for improving parenting skills for children with autistic disorders was modified and applied to improve parent–child communication skills and self-management techniques. The study found a significant pre- to post-changes in the sample of study (Sakr etal., Reference Sakr, Gabel and Fadly2015).
A significant portion of CBT studies in children and adolescents have considered aggression, disruptive and oppositional behaviour. All studies concluded a positive outcome on applying the programme for behaviour modification (Morsy etal., Reference Morsy, Desouky and Elhebawy2015).
CBT with patients suffering from medical conditions
In Egypt, several studies report the efficacy of CBT in reducing distress associated with general medical conditions. A study in 2003 has compared efficacy of CBT for irritable bowel syndrome compared with medication. CBT was highlighted as equally effective as medication in treating the syndrome (Heissam and Sobhy, Reference Heissam and Sobhy2003). Another study examined CBT to reduce negative emotions associated with tinnitus and hyperacusis and to improve the patient’s psychological state. The study concluded a positive effect of CBT on the patients’ coping with tinnitus and hyperacusis, as well as reducing distress, associated depression and anxiety symptoms, and sleep difficulties (Salama etal., Reference Salama, Ghannoum and Hosni2011). Another randomized controlled study tested efficacy of CBT for treatment of depressive disorders in patients with chronic hepatitis. The study included 100 patients diagnosed with chronic hepatitis. CBT was applied to the study group while the control group received supportive therapy and ventilation. The study concluded that CBT is effective in decreasing symptoms of depression in the study sample (Fouad etal., Reference Fouad, Elsafy, Abu-Hendy and Abouhashim2012). Another sample of 20 patients was selected from cancer patients. The sample was randomized into two groups. The results showed a significant positive relationship between depression and death anxiety among the sample study of cancer patients. Results demonstrated superiority of the intervention group over the control group (Abdelhalim etal., Reference Abdelhalim, Hafez and Shehata2016). Another sample of 44 patients on haemodialysis were selected randomly and recruited for a study. The study results revealed that there was a statistically significant difference in scores of depression, anxiety and coping strategies between pre- and post-measure for the intervention group who received a CBT nursing programme (Elmonshed etal., Reference Elmonshed, Mahgoub, El-Boraie and El-Etreby2017). A different sample of 10 faculty students blinded since birth and suffering from anxiety symptoms were selected, and then randomized into two groups. One group received supportive counselling and the other received CBT for anxiety symptoms. The study group showed significant pre- to post-study changes that were sustained on follow-up (Elashmawy etal., Reference Elashmawy, Hareedy and Allam2017). A recent study investigated efficacy of CBT for decreasing depressive symptoms in children diagnosed with diabetes mellitus compared with supportive measures. The study proved a positive outcome (Elareishy etal., Reference Elareishy, Mansour and Elsayed2017).
CBT with elderly adults
Geriatric insomnia remains a challenge for service providers because of the lack of evidence-based clinical guidelines and limited treatment options available (Krishnan and Hawranik, Reference Krishnan and Hawranik2008). Non-pharmacological treatments, including CBT for insomnia, have shown to be highly effective in the treatment of insomnia in all age groups. Hence, it was recommended as a first-line and long-term strategy for management of insomnia in the elderly (Bloom etal., Reference Bloom, Ahmed, Alessi, Ancoli-Israel, Buysse, Kryger, Phillips, Thorpy and Vitiello2009). A study was conducted to examine the effect of CBT on quality of sleep pattern among Egyptian elderly people with insomnia. The study found significant improvement after application of the therapy programme which was maintained on follow-up (Elgahsh and Mohsen, Reference Elgahsh and Mohsen2016).
CBT with criminal offenders
Out of several theoretical orientations and types of psychological interventions for criminal activity, behaviour therapy and CBT appear to be a superior intervention in reducing recidivism rates (Illescas etal., Reference Illescas, Sánchez-Meca and Genovés2001). For sexual offenders, moreover, classical behavioural and CBT approaches indicated the strongest efficacy (Lösel and Schmucker, Reference Lösel and Schmucker2005).
A modified programme based on CBT for sexual offenders was studied in different locations and correctional facilities in Egypt. The programme proved efficacy on pre- to post-treatment measures. The study recommended its replication on different types of sexual offenders for further support (Mekawy and Abou-zaid, Reference Mekawy and Abou-zaid2012).
For criminal incarcerated criminals in Egypt, a CBT efficacy study was conducted to improve anger management skills among a sample of adult criminal offenders. The study was carried out at Liman-Tora Prison. The sample consisted of 40 institutionalized violent prisoners, age range 18–45 years, institutionalized for no more than 3 years, and demonstrating no obvious cognitive impairment and no current substance use, or any psychiatric disorders. Results revealed highly statistically significant differences between pre- and post-measures and on follow-up among the studied sample. The study recommended that anger management interventions based on CBT should be maintained as an important component of any rehabilitation programme for criminal offenders and in correctional settings (Elgenadi etal., Reference Elgenadi, Abd-elhalim, Hamdy and Sabry2014).
For juvenile delinquents, methods of addressing their problems remain conventional and rigid. Behaviour therapy is the most logical strategy. A local study aimed at identifying the effect of CBT on the behaviour of juvenile delinquents resident in correctional institutions in Alexandria. The study was carried out on 40 juvenile delinquents with ages ranging from 11 to 17 years. The intervention programme revealed positive outcomes on all measures (Yossef etal., Reference Yossef, Fikry, Oueda and Abo Nazel2011).
Discussion
The last decades in Egypt have observed the inclusion of cognitive behaviour theories in the academic curriculum of undergraduate psychology students. Yet residency programmes for psychiatrists remained immune to this influence. To date, no structured psychotherapy training is included in residency programmes. In-depth knowledge and training of CBT can only be pursued during graduate studies, e.g. MSc and PhD programmes. In summary, education and training in CBT is left to self-directed learning efforts.
CBT is an evolving, adaptive approach that is widely used in many different ways to deal with a range of psychological problems with established international evidence of efficacy. Unfortunately, no systematized platform for the display of research and studies could be found in Egypt. Exhaustive efforts were required in order to identify and review national studies of CBT in Egypt. A short review of the dispersed local body of research evidence has indicated that CBT can be effective in different Egyptian cultural contexts with a variety of psychological problems. Nevertheless, there are only a small number of internationally published outcomes in Egypt contexts. The local studies have limitations. Many have small sample sizes and therefore cannot be generalized. Despite the fact that almost all studies have mentioned the necessity of adaptation of the applied CBT programme, very few have discussed the modification process. Moreover, many studies have not included a follow-up period to maintain results of intervention.
Further research in this area with good sample sizes and robust methodology, using CBT adapted to the local population, will demonstrate the benefits and support the evidence from other countries.
Effective provision of CBT can only be facilitated by adequate training and supervision. Ongoing clinical supervision for service providers should be offered and regulated with clearly defined responsibilities of the clinical supervisors. Psychiatrists are not hindered by the language barrier and are oriented with the international field of psychiatry. A good starting point would be to ensure that the training of cognitive therapy should be adequately covered in Egypt psychiatrists’ training programmes, alongside a greater emphasis on evidence-based practice with all its benefits and flaws.
It is imperative that psychotherapy is relevant to the needs of the country and accessible to all who might benefit. Strategies to address the disparity between need and provision of CBT are exhaustive. An initial step is to review the available national governance. The regulating laws for the practice and provision of psychotherapy and hence CBT require prompt revision to ensure adequate practice; for instance, setting clear standards of practice, tactics to ensure compliance with statutes and regulations, confidentiality and information protection (especially with the emergence of electronic communication and involvement of the internet and the social media into the practice of psychotherapy), reporting obligations, and conflict of interest.
Acknowledgements
We are sincerely grateful to the Egyptian pioneers of psychotherapy in general and cognitive behaviour therapy for their assistance in creating the original work and providing required information. We also thank our colleagues for their continuous encouragement to complete this work.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
The authors have no conflicts of interest with respect to this publication.
Ethical statement
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the APA.
Key practice points
(1) Efficacy of providing CBT to Egyptian patients with different psychiatric disorders.
(2) Adaptability of CBT to cultural influences in Egypt.
(3) Needs of education and training for providing CBT in Egypt.
(4) Implications for strategic policy planning to provide CBT in the national health coverage in Egypt.
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