Psychotherapy has historically developed within Western individualist paradigms. Contemporary global mental healthcare increasingly requires adaptation to local cultural systems, particularly in low- and middle-income countries (LMICs), where access constraints intersect with deeply embedded social structures. The World Federation for Psychotherapy (WFP), established in 1934, promotes culturally responsive, accessible and evidence-based psychotherapy across diverse settings. This shift aligns with emerging perspectives in positive psychiatry, which emphasise resilience, meaning and social context as central to mental health, particularly in diverse and resource-constrained environments.Reference Jeste, Palmer, Rettew and Boardman1
The challenge of cultural grounding
Discussions at the 2025 WFP Regional Meeting in Manila 2 underscored the need to balance theoretical integrity with cultural contextualisation. A central question is whether adaptation risks diluting theoretical coherence or extends the applicability of established models.
Cultural grounding through functional equivalence
This paper advances the thesis that culturally grounded adaptations preserve theoretical fidelity by maintaining core therapeutic mechanisms – particularly common factors – while modifying their expression to align with local meaning systems. Cultural adaptation thus operates through functional equivalence, allowing variation in form while preserving therapeutic function.
Illustrating the framework across cultures
The objective is to examine how such adaptations preserve core mechanisms while enhancing contextual relevance, using practice-based vignettes from the Philippines, Uganda and Indonesia.
Method
This paper adopts a qualitative, practice-informed interpretive approach based on expert clinical presentations from the 2025 WFP Regional Meeting in Manila, 2 supplemented by relevant literature.
Cultural and clinical knowledge was derived from the following:
-
(a) locally developed adaptations within clinical settings;
-
(b) cultural constructs explicitly identified and operationalised in practice;
-
(c) literature on psychotherapy processes, trauma-informed care and structural determinants.
Cultural constructs were identified inductively from clinician-led adaptations rather than selected a priori.
Each vignette was analysed using a five-step framework:
-
(a) identification of core therapeutic mechanisms;
-
(b) identification of embedded cultural constructs;
-
(c) translation into observable clinical practices;
-
(d) embedding within structural and trauma-related context;
-
(e) evaluation of fidelity preservation.
Across settings, therapist preparation emphasised supervision, reflective practice and culturally informed clinical reasoning rather than rigid adherence to manuals.
Taken together, these steps can be understood as a provisional model for cultural adaptation in psychotherapy. In the present analysis, core therapeutic mechanisms were not specified a priori by the authors but were identified inductively from clinician-led adaptations of evidence-based models. Within each context, clinicians implemented established psychotherapies and documented how therapeutic processes and techniques were modified in accordance with local relational norms and cultural mores. These culturally congruent practices were then analysed by the authors to infer the underlying therapeutic mechanisms, and to examine how structural and trauma-related realities shaped their expression while preserving intended therapeutic function. This sequence offers a pragmatic and potentially transferable approach to cultural adaptation while allowing for necessary contextual variation.
This analysis is descriptive and hypothesis-generating.
Common factors and cultural context
Psychotherapy outcomes are strongly associated with common factors – therapeutic alliance, empathy, goal consensus and corrective emotional experience. Reference Wampold and Imel3–Reference Nahum, Tasman, Alfonso, Sonmez, A and KN5 These mechanisms account for a substantial proportion of treatment effects across modalities. Reference Pedersen, Lakshmin, Schafer, Watts, Carswell and Willhoite6
Cultural grounding can be understood through functional equivalence, a concept from cross-cultural psychology in which the same underlying function is preserved despite variation in observable form. Reference van de Vijver and Leung7 In psychotherapy, core mechanisms remain operative even when expressed through culturally distinct relational practices. This position is consistent with contemporary frameworks in positive psychiatry, which situate mental health within systems of meaning, resilience and social connectedness and emphasise the integration of cultural context into clinical care. Reference Jeste, Palmer, Rettew and Boardman1
A focus on trauma is warranted. In many LMIC contexts, distress is shaped by chronic, collective and structurally mediated stressors – poverty, migration, illness and social disruption – often manifesting as cumulative and relational trauma. Trauma-informed care therefore functions as a foundational stance, modulating alliance formation, affect regulation and pacing. Reference Landolt, Cloitre, Schnyder, Jensen and Sachser8 These perspectives align with models that emphasise adaptive functioning and meaning-making under conditions of adversity. Reference Jeste, Palmer, Rettew and Boardman1
Within this framework, cultural adaptation does not replace therapeutic mechanisms but translates them into culturally intelligible forms.
Congress-based vignettes
Philippines: kapwa and pakikiramdam in interpersonal psychotherapy
Interpersonal psychotherapy (IPT) was adapted for extended family contexts, preserving core mechanisms – therapeutic alliance, affective processing and role negotiation – while reframing them through kapwa (shared identity) and pakikiramdam (relational attunement). Reference Enriquez9
Alliance was established through indirect communication and sensitivity to relational cues. Therapists used prompts such as ‘What happened in the family?’ rather than directly eliciting internal emotional states, allowing affect to emerge through relational narratives.
Emotional processing occurred through accounts of family obligation, role strain and interpersonal harmony rather than discrete affect labelling. This represents a culturally congruent pathway to affective understanding.
Trauma-informed care was embedded through non-confrontational pacing and preservation of relational dignity, particularly in contexts of migration-related separation and intergenerational conflict.
Despite these modifications, IPT’s core mechanisms – development of alliance, facilitation of affective understanding and renegotiation of interpersonal roles – were preserved. Cultural constructs shaped expression without altering function. Reference Wampold and Imel3–Reference Pedersen, Lakshmin, Schafer, Watts, Carswell and Willhoite6
Uganda: ubuntu in group supportive psychotherapy
Group supportive psychotherapy, validated in randomised trials, Reference Nakimuli-Mpungu10 retained behavioural activation as its core mechanism while integrating ubuntu, a framework emphasising shared humanity.
Behavioural activation was implemented through structured group activities, including communal work and livelihood tasks, increasing engagement and reducing avoidance.
Storytelling enabled participants to share experiences of illness, stigma and loss. Collective problem-solving reinforced participation and sustained behavioural engagement.
Trauma was addressed through communal processing of shared adversity, transforming individual distress into socially held experience.
The use of trained lay health workers and group delivery enhanced scalability.
Empirical evidence indicates preservation of the core mechanism: behavioural activation remains intact whereas communal participation strengthens engagement and adherence. Reference Jeste, Palmer, Rettew and Boardman1,Reference Nakimuli-Mpungu10
Indonesia: intergenerational obligation in psychodynamic training
A psychodynamic training model preserved core mechanisms – transference, resistance and reflective insight – while embedding intergenerational obligation and hierarchical relational norms. Reference Lukman, Wiguna and Soemantri11
Training utilised metaphor and narrative distancing. Trainees explored interpersonal conflict through third-person scenarios or culturally familiar moral narratives, enabling reflection without direct confrontation.
Reflective capacity was cultivated through indirect engagement with relational dynamics, consistent with norms of respect for authority.
Trauma-informed principles were incorporated through symbolic processing, allowing exploration of developmental and relational trauma in psychologically safe ways.
Core psychodynamic processes were preserved, with culturally adapted forms functioning as alternative pathways to insight. This aligns with broader observations in the Asia-Pacific region. Reference Alfonso and Botbol12
Shared themes
Across cases, psychotherapy preserved core mechanisms while adapting their expression to local relational systems. Trauma sensitivity was operationalised through culturally congruent forms of emotional containment: indirect attunement, communal processing and symbolic expression.
These patterns indicate that cultural adaptation functions through translation rather than by substitution of therapeutic mechanisms.
Implications for practice
Three practice-oriented implications emerged.
First, locally led training systems are essential. The Indonesian example demonstrates that clinicians must be trained to preserve underlying mechanisms while adapting their expression.
Second, community-based and task-shared models enhance scalability. The Ugandan model shows that core mechanisms can be delivered effectively outside specialist settings when embedded in culturally meaningful practices.
Third, effective adaptation requires translation of core mechanisms into culturally congruent forms. The Filipino IPT adaptation illustrates how alliance and empathy must align with local relational norms.
These implications are hypothesis-generating but grounded in consistent cross-context patterns.
Conclusion
Cultural adaptation in psychotherapy represents expansion rather than dilution. Across contexts, adaptation operates through functional equivalence: core mechanisms are preserved while their expression is translated into locally meaningful forms.
The common factors model provides a bridge between global theory and local practice. This orientation is consistent with contemporary frameworks in positive psychiatry, which emphasise culturally grounded pathways to resilience, meaning and well-being across diverse populations. Reference Jeste, Palmer, Rettew and Boardman1
Cultural grounding is therefore not a departure from psychotherapy’s scientific basis but a condition for its global applicability.
Data availability
No primary data-sets were generated or analysed for this manuscript. All materials supporting the findings are contained within the article and its referenced sources.
Author contributions
A.L.J. conceptualised the manuscript, led drafting and integrated the theoretical framework. D.V.J. contributed to the positive psychiatry and social determinants framework and critically revised the manuscript. U.S. contributed trauma and cultural adaptation perspectives and critically revised the manuscript. C.D.D. contributed to synthesis of regional psychotherapy adaptations and manuscript revision. C.A.A. contributed to conceptual development, global psychotherapy framing and final revision. All authors approved the final manuscript and agree to be accountable for all aspects of the work.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
Open access
eLetters
No eLetters have been published for this article.