What Drives Outcomes In Cognitive Behavioral Therapy? Cultural Mechanisms In Substance Use Treatment across Global Contexts

Background and Purpose: Substance use disorders (SUDs) remain a major contributor to global morbidity and mortality, disproportionately affecting low- and middle-income countries where treatment access remains limited. Cognitive behavioral therapy (CBT) is one of the most widely used evidence-based interventions for SUDs; however, standard CBT protocols were largely developed in Western, high-income contexts and may not adequately address the cultural values, lived experiences, and structural realities shaping substance use in non-Western, non-high-income settings. Cultural adaptation has been proposed as a strategy to improve the relevance, accessibility, and effectiveness of CBT across diverse cultural contexts. Recognizing the need to strengthen this evidence-based intervention where the burden of SUD is greatest, this scoping review maps the existing global evidence on culturally adapted CBT as an intervention for SUDs, with particular attention to adaptation processes, implementation characteristics, and outcomes of such implementations.

Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. A systematic search was conducted across nine databases (Academic Search Complete, APA PsycInfo, CINAHL, Education Source, Health Source, ERIC, Psychology and Behavioral Sciences Collection, PubMed, Science and Technology Collection, and SocINDEX) to identify peer-reviewed empirical studies published in English that implemented culturally adapted CBT interventions for SUDs. Studies were included if they explicitly described cultural adaptation procedures. Data were extracted on study design, participant characteristics, country of implementation, cultural adaptation strategies, implementation indicators (e.g., feasibility, fidelity, acceptability), and substance use outcomes.

Results: Of the 667 articles identified, nine studies met the inclusion criteria. Randomized controlled trials (RCTs) and secondary analyses of RCTs were the most common study designs (44.4% respectively). The majority of studies were conducted in the United States (77.7%), while only two were conducted outside the U.S., both in Kenya. Hispanic/Latino/Latinx populations in the United States were the most frequently represented racial/ethnic group in the included studies (77.7%). Cultural adaptations included both surface-structure modifications (e.g., language translation and culturally relevant examples) and deep-structure adaptations (e.g., integration of familism, spirituality, and ethnic identity). All studies reported statistically significant reductions in substance use following participation in the culturally adapted CBT intervention compared to control and treatment-as-usual groups. Several studies also identified culturally salient mechanisms (e.g., familism and religiosity) that moderated treatment engagement and outcomes. However, reporting of implementation indicators was inconsistent, and most studies focused only on short-term outcomes (e.g., post-treatment or 3–6-month follow-ups).

Conclusions and Implications: Culturally adapted CBT interventions show promise for reducing substance use while improving treatment relevance for culturally diverse populations. However, the evidence base remains geographically skewed toward U.S.-based Hispanic/Latino/Latinx settings. This imbalance constrains the generalizability of current findings and highlights the need for broader global research. Future studies should prioritize culturally adapted CBT interventions implemented across more diverse geographic and racial/ethnic settings, as well as longer-term evaluations of treatment effectiveness. Expanding research on culturally responsive CBT interventions is essential for strengthening equitable substance use treatment systems and ensuring that evidence-based care is responsive to the cultural and social contexts shaping substance use and recovery.