A Study on the Effectiveness of Cognitive Behavioural Therapy for Obsessive Compulsive Behaviour in Iraq: Lessons for Cross-cultural Practice

  • Angie CucchiEmail author
  • Marco Tullio Liuzza
  • Zainab Ali Saleem
  • Nesif Jasim Al Hemiary


Given the emphasis on Cognitive Behavioural Therapy (CBT) as the “golden standard” treatment for Obsessive Compulsive Disorder (OCD) in the UK, some authors have called for the application of this psychotherapeutic approach in the Arab world. This study, carried out in Iraq, is a quantitative single-group design with pre- and post-assessment. Symptoms were assessed in relation to the CBT treatment and a single time follow-up evaluation was carried out after 6 months. Findings suggested a positive impact of CBT, with a significant effect for the number of sessions. The effect was bigger at 6 months follow-up, even when socio-economic status (SES) was controlled for. Initial findings suggest that the analytic nature of CBT might be a useful tool to tackle OCD in Iraq. However, local cultural habits ought to be taken into consideration. Results are discussed in relation to cross-cultural issues, suggested adaptations and the need to work more holistically with indigenous services.


Cognitive Behavioural Therapy Obsessive Compulsive Disorder Effectiveness Cross-cultural Middle East 



We wish to thank the participants of this study.

Compliance with Ethical Standards

Ethical Standard

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. Al Riyami, A., Al Adawi, S., Al Kharusi, H., Morsi, M., & Jaju, S. (2009). Heath services utilization by school going Omani adolescents and youths with DSMIV mental disorders and barriers to service use. International Journal of Mental Health Services,3(22), 1–11.Google Scholar
  2. Al Rowais, S., Al Faris, E., Mohammad, G., Al Rukban, M., & Abdulghani, H. (2010). Traditional healers in Riyadh region: reasons and health problems for seeking advice. A household survey. Journal of Alternative and Complementary Medicine,16(2), 199–204.CrossRefGoogle Scholar
  3. Al Sharbati, Z, Al Sharbati, M, Gupta, I. (2014a). The art of psychotherapy in Oman: practice and limitation. In Neurological Disorders: Clinical Methods. iConcept Press.Google Scholar
  4. Al Sharbati, Z, Al Sharbati, M, Gupta, I. (2014b). Obsessive compulsive disorder: the old and the new problems. In InTechOpen, DOI: Available from: Google Scholar
  5. Al-Abdul-Jabbar, J., & Al-Issa, I. (2000). Psychotherapy in Islamic society. In I. Al-Issa (Ed.), Al-Junun: Mental illness in the Islamic world (pp. 277–293). Madison, CT: International Universities Press.Google Scholar
  6. Al Hemiary, N., & Al Hasnawi, S. (2009). Seeking help from faith healers among Iraqi patients with obsessive – compulsive disorder. 2009. Journal of Faculty Medicine Baghdad,51(4), 385–387.Google Scholar
  7. Al Hemiary, N., Al Hasnawi, S., & Al-Diwan, J. K. (2014). Obsessive compulsive disorder in Karbala, Iraq: a preliminary report. Karbala Journal of Medicine, 7(2), 2015–2017.Google Scholar
  8. Al-Humairi, A. (n.d.). Yale Brown measure of compulsive obsession is complete. Academy of Psychology. Retrieved from: Accessed on: 25–10-19.
  9. Al-Sabaie, A., Fathelaleem, A., & Al-Hamad, A. (1992). Obsessive compulsive disorder. Annals of Saudi Medicine, 12, 6. Scholar
  10. Azhar, M. Z., & Varma, S. L. (2000). Mental illness and its treatment in Malaysia. In I. Al-Issa (Ed.), Al-Junun: Mental illness in the Islamic world (pp. 163–185). Madison, CT: International Universities Press.Google Scholar
  11. Baer, L., & Blais, M. A. (Eds.). (2010). Handbook of clinical rating scales and assessment in psychiatry and mental health. New York: Humana Press.Google Scholar
  12. Beck, A. T. (1970). Cognitive therapy: nature and relation to behaviour therapy. Behavior Therapy, 1, 184–200.CrossRefGoogle Scholar
  13. Beck, J. (2011). Cognitive therapy: basics and beyond. London: the Guilford Press.Google Scholar
  14. Bentall, R. (2003). Madness explained: psychosis and human nature. London: Penguin Group.Google Scholar
  15. Bürkner, P. C. (2017). brms: an R Package for Bayesian multilevel models using Stan. Journal of Statistical Software, 80(1), 1–28. Scholar
  16. Clark, D. (1999). Cognitive behavioral treatment of obsessive compulsive disorders: a commentary. Cognitive Behaviour & Practice, 6(4), 408–415.CrossRefGoogle Scholar
  17. Cordioli, A. V., Heldt, E., Bochi, D. B., Margis, R., de Sousa, M. B., Tonello, J. F., et al. (2003). Cognitive-behavioral group therapy in obsessive-compulsive disorder: a randomized clinical trial. Psychotherapy and Psychosomatics, 72, 211–216.CrossRefGoogle Scholar
  18. Eisen, J. L., Goodman, W. K., Keller, M. B., et al. (1999). Patterns of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study. The Journal of Clinical Psychiatry, 60(5), 346–352.PubMedCrossRefGoogle Scholar
  19. El Dawla, A., Assad, T., El Habiby, M. M., Shorub, E. M., & Kasem, R. (2015). Obsessive–compulsive symptoms in Egyptian schizophrenic patients. Middle East Current Psychiatry, 22, 21–26.CrossRefGoogle Scholar
  20. Fernando, S. (2014). Mental health worldwide: culture, globalization and development. London: Palgrave MacMillan UK.CrossRefGoogle Scholar
  21. Foa, E. B., & Kozak, M. J. (1996). Psychological treatment for obsessive-compulsive disorder. In M. Mavissakalian & R. Prien (Eds.), Long-term treatments of anxiety disorders (pp. 285–309). Washington, DC: American Psychiatric Press, Inc.Google Scholar
  22. Glenn, D., Golinelli, D., Rose, R. D., et al. (2013). Who gets the most out of cognitive-behavioural therapy for anxiety disorders?: The role of treatment dose and patient engagement. Journal of Consulting and Clinical Psychology, 81(4), 639–649. Scholar
  23. Goodman WK, Price LH, Rasmussen et al. (1989) The Yale-Brown obsessive compulsive scale. development, use and reliability. Archives of General Psychiatry, 46, 1006–1011.PubMedCrossRefGoogle Scholar
  24. Hamdan, A. (2008). Cognitive restructuring: an Islamic perspective. Journal of Muslim Mental Health, 3(1), 99–116.CrossRefGoogle Scholar
  25. Hasnawi, S., Sadik, S., Rasheed, M., Baban, A., Al-Alak, M., Othman, A., Othman, Y., Ismet, N., Shawani, O., Murthy, S., Aljadiry, M., Chatter Ji, S., Al-Gasseer, N., Streel, E., Naidoo, N., Mahmud Ali, M., Gruber, M., Petukhova, M., Sampson, N., & Kessler, R. (2009). The prevalence and correlates of DSM-IV disorders in the Iraq Mental Health Survey (IHMS). World Psychiatry, 8, 97–109.Google Scholar
  26. Hiltunen, A. J., Kocys, E., & Perrin-Wallqvist, R. (2013). Effectiveness of cognitive behavioral therapy: an evaluation of therapies provided by trainees at a university psychotherapy training center. PsyCh Journal, 2(2), 101–112. Scholar
  27. Hodge, D. (2008). Constructing spiritually modified interventions: cognitive therapy with diverse populations. International Social Work, 178(2), 51–192. 26.Google Scholar
  28. Hodge, D., & Nadir, A. (2008). Constructing spiritually modified interventions: cognitive therapy with diverse populations. International Social Work, 51(2), 178–192.CrossRefGoogle Scholar
  29. Husain, A., & Ross-Sheriff, S. (2011). Cultural competence with Muslim Americans. In D. Lum (Ed.), Culturally competent practice: a framework for understanding diverse groups and justice issues (4th ed., pp. 358–389). Belmont, CA: Brooks/Cole.Google Scholar
  30. Husein, A., & Hodge, D. (2016). Islamically modified cognitive behavioral therapy: enhancing outcomes by increasing the cultural congruence of cognitive behavioural therapy self-statements. International Social Work, 59(3), 393–405.CrossRefGoogle Scholar
  31. Iraq Mental Health Survey, Ministry of Health, Iraq 2006/2007. Retrieved from: Accessed on 12–10-19.
  32. Johnson, T. J., & Friborg, O. (2015). The effects of cognitive behavioural therapy as an anti-depressive treatment is falling: a meta-analysis. Psychological Bulletin, 141, 747–768.CrossRefGoogle Scholar
  33. Karanicolas, P. J., Farrokhyar, F., & Bhandari, M. (2010). Practical tips for surgical research: blinding: who, what, when, why, how? Canadian Journal of Surgery, 53(5), 345–348.PubMedCentralPubMedGoogle Scholar
  34. Kraus, M., Cote, S., & Keltner, D. (2010). Social class, contexualism and empathic accuracy. Psychological Science, 21, 1716–1723.PubMedCrossRefGoogle Scholar
  35. Ljótsson, B., Hedman, E., Mattson, S., & Andersson, E. (2017). The effects of cognitive-behavioural therapy for depression are not falling: a re-analysis of Johnsen and Friborg (2015). Psychological Bulletin, 143(3), 321–325.PubMedCrossRefGoogle Scholar
  36. Maina, G., Albert, U., & Bogetto, F. (2001). Relapses after discontinuation of drug associated with increased resistance to treatment in obsessive-compulsive disorder. International Clinical Psychopharmacology, 16(1), 33–38.PubMedCrossRefGoogle Scholar
  37. McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., Stein, D. J., Kyrios, M., Matthews, K., & Veale, D. (2015). Efficacy of cognitive behavioural therapy for obsessive-compulsive disorder. Psychiatry Research, 227, 104–113.PubMedCrossRefGoogle Scholar
  38. Medecins Sans Frontiers (2013). Healing Iraqis: the challenges of providing mental health care in Iraq. Retrieved from: Accessed on 22–10-19.
  39. Ministry of Health (Ed.). (2008). Annual report. Iraq: Ministry of Health ed.Google Scholar
  40. Moritz, S., Irshaid, S., Beiner, A., Hauschildt, M., & Miegel, F. (2019). Acceptance and efficacy of a metacognitive self-help intervention in an Arabic-speaking mixed patient sample with depression and/or obsessive–compulsive disorder: a randomized controlled trial. Journal of Experimental Psychopathology. Scholar
  41. National Institute for Health and Clinical Excellence (2005) Obsessive compulsive disorder: care interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. Retrieved from: . Accessed on 13–3-18.
  42. NHS Digital (2014). Psychological therapies, annual report on the use of IAPT services- England. Retrieved from: Accessed on 19–10-19.
  43. O’Connell, N. S., Dai, L., Jiang, Y., Speiser, J. L., Ward, R., Wei, W., et al. (2017). Methods for analysis of pre-post data in clinical research: a comparison of five common methods. Journal of Biometrics & Biostatistics, 08(01), 1–8. Scholar
  44. O’Neill, J., & Feusner, J. D. (2015). Cognitive-behavioral therapy for obsessive–compulsive disorder: access to treatment, prediction of long-term outcome with neuroimaging. Psychology Research and Behavior Management, 8, 211–223. Scholar
  45. Öst, L. G., Havnen, A., Hansen, B. & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014. Clinical Psychology Review, 40,156-69. PubMedCrossRefGoogle Scholar
  46. Picinelli, M., Pini, S., Bellantuono, C., & Wilkinson, G. (1995). Efficacy of drug treatment in obsessive-compulsive disorder - a metanalytic review. The British Journal of Psychiatry, 166, 424–443.CrossRefGoogle Scholar
  47. Raftery, A. (1995). Bayesian model selection in social research. Sociological Methodology, 25, 111–163.CrossRefGoogle Scholar
  48. Rathod, S., Phiri, P., Kingdon, D., Gobbi, M. (2010). Developing Culturally sensitive Cognitive behaviour therapy for Psychosis for Ethnic minority patients by Exploration and Incorporation of Service Users’ and Health Professionals' Views and Opinions. Journal of behavioural and Cognitive Psychotherapies, 38, 511-33PubMedCrossRefGoogle Scholar
  49. Ravizza, L., Barzega, G., Bellino, S., Bogetto, F., & Maina, G. (1996). Drug treatment of obsessive-compulsive disorder (OCD): long-term trial with clomipramine and selective serotonin reuptake inhibitors (SSRIs). Psychopharmacy Bullettin, 32(1), 167–173.Google Scholar
  50. Romano, S., Goodman, W., Tamura, R., & Gonzales, J. (2001). The collaborative research group long-term treatment of obsessive-compulsive disorder after an acute response: a comparison of fluoxetine versus placebo. Journal of Clinical Psychopharmacology, 21(1), 46–52.PubMedCrossRefGoogle Scholar
  51. Sadik, S., Bradley, M., Al-Hasoon, S., & Jenkins, R. (2010). Public perception of mental health in Iraq. International Journal of Mental Health Systems, 4, 26. Scholar
  52. Sayyal K. (2009). Healing Iraqis: the challenges of providing mental health care in Iraq. Doctors without borders. Retrieved from:
  53. Shooka, A., Al Haddad, M., & Raees, A. (1998). OCD in Bahrain: a phenomenological profile. The International Journal of Social Psychiatry, 44(2), 147–154.PubMedCrossRefGoogle Scholar
  54. Simpson, H. B., Liebowitz, M. R., Foa, E. B., Kozak, M., Schmidt, A. B., Rowan, V., Petkova, E., Kjernisted, K., Huppert, J. D., Franklin, M. E., Davies, S., & Campeas, R. (2004). Post-treatment effects of exposure therapy and clomipramine in obsessive compulsive disorder. Depression and Anxiety, 19(4), 225–233.PubMedCrossRefGoogle Scholar
  55. Simpson, H. B., Franklin, M. E., Cheng, J., Foa, E. B., & Liebowitz, M. R. (2005). Standard criteria for relapse are needed in obsessive-compulsive disorder. Depression and Anxiety, 21(1), 1–8.PubMedCrossRefGoogle Scholar
  56. Slone, M., & Shoshani, A. (2014). Psychiatric effects of protracted conflict and political life events exposure among adolescents in Israel: 1998-2011. Journal of Traumatic Stress, 27, 353–360. Scholar
  57. Thomas, J. (2013). Psychological wellbeing in the Gulf States. Hampshire: Palgrave Macmillan.CrossRefGoogle Scholar
  58. Thorén, P., Asberg, M., Cronholm, B., Jörnestedt, L., & Träskman, L. (1991). The clomipramine collaborative study group. Clomipramine in the treatment of obsessive-compulsive disorder. Archive of General Psychiatry, 48, 730–8. 3.CrossRefGoogle Scholar
  59. Veale, D. (2007). Cognitive–behavioural therapy for obsessive–compulsive disorder. Advances in Psychiatric Treatment, 13, 438–446. Scholar
  60. Wagenmakers, E. J. (2007). A practical solution to the pervasive problems of p values. Psychonomic Bulletin & Review, 14(5), 779–804.CrossRefGoogle Scholar
  61. Walker, K., & Christmas, D. (2017). Understanding challenges around implementation of specialist service recommendations for obsessive-compulsive disorder. British Psychological Bulletin. Scholar
  62. Weatherhead, S., & Daiches, A. (2010). Muslim views on mental health and psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice, 83, 75–89.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.School of Psychotherapy and PsychologyRegent’s University LondonLondonUK
  2. 2.St. Mary’s University, TwickenhamTwickenhamUK
  3. 3.Department of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
  4. 4.Department of Psychiatry. Al-Yarmook Teaching HospitalBaghdadIraq
  5. 5.College of Medicine, Department of Medicine, Section of PsychiatryUniversity of BaghdadBaghdadIraq

Personalised recommendations