Why western mental health models fail in Pakistan

2026-02-23 - 21:34

Dr Abrar Umar Mental health is no longer a taboo subject in Pakistan. Depression, anxiety and substance use disorders are now discussed in drawing rooms, classrooms and policy forums alike. The language of “evidence-based treatment” has entered professional discourse and psychological therapies are increasingly promoted as solutions. Yet, despite this apparent progress, the results remain troubling. Treatment dropout is common, relapse rates are high and many patients quietly disengage from care. It is time to confront an uncomfortable reality: much of our mental health practice is built on models that were never designed for our social world. Most psychological therapies used in Pakistan, particularly cognitive behavioural therapy (CBT), originate from Western societies. These models were developed in cultural settings that emphasize individual autonomy, emotional disclosure and personal choice. In Pakistan, distress unfolds differently. It is embedded in family systems, moral expectations, religious interpretations and social surveillance. When therapy fails to recognize this, it risks becoming technically sound but practically ineffective. There is a widespread assumption that if a treatment is labelled “evidence-based,” it must work everywhere. This assumption is misleading. Evidence is always produced within a context. Human cognition does not operate independently of culture, nor do emotions arise in isolation from social meaning. Guilt, shame, responsibility and self-control carry different weight across societies. A therapeutic model that ignores these differences may appear scientific, yet remain disconnected from the patient’s lived experience. This gap is especially visible in the treatment of substance use disorders. In Pakistan, substance use is rarely understood as a health condition alone. It is moralized, criminalized and often interpreted as a failure of character or faith. Families frequently approach treatment with anger, fear or shame, rather than understanding. Standard Western CBT manuals, which focus narrowly on individual thoughts and behaviours, struggle to engage with this moral and relational terrain. Patients may attend sessions, repeat therapeutic language and still feel internally unmoved. Family dynamics further complicate treatment. In Pakistani society, decisions about care are seldom made by individuals alone. Families influence when treatment begins, whether it continues and what is disclosed in therapy. Western therapeutic frameworks, which assume strict individual autonomy, often clash with this reality. When therapy excludes family realities altogether, it operates in a vacuum. Language also plays a critical role. Psychological concepts developed in English do not always translate meaningfully into Urdu or regional languages. Terms commonly used in therapy—such as cognitive distortions or coping strategies—may sound abstract, confusing or culturally alien when translated literally. Without conceptual adaptation, therapy risks becoming a mechanical exercise rather than a transformative process. None of this suggests that therapies like CBT should be discarded. CBT remains one of the most rigorously studied psychological interventions globally. The problem lies not in the science, but in its uncritical application. What Pakistan needs is not imported manuals, but culturally adapted interventions that retain scientific structure while engaging local realities. Evidence from locally conducted clinical research suggests that culturally adapted psychotherapies lead to better engagement and retention, particularly in the treatment of substance use disorders. Such adaptation respects cultural values while maintaining scientific integrity. It bridges the gap between global knowledge and local realities. Culturally adapted CBT acknowledges that while therapeutic principles may be universal, their delivery is not. Adaptation involves modifying language, metaphors, session structure and therapeutic focus to reflect family systems, moral frameworks and social pressures. Crucially, such adaptation must be systematic and evidence-driven, not improvised or intuitive. The implications go beyond Pakistan. Many low- and middle-income countries face similar challenges, yet global mental health initiatives continue to promote uniform solutions. Pakistan’s experience serves as a reminder that mental health care cannot be copy-pasted. Cultural intelligence is not an optional add-on; it is central to effectiveness. If mental health services in Pakistan are to improve meaningfully, institutions and policymakers must prioritize culturally grounded, evidence-based psychotherapies. Awareness campaigns alone will not suffice. Nor will imported models, however well-intentioned. Sustainable progress requires interventions that are scientifically sound and culturally credible—designed not just to be delivered here, but to work here. —The writer is a professor of public health and works in the area of culturally adapted psychological interventions.