Gained in translation
- Solfrid Raknes
- Jan 1, 2018
- 12 min read
Updated: 5 hours ago
What happens when psychological interventions travel across borders—between languages, cultures, and realities shaped by peace, trade, war, poverty, and displacement? While meaning can get lost in translation, something new can also be gained. This essay explores how mental health tools rooted in cognitive behavioral therapy (CBT) can evolve through adaptation and become more relevant in radically different settings. Drawing from fieldwork in Norway, Lebanon, Tanzania, and Ukraine, I share lessons learned about co-creation, cultural sensitivity, and the power of collaboration across borders.
Sofia Coppola’s Lost in Translation (2003) portrays two foreigners in Tokyo who feel disconnected from their surroundings and each other. The film shows how meaning can be lost in translation, both linguistically and emotionally. Similarly, when mental health interventions are adapted to new languages, cultures, and contexts, nuances and meanings risk being overlooked, potentially affecting their relevance, usefulness, and effectiveness. Simultaneously, adapting an intervention can potentially lead to innovation - making it more powerful and relevant than the original version.
Translating an intervention that deals with inner dialogue and cognitive patterns is inherently risky - language carries cultural assumptions, and what resonates in one setting may not translate clearly into another. Also, the translation and adaptation of mental health interventions, such as cognitive behavioral therapy (CBT), involves more than language - it requires reshaping the approach to fit new cultural, national, and economic landscapes. Given that most evidence-based mental health interventions have been tested in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries, there is a growing need to understand how such interventions translate - or fail to translate - across different cultural, linguistic, religious, and economic contexts.
In this essay, I reflect on nearly two decades of developing, adapting, implementing, and evaluating mental health interventions across Nothern and Eastern Europe, the Middle East, North America, and Africa. My work began with Psykologisk førstehjelp (1), a CBT-based tool for children and adolescents that became the country’s first bestseller in its category, broadly implemented in schools and school health services in Norway. It earned the Norwegian Psychological Association’s 2013 award for popularizing psychology. This laid the groundwork for the Helping Hand (Full link: https://attensi.com/helping-hand/ ) (2), an interactive digital game for adolescents now available in Arabic, English, French, Norwegian, and Ukrainian and recognized with the World Economic Forum’s Youth Mental Health Challenge Prize in 2022. More recently, I co-created Magic Mitten (full link: https://magicmitten.org/ ) (3), a toolkit for children affected by war. UNESCO Hungary promotes it, and the Magic Mitten is available in five languages. Furthermore, from nearly three years in Tanzania, where I have facilitated a cultural collective for mothers of children with disabilities and been involved in the benefits of such programs, I’ve gained firsthand insight into the complexities of adapting psychological tools to vastly different realities. Now, I am in Vinnytsia, Ukraine, with Doctors Without Borders, managing a team implementing PTSD treatment for people affected by war.
This essay does not comprehensively analyze the risks of adapting mental health tools across contexts. It does not provide a step-by-step guide to adapting CBT-based interventions. Neither does it delve deeply into what can go wrong or how meaning may be lost when such methods meet real lives in radically different settings. Instead, this attempts to share insights on translating and adapting CBT-based methods based on my fieldwork and experiences as an innovator, psychologist, and researcher across various contexts. This essay aims to explore the possibilities - what might be gained - when mental health interventions are translated and adapted across economic, linguistic, cultural, and religious borders.
The therapist is not a tool
During my work at the PTSD clinic this week, I sat down with a young psychologist who had just faced one of the most challenging moments in our profession: a patient making a suicide attempt during therapy. First and foremost, I wanted to support her - to normalize the waves of stress, doubt, and responsibility that often follow such experiences for young professionals. I told her that the main reason for our conversation was not to assess her actions but to care for her as a person.
At one point, I said: “You know, as therapists, we are tools - and even the strongest tools need care and repair after heavy use.”
Later, the translator quietly approached me. "It sounds so harsh when you say 'therapists are tools,'" she said. "I softened it when I translated, but many here understand English too, and I'm not sure it landed the way you meant it."
In Ukraine, as a post-Soviet state in war, there is a deep sensitivity around language that suggests exploitation or dehumanization. People here know too much about what it is like to be treated as instruments rather than human beings; they have experienced the threat of big systems. The translator revealed how a word I had thought was fairly neutral carried very different connotations here. This was just one of many moments where skilled translators have helped me better understand how to communicate more sensitively - teaching me how words and metaphors should be adapted to a specific context when used in a mental health program.
Amplified impact in low-resource contexts
Psychological interventions often have a more pronounced impact when implemented in low-resource settings within low- and middle-income countries. This is mainly due to the heightened need for mental health support and the scarcity of available services in such contexts. Yet, those most affected by conflict, displacement, and poverty often remain without adequate access to mental health support (4, 5, 6). Most psychotherapies are developed, tested, and delivered in high-income settings, typically reaching individuals in relatively stable, well-resourced environments on a war's "right" side. Fortunately, when thoughtfully adapted to new contexts, interventions can become highly valuable, helping to fill critical gaps in mental health infrastructure in settings where the needs are greatest.
One example of a mental health intervention adapted into many contexts and languages is Helping Hand, a CBT-based adolescent intervention. Initially developed in Norway, where studies have demonstrated positive effects on symptoms of anxiety and depression when implemented as a school-based intervention among Norwegian adolescents (7, 8, 9). A digital, gamified version of Helping Hand was then developed in collaboration with end users in Norway and Lebanon and successfully implemented with Syrian refugee adolescents in Lebanon (10). When delivered as a universal intervention for adolescents aged 13–17 in schools and refugee settlements, 85% of participants who initially reported moderate to high levels of anxiety and/or depression, as assessed by the SCAS (full link: https://www.scaswebsite.com/ ), reported symptom levels within the normal range following the intervention (11). Helping Hand is now implemented for thousands of adolescents annually in Lebanon and Jordan and is about to launch in Iraq and Greece through an NGO that focuses on the needs of Syrians affected by war (12). Notably, the outcomes among refugee adolescents are stronger than those observed when implementing the same intervention as a universal school-based program in Norway. Further, similar results were achieved when the HH was piloted in Ukraine during the first year after the full-scale invasion (13). The significant reduction of adolescents with anxiety and depression symptoms, when implemented among adolescents affected by war, highlights the potential impact of adaptations of interventions to new contexts to improve access to evidence-based mental health interventions.
Remote, rapid, and relevant
The urgency and unpredictability of war and disaster demand new ways of delivering support - especially when traditional methods are no longer feasible. As the Norwegian saying goes, nøden lærer naken kvinne å spinne - literally translated: “necessity teaches the naked woman to spin.” In English, a similar expression is “necessity is the mother of invention.” This has undoubtedly been the case in how we think about training those who deliver psychosocial interventions. With limited access to in-person supervision, new models for digital guidance, remote learning, and rapid deployment have emerged - reshaping what it means to equip facilitators under pressure. For example, right after the onset of the war in Ukraine, all Helping Hand training and supervision for group facilitators had to be conducted online, and I had not been in Ukraine yet due to the safety restrictions. Despite these limitations, adolescents reported that Helping Hand equipped them with essential skills to manage uncertainty, anxiety, and distress. Additionally, the group facilitators, who needed tools to support adolescents and lacked local resources, described the program as highly practical and feasible to implement during the war when in-person contact was restricted.
Know your translator, know your audience
Understanding the local context and needs can lead to different opinions about what intervention is beneficial. The time spent before deciding to adapt an intervention that already exists helps ensure that programs are relevant, sustainable, and genuinely beneficial. This involves spending time in the community, engaging with key stakeholders, reviewing existing support systems, and - most importantly - listening carefully to the people the intervention serves.
Before facilitating the Uhuru Mama Collective, a grassroots initiative supporting mothers raising children with disabilities in deep poverty, I lived in Dar es Salaam, Tanzania, for a year. As a CBT-trained psychologist, my initial idea was to introduce a structured CBT- program for mothers of disabilities. However, through ongoing interaction with Tanzanian people and systems - and with the help of Miss Faines, my translator and former Swahili teacher - I saw that income generation and peer connection were more urgent priorities for mothers of children with disabilities growing up in poverty. Miss Faines played a crucial role in this process. She didn’t just translate words; she helped me understand their meaning in context - the emotions, the social nuances, and the cultural weight behind what was expressed. This insight helped shape the intervention into a space where mental health was supported not through formal therapy but through shared opportunities for making money, experiences, mutual care, and skill-building.
The collective's impact on its members is powerful. Mothers reported reduced fear, increased confidence, and a stronger sense of belonging. One woman shared: “My fear is decreasing because my self-confidence has increased. I know children with special needs are many - not just my child - and I see how other children are loved by their parents.” Another said, “Through this partnership, we have created trust and rely on each other. Our closeness has increased. And we can go to funerals!” The last sentence was not immediately clear to me; how is it a good indicator of an intervention that it leads to you attending more funerals? I asked. Through conversations with my translator and the mothers, I came to understand that attending funerals in Tanzania serves a function similar to accessing the welfare state in Scandinavia. Beyond being an expression of care and solidarity, funerals are vital to the social safety net - providing support, connection, and a sense of belonging within the community. Beyond the personal gains, teachers and community members also noticed improvements in the children’s lives - better school attendance, more social participation, and greater emotional stability (13). The Uhuru Mama Collective has shown me that mental health support doesn’t always have to look like therapy. Sometimes, the most effective interventions emerge from within the community itself. Although I began with a plan rooted in my expertise, I’m grateful that I paused to listen and adjust. Moving from “What can I bring?” to “What can work here?” - with the help of my translator and communication with the target population themselves - made all the difference and has created much more fun, an intervention I believe is sustainable.
Magic when needed
Magic Mitten is a mental health toolkit designed to help children affected by war regulate their emotions through storytelling, sensory engagement, and cognitive strategies. Available as an app, a booklet, and a group facilitator manual, it can be delivered as an eight-session intervention. Carefully structured, Magic Mitten offers practical coping techniques children can use in daily life to manage stress, uncertainty, traumatic memories, and loss. Initially developed for Ukrainian children, the program is now promoted by UNESCO Hungary and has been implemented in various settings to support displaced children. In Norway, it was introduced through schools and school health services as part of a psychosocial initiative for Ukrainian refugee children (5). Feedback was positive - children reported, “This program has taught me how to chill!” In Lebanon, the program was used with Syrian refugee children preparing to return home following the fall of the Assad regime. There, many children reflected, “This program taught me how to be grateful, patient, and hopeful.” More recently, Magic Mitten has been implemented among children in Gaza. As I reviewed early reports and watched video clips of a local facilitator leading the sessions - fully engaging the children in exercises and stories - I felt deeply moved by the power of thoughtful translation and cultural adaptation. Tools like Magic Mitten remain meaningful across contexts through collaboration across borders. When we use courage to reach out, collaborate with local resources, and adapt with care and humility, such tools can be resources for those who need them most.
As good as it gets
Ultimately, what gets "lost" in translation can sometimes be replaced - or even surpassed - by what is gained when an intervention is adapted into new contexts through genuine collaboration, deep listening, and cultural humility. If we let the song Always Look on the Bright Side of Life from As Good as It Gets inspire us, we might move beyond the comfort of tightly controlled settings and take some risks - allowing mental health interventions to travel across borders and reach new contexts. Through international collaboration, new perspectives can evolve. Whether through a local facilitator in Gaza bringing Magic Mitten to life or a Tanzanian mother finding confidence in a community collective, we see that adaptations of a mental health intervention lie in the tools we bring and the relationships we build. When we co-create with those we aim to support and collaborate with, interventions do more than translate - they resonate. And in that resonance, something new and powerful can be found.
Recommendations
Navigating different cultural landscapes requires more than linguistic precision - it demands cultural understanding, patience, and a genuine openness to seeing the world through others' eyes. Meaningful adaptation begins with curiosity, humility, and a willingness to slow down and truly listen.
Take your time. Building trust and understanding in a new context is neither linear nor a two-day quick fix. Seek out and value the existing strengths and resources within the culture you are entering; the local mental health workers, teachers, social workers, and translators have been key to my understanding. A deeper cultural understanding enhances the relevance of interventions and allows for a richer, more meaningful impact.
Translators play a far greater role than simply converting words from one language to another. They can be cultural guides, nuance detectives, and meaning protectors. Investing time in building strong relationships with translators is essential - not only to express yourself clearly but to understand what you hear and see and to learn how to communicate in ways that genuinely resonate with the local reality. Translators often hold subtle knowledge about what can be said, how it should be said, and when it is better to listen.
Equally important is leaning into the collective wisdom of your intervention's end users; they bring live expertise that external knowledge cannot replace. Coming from an individualistic tradition, it can be easy to overestimate the role of individual therapy and expertise. But in collectivistic contexts, success often depends on how well you integrate into shared processes of adaptation, trust, and learning. Genuine collaboration is not a side note; it is the method. Ultimately, creating meaningful psychological support across cultures means letting go of the idea that we are bringing solutions and embracing the idea that we are co-creating them. □
References
Raknes S. (2010). Psykologisk førstehjelp. Barn. Oslo: Gyldendal Akademisk.
Helping Hand. https://attensi.com/helping-hand/
Magic Mitten. https://magicmitten.org
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Pictures and videos of this publication are shared in cooperation with The London House of Consultants Child smile initiative: HASSAN, ASEEL and NADA.
