Holistic Psychotherapeutic Approach in Elderly Burn Patients: A Consultation-liaison Psychiatry Case Series Integrating Supportive, Family-involved and Spiritual Interventions

SUMMARY

Burn injuries in elderly patients often present complex clinical and psychological challenges, especially when compounded by functional decline, emotional vulnerability, and spiritual distress. This case series illustrated a holistic psychotherapeutic approach implemented in a consultation-liaison psychiatry (CLP) setting for three elderly burn patients, each with unique psychological and spiritual needs. Interventions included supportive psychotherapy to address anxiety and mood disturbances, involvement of family members to enhance emotional security and reduce treatment resistance, spiritual facilitation aligned with patients’ religious values, and cognitive reorientation techniques to manage episodes of acute confusion and delirium. These tailored approaches proved effective in improving patients’ emotional adjustment, cooperation with care, and treatment adherence. The integration of psychotherapeutic, familial, and spiritual interventions underscores the importance of culturally sensitive and individualized CLP strategies for elderly burn survivors. However, the findings are limited by the small sample size and the qualitative nature of the data, which may restrict generalizability. Nevertheless, these observations highlight the value of interdisciplinary collaboration in optimizing recovery and psychological well-being among older adults in burn units.

Introduction

Burn injuries in older adults pose a unique clinical challenge due to a combination of physiological frailty, cognitive vulnerability, and psychosocial sensitivity.^1,2 Age-related declines in mobility, sensory function and immunity increase the risk of injury and complicate recovery, with heightened susceptibility to infection, delayed healing and delirium, particularly in intensive care settings.^2-4 In this series, one patient developed delirium on day eight, highlighting the importance of early cognitive reorientation and close mental status monitoring.^5,6

Delirium in medically ill older adults has long been recognised as an acute confusional state reflecting a failure of brain adaptation to stress.⁷ Classic works described delirium as a multifactorial syndrome in which biological vulnerability interacts with psychological stressors, underscoring the need for both medical stabilisation and emotional containment.^3,7,8 In this context, supportive psychotherapy plays a vital role in maintaining orientation, reducing fear, and preserving the therapeutic alliance between patient and clinician.^3,7-9

Psychological responses, often under-recognised in the elderly, may manifest as anxiety, demoralization, or difficulty adjusting to hospitalisation.^1,2 All three patients were diagnosed with adjustment disorder with mixed anxiety and depressive features, shaped by personality traits and life stressors such as perfectionism, caregiving roles, or hospitalisation fears.^1,2,10

Beyond the patient, burn trauma deeply affects the family, who are frequently thrust into caregiving roles while experiencing fear, guilt, or emotional exhaustion. This shared burden underscores the importance of family-centred care, where relatives are supported and actively engaged in the recovery process.¹¹ Nevertheless, the psychosocial and psychiatric dimensions of burn care in older adults remain underrepresented in the literature, particularly concerning the integration of psychotherapeutic and spiritual approaches into rehabilitation practices.^12-18

Spirituality also plays a vital role in coping, with patients drawing strength from religious practices and meaning-making frameworks; when integrated through culturally sensitive communication, it contributes to psychological stability and acceptance.^14-17 Overall, this case series aims to illustrate how an integrative consultation-liaison psychiatry (CLP) approach, which combines supportive psychotherapy, family involvement and spiritual facilitation, can address the multifaceted psychological challenges in elderly burn patients.^12-18

Case report

Case 1

A 65-year-old man, owner of a small home industry, sustained flame burns involving approximately 19.5% of his total body surface area (TBSA), affecting the face, neck, anterior torso and both hands following a sudden kitchen gas stove / liquefied petroleum gas (LPG) explosion in an enclosed space. He was initially managed at a community health centre and subsequently referred to the burn unit with partial- to deep-dermal burns and signs of inhalation injury (singed facial hair, mild respiratory distress).

During the early days of hospitalisation, the patient exhibited symptoms of anxiety and low mood, expressing existential distress over the incident while simultaneously showing gratitude for having survived. As part of early psychological support, spiritual interventions were initiated, including facilitation of his routine prayers and affirming his belief that the burn injury represented a spiritual trial through which his faith and virtue would be elevated. This spiritual framing appeared to offer emotional grounding and resilience.

However, on hospital day 8, he developed an acute confusional state, coinciding with a significant deterioration in his medical status. The patient spiked a high fever (38.7°C) and laboratory tests showed severe hypokalemia (serum K⁺ 2.7 mEq/L), hypoalbuminemia (2.52 g/dL), and leukocytosis (14.94x10³/μL). Clinically, he became disoriented, intermittently agitated, and experienced visual hallucinations (e.g., seeing “ghosts” at his bedside), which significantly heightened his fear and cognitive disorganisation. A psychiatric assessment confirmed delirium (non-dementia-related) along with an adjustment disorder with mixed anxiety and depressed mood. The care team implemented a holistic psychotherapeutic plan combining supportive psychotherapy (reality orientation, emotional validation, and structured engagement), family-based support and psychoeducation, and appropriate pharmacologic management.

Low-dose haloperidol (0.5 mg orally as needed; 2.5 mg intramuscularly for agitation) was administered alongside environmental and cognitive reorientation strategies. Over the ensuing days, his delirium resolved as his physical condition improved, including stabilisation of fever, potassium levels and inflammatory markers. As his orientation and emotional state improved, he transitioned from initial despair to a more emotionally stable and hopeful state.

Case 2

A 63-year-old widowed woman, who owned and managed a small building supply business, sustained superficial-to-full-thickness burns involving 25% TBSA following an LPG explosion at her residence, with injuries affecting her face and extremities. She was admitted for acute burn management and, by the third day of hospitalization, began showing signs of psychological distress, becoming tearful and anxious upon learning that her treatment would involve multiple debridement procedures. Although her pain had decreased from 10/10 to 5/10, she remained deeply preoccupied with the condition of her business and expressed a strong desire to return home.

Her enforced inactivity, in contrast to her previously active lifestyle, contributed to restlessness, low mood and sleep disturbances. These were aggravated by light sensitivity, which was alleviated by using a folded underpad as an improvised eye cover. On psychiatric evaluation, she was alert and oriented, with a dysphoric (anxious and sad) affect but no cognitive deficits. Screening assessments revealed a score of 6/15 on the Geriatric Depression Scale – 15 item (GDS-15), indicating mild depressive symptoms, and a score of 20/63 on the Geriatric Anxiety Inventory (GAI), reflecting mild anxiety. The findings supported a diagnosis of adjustment disorder with mixed anxiety and depressed mood.

An integrated therapeutic approach was initiated. Through supportive psychotherapy, the patient received reassurance, was coached in relaxation techniques, and was introduced to guided imagery. She visualized herself back home wearing her favourite housedress, sweeping the yard - imagery that helped restore calm and boosted her motivation to recover. Family-based intervention was arranged to provide emotional support and assist in managing her business during hospitalization.

Spiritual support was facilitated in accordance with her faith: the team supported her in performing salat in bed and encouraged daily dhikr, both of which she described as deeply calming. The CLP team also coordinated consistent environmental adjustments, including the use of the eye cover at night. To further support sleep and relieve anxiety, a low-dose anxiolytic (clobazam 5 mg at bedtime) was prescribed.

By hospital day 13, as her physical and psychological condition improved, she was transferred within the burn unit to a ward designated for stable patients. Her mood and anxiety symptoms had substantially improved; she showed better acceptance of the treatment process, and she remained cognitively intact with no signs of delirium throughout her stay.

Case 3

A 70-year-old woman with hypertension, chronic arthritis, gastritis and prior eye surgeries sustained deep partial-thickness scald burns (9% TBSA) to the left abdomen and thigh after her husband accidentally spilled boiling tea on her. She was transferred to a tertiary burn centre following infection, pneumonia, and an upper gastrointestinal bleed, likely worsened by her underlying gastritis.

By hospital day four, psychiatry was consulted for emotional distress. Though cognitively intact, she exhibited depressed mood, anxiety, and passive suicidal ideation (e.g., “just kill me”), alongside beliefs that her family had abandoned her. Visitation was restricted due to her medical condition. Diagnosed with adjustment disorder with mixed anxiety and depressed mood, she also demonstrated narcissistic personality traits, struggling with loss of control.

The CLP team initiated supportive psychotherapy, cognitive reframing, and family-based intervention involving her son and daughter-in-law. As a devout Muslim, she was encouraged to engage in religious coping, including prayer and dhikr. Spiritual support was facilitated by the care team. Pharmacologically, she received low-dose bedtime benzodiazepine and sertraline 25 mg daily.

By day six, her mood and cooperation improved markedly. However, on day ten, she again became withdrawn and tearful due to limited contact with her children. The CLP team relayed her message, and her son agreed to wave to her from outside the isolation room. She was visibly moved and emotionally stabilised after this visit.

Unique challenges and tailored interventions for each case

Case 1

This patient’s journey was marked by an acute confusional state (delirium) superimposed on adjustment disorder, illustrating the need for flexibility in the psychotherapeutic approach. His supportive psychotherapy initially focused on addressing anxiety and existential distress (using techniques like empathic listening and spiritual reframing of the event as a divine test), which helped ground him emotionally. When he developed severe delirium due to medical complications, the therapeutic focus shifted to basic reality orientation and reassurance, coordinated with prompt medical and psychopharmacologic management. As his delirium cleared, the prior spiritual and supportive groundwork facilitated a rapid restoration of hope and cooperation with rehabilitation, demonstrating the efficacy of integrating spiritual meaning with supportive care in elderly burn patients.

Case 2

This patient’s case highlighted challenges related to loss of autonomy and role responsibilities during hospitalisation. Her preoccupation with managing her small business and frustration with enforced inactivity required a supportive approach centred on realistic reassurance, relaxation training, and guided imagery to maintain her sense of purpose. The psychotherapy was uniquely tailored to incorporate elements of her daily routine (for example, visualizing herself performing familiar tasks at home) as a calming technique, while engaging her family to temporarily handle her business affairs so she could focus on recovery. This approach addressed her mild depressive and anxiety symptoms effectively, preventing escalation into more severe distress or delirium. By the time of her transfer to a step-down ward, she had accepted the treatment process and remained emotionally stable, illustrating the benefit of combining psychological support with practical problem-solving for an active older patient.

Case 3

This patient presented with profound feelings of helplessness and perceived abandonment, exacerbated by strict isolation precautions and underlying personality traits (narcissistic). The supportive psychotherapy for her was uniquely challenging, as it needed to counteract her passive suicidal ideation and her struggle with loss of control. The CLP team emphasized cognitive reframing to instil hope and made special arrangements to reconnect her with family (such as facilitating a distanced visual visit), which had an immediate positive impact on her mood. In tandem with spiritual support (encouraging prayer and dhikr) and pharmacotherapy (low-dose bedtime benzodiazepine and initiation of sertraline for depression), these interventions gradually alleviated her despair and anxiety. Her case underscores the complexity of treating severe adjustment disorder in an elderly burn patient who is medically fragile and isolated, and it required a creative, multi-modal approach to restore her will to recover.

Discussion

Major burn injuries in older adults often precipitate significant psychological distress – ranging from acute delirium to longer-term anxiety and depressive symptoms.^1-3 In the context of consultation-liaison psychiatry (CLP), a holistic therapeutic approach is essential to address the complex emotional and cognitive needs of elderly burn patients.^12,15 Crucially, a burn injury is not only a personal trauma but also a family-centred experience, in which the roles, responses and participation of family members become integral to the patient’s recovery.^{10,11,19,20,21} This highlights the importance of involving families not just as visitors or passive supporters, but as active participants in care and rehabilitation planning, both during hospitalization and in preparation for postdischarge adjustment.^{12,14,17,21,22}

Supportive psychotherapy for elderly burn patients

In the burn unit setting, building a strong therapeutic alliance requires consistent, empathic engagement at the bedside amid intense pain and procedural stress.²³ Elderly burn patients often endure isolation (due to infection precautions or immobility), unpredictable pain levels, and repeated invasive treatments, which can foster fear and hopelessness.^1,2 Psychiatrists and therapists proactively addressed these challenges by simply being present during crises - for example, joining a patient during dressing changes to provide company and reassurance.^9,22,23 In Case 2, a therapist’s decision to sit beside the patient during light-sensitive periods (even fashioning an improvised eye cover) not only comforted her but also demonstrated concern for her well-being, laying the groundwork for trust.^9,23 Case 1’s alliance was strengthened by acknowledging his spiritual framework; early sessions began by honoring his prayers and framing the injury within his belief system, which helped him feel understood and supported.^9,22 Such approaches align with evidence that untreated acute burn pain and distress can lead to prolonged psychological sequelae (e.g. depression, PTSD) underscoring the need for early compassionate intervention.^1,18,22,23 By actively validating patients’ immediate struggles - whether fear of a painful debridement or frustration over lost independence - therapists converted moments of vulnerability into opportunities for connection.^9,22,23 These concrete acts of empathy and problem-solving (e.g. coordinating family assistance for a worried business owner) were key to establishing a reliable alliance in a high-stress medical environment.^{11,18,20,21,24}

Emotional expression and validation

Elderly burn patients frequently feel intense vulnerability and may hesitate to verbalize distress.^1,2 Supportive therapy therefore begins by inviting safe emotional ventilation.^9,22 Clinicians encouraged patients to share fears or guilt, even when these thoughts seemed irrational. In Case 3, for instance, the patient’s tearful declaration “just kill me” and complaints of abandonment were met with nonjudgmental listening.^1,25,26

This simple act of hearing her pain provided immediate relief and signaled that her feelings were valid. Therapists normalized these reactions (“Anyone in your situation would feel scared and alone”) and gently explored underlying worries.^9,22 Such empathic validation is crucial for older adults who might otherwise suppress distress to avoid burdening others.^1,22 In our series, giving each patient space to express sadness or anger (e.g. about body image loss or helplessness) allowed them to offload emotional tension. Over time, this built resilience: once patients felt heard, they became more engaged and open to therapeutic guidance.^18,24,25

Reassurance, suggestion and cognitive reframing

With a foundational alliance in place, supportive psychotherapy offered realistic reassurance and gentle cognitive reframing to counteract catastrophic thinking.^9,22 Burn patients often experience threatening thoughts about their future, autonomy, or meaning in life. For example, one patient anguished “My life is over because of these burns.” The therapist responded by reframing: “Your life has certainly changed, but you still have much purpose and people who care,” shifting the focus to recovery goals.^24,27,28 In Case 1, the patient initially blamed himself, seeing the accident as divine punishment. Through collaborative dialogue, this was reframed as a spiritual test of endurance, which significantly reduced his guilt and despair.^22,27

Similarly, Case 3’s feelings of loss of control were addressed by focusing on small, regained strengths (e.g. “You’ve managed to overcome so many hurdles already”). Therapists also offered practical reassurance: in Case 2, the woman’s concerns about her unattended shop were met by coordinating family help, relieving guilt and allowing her to focus on healing. Across cases, repeated clear and calm explanations (for instance, walking through the steps of an upcoming wound care procedure) alleviated fear of the unknown.^1,2,9,21-23 These interventions echo the supportive psychotherapy principle that therapists act as steady guides - using suggestion and grounded optimism to help patients reinterpret hopeless thoughts in a more adaptive light.^9,22 By consistently reinforcing each patient’s intrinsic strengths and support systems, the team restored a sense of agency even as patients faced functional decline.^9,22-25

Relaxation and guided imagery

In addition to verbal coping techniques, relaxation strategies, such as deep breathing exercises, progressive muscle relaxation and guided imagery, are introduced to help manage anxiety and pain in burn patients.^28-34 These methods can enhance the effectiveness of analgesics by reducing muscle tension and improving blood flow, which in turn alleviates distress and gives patients a greater sense of control over their treatment.^29-32

For older adults fearful of medical procedures, non-pharmacological techniques like guided imagery and relaxation can enhance a sense of control and ease procedural anxiety.^30-34 One patient notably imagined a familiar home routine during wound care, resulting in reduced distress. Such approaches have been shown to lower both anxiety and perceived pain in burn patients.^29-31,34,35

Accordingly, they are recommended as adjuncts to analgesic regimens as part of a comprehensive, individualized pain management plan.^6,36-38 Burn pain is multifaceted - encompassing background, breakthrough, and procedural pain - so an effective approach must be multidisciplinary and dynamic, addressing all three types of pain while incorporating techniques that increase the patient’s sense of control and well-being.^6,12,29-38 These relaxation and imagery interventions not only help manage the immediate pain and anxiety of procedures, but also empower patients (particularly the elderly) by actively involving them in their own pain management and recovery.^1,2,28-35

Delirium management and reorientation

Delirium is a common complication in elderly burn patients, often emerging within the first week due to infection, pain, medication, or sensory overload.^3-8 In such cases, supportive psychotherapy expands to include cognitive reorientation and environmental stabilisation.^5,39 Effective strategies involve gentle reminders of time, place, and purpose of hospitalisation, visible clocks and calendars, and structured routines. Ensuring access to sensory aids (e.g., glasses, hearing aids) and maintaining a calm, predictable environment can significantly reduce confusion.^6-8,39-45

The therapist, along with the broader care team, plays a vital role in containing fear and disorientation through repeated, simple explanations and consistent reassurance.^{6,9,22,27,39-44} Family involvement is also essential: familiar voices and faces help anchor the patient, and involving relatives in orienting conversations reinforces stability.^{6,19,21,46-48}. In our first case, these interventions, combined with low-dose haloperidol for agitation, resulted in resolution of delirium and restoration of emotional coherence. This case highlights how supportive psychotherapy, in conjunction with prompt medical management and the engagement of family and spiritual resources, can successfully navigate acute complications like delirium in elderly burn patients.^3-8,33,40-44

Family involvement and psychoeducation in elderly burn care

Burn injuries in the elderly are often experienced as collective trauma, affecting not only the patient but also their family. When the emotional distress of family members is not adequately addressed, it can intensify the patient’s psychological burden.^{11,19-21,42,46-48} A holistic consultation-liaison psychiatry (CLP) approach emphasizes early family involvement, not only as sources of emotional support but also as recipients of structured psychoeducation.¹² By providing families with knowledge and coping tools, the care team enhances their ability to support the patient, creating a more stable and empathetic healing environment.^19,21,48-51

Family presence and emotional support

One key intervention is encouraging family presence and comfort. Allowing and welcoming family members to be with elderly burn patients (as the medical condition permits) provides reassurance that the patient is loved and not alone in their ordeal. Frequent family visitation has been shown to significantly calm patients and reduce anxiety.^20,46-50 A recent trial found that structured daily family presence in a burn ICU significantly lowered patient anxiety levels and improved family satisfaction compared to minimal visitation.²⁰ For older patients who may feel especially vulnerable or fear being a burden, having loved ones at the bedside, even round-the-clock in shifts, can offer a sense of security and familiarity.^6,46-50

Case example: In one case, an elderly widowed business owner became increasingly anxious during recovery due to concerns about her store and feelings of isolation. The CLP team facilitated regular calls and arranged family visits in shifts. Their involvement not only reassured her emotionally but also helped manage her business, allowing her to focus on healing. In another case, a patient showed signs of depressive distress, wrongly thinking she had been abandoned. A brief, creative intervention, that is a visual visit from her son, quickly restored her sense of connection and improved her mood.

Family psychoeducation and empowerment

Family psychoeducation is a key component of CLP intervention in elderly burn care. By educating families about recovery processes, common emotional responses like delirium or mood swings and care-giving strategies, the CLP team reduces their anxiety and confusion, improving both patient support and overall care quality.^{12,46-48,50,51} Research shows that structured education decreases caregiver burden and enhances caregiving outcomes.^21,51 Interventions often include guidance in empathetic listening and providing orientation cues, such as date, time, or upcoming procedures, to help disoriented patients stay grounded.^{39,42,47,50,51} Moreover, addressing practical concerns (e.g., managing the patient’s business) reduces guilt and anxiety, as illustrated in the case of a widowed shop owner, and prevents premature discharge against medical advice.^11,21,50,51

Addressing family strain and dynamics

A holistic CLP approach remains sensitive to the psychological and practical challenges faced by the patient’s family during burn recovery. Even when treatment is covered by insurance, families still experience indirect financial strain, such as lost income and daily expenses, while accompanying the patient. Emotional burden may arise from caregiver fatigue, unresolved family tensions, or disagreements on care decisions, particularly in elderly patients.^11,19,50 The healthcare team proactively supports the family through counseling, psychosocial referrals, or peer support.^{11,19,21,46-51} When hospitals fail to provide sufficient guidance, families may feel overwhelmed; conversely, emotional support and clear information enhance their coping capacity and allow them to better support the patient.^19,21

By recognizing the family as a vital part of the patient’s recovery system, the CLP team actively involved them in decision-making, education, and emotional support. Research affirms that strong family engagement enhances physical healing, mental health, and quality of life in elderly burn patients, making them empowered partners in care rather than passive observers.^12,46-51

Spiritual coping and psychotherapy in elderly burn patients – literature support

Burn injuries in the elderly often provoke existential distress, including feelings of divine punishment, loss of dignity, and questioning of life’s meaning.^16,52,53 Addressing these spiritual concerns is critical, as studies affirm that supporting spirituality enhances emotional resilience, promotes post-traumatic growth, and improves coping.^14-17,52,54 Positive religious reframing, such as interpreting trauma as a test of faith, has been consistently linked to better psychological outcomes.^{14,15,17,52,54} In our case series, helping patients find purpose in suffering fostered emotional stability and strengthened their motivation to recover. For example, our first patient found comfort in believing that surviving the accident was a divine test of faith (a perspective that imbued his suffering with spiritual meaning), and the second patient similarly attained calm by continuing her routine of daily prayers (salat) and recitations (dhikr) from her hospital bed. These tailored spiritual interventions reinforced their emotional stability and coping during the recovery process.

Religious rituals also played a key therapeutic role. Enabling patients to perform prayer (salat), engage in dhikr, or use tayammum helped reduce anxiety and restored a sense of connectedness.^14-17 These practices, when respected and supported in hospital settings, have been shown to lessen pain, improve sleep, and enhance trust in care.^14,16,17,31 Notably, the patient in Case 3 who expressed hopelessness (“just kill me”) benefited from gentle re-engagement in religious coping. Her transition from despair to gratitude reflected the documented effect of spiritual meaning-making in reducing demoralization.^{14,15,52,54,55} Supporting religious needs through individualized interventions, such as aligning care with prayer routines and validating the permissibility of modified practices, was essential.

Spirituality is inherently influenced by cultural, ethnic and religious contexts. While prayer and dhikr served as key coping strategies in our patients, spiritual expression may vary widely across belief systems, traditions and personal experience.^56,57 Recognizing this diversity is essential for culturally sensitive care, as clinicians must tailor spiritual support to each patient’s worldview and preferences rather than apply uniform interventions.⁵⁷

Limitations and generalizability

This case series is limited by its small sample size and qualitative, descriptive nature, which restricts generalizability to wider populations. As the data were drawn from a single tertiary burn unit, the findings largely reflect a local institutional context and clinical culture. Nevertheless, these cases provide valuable preliminary insight into the integration of supportive psychotherapy, family involvement and spiritual care for elderly burn patients. Future multi-centre and mixed-methods studies are needed to explore the reproducibility of this holistic approach and to examine outcome measures more systematically.

Conclusion

In conclusion, this case series underscored the critical impact of a holistic consultation-liaison psychiatry approach in managing elderly burn patients. By integrating supportive psychotherapy, active family involvement and spiritual care, the multidisciplinary team effectively addressed the complex interplay of delirium, anxiety, depression and existential distress precipitated by burn trauma in older adults. Each case demonstrated that supportive psychotherapy - through empathic listening, emotional validation, cognitive reframing and relaxation techniques - helped alleviate acute psychological symptoms and strengthened the therapeutic alliance. At the same time, family participation provided essential emotional support and continuity, reassuring patients of their value and easing concerns (such as worries about home or business) that could hinder recovery. Spiritual interventions further empowered patients by honouring their faith and meaning-making processes, transforming despair into hope and imbuing suffering with a sense of purpose.

Overall, the CLP-guided holistic psychotherapeutic model facilitated notable improvements in mental status, coping and engagement in rehabilitation for all three patients. Delirium was successfully managed with a combination of reorientation strategies, low-dose medication and family presence, while adjustment disorder symptoms markedly abated as patients found comfort in family support and spiritual practices. This comprehensive approach highlighted the importance of treating not just the burn wounds but the whole person - mind, body and spirit - especially in vulnerable geriatric populations. By proactively addressing psychological and spiritual needs alongside medical care, the CLP team fostered resilience, improved treatment adherence, and enhanced overall quality of life during a challenging recovery. These cases advocated for holistic, family-centred and spiritually sensitive psychotherapeutic interventions to become a standard component of burn care for older adults, illustrating how collaboration between burn care specialists and CLP professionals can optimise outcomes in this high-risk group.

Future studies with larger and more diverse samples are warranted to validate and extend these findings, ensuring that holistic CLP models can be adapted effectively across varied healthcare and cultural settings.