Cognitive behavioral therapy (CBT) is effective across disorders, yet its cultural adaptability remains under-theorized and inconsistently evaluated. This review examines how cultural adaptations of CBT are designed, evaluated, and interpreted across epistemological paradigms. We conducted a PRISMA − guided systematic review of empirical studies on culturally adapted CBT (CA-CBT) published between 2014 and 2024. Searches were conducted in Scopus (final search: 15 February 2024). Eligible studies were coded using a structured extraction matrix and analyzed via reflexive thematic analysis within a cross-paradigmatic framework. Most studies adopted a positivist orientation (74 %, n = 26), with fewer interpretivist designs (26 %, n = 9) and none explicitly critical. Across settings, cultural adaptation was generally associated with improvements in symptoms, engagement, and retention – particularly when deep-structure modifications, such as integrating religious frameworks, culturally resonant metaphors, and community participation, were implemented. Effects varied by population and context, underscoring heterogeneity and the need for cautious interpretation and careful implementation. Interpretivist contributions illuminated cultural safety, therapeutic alliance, and identity restoration – dimensions rarely captured by symptom metrics. Overall, the findings support reframing cultural adaptation as a transformative process rather than a peripheral technical adjustment. We offer a pragmatic framework that aligns empirical rigor with cultural legitimacy and, with attention to structural responsiveness, to inform research design, therapist training, and policy aimed at context-responsive and equitable CBT globally.