How did you become interested in culturally responsive CBT?
Initially, I had more of an interest in languages and cultures, and I knew to study languages I would have to move places and be immersed in cultures. After high school I started moving places where I could study different languages. I moved to New Mexico for a couple of years and then overseas. I attended the University of North Wales for a year and lived in France for a year, studying Spanish and Welsh and French.
The other piece was that I wanted to be in a helping profession. I wanted to have some sort of skill where I could actually be helpful to people, and that’s where the psychology piece came in. I found a clinical psychology doctoral program at the University of Hawaii that was very strong on connecting cultural issues and influences to psychology and clinical psych in particular. Another big influence was meeting my former husband when I was in France. He’s Tunisian and he immigrated back to the US with me. He is Arab and Muslim and North African, and living with him for 16 years in the US during many of the political things that have gone on influenced me as well.
Our trainees frequently ask us whether CBT is effective and appropriate for Black, Indigenous, People of Color and individuals with diverse identities. What is the historical context for this concern? In your opinion, what sort of steps should we consider as a CBT community and a field to improve the experience and treatment outcomes of clients with diverse identities and experiences?
I’ll address the historical concern first. The kinds of problems I see with CBT are the same problems with psychology in general. All the major psychotherapies were developed by a very homogeneous group of people, primarily people who were White, male, able-bodied, heterosexual, and of Christian or secular heritage. As a result, they had a particular perspective in the world. The assumptions and values that were embedded in their perspectives weren’t challenged by people of other cultures or backgrounds. So that’s a problem in psychology in general, and it’s trickled down into psychotherapy in many forms.
One of these forms is the emphasis we have on particular practices, approaches, and values— for example, the emphasis on individualism. Psychotherapy in general has been more geared towards individual therapy. We do have family and couples approaches, but I would say in general, most of the approaches are geared towards individuals. We also tend to place value on assertiveness over harmony, and value the individual well-being over community well-being— those are just a few examples.
With CBT in particular, there are some specific limitations. I’ll talk about those in the workshop, but one example is CBT’s focus on the present. The limitation or challenge with that is that we have to remember to think about cultural histories that profoundly affect people, both in terms of negatives and positives. Generational traumas have been passed down, and generational strengths and supports have been passed down too. That’s something in CBT that we need to be especially careful to look for.
Having said all that, I find the limitations really interesting. I don’t mind when people bring up criticisms or say, “I don’t think that’s going to work with people of my culture.” I say, “Okay, let’s look at that. Why not? Let’s figure out a way to make it work better.” The way I approach CBT is not to look at it in such a rigid way, but rather how to make CBT fit whomever it will help.
With regard to working with people of color and Indigenous people, and what can be done more generally to level the playing field and make therapy and CBT in particular more helpful to more people: There is a lot going on right now, compared to when I started graduate school. We’ve got increasing numbers of graduate students who are people of color, who are gay and transgender, and they’re bringing new perspectives into the classrooms. They challenge their professors— who are still predominantly homogeneous— to be more inclusive and that in turn challenges researchers to study approaches that apply to a broader range of people. We need mentoring and learning on the parts of supervisors and professors who are members of the dominant culture. When I use the phrase “dominant culture,” I’m talking about White people predominantly, but also people who are heterosexual, and able-bodied, and people who are of Christian or secular heritage who don’t know anybody who’s Muslim or anybody who’s Buddhist. We need to broaden awareness.
Of the barriers I see right now to diversifying the field of psychology, one of the biggest is money. It just costs so much to go to graduate school. We have to find a way around that. I also see logistical barriers, social barriers, and physical barriers. People with disabilities are very underrepresented, too. And then you talk about people who have multiple intersecting identities— for example, people of color who have disabilities. There are just so many obstacles stacked against them, structural things that are embedded in society and in the field.
Frequently, clients come to seek support and treatment as a result of oppressive context, such as discrimination or racism. Can CBT, as a modality, be helpful to these clients? If so, what clinical adaptations might be most important?
I think it’s ironic that CBT has its roots in behavior therapy because behavior therapy was all about environment. All these -isms—racism, sexism, heterosexism, ableism, ageism— are about social and physical environments. And yet, because the field of behavioral and cognitive behavioral therapy has been so homogeneous, members of the dominant culture didn’t pay attention to these things. Now people are paying attention and beginning to say, “We need to look at these structural barriers in addition to what’s going on in a person’s mind.” It isn’t all about what a person thinks. It’s also about what’s going on in the larger environment and in the therapy setting. Even the identity of the therapist and the identity of the client and the interaction of those identities— they all have meaning.
Structural systems of oppression and privilege affect the coping strategies available to people. We need to take these into account, and I do see CBT as being able to do that. We have to pay very deliberate attention to environmental influences. We can also use CBT to look at internalized beliefs and thoughts. We know that that racism, sexism, and heterosexism can be internalized in the form of self-talk. It can be very hurtful and harmful to people, and CBT can be helpful in that regard.
One example of how I modify CBT, is with what I call the prevention of premature cognitive restructuring. Because there’s such an emphasis on the cognitive with CBT, if you don’t understand the person’s larger environment and the systems they live in, it can be easy to jump right into trying to change their thinking about it. To give you a concrete example, say I’m White and a Black client comes to me and tells me that he’s experiencing racist comments from a particular colleague. If I say to that client, “Are you sure that that was racist? Are you sure they didn’t mean it a different way?” that would be perceived as naive and really off the mark, and I’d probably just completely lose the client. One thing that therapists need to be doing is really paying attention to and validating the experiences of members of marginalized groups who are talking about these kinds of oppressive experiences.