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THE BECK INSTITUTE
CLINICAL CONVERSATIONS
When my father, Aaron T. Beck, MD, developed cognitive behavior therapy (CBT) in the 1960s and 1970s, most research in the social sciences was being conducted on college students—who were overwhelmingly male, middle- to upper-class, and of European descent. Since then, it has been rightly observed that much additional work was needed to adapt CBT not only for a range of psychiatric disorders and psychological problems, but for a range of populations including individuals from diverse cultures, backgrounds, and racial identities. Over the last 6 decades, much work has been done to make CBT more widely applicable—and Janeé M. Steele, PhD, has contributed significantly to the literature with her book Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing. I recently sat down with Dr Steele to learn more about how clinicians from all backgrounds can not only address issues of race in session, but empower Black clients with a sense of personal pride in their identities.
Judith S. Beck, PhD: Research shows that Black Americans who have been exposed to racism often experience depression, anxiety, trauma, and low self-esteem. How is CBT particularly well-suited to empowering Black Americans to overcome these challenges?
Janeé M. Steele, PhD: A growing body of research documents the effectiveness of CBT for racially diverse populations, including Black Americans. Yet CBT has historically been viewed as somewhat limited in its applicability to people of color. For example, one limitation of traditional CBT when working with Black clients who have experienced racism may be inadequate attention to oppressive systems and other societal influences that contribute to the client’s problems. This is limiting because without attention to these influences, clients may feel as though they are being blamed for their problems, leading to negative outcomes including worsened symptoms, dissatisfaction with therapy, or early termination. However, with appropriate cultural adaptations, CBT may significantly benefit clients who are dealing with the psychological impact of racism by helping them see the ways they are internalizing negative messages they receive about their racial identity and teaching them strategies to manage this and other harmful effects of racism such as depression, anxiety, and trauma.
In my recent book, Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing, I describe a case that illustrates this point. Michelle was a 37-year-old Black woman with performance anxiety. As the only person of color at her job, she worried excessively, and often experienced worsened task performance while being observed by her supervisor and coworkers. Early in therapy, I was intentional in asking questions about the impact of race on her situation and she confirmed that some of her concerns were about being falsely labeled by negative racial stereotypes. In response, I approached CBT with the goal of being sensitive to Michelle’s lived experience as a racial being. I enhanced psychoeducation to include information about culture-specific factors of anxiety such as stereotype threat, which refers to worsened performance due to the fear of negative stereotypes about one’s social group. I was careful to avoid questioning that would imply Michelle’s concerns about being the only person of color at work were irrational or distorted.1 I also helped Michelle modify the negative self-appraisals she developed in response to her situation, and she learned how to engage in feared situations while affirming her racial identity and attributing her anxiety to stereotype threat rather than personal deficits.
As shown in the case of Michelle, with appropriate cultural sensitivity, CBT may offer clients insights into specific ways racism contributes to their problems. It may also help them gain new strategies to cope with or even challenge racism and its psychological effects. Beyond this, other aspects of CBT make this form of therapy especially useful in addressing the psychological distress, sense of powerlessness, and internalized anti-Black attitudes that may occur as a result of racism.2 These include CBT’s emphasis on personal empowerment, its attention to client strengths and support systems, and affirmation of one’s own sense of identity. The active, problem-focused, and time sensitive nature of CBT also furthers its usefulness.
Beck: What are some of the ways that providers need to adapt CBT to help Black clients address negative core beliefs that have resulted from experiences of discrimination or racism?
Steele: One manifestation of racial oppression I frequently encounter during therapy is internalized racism. Internalized racism refers to self-hatred that develops because of one’s conscious or unconscious belief in the inferiority of their racial group. From a CBT perspective, this equates to hurtful and stigmatizing core beliefs in which individuals devalue themselves or other members of their race. In Racism and African American Mental Health, I highlight several themes I have seen reflected in core beliefs associated with internalized racism. These themes include inferiority, inadequacy, personal blame, powerlessness, and belief in a just world. Following a longitudinal conceptualization of cognitions, these core beliefs often result in maladaptive rules for living and are frequently associated with avoidance or numbing coping strategies to compensate for the perceived deficits reflected in each core belief.
Let’s return to the case of Michelle once more to illustrate what negative race-related core beliefs might look like in a client experiencing internalized racism and how a clinician might address these beliefs using CBT. Recall that Michelle experienced performance anxiety on her job due to fears of confirming negative racial stereotypes about Black individuals. Recognizing the need to deconstruct the role of race in her thinking, I used Socratic questioning to learn more about the negative racial stereotypes to which she had been exposed and her reactions to these stereotypes. Some examples of the questions I asked included, “What are the stereotypes associated with being Black?” and “How do these stereotypes affect the way you see yourself and people in your racial group?” I then continued this dialogue asking questions such as, “How did you learn these stereotypes?” and “Where did these stereotypes come from?” to learn more about salient life and cultural experiences that brought these stereotypes into her awareness. Michelle shared that she was primarily concerned about being viewed negatively because of stereotypes that Black individuals are lazy and unintelligent. She reported learning about these stereotypes mostly through her elementary school experience, where she and other Black children were isolated and subjected to insensitive comments. Michelle added that Black individuals are also frequently portrayed according to these stereotypes on TV and in the media.
Upon learning about the significance of Michelle’s elementary school experiences, we examined one specific situation from this time in her life, and I used a traditional CBT intervention, the downward arrow technique, to uncover one of her negative race-related core beliefs: “Black people don’t fit in.” We then worked on modifying this belief to reflect something that would be more functional. Acknowledging that Black individuals who live in their authentic selves often do not fit into dominant cultural standards, I was careful to approach this task in a way that honored her experiential reality. This meant that I did not ask Michelle to examine the evidence for and against her core belief, as this might have invalidated her experience and potentially led to a cultural rupture in the therapeutic relationship. Instead, Michelle and I focused on developing a new core belief that was as absolute as the old belief and would allow her to feel confident despite demeaning messages received from society. She eventually arrived at the new core belief, “Black people are valuable,” which she strengthened using strategies such as a positive data log and a historical review of experiences leading to the old belief.
Beck: Some providers may feel hesitant to discuss racial issues in session, especially if they have not personally experienced racism. How can providers of European descent approach issues of race and racism with Black clients?
Steele: New directions in psychology suggest that in addition to cultural humility, taking opportunities to discuss racial issues in a therapeutic setting that feels safe to the client is a critical feature of a multicultural orientation in therapy.3 Unfortunately, many clinicians, especially providers of European descent, may experience challenges while discussing issues of race and racism. One major challenge is discomfort due to feelings of apathy, guilt, and vulnerability that arise while discussing race. Another challenge is fear of offending clients when initiating these discussions, especially if one has been socialized to believe that discussions about race are rude or embarrassing.
Use of CBT strategies during supervision, consultation, or through one’s own reflective practice can help clinicians become more comfortable approaching issues of race and racism with Black clients. For example, applying the cognitive model can help clinicians target the central thoughts interfering with their ability to initiate discussions about race, ethnicity, and culture. This may be done by asking oneself questions such as, “What is going through my mind, what am I thinking?” “What is upsetting about this thought?” and “What emotions do I feel?” Clinicians may also use a strategy such as the sideways arrow technique4 to explore their thoughts at a deeper level, asking questions such as “What am I worried will happen?” “If that were to happen, what am I concerned would happen?” and “If that were to happen, what is so bad about that?” A clinician working with Michelle, for example, might be worried about broaching race and saying something upsetting. The clinician might then think that this, in turn, could produce a rupture in therapeutic relationship that would cause Michelle to have negative feelings, limit her disclosure, or in a worse-case scenario, lead to premature termination. The clinician might worry that this, in turn, would cause negative feelings like embarrassment or guilt.
Once the clinician has identified thoughts that interfere with approaching issues of race and racism with Black clients, they can work with them using CBT strategies such as advantage/disadvantage analysis to explore the advantages and disadvantages of holding onto vs changing their beliefs about discussing race. They could also use decatastrophizing questions such as “What’s the worst that could happen?” and “What could you do then?” or questions to gain distance such as “What would you tell another clinician in this situation?” to address these beliefs. There are also strategies clinicians can use to more skillfully approach the actual task of addressing race during therapy. For example, clinicians can use a tool such as the Cultural Formulation Interview5 during the intake process to learn more about how the client believes race influences their problems and ways of coping. To facilitate safety in the relationship, clinicians can also verbalize cultural differences and power differentials within the therapeutic relationship and acknowledge limitations in understanding due to their cultural worldview.
Beck: What are some important considerations in developing a strong therapeutic relationship with Black clients?
Steele: When working with Black clients, the clinician’s ability to build strong therapeutic relationships is critical to the process of change—given stigma contributing to the underutilization of mental health services in the Black community, the sensitive nature of race and racism, and the amount of vulnerability required to discuss these topics. Because of the historical legacy of racism in formalized systems of help, some Black individuals are reluctant to attend therapy. Moreover, due to spiritual beliefs which interpret the use of therapy as a lack of faith in God and familial strictures against the public airing of one’s dirty laundry, personal fortitude and reliance on prayer or the church when external help is needed may be preferred methods of coping compared with professional help-seeking. Therefore, at a minimum, clinicians should use basic counseling techniques throughout therapy to develop a bond that is perceived as secure, warm, and friendly to establish safety in the therapeutic relationship. This includes use of encouragers such as head nods and facial gestures, as well as skills such as empathy, probes, reflection of feeling, and open-ended questions. Clinicians should also be proactive in addressing race during therapy, as failure to do so may be viewed as a racial microaggression.
In addition to use of the counseling techniques, clinicians working with Black clients on issues related to racism should also be intentional in their use of validation. Validation refers to the clinician’s ability to communicate that they understand the client’s reactions and that these reactions make sense given their life context or current situation. Within society, denial of racism is one of the ways anti-Black attitudes and discriminatory practices are covertly promoted and upheld. Denial also adds to the psychological distress Black individuals experience as a result of negative race-based encounters, contributing to confusion about what occurred, and later on, shame for not standing up for oneself. Accordingly, taking the time to validate Black clients’ perceptions of these events can be cathartic because it confirms that their experiences are real and that their reactions are reasonable. In the case of Michelle, for example, I sought to validate her experience by acknowledging that we live in a society where racist events occur, with a statement such as “It makes sense that you would experience anxiety as a result of these stereotypes; they are common and they are unfair,” and recognizing the difficult emotions that arise in the face of her experiences with another statement such as, “Thank you for trusting me enough to share something so painful.”
Beck: What is the importance of expanding the focus of treatment beyond symptom reduction to cultivate racial empowerment and a sense of pride in one’s racial identity, and how can providers create opportunities for clients to strengthen positive beliefs related to race?
Steele: Empowerment and pride in one’s racial identity are essential components of healing from the effects of racism. Empowerment, which broadly consists of critical consciousness and committed social action, helps individuals view their experiences as part of a collective struggle, which in turn, promotes a greater sense of connectedness to the community, resistance, and agency. Similarly, racial pride, which refers to a sense of self-confidence derived from admiration of the history, strengths, and accomplishments of Black individuals, serves as a protective factor against the effects of racism, contributing to less race-based stress and greater overall psychological well-being. Accordingly, expanding the focus of treatment to include the cultivation of racial empowerment and pride in one’s racial identity actually aids the reduction of symptoms by mitigating the sense of powerlessness clients feel in response to racism and lessening the internalization of demeaning, anti-Black messages they receive from society.
In Racism and African American Mental Health, I describe several interventions clinicians may use to increase critical consciousness, encourage social action, and facilitate racial pride. Bibliotherapy using the structured approach developed by Hynes and Hynes-Berry,6 for example, is one strategy clinicians may use to help clients expand insight into their experiences with racism by providing opportunities to explore what was learned from passages within the book and the personal feelings that arise. With guided discovery, CBT clinicians can also use this exploration to uncover maladaptive beliefs that can be modified using information learned from the book to influence future beliefs, attitudes, actions, and ways of being. Some of the questions I provide in Racism and African American Mental Health to guide this process include, “Which passages helped you gain a deeper understanding of yourself and/or the world around you?” “When have you experienced situations similar to the situation connected to the passage you identified?” “What beliefs or ideas are challenged by the passage you identified?” and “How do these insights change how you see yourself/the world around you?”
Judith S. Beck, PhD
Beck: Thank you so much Dr Steele for your time and for your tireless work in advancing and advocating for culturally adapted CBT with Black clients. There is no doubt that your work will benefit many!
Dr Beck is president of Beck Institute for Cognitive Behavior Therapy in Bala Cynwyd, Pennsylvania, and a clinical professor of psychology in psychiatry at the University of Pennsylvania in Philadelphia.
Janeé M. Steele, PhD
Dr Steele is a licensed professional counselor and certified CBT therapist, as well as a member of the core faculty at Walden University. She is also the co-author of the book, Black Lives Are Beautiful: 50 Tools to Heal From Trauma and Promote Positive Racial Identity, and author of the book, Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing.
References
1. Graham JR, Sorenson S, Hayes-Skelton SA. Enhancing the cultural sensitivity of cognitive behavioral interventions for anxiety in diverse populations. Behav Ther (N Y N Y). 2013;36(5):101-108.
2. Hays PA, Iwamasa GY, eds. Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, and Supervision. American Psychological Association; 2006.
3. Hook JN, Davis D, Owen J, DeBlaere C. Cultural Humility: Engaging Diverse Identities in Therapy. American Psychological Association; 2017.
4. Waltman SH, Codd T III, McFarr LM, Moore BA. Socratic Questioning for Therapists and Counselors: Learn How to Think and Intervene Like a Cognitive Behavior Therapist. Routledge; 2021.
5. Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Association; 2013.
6. Hynes AM, Hynes-Berry M. Bibliotherapy—The Interactive Process: A Handbook. North Star Press; 1986.