Diversity in CBT Work
The Oxford Dictionary defines diversity as ‘the state of being varied’. In fact, each human being is different from any other, given the wide range of nature- and nurture-related variables that each of us comprises.
However, people are often notionally grouped – for example, the Equality Act 2010 identifies nine ‘protected characteristics’ (on the basis of which discrimination is illegal): age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership, and pregnancy and maternity.
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Diversity in CBT Work
Importance of the Core Conditions
While these elements can strongly influence how we see ourselves and the world, we must never assume as therapists how a client identifies themselves: it is always important to work with empathy to enter the client’s frame of reference – that is, to consider fully the client’s idiosyncratic way of thinking and behaving (and so feeling).
Since effective CBT relies on identifying and evaluating thoughts and behaviours, understanding how the individual client thinks is vital. While their apparent group might offer possible clues to this, we must not make assumptions.
Moreover, diversity may exist at all levels of cognitions – core beliefs (schemas), rules for living and negative automatic thoughts (NATs) – as well as behaviours.
Once we have used empathy to understand the client’s way of thinking and behaving, we must respond with unconditional positive regard (UPR) – never judging a client for their difference from us or any way of living that is more familiar to us.
Similarly, each therapist has their own way of viewing themselves and the world – it is important that we understand the impact that our own heritage and experience has had on this, and to maintain good awareness of this when working with clients.
As Sanders et al. (2009. p.26) state, ‘distress is a culturally constructed concept’. Although ‘the symptoms of mental disorders are found worldwide’ (NIMH, 2001: pages unnumbered), the way these are categorised and therefore defined may vary markedly between cultures.
In Western cultures, mental health care is embedded in science/medicine, which stresses the importance of objective, statistically significant evidence (e.g. from randomised controlled trials: RCTs) in defining conditions and determining appropriate treatments.
Other cultures may see symptoms of emotional distress differently. For example, Leach (2017: pages unnumbered) writes:
‘But what if an individual said they could hear the voices of their dead ancestors or reported that they had been temporarily abducted by aliens? Would they be considered ‘mad’ or believed? The answer to that question might depend on whether they lived in Europe, Africa or America.’
While CBT fits with – and is derived from – the Western scientific culture (e.g. having a solid research base and so being promoted by the National Institute for Health and Care Excellence: NICE), it is in fact flexible in its applicability to different cultures.
For example, Seligman (2006. p.383) points out that CBT offers ‘a large repertoire of interventions to address almost any concern’ and is ‘not intrusive’ (through not emphasising ‘the unconscious, the early years of development, or the covert meanings of dreams and body language’).
Various studies have evidenced the effectiveness of CBT with multicultural groups, e.g. reducing depression in low-income young African American and Latina women (Miranda et al., 2003), and PTSD in Cambodian refugees (Hinton et al., 2009).
Young (2006, pp.26–p27) noted that research has pinpointed schema triggering to certain areas of the brain – so demonstrating that biological factors influence clients’ patterns and schemas.
Because the amygdala (the part of the brain responsible for the fight, flight or freeze response) stores emotional memories (e.g. those acquired through experiencing trauma), it can activate without the cognitive systems. This means that clients’ schemas may be beyond their conscious control.
Other possible biological factors influencing clients’ patterns and schemas include genetic predisposition, substance addiction, disability, family position (vis-à-vis number of siblings), sexual orientation and gender.
Social factors (e.g. social status, living arrangements, involvement in social media, and attachment history) also influence schemas.
These are reflected in the idiosyncratic predisposing, precipitating and protective factors that we include in the CBT formulation.
This information can be used to help us empathically understand the client’s experience to date (i.e. from the client’s phenomenological perspective), and hence to tailor our overall approach and specific interventions to the needs of the client, so improving the likelihood of CBT being an effective treatment for the client.
Tailoring Therapy to Idiosyncratic Needs
When assessing a client and producing their initial formulation, it is therefore important to be sensitive to the issues of diversity relating to that client – and also not to make assumptions about them based on any given aspect of their diversity.
For example, two Afro-Caribbean men of the same age may have very different problems as a result of their experiences to date.
As Beck observed (1976, p.27–28):
‘The therapist must adapt his own personal style so that it meshes with that of the patient … Although correcting unrealistic automatic thoughts is an important element in treating a patient, the totality of the meaning of the patient’s experience is crucial. At times, the meanings people give to a situation may not be formulated but rather will have to be drawn out by the therapist.’
Creativity is a key skill in this, as we adapt our interventions to fit the idiosyncratic needs of each client.
Just as each client is unique, so their needs are similarly diverse – and as therapists, we should be sensitive to each client’s idiosyncratic needs in order to maximise the possibility of their completing their course of CBT sessions.
Barriers to CBT
Some aspects of diversity may prevent clients from accessing CBT at all, while others make it more difficult or slow for them to do so.
For example, if a client can afford private therapy, they are likely to be able to access CBT far more quickly and at a wider choice of locations than is available for those needing free or low-cost therapy, e.g. through the local IAPT (Improving Access to Psychological Therapies) service or counselling charities.
Also, many IAPT services structure their stepped-care model in a way that expects clients to try online and/or group sessions before being able to have one-to-one sessions.
Some people may in effect be excluded from these services by, for example, not being familiar with or having access to a computer (e.g. older people who have not encountered computers in their work and do not have one at home) or struggling with social anxiety (e.g. those with a social isolation schema).
Most initial assessments for IAPT take place over the phone too, which may pose difficulties for clients who are hard of hearing or do not have a private place to receive phone calls.
Other factors that might prevent clients accessing CBT include:
- race and culture (e.g. some ethnic groups believe that problems should not be shared with people outside the family network)
- ignorance of what CBT is
- personal pride (feeling they should be able to sort out their own difficulties)
- denial/distortion of problems
- preference for a therapist of a particular gender or background
- work patterns
- bad past experience of therapy
- transport issues (e.g. reliance on public-transport routes)
- carer responsibilities
- where they live (sometimes referred to as the ‘postcode lottery’)
A report by NICE (2019) – NICE Impact Mental Health – declares a commitment to improving access to psychological therapies, and to people’s choice and control over their care.
It adds that increasing access to evidence-based psychological therapies for people with common mental health conditions is a priority in the Five Year Forward View for Mental Health and the NHS Long Term Plan.
Providers of CBT services need to be aware of the wide range of potential barriers, and to be open to flexibility in adapting services to meet the needs of their local population, offering a service that is as adaptable as possible to idiosyncratic needs instead of offering a ‘one-size-fits-all’ service.
For example, while online CBT may be highly appropriate for self-motivated and computer-literate people who cannot easily access physical premises for face-to-face therapy (e.g. due to disability or to remote place of living), it would also be important to offer the service in a different way for those who are less comfortable with technology (or perhaps to team up with an IT-training programme to help them acquire the skills, if they would like to do so).
Similarly, people struggling with depression may not have the motivation to undertake online therapy, which depends on a reasonable level of motivation and self-organisation.
Telephone counselling is another option that can be highly convenient for some and not at all desired by others.
The modality of CBT is well suited to people who cannot easily access therapy as it provides psycho-education and teaches them a model that helps them not only understand the origins of their difficulties (and so have more self-compassion) but also learn how they can break maintenance cycles using CBT tools and techniques.
Thus, they become their own therapists, reinforcing their autonomy and making them less dependent on the availability of therapy in future.
In fact, CBT is well placed to be applicable to clients of different cultures as CBT therapists neither themselves diagnose emotional disorders by name (as this is generally the preserve of doctors) nor dictate to the client what their problem is.
Instead, they focus on thoughts, feelings and behaviours – features of human life common to us all in one form or another – that the client themselves identifies as unhelpful to their mental wellbeing.
So long as clients are suitable for CBT – for example, as assessed by Safran and Segal’s Suitability for Short-Term Cognitive Therapy Rating Scale – they can receive effective treatment, regardless of their culture.
However, it is possible that some cultures might make a client less suitable for CBT, for example if working collaboratively does not naturally fit with their cultural model.
In this case, signposting them towards self-help resources (of which many exist in the area of CBT – for example, Greenberger & Padesky’s Mind over Mood book (1995), and the website www.getselfhelp.co.uk) may be helpful.
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Diversity in CBT Work
Beck A (1976) Cognitive Therapy and the Emotional Disorders, International Universities Press
Greenberger D & Padesky C (1995) Mind Over Mood: Changing How You Feel by Changing the Way You Think, Guilford
Hinton D, Hofmann S, Pollack M and Otto M (2009) ‘Mechanisms of Efficacy of CBT for Cambodian Refugees with PTSD’, CNS Neuroscience and Therapeutics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494047/
Leach, J (2017) Cultural Differences in Mental Health?, OpenLearn: https://www.open.edu/openlearn/body-mind/health/cultural-differences-mental-health
NICE (2019) NICE Impact Mental Health, NICE
NIMH (2001) Mental Health: Culture, Race, and Ethnicity, National Institute of Mental Health: https://www.ncbi.nlm.nih.gov/books/NBK44249/
Miranda J, Chung J, Green B, Krupnik J, Siddique J, Revici D et al. (2003) ‘Treating depression in predominantly low-income young minority women: A randomized controlled trial’, The Journal of the American Medical Association
Sanders P, Frankland A and Wilkins P (2009) Next Steps in Counselling Practice: A students’ companion for degrees, HE diplomas and vocational courses, PCCS Books
Seligman L (2006) Theories of Counseling and Psychotherapy: Systems, Strategies, and Skills, Pearson Prentice Hall
Young J, Klosko J & Weishaar M (2006) Schema Therapy: A Practitioner’s Guide, Guilford Press