KEY POINTS

• Therapy is a collaborative, dynamic process, and being culturally competent as a therapist requires constant attention.
• Cognitive-behavioral therapy (CBT) may imply that negative thoughts are incorrect, which can be invalidating to those experiencing oppression.
• CBT techniques such as exposure therapy or behavioral activation should be adapted for people in experiencing forms of oppression.

In a previous post, I talked about how cognitive behavioral therapy traditionally focused on fairly privileged groups (educated, rich/higher income) and how this therapy has been adapted to those who are less privileged. In this post, I want to address how cognitive behavioral therapy has to be adapted for people who experienced forms of oppression such as racism, misogyny, and ableism. While I will talk about cognitive behavioral therapy, some of the general principles will apply to other forms of therapy.

For those new to cognitive therapy, the typical techniques involve identifying negative, automatic thoughts and trying to come up with more realistic alternative thoughts. Implicit in this technique is the idea that the automatic thoughts are incorrect or at least exaggerated. However, for someone who has experienced some form of oppression, this can be invalidating. So instead of challenging thoughts about the truth of the experience or the intent of the other person, cognitive therapy would need to focus on the meaning of those experiences and not internalizing the oppression.

Since this is very abstract, let’s take an example. A black client goes to the store to buy groceries and is asked for identification even though they are not buying anything that requires identification. The client notices that no other customer is asked for identification, even those buying alcohol. The client might reasonably think “That’s racist, they think I stole this credit card.” Now cognitive therapy would not necessarily focus on reappraising that thought about the clerk’s intent. Instead, the therapist might work with the client to identify cognitive distortions in the other person (jumping to conclusions) and finding ways to counteract those thoughts so the client does not start to believe the other person’s cognitive distortion.

Another way that cognitive therapy would need to be adapted for people experiencing oppression is acknowledging that some negative thoughts are realistic. For example, someone with a progressive form of multiple sclerosis would expect their disease to continually worsen. This client would reasonably expect that others might not react well to their progressive disability. Instead of reframing the thought, cognitive therapy might focus on how to cope with these potential outcomes so the client can feel prepared as their disease worsens.

The behavioral part of cognitive behavioral therapy also needs to be adapted for those experiencing oppression. One technique for anxiety is exposure therapy in which a client gradually engages in situations that provoke anxiety. For someone with a medical condition or disability, that fear for certain situations might be valid and the activities need to be either modified or therapy should focus on building coping skills instead. For example, exposure therapy for social anxiety might involve having someone ask an acquaintance for help moving something. If the person has an invisible medical condition or disability, this activity might lead to mistreatment because the acquaintance does not believe the person is actually disabled or needs help because the disability cannot be seen. For this client, the activity of asking for help moving something would be substituted with another experience, such as asking someone for directions.

Another behavioral part of cognitive behavioral therapy is behavioral activation. Behavioral activation involves engaging in pleasant activities or activities that give a sense of accomplishment as a way to treat depression. However, for people with few financial resources, the options for activities could be limited. People with few financial resources may also need to spend a large amount of time working or commuting (sometimes called super commuting). This could limit the possibilities for behavioral activation.

I have only covered a few of the many ways that cognitive behavioral therapy, or therapy in general, should be adapted for people experiencing forms of oppression. Therapy is a collaborative, dynamic process, and being culturally competent as a therapist requires constant attention. Therapists, cognitive behavioral and otherwise, should be aware of how to alter their therapeutic approach based on a client’s unique experiences and needs.