CBT May Not Be the Best Fit For Black Patients Seeking Therapy

Racial disparities often lead to poor mental health. Now, a study published in Cognitive Behaviour Therapy found that cognitive behavioral therapy (CBT) may not be the best fit for Black patients seeking therapy.

Researchers assessed therapists’ judgments of the appropriateness of different clinical CBT strategies to treat depression in Black and white patients.

They found that therapists thought cognitive change strategies were better suited for white patients while validation techniques were more aligned with the needs of Black patients.

Given how extensively CBT approaches tend to be used, these findings should inform best therapy practices for working with Black clients.

Understanding the Research

Researchers recruited 218 North American therapists who found that validation strategies were deemed more crucial than cognitive change strategies for Black clients.

Researchers rated cognitive change strategies as equally important and impactful for white clients, and therapists with positive racial attitudes judged both cognitive change and validation strategies as therapeutic for Black clients.

Since study recruitment was limited to the U.S. and Canada and the sample of therapists was predominantly white (84.4%), it should be noted that there are limitations to the study.

Discrimination May Be At Play

Deidra Thompson, DNP, FNP-C, PMHNP-BC, faculty member of Walden University’s MSN Psychiatric-Mental Health Nurse Practitioner program says, "Cognitive behavioral therapists guide patients in reframing negative, maladaptive thoughts into more positive ones."

Thompson suggests that therapists should avoid challenging minority patients’ thoughts and beliefs, and recommends validating them instead.

Therapists may fear that using cognitive change strategies for Black patients would cause them to feel that they are not being heard or that their experiences are not being understood.

Cognitive behavioral therapy can be an effective treatment for depression, anxiety, and insomnia, and Thompson notes that the way in which one cognitively appraises an event can have a significant impact on mood.

She explains, "Reframing the cognitive process into a more adaptive thought process while implementing positive coping skills can build resilience. This can help one to adapt to challenging situations and maintain an acceptable level of functioning in the face of adversity." 

Discrimination may play a role in therapists not believing that the same therapeutic techniques work for all, as Thompson notes how a 2008 study found that physicians were more likely to recommend home care rather than hospital care for Black patients, and hospital inpatient care and additional days of antibiotic treatment for white patients.

Thompson highlights the importance of seeking help, especially from those who are culturally and racially competent.

"Individuals who are suffering from mental illness symptoms should seek help. A comprehensive evaluation by a mental health professional can help to establish a diagnosis."

Patients should partner with providers to develop a treatment plan that resonates, according to Thompson.

"Patients should identify goals, express any fears, and ask questions freely until satisfied," she says. 

"Providers can also seek cultural competence training. A culturally competent provider is aware of their own culture and biases, which can help in recognizing and avoiding them, as well as identifying and minimizing barriers to care among populations," she notes.

Therapists should take the time to build rapport with their clients and ensure that their patients feel heard and valued. Thompson says that cognitive behavioral therapists should strive to identify and challenge negative thoughts without discounting the impact that the experience has on patients.

Validation May Be the Missing Ingredient

Neuroscientist and clinical social worker Renetta Weaver, LCSW-C, says, "The takeaway is that research conducted among therapists suggests significant differences in the treatment approaches used."

"Increased therapeutic effectiveness of CBT among client populations that identify as persons of color is enhanced by treatment approaches where the use of validation is offered first," she explains.

Validation may be the key element in building rapport between the therapist and the client, according to Weaver.

"Clients need to know that they can trust, not just by words, but through their feelings," she says.

Weaver highlights, "Clients with a highly sensitive amygdala, due to systemic stress and trauma, need a mechanism to help them feel safe before they let their guard down. For persons of color, who often have a mistrust of the medical system, validation is the catalyst for change."

The one thing Weaver wishes the public would know about this issue is the unconscious bias and stigma that CBT potentially fosters.

"In my clinical opinion, anything outside of the CBT framework can easily be judged as resistant, non-compliant, or misdiagnosed as a personality disorder," she states.

"While I agree that CBT is a great evidence-based tool, I do believe there is more than one way to heal. I believe clients who are invited and encouraged to participate in their healing, by telling us what aligns with them based on the options we present to them, will develop greater trust in themselves and therapy," she explains.

This study fits into the greater body of research which highlights the need for equitable medical care for all patients, according to Thompson. "Equitable treatment is nuanced by cultural attunement," she says.

Weaver further explains, "Cultural humility is where the therapist is willing to learn and takes a step further by inviting a session that is a dialogue, not a monologue. Listening and learning is an example of validation."

As a CBT therapist, Weaver used to feel that something was missing from its effectiveness with clients, and her quest to find what was missing led her to something called complementary alternative medicine (CAM).

"CAM approaches, like yoga, meditation, and creative arts, are often embraced by clients who come from cultures that historically and regularly engaged in these practices," she explains.

When Weaver offers these strategies in combination with CBT, she notes that she gets buy-in and engagement from clients.

"I am not recommending CAM only; however, I am suggesting that you find a way to validate your clients. After all, research suggests that validation as the foundation is a therapeutic tool that is the catalyst for change," she says.