Cognitive Behavioral Therapy and Issues of Diversity: African Americans

by Laurel O. Brockenberry, M.S.
Doctoral Candidate, Clinical Psychology Ph.D. Program, Virginia Consortium Program in Clinical Psychology

To properly adapt cognitive-behavioral therapy (CBT) to a client, prioritizing treatment adherence and attendance is important. Cultural components and modifications into treatment are necessary to review, as treatments adapted for clients’ cultural group are shown to be more effective than traditional treatments (Smith, 2011).  Psychotherapy and pharmacotherapy are reported to be utilized less in African American samples versus Caucasian samples (González et al., 2010). The underutilization of mental health services among this population has been replicated in other samples as well, indicating that this concept may be specifically engrossed in culture or shared experiences (Neighbors et al., 2008, Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). A meta-analysis of mental health stigma found that African Americans were more likely to report sub-themes of stigma associated with “weakness”, “keeping it in the family”, and “nondisclosure”, which negatively affects their seeking of formal mental health services (Clement et al., 2015; Corrigan, et al., 2014). 

Mental health stigma, including perceptions of therapy as being irrelevant to personal problems, family stressors, lack of awareness of available resources, and mistrust of providers, have been associated with decreased help-seeking for mental health services (Henderson et al., 2013; Williams et al., 2013). Such perceptions, especially mistrust, might also affect the therapeutic alliance, which is a core component of CBT and necessary for successful intervention (Beck, 2011). If the therapeutic alliance is not based in trust, then treatment adherence and receiving relevant information from the client might be difficult. As a result, the initial portion of the CBT intervention should focus on directly exploring the possibility of these perceptions, specifically via the use of psychoeducation. Providing validation and information on the commonality of mental health disorders, available resources, and connecting the client’s experiences to mental health perceptions might provide some support to combat these stigmas that disrupt engagement in mental health services. Psychoeducation focusing on the purpose of CBT, course of treatment, the process of therapy, discussion of the expectations regarding therapist and client roles, and review of how racism or discrimination could impact presenting concerns may help attrition as well as provide a framework for the therapeutic alliance to thrive off of (Ward & Brown, 2015).  

 Increased family engagement is also a modification that might prove useful when working with African American clients. African American culture focuses on family unity and strong bonds of kinship (Kohn, 2002; Hines & Boyd-Franklin, 2005). There is a traditional sense of cohesiveness and family pride that can provide instrumental and social support (Hines & Boyd-Franklin, 2005). Therefore, family, including extended family and those included in the extended kinship framework, should be considered and may be useful for treatment. The use of the family and kinship framework might be helpful for treatment adherence outside of therapy sessions (Kohn, 2002). Further, family engagement in the treatment might reduce the culture-specific stigmas that affect the attrition rates of African Americans, which may encourage the client to have a more active role in their treatment. 

Some traditional models of CBT could overlook the importance of spirituality or religion in the African American culture, even when incorporation of spirituality could be beneficial for treatment. Spirituality, or religion, is a core aspect of African American culture and is often used for comfort (Hines & Boyd-Franklin, 2005; Ward & Brown, 2015). Therefore, incorporating the discussion of spirituality with African American clients to gauge its importance in their life is useful. Further, identifying significant support systems in the Church, and incorporating those support systems into treatment could be beneficial.  Finally, the use of spiritual or religious activities, like meditation or prayer, might be useful tools for the client’s progression of treatment since they may be familiar and could provide the client with comfort. 

Standard CBT tends to focus less on the developmental aspect of psychological disorders and instead on the present (Beck, 2011). As a result, a therapist working with African American clients might miss developmental information specific to their culture that could have been useful to identify important pieces of their past and the development of their core beliefs.  For example, African Americans report more chronic stress related to discrimination than Caucasians (Kelly, 2006). Studies show that racism and instances of prejudice have been associated with depressive symptoms and psychological distress in African Americans (Ward & Brown, 2015). As a result of this information, CBT may need to be modified for African American clients. Modification could include spending more time on African American clients’ history than would be standard.  A discussion about racism with African American clients might be useful to determine how prevalent the instances may be, and whether they are a cause of the psychological symptoms present today (Ward & Brown, 2015).  As a therapist, focusing on validating their emotions regarding their experiences of racism and prejudice, as well as encouraging the discussion of such instances, is useful in terms of strengthening the therapeutic alliance and providing information for the case conceptualization that was not available before. 

Overall, standard CBT may be useful to African American clients because of its focus on being nonjudgmental, being collaborative with problem-solving, and empowering clients through skill-building and strengthening of their support systems (Beck, 2011). But including modifications like a greater emphasis on psychoeducation and family engagement would be beneficial for treatment compliance and attrition as well as to strengthen the relationship between therapist and client (Kohn, 2002). If identified as a strength, the use of spirituality or spiritual mentors for treatment can increase the success of the interventions by incorporating client experiences and beliefs into therapy, which will further strengthen both the therapeutic alliance and case conceptualization (Kohn, 2002). Finally, discussions regarding racism and discrimination with African American clients may prove useful due to the association between experiences of racism and psychological distress (Ward & Brown, 2015). The African American community is diverse in many ways, and such modifications may not be useful for all African American clients. But therapists should focus on determining potential modifications to increase treatment adherence and relevancy to their clients’ concerns.   

References

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press.

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine45(1), 11–27.  https://doi.org/10.1017/S0033291714000129

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care. Psychological Science in the Public Interest15(2), 37–70. https://doi:10.1177/1529100614531398

González, H. M., Vega, W. A., Williams, D. R., Tarraf, W., West, B. T., & Neighbors, H. W. (2010). Depression Care in the United States. Archives of General Psychiatry67(1), 37–46. https://doi:10.1001/archgenpsychiatry

Hays, P. & Iwamasa, G. Y. (2006). Cognitive-behavioral therapy with African Americans. Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision, 97-116. https://doi.org/10.1037/11433-000

Henderson, C., Evans-Lacko, S., & Thornicroft, G. (2013). Mental illness stigma, help seeking, and public health programs. American Journal of Public Health103(5), 777–780. https://doi:10.2105/AJPH.2012.301056   

Hines, P. M., & Boyd-Franklin, N. (2005). African American Families. In M. McGoldrick, J. Giordano, & N. Garcia-Preto (Eds.), Ethnicity and family therapy (p. 87–100). The Guilford Press.

Neighbors, H. W., Woodward, A. T., Bullard, K. M., Ford, B. C., Taylor, R. J., & Jackson, J. S. (2008). Mental Health Service Use Among Older African Americans: The National Survey of American Life. The American Journal of Geriatric Psychiatry16(12), 948–956. https://doi:10.1097/JGP.0b013e318187ddd3

Smith, T. B., Rodríguez, M. D., & Bernal, G. (2011). Culture. Journal of clinical psychology67(2), 166–175. https://doi.org/10.1002/jclp.20757

Substance Abuse and Mental Health Services Administration. (2015). Racial/ethnic differences in mental health service use among adults. Retrieved from https://www.samhsa. gov/data/sites/default/files/MHServicesUseAmongAdults/ MHServicesUseAmongAdults.pdf 

Ward, E., & Brown, R. L. (2015). A Culturally Adapted Depression Intervention for African American Adults Experiencing Depression: Oh Happy Day. The American Journal of Orthopsychiatry85(1), 11–22. https://doi:10.1037/ort0000027

Williams, M. T., Beckmann-Mendez, D. A., & Turkheimer, E. (2013). Cultural barriers to African American participation in anxiety disorders research. Journal of the National Medical Association105(1), 33–41. https://doi:10.1016/s0027-9684(15)30083-3   

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