Cultural Differences and Cognitive Therapy

The question of how cultural differences impact the practice of CBT has been highlighted by a special series on cultural considerations in using acceptance and mindfulness-based treatments in Cognitive and Behavioral Practice (February, 2013) and a special series on cultural competence in the Behavior Therapist (June, 2013). Back in the old days, many Americans were oblivious to cultural differences and/or presumed that their beliefs and customs were superior to everyone else’s beliefs and customs. In this day of increasing diversity we are increasingly aware of cultural differences and increasingly aware that we each have our own biases. How does this impact the practice of Cognitive Therapy?

There has been limited research on the ways in which cultural differences may impact the practice of CBT, but there is good reason to believe that the impact is there. Research shows that individuals from different cultures tend to think about different things and tend to think about them differently, using different reasoning processes. This obviously could have important implications for CBT with its focus on addressing the client’s thoughts and thought processes. Cultural norms regarding what behavior is “appropriate” in different situations can have a major impact. Also, cultural norms (both the client’s and the therapist’s) impact interpersonal interactions and therefore impact the therapeutic relationship that is central to psychotherapy. Furthermore, when the therapist’s world-view, experience, and expectations are different from the client’s, this can complicate the process of developing a shared understanding of the client’s problems and possible solutions.

Early work on Cognitive Therapy (CT) was done in an era when cultural differences received little attention, and a quick glance at the indexes of seminal works such as Cognitive Therapy of Depression (Beck, Rush, Shaw, & Emery, 1976) reveal no listings for “culture”, “race”, or “ethnicity.” Does this mean that CT presumes that cultural differences are unimportant or that all recipients of CT should be indoctrinated into the dominant culture? From the beginning, CT has advocated an individualized approach where the therapist endeavors to understand the individual’s problems in the light of the client’s world-view and interpersonal context. For example, in discussing common pitfalls in learning Cognitive Therapy, Beck et al. (1976, p.27-28) assert “The therapist must never lose sight of the fact that he [sic] is engaged with another human being in a very complicated task… 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 fully formulated but rather will have to be drawn out by the therapist.” The unspoken (and possibly naive) assumption was that psychopathology and psychotherapy are based on universal principles that apply across cultures and that an individualized understanding would be sufficient to encompass individual, familial, and cultural influences. Does this mean that we don’t need to attend to cultural differences?

Culture is complex and multi-faceted. My own heritage is half New England Protestant and half Midwestern. However, I grew up in a blue-collar neighborhood in the Deep South during the last days of segregation, went to college at the end of the anti-war movement, and briefly became a Born-Again Christian. What is my culture? When I’m working with a Puerto Rican male who grew up in a military family, partly in rural Puerto Rico and partly in urban Chicago, how do my cultural influences and the client’s cultural influences affect our work together? I could rely on generalizations about Puerto Ricans, military families, and Chicagoans, but those may be misleading. An individualized understanding of the client’s problems in light of his world-view and interpersonal context is a good starting place. However, it seems to me that it also is important for me to be aware of my own cultural influences, to watch for any aspects of our cultural backgrounds that impact therapy, and to be willing to address any cultural issues that arise.

In 2003 this topic surfaced in a discussion on the Academy of Cognitive Therapy’s listserv and a number of comments from that discussion (posted with the authors’ permission) can be found in the archives of the Cognitive Therapy forum at https://www.behavior.net/forums/cognitive/1996/msg1649.html. The consensus seems to be that culture has important influences on all of us and that we need to make a persistent attempt to maintain a collaborative relationship, to look at problem situations from the client’s point of view, and to use guided discovery to help clients find solutions that work for them in their social context. However, in order to do this, we need to be aware of our own biases and we need to be alert for assumptions, expectations, and preconceptions on the client’s part that may interfere with therapy. The archives also include a thread discussing CT with religious clients (at https://www.behavior.net/forums/cognitive/1996/msg342.html) that illustrates some of these points.

The wide range of cultures encountered in general clinical practice is such that it is not humanly possible for the therapist to be knowledgable about every culture they encounter. If we can recognize the limits of our understanding of individuals whose backgrounds are very different from our own, we can guard against relying on simplistic stereotypes and work with them to understand their experience. For example, when a young Roma (sometimes known as Gypsy) woman mentioned that she was involved in a lesbian relationship with an african-american partner it was immediately apparent that we were way beyond my understanding of Roma culture. Fortunately, the client was able to enlighten me about her family’s attitudes towards homosexuality, inter-racial relationships, and other important issues.

Hopefully, the increased awareness of cultural differences will lead to a body of research that will help us better take cultural issues into account in the future. At this stage in the game, it is clear that none of us is free of bias. We need to be careful not to rely on stereotypes in a well-meaning attempt to be culturally sensitive. Instead, we need to educate ourselves about the experiences of individuals from diverse backgrounds, to be aware of the ways in which our own history, beliefs, values, and experiences have shaped us, and to proactively invite conversation about cultural differences in Cognitive Therapy. We can encourage our clients to educate us about their cultures, to alert us when cultural differences seem relevant to therapy, and to help us to recognize cultural issues as they emerge. An atmosphere of collaboration and respect seems necessary if we are to be able to address differences constructively.

Diverse group image available from Shutterstock.