CBT with Minority Clients (Panel discussion at AABT 2001)

CBT with Ethnic Minority Populations
Anhalt, Fudge, Iwamasa, Preciado & Venner (and a few of my thoughts)

Are ethnic minority populations (and populations elsewhere in the world) different in ways that mean CBT isn’t applicable or that it needs to be applied differently? This issue has been raised vigorously by some but there is limited empirical evidence. Anecdotally, there are reports that CBT works with ethnically diverse populations but the available data is quite limited. As the United States becomes more and more ethnically diverse, this becomes a bigger issue. (Other are inclined to think that CBT is based on empirically derived principles and is effective independent of ethnicity, race, or culture. There isn’t much data to support this view either.)

There are major issues of discrimination, lack of economic opportunity, inadequate access to healthcare, lack of political power, lack of social and economic inclusion, and the way in which members of the majority population respond. These are societal issues which are independent of CBT but are part of the context in which CBT is provided. They have a substantial impact on the efficacy of CBT. For example, we cannot provide effective CBT if adequate funding mechanisims aren’t in place.

It isn’t ethnicity itself that’s relevant to treatment. The therapist’s assumptions, preconceptions, and biases will have an impact. The individual’s upbringing, familial and cultural, will have an impact. The individual’s preconceptions and attitudes towards members of the therapist’s ethnic group will have an impact.

Many attempts to look empirically at the impact of ethnic identity have been simplistic. Simply coming up with good measures of ethnic identity is difficult. There may well be important differences in norms for behavior, beliefs and values, etc. which have a big impact on treatment. Do members of ethnic minorities mean the same thing by “depression,” are traditional assessment measures applicable? Do empirically-validated treatment approaches need to be “tweaked” or can they be applied “as is?”

It isn’t clear whether traditional experimental designs are applicable with ethnic minority populations. We may emphasize issues of internal validity to the exclusion of external validity.

We also have our assumptions and preconceptions about subgroupings which are based on characteristics other than ethnic identity (drug abusers, Viet Nam Vets, phobics).
Just because a therapist belongs to an ethnic minority does not mean that they are free of racism and bias, including racisim and bias towards their own ethnic group.
Ethnic groups are not homogenous. It doesn’t make sense to devise a CBT for Hispanics, CBT for Asian Americans, etc.
Curiosity and respect are essential. If you are attentive to these issues and are willing to learn from your clients, this helps.

If treatment becomes more and more manualized this leaves less room for individualizing treatment. Even if the manual leaves room for individualization, trainees (in their insecurity) are likely to rely on following the rules rather than on thinking in terms of adapting the approach to the needs and characteristics of the individual.

Members of ethnic minority groups tend to underutilize mental health services. Are there cultural or ethnic factors which cause this? Is it a matter of services not being available, not being accessible, or not being provided in an appropriate language and interpersonal context? Is it a matter of individuals not being aware of the services that are available, not seeing the services as being appropriate, or of stigma?

Individual psychotherapy provided in a clinic or therapist’s office may not be the most appropriate way to provide mental health services to everyone. Psychoeducationaal workshops provided in churches, provided through community groups, etc. may be more appropriate. Forming collaborative relationships with the community and offering the services that the community wants is important. (One major impediment is financial. How does the therapist earn a living if they’re providing community-based services or preventive services? As a clinician I can get paid for providing psychotherapy in my office but how do I get paid for providing community-based services or preventive services?)

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