To Be Anti-Oppressive, CBT Must Consider Identity

Clients look to us to help them manage thoughts, but we need to acknowledge context of their lives, too.

Source: Used with permission from Anti-Racism Space.

Cognitive behavioral therapy (CBT) is a therapeutic strategy that benefits clients whose issues range from addiction, psychotic disorders, depression, anxiety, anger, eating disorders and stress in general. It is one of the most important tools in a therapeutic toolbox. The strategies are tangible, and clients walk away being able to challenge their own thoughts, reflect on their actions and impact their emotions. However, CBT has to take into consideration the identity of the client, in order to be anti-oppressive.

Take this example from a notable CBT manual about a man with a social phobia who goes to a doctor's office:

“As he sits down in the waiting room, he looks around and thinks that everyone is looking at him, judging him, and criticizing him (exaggerated perception of probability). [..] In this example, the man’s perceptions of threat are exaggerated, as most people sitting around in waiting rooms are not paying attention to anyone else; rather, they are typically absorbed in their phone, watching TV, reading, or napping."

The manual then explains that, even if someone in the waiting room is judging the man, the opinion of a stranger is unlikely to affect his life. They claim this won't affect how a doctor treats him, the quality of his care, or his relationship with his significant others. The texts says his internal alarm system is unnecessarily activated.

Taking Context Into Account

However, without taking into consideration the man's context, what he was born into, the intergenerational trauma of his lineage, we cannot make these statements about his thoughts with such determination.

It is quite possible that this person was born into a racist and classist system and feels stuck in a place where he does not feel safe. Or, if the man is gay, and has just had a recent situation where he was attacked for his queerness, then he will be hyper-aware of his surroundings, especially at the doctor’s office. If a Jewish man reads about anti-Semitic attacks in his town on the way to the doctor, he may be overly-vigilant about his treatment in the waiting and treatment rooms.

Many therapists may recognize this context but the CBT text does not teach us to recognize it. We have to apply it ourselves.

Negative Thoughts Are Not Always Irrational

Therapists can even teach clients CBT so well that the clients learn to apply it to their lives when they are experiencing racial or identity trauma, without considering the resilience that the "negative thoughts" provided.

Instead, we as therapists should validate the negative thoughts, because survival is one reason that one may have developed such thinking, and it may be protective in these situations. This is not to say that we should promote jumping to conclusions or other cognitive distortions, but that before we encourage the client to think differently, we should normalize, recognize and accept those thoughts.

In fact, this is how ancestral trauma works. Our ancestors experienced trauma, we inherit their anxiety about preventing it from occurring again, and we experience similar stress in our own lives, and we regurgitate the anxiety.

For those who are faced with marginalization, the opinion of one random stranger can affect one's life in a lot of ways. If the man in the CBT example is Asian or gay or Muslim and recently targeted for any of those identities, and he accidentally bumps into or speaks too loud, he can be perceived to be problematic and face dire consequences, because of the other person’s racial bias. His anxiety or anger in the situation can impact how the doctor treats him, and it does.

This can then compromise the quality of his healthcare. And, it can certainly affect how significant others in his life feel about him. They can worry more, wish he was less defiant with his services, etc. Simply put, small interactions can greatly impact his life.

The acknowledgement is the therapy. The CBT can still be effective, but without this time spent with acknowledgement or validation, we can’t do any cognitive restructuring which is indicated as a strategy in CBT manuals.

If a client is working with a therapist who is unable to apply anti-oppressive knowledge to their CBT practice, a therapist who doesn’t apply knowledge of the systematic racism in any country, a therapist who sees their client's experience only as a social phobia or an irrational belief system, then this client will not be able to make long-lasting changes to their anxiety and PTSD from insidious and intergenerational trauma.