It is a common recommendation that psychotherapists modify their therapeutic techniques with specific cultural adaptations to personalize treatment for each client. However, little research has investigated these therapeutic adaptations and how they are used in clinical practice. New research published in Cognitive Behaviour Therapy found that therapists find it less appropriate to use cognitive change therapeutic techniques with Black patients compared to White patients.
Cognitive behavioral therapy (CBT) is a well-established treatment for depression and works by helping patients identify and adjust maladaptive thought and behavior patterns. Therapists help patients to do this using cognitive methods to bring about cognitive change to then decrease symptoms of depression.
Study authors Iony D. Ezawa and Daniel R. Strunk looked at existing data on CBT treatment of depression and found that therapists utilized cognitive methods less extensively when they worked with Black patients compared to when they worked with White patients. Why this difference is observed is not clear.
“Some psychologists have suggested that culturally competent therapists working with minority patients would be well-advised to avoid questioning the validity of patients’ thoughts and beliefs, and instead validate their patients’ self-reported experiences,” explained the researchers. “Were therapists using other techniques, such as validation (i.e. affirming patients’ experiences are understandable and make sense), in place of cognitive methods? Or perhaps, were there some clinical characteristics other than race that might account for these differences? Furthermore, might these differences be related to therapists’ own racial attitudes?”
They sought to answer these questions by conducting an experiment to examine therapists’ judgments of the appropriateness of different clinical CBT strategies (e.g., cognitive change and emotional validation) to treat depression in either White or Black patients. The researchers recruited 218 American and Canadian therapists to complete the study (most of whom were White: 84.4%).
Each participant was presented with four clinical case vignettes which contained information about the depressed patient’s background, their presenting problem, and an image of the patient. Therapists either received all Black patients or all White patients (manipulated by the image of the patient). Images were chosen from the Chicago Face Database and were matched on gender, age, and attractiveness.
Participants also answered a series of questions measuring their judgment of the appropriateness of several clinical strategies with each patient. They also completed measures of racial attitudes toward Black people and social desirability (i.e., the tendency to respond in a way that is socially desirable rather than truthful).
Results show that, in general, therapists thought cognitive change strategies were more therapeutic for White patients and indicated they’d spend more time working on cognitive change strategies with White patients than Black patients. On the other hand, therapists thought validation techniques were more therapeutic for Black patients than White patients.
Overall, validation strategies were rated as more important than cognitive change strategies for Black patients, but these strategies were rated equally important for White patients. Racial attitudes were related to these judgments in that more positive racial attitudes were associated with judging both cognitive change and validation strategies as therapeutic.
“These findings support our hypothesis that therapists tend to regard validation strategies as more appropriate to use than cognitive change strategies when treating Black patients. We suspect that therapists were inclined to think that using cognitive change strategies would risk suggesting that the therapist does not believe or fully appreciate the patients’ experience.”
The researchers cite some limitations to this work. Although using vignettes of patients that only differed on the image gave necessary experimental control for the study, this might have also limited the scope of the therapists’ judgments.
The study was titled: “Working with Black vs White patients an experimental test of therapist decision-making in cognitive behavioral therapy for depression“.
