Enhancing the Cultural Sensitivity of Cognitive Behavioral Interventions for Anxiety in Diverse Populations

The diversity among individuals living in the United States has rapidly increased over the past few decades with people of color making up 36.2% of the United States population in 2011 (US Census, 2011). In addition, 3.4% of adults living in the United States identify as gay, lesbian, bisexual, or transgender in 2012 (Gallup Study, 2011) and 32.8% of Americans experience physical functioning impairments or disabilities in 2011 (National Health Survey, 2011). While these statistics represent just a few of several marginalized and underserved populations in the United States, this rapid increase highlights the importance of focusing on the mental health needs of diverse populations including the treatment of anxiety disorders within marginalized populations. In reference to diverse populations, we will use the term “marginalized groups”, which refers to groups that are often perceived negatively in society, which can result in separation or exclusion from mainstream society, unequal treatment, unequal access to resources, and overall social devaluation (Sue, 2010). In the context of the United States, marginalized groups can include racial and ethnic minorities, LBGT individuals, women, people who identify as working class, and individuals with disabilities. Because clinicians with higher levels of cultural competence experience more favorable outcomes with their clients (Sue, 2001), utilizing multicultural competency to effectively tailor CBT may better serve the mental health needs of marginalized populations (Hofmann, 2006; Pantalone et al., 2009; Safren, 2001). These papers highlight the need for including cultural considerations in CBT, provide a framework for incorporating multicultural principles, and provide suggestions to consider when working with marginalized populations, while the current paper focuses on a few specific examples of how we have adapted CBT in our work treating individuals with social anxiety disorder.

Specifically, in this paper we will explore ways to enhance common elements of CBT for anxiety disorders in diverse populations. Through case examples taken from our work on a CBT treatment study for social anxiety disorder, we will discuss our use of CBT strategies with individuals who identify with marginalized statuses and the ways that we have integrated multicultural perspectives.

CBT for Anxiety

CBT has been efficacious in treating anxiety disorders among majority White populations for decades (Deacon & Abramowitz, 2004); however, studies exploring more general efficacy of CBT for anxiety have often neglected to take marginalized status into consideration. For example, Stewart and Chambless (2009) conducted a meta-analysis of 57 effectiveness studies of CBT for adult anxiety disorders and found CBT to be effective across samples; however, in only six (10.5%) of these studies did African Americans or Caribbean Americans of African descent make up at least 20% of the sample and in only two (3.5%) did Latinos make up at least 20% of the sample.

There have been a few studies that explicitly explored the efficacy of CBT in marginalized groups. For example, a study of exposure-based CBT for Latino and European American youth with anxiety disorders, found that both Latino and European American youth responded positively to the intervention (Pina et al., 2003). Additionally, case examples have shown the effectiveness of culturally sensitive CBT for GLB clients suffering from anxiety (Martell, Safren, & Prince, 2004) and for two clients who immigrated to the United States from China and Central America (Weiss et al., 2011). Given the overwhelming evidence for the efficacy of CBT in majority White, heterosexual populations and limited examples in diverse samples, it is important to think of ways to enhance CBT to better serve marginalized populations. One such avenue is to explore ways to include multicultural perspectives into CBT.

Defining Multiculturalism and Multicultural Counseling Perspectives

Multiculturalism is characterized by the theoretical and philosophical ways that cultures vary in norms, values, worldviews, and traditions, with an emphasis on there being no superior or inferior status and an assumption of equality across cultures (Talbot, 2003). Within the field of psychology, multicultural counseling can be described as a therapy process that applies treatment approaches and therapy goals that are consistent with the life experiences, contexts, and cultural values of clients from diverse backgrounds. Hays (2008) presents an acronym, the ADDRESSING framework, to help clinicians attend to the diverse backgrounds and lived experiences of clients, while keeping their own backgrounds and identities in mind. This framework focuses on nine cultural factors that merit attention in the context of therapy (the parenthetical additions are our own expansions): Age and generational influences, Development disabilities, acquired Disabilities, Religion and spiritual orientation, Ethnicity (and race), Socioeconomic status, which includes education, Sexual orientation, Indigenous heritage, National origin (and generational status), and Gender. In the context of these facets of identity, multicultural counseling focuses on issues of power, privilege and marginalization and the impact of these constructs on the experiences of clients from diverse backgrounds. Power is the ability to decide who has access to resources, while privilege is characterized by the advantages and benefits afforded to members of the dominant group in society.

At the core of multicultural counseling is the ability to connect with clients and understand influences on identity development and diverse world perspectives referenced in the ADDRESSING framework. Sue and Sue (2004) describe two different approaches to counseling, the etic and emic approaches, with the latter being a multicultural approach. The etic approach, which describes the way that therapy is traditionally practiced, is housed in the theory of cultural universality and operates under the assumptions that prevention and intervention approaches are universal, that disorders like anxiety appear similarly across cultures, and that the most effective treatment approach for anxiety disorders should be uniformly applied cross-culturally. Although this approach is wide-spread, it may impose dominant group cultural biases on clients from diverse backgrounds (e.g. that all clients hold the dominant group value of individuality). The emic approach challenges the assumptions that mental health difficulties are of the same nature and development across cultures. This approach suggests that culture and life experiences significantly influence the development, course, and expression of anxiety, and should also influence our prevention and intervention efforts.

Integration of Multicultural Perspectives and CBT for Anxiety

As highlighted in the literature on multicultural competency, attention should be paid to tailoring treatments for anxiety disorders to better serve individuals from diverse and marginalized populations (Fuchs et al., in press; Sue & Sue, 2004). There are several ways that we can enhance the cultural sensitivity of common components of CBT for anxiety. While some of these suggests are specific to CBT, others are related to the process elements relevant for a wide range of therapeutic approaches. Specifically, clinicians can begin to think of ways to cultivate a general therapeutic attitude or “therapeutic stance” that involves the appreciation and understanding of the complexities of clients’ lived experiences. In addition, we can tailor psychoeducation, cognitive restructuring, and exposure processes to better reflect the struggles specific to clients from traditionally marginalized groups. What follows are some examples of the ways that we have used this multicultural lens within CBT for social anxiety disorder within our practice. We have chosen to focus on a few specific CBT elements here, recognizing that we are intentionally omitting many other commonly used CBT techniques.

Therapeutic Stance

Integrating a multicultural perspective with CBT for anxiety requires clinicians to educate themselves about the modal experiences of individuals from diverse cultural backgrounds. Because modal experiences do not describe the full range of varied experiences within any group, clinicians must also remain open to each client’s individual experiences and life contexts. This self-education begins by learning about the history, beliefs, values, and modal experiences of diverse groups (including institutional and systemic barriers to mental health treatment) which will enable clinicians to connect with clients’ experiences, improving their case conceptualizations and intervention approaches (see Sue & Sue, 2008 for a list of resources). An important facet of the modal experiences of diverse groups is the way each group experiences marginalization within our societal context. As described above, marginalization is characterized by being perceived negatively in society, which can result in separation or exclusion from mainstream society, unequal treatment, unequal access to resources, and overall social devaluation. Experiences of individuals from marginalized groups may include barriers to healthcare, jobs, and experiences of social injustices and threats to their civil liberties. These oppressive experiences often play a significant role in clinical presentations of anxiety and can affect the development of the therapeutic relationship and the effectiveness of cognitive behavioral interventions (Hunter & Schmidt, 2010; Soto et al., 2011). For instance, it may be difficult for a client from a working class background who works 70 hour per week and has 3 children to engage in therapy, particularly a therapy that involves a significant amount of time outside of work and away from family. If the clinician is aware of the client’s life context, treatment can be tailored to the needs of the specific client given his identity status, perhaps by integrating exposures into his daily life.

In addition to these more systemic experiences of marginalization, discrimination has shifted and often manifests in more covert forms of discrimination coined microaggressions (Pierce et al., 1978). Microaggressions are intentional or unintentional disparaging comments, slights, or environmental indignities based on an individual’s marginalized group status (Sue & Sue, 2007) that occur in many different forms and affect a diverse range of marginalized groups. For example, a racial microaggression may be when a White woman clutches her purse as an individual of color approaches on the sidewalk. Gender microaggressions include women professors being referred to as “Ms.” while their male counterparts are referred to as “Dr.” A sexual orientation microaggression may be when two men holding hands in public are told not to flaunt their sexuality. Experiences of microaggressions can contribute to the anxiety individuals experience in their everyday life contexts. Educating ourselves about such experiences is the first step in providing a safe and effective therapeutic environment.

Inviting in conversations about marginalized statuses

As highlighted in Hays’s (2008) framework, it is important to introduce issues that clients from diverse backgrounds may experience based on their marginalized identities early in treatment. Clinicians can begin this conversation by introducing some of their own identities and checking in with clients about any concern surrounding potential differences or similarities.

In addition, addressing potential experiences of discrimination or marginalization in the beginning sessions of therapy can show clients that the therapy room is a safe space where these experiences can be discussed. We systematically do this in the initial therapy session when assessing the situations that create the most anxiety for our clients and by asking clients whether the identity of individuals they are interacting with influences their experiences of social anxiety. For instance, with an African American client who was experiencing significant anxiety interacting with her colleagues, her White male therapist explicitly asked if the race and/or gender of her coworkers played a role in her anxiety and whether she had experienced racism at work. In this context, the client expressed gratitude to the therapist for initiating a conversation about race in the therapy room and acknowledged that she had much more anxiety at work than other places, partly because her coworkers were mostly White. We then talked about the difficult experiences of racism she endured at work, which included her boss consistently calling her by the name of the only other African American employee even after being corrected several times.

By having this explicit conversation about race in the initial therapy session, we were able to tailor both the cognitive restructuring and exposures to her lived experiences of marginalization. Because individuals from marginalized statuses are socialized to not talk about experiences of marginalization, particularly to individuals who do not identify with the same marginalized status, it is especially important that the clinician, who typically holds more power and privilege in the therapy context (i.e.- does not identify with marginalized statuses or holds power in the room as a therapist), initiates these conversations. These types of conversations open the door for further discussion about experiences of discrimination, thereby helping clinicians to think deeply about issues of marginalization in their case conceptualizations and enhance the application of treatment components.

Enhancing Psychoeducation

It is common practice for clinicians to provide psychoeducation about the function of emotions and the cycle of anxiety when treating clients struggling with anxiety. With clients from traditionally marginalized backgrounds it is important to connect aspects of psychoeducation directly to their lived experiences. For example, when describing the ways anxiety develops with a 34 year old Latino male visually impaired client, Carlos, we connected the psychoeduction to experiences Carlos shared with us related to aspects of his identity. For instance, we talked explicitly about Carlos’s experiences of people walking away from him in the middle of conversations without him knowing—something that happened often because of his visual impairment. We discussed how it makes sense to fear these social situations considering the number of embarrassing situations he has found himself in when he has been unaware that others had already left the conversation. Carlos also mentioned that in his childhood his mother had been very concerned about his grammar while interacting with others because she thought that people would judge him more stringently due to his visual impairment. It was transformative for Carlos to hear and understand the ways that he learned to be anxious through these experiences. Carlos was also able to engage more effectively in therapy because of our explicit validation and acknowledgment of the unfair ways that he was often treated because of his visual impairment.

Adapting Cognitive Restructuring

Another common component of traditional CBT for anxiety is the use of cognitive restructuring. CBT often focuses on assumptions that individuals experiencing pathological anxiety are victims of faulty, irrational thinking and that therapy should help clients become aware of these irrational or automatic thoughts and change them through cognitive restructuring. When working with clients from traditionally marginalized backgrounds clinicians need to think deeply about the ways they are teaching clients to restructure their thoughts and the implications of these decisions. One of the challenges is that individuals from marginalized groups often have negative and automatic thoughts that are not irrational given their experiences. For instance, a client of color may express that they fear social situations with their White peers because they fear that their White peers may say something racist in their interactions. In such cases where the client feels discriminated against, questioning the validity of the client’s fears that racism is possible enacts a microaggression that can contribute to and exacerbate the client’s experiences of anxiety, and become a barrier to positive therapeutic change (Chang, 2010). Instead, clinicians should explicitly validate these experiences by allowing the client to talk openly about his or her experiences of discrimination, validating the painful emotions that may arise in the face of these experiences, and explicitly acknowledging that we live in a society where these painful experiences occur. At the same time, the clinician may choose to help the client reframe what these experiences mean about him or her. As seen in the examples below, cognitive restructuring can address the biases in what living in an oppressive society means about the client (i.e. “there is something wrong with me because I am gay”), but should not challenge that incidents of discrimination do exist or that a specific incident was discriminatory. For example, a clinician would not want to ask for other explanations for why a jewelry store clerk would not wait on a client without explicitly having discrimination being one of the “valid” possibilities. In our work with a 25 year African American female, Corinna, we shifted our use of the common cognitive restructuring “disputing” questions to target the negative self-focused automatic thoughts that came up for her around experiences of racism. Corinna worked as a receptionist at a large medical practice that serviced a predominantly White customer base. She feared going to work because of previous experiences of racism which contributed to her difficulties interacting with her coworkers and customers. We began by validating the emotions that came up for her when she experienced racism and explicitly acknowledged that we live in a world where social injustices occur and that it is unfair that she has to experience these social injustices. Her initial automatic thoughts were, “People will judge me because I am Black” and “People will think I’m stupid because I am Black.” Some commonly used disputing questions would result in the client asking herself, “Am I 100% sure people will judge me based on my skin color?” and “What evidence do I have that people will think I’m stupid based on my race?” However, the use of these disputing questions in this context would invalidate the client’s painful experiences and serve as barriers for effective intervention because she has likely had many experiences where people have judged her because of her skin color or have thought that she is inferior because of her race. Instead, we chose to target the internalization of racism by asking her disputing questions that referenced her competence, intelligence, and self-worth, rather than the experiences themselves. For example, we asked her, “What evidence do you have that you are stupid?” For this particular client, she was able to point to her strong grades as well as family members and friends who consistently applauded her for her work ethic and intelligence. The goal of this line of questioning was to help Corinna develop a defense against the internalization of racism and to have a rational response that might remind her that often her negative self-focused thoughts that arise in the face of discrimination are untrue. The rational response she developed was, “Even though I sometimes feel stupid, I have always done well in school and I know that I am a worthwhile and intelligent person.” By validating her experiences of racism, while simultaneously disputing the veracity of her negative self-focused thoughts, Corinna was able to attend work and engage with her coworkers and customers in a way that felt safe and productive.

Another example of modifying cognitive restructuring techniques is illustrated with a 21 year old White male client, Tim, who identified as gay and presented with social anxiety surrounding his interactions with the other players on his football team. He said that even though he had not come out to his team, he felt like less of a football player because of the insensitive jokes that were told in the locker room. Upon further exploration, much of Tim’s anxiety was the result of feeling as if her were less of a “man” than the other men on his team. During therapy, we discovered that these feelings stemmed from a history of hearing offensive and crude jokes in football locker rooms since childhood which often insinuated that men who are gay are not really “men.” Rather than focusing disputing questions on the presence of homophobia and heterosexism in his daily experiences, we instead validated his experiences of heterosexism and allowed time for an open conversation about the ways that it is unfair that he experiences discrimination based on his sexual orientation. The disputing questions and cognitive restructuring process then focused on the meaning of being a man. Over the course of treatment, we were able to come to a less rigid meaning of maleness and help Tim develop the rational response, “There is not one way to be a man and I can make choices about my gender identity.” This rational response helped Tim combat the internalization of heterosexism that he was experiencing on a consistent basis with his teammates. It also motivated him to work on ways that he might ask his teammates to stop making offensive jokes.

Modifying Exposure Situations

Exposure is a commonly used CBT method to treat anxiety. There are specific ways that we can enhance exposure experiences for individuals from marginalized backgrounds who are struggling with anxiety. As an example, we saw a client who identified as a 26 year old, Puerto Rican woman who experienced a significant amount of social anxiety in many situations. As therapy progressed, a pattern evolved in Maria’s automatic thought process in that she tended to experience social anxiety in situations that involved men, including dating situations, her job as a bank teller, and with male professors in school. In conceptualizing Maria’s case, we called upon our knowledge and understanding of Puerto Rican modal cultural experiences and the gender roles that exist within this culture, specifically that traditional Puerto Rican families give men authority over women (Sue & Sue 2004). With this knowledge in mind, we were able to explicitly ask Maria about her family background to get a sense of whether or not her cultural values were in line with traditional Puerto Rican standards. It is important to note here, that we did not make the assumption that Maria had traditional values based on her cultural background, but drew upon our knowledge of modal experiences within Puerto Rican culture and explicitly asked her if these values applied to her lived experiences. Maria’s core beliefs about her role as a woman within the context of her work as a bank teller, her interactions with male faculty and students, and in dating situations were based in the ways that she learned to defer to male figures when growing up. By addressing Maria’s cultural understanding of gender roles within these contexts, we were able to explore and tailor her exposures based on her choices around her interactions with men that felt in line with her cultural values. Maria was able to practice raising her hand in class and commenting on the material being presented by male professors because she valued her education and wanted to engage in class; however, she did not feel comfortable being more assertive in dating situations as assertive behavior within these contexts was not in line with her cultural values. This meant that we did not work on these situations in therapy, however, we expressed to her that we could talk about this decision more at any point in therapy.

As another example, a White, 55 year old female client, Sarah, presented to therapy to reduce the social anxiety she experience with her colleagues at the architecture firm where she worked. She described having multiple experiences of marginalization at work based on her conservative religious views, which were different from those expressed by many of the people in her workplace. Specifically, she talked about how her colleagues would shift the conversation from work-related topics to conversations about religion which would result in them questioning her character when she expressed different viewpoints. Given her experiences with coworkers inappropriately chastising and alienating Sarah at work, the exposures we planned were not focused on talking with coworkers about her views but instead focused on helping her to assertively end the conversations by saying that it made her uncomfortable to talk about her religious views at work and that she would prefer to focus on the work projects. In addition, we helped Sarah plan between-sessions exposures that might help her feel less isolated in her life by reconnecting with friends who shared her religious views.

In a different example, a 22 year old client, Tonya, who identified as a Korean American male-to-female transgender individual reported experiencing significant anxiety with one-on-one social interactions and public speaking, particularly when talking about issues related to her identity as a transgender woman. She felt that her anxiety was preventing her from following her dream of being an advocate for transgender issues. In therapy, we did a progression of exposures that began with one-on-one conversations to help her become more comfortable about her fears of interacting with other people more generally. Next we moved on to one-on-one conversations about the transgender issues she wanted addressed on campus. To address her public speaking fears, we then had her prepare two five minute speeches about mitosis and adolescent development (two things she was learning about in her courses). Finally, we had her prepare a speech that advocated for gender neutral bathrooms on campus. Following session, she then gave this speech in front of her University’s student assembly. This last speech represented the convergence of her general social fears about giving speeches and her more specific fears related to her ability to be an advocate for transgender rights.

Conclusions

Given both the evidenced efficacy of CBT for anxiety and the focus on culturally competent practice in psychology, researchers and clinicians need to begin thinking of ways to integrate multicultural counseling and CBT. While the research, training, and application of culturally competent psychotherapy have increased over the last several decades, there is a continued need for culturally responsive clinicians to deliver CBT for diverse populations experiencing anxiety. We hope that the few examples presented here provide some ways that principles of multicultural counseling can be used to enhance CBT for clients from diverse populations.