Adapting CBT to meet clients’ needs

July 2023

Cognitive behavior therapy (CBT) is one of the most widely used forms of psychotherapy in the mental health professions. It is also the most empirically tested modality, with more than 2,000 evidence-based studies, according to the Beck Institute for Cognitive Therapy and Research, a nonprofit organization (co-founded by the late Dr. Aaron Beck, the psychiatrist who developed CBT) that works to advance CBT and train mental health practitioners and organizations around the world.

This short-term, highly structured form of therapy helps clients pinpoint and examine negative thoughts to reframe their thinking so they can develop a pragmatic view of difficult situations and learn to better manage them. CBT can be used to treat a wide range of mental health conditions, including anger, eating disorders, stress and attention-deficit/hyperactivity disorder.

Vanessa Teixeira, a licensed mental health counselor who specializes in trauma-focused CBT (TF-CBT), says one advantage to using CBT with clients is that it is “simple, concrete and makes sense.” Clients learn “why they are thinking what they are thinking, feeling what they are feeling and behaving how they are behaving,” Teixeira explains. “Once they have that knowledge, they can choose to actively participate in their treatment by making certain simple and concrete changes to their thinking and behavior.”

Positive therapeutic outcomes

CBT is most commonly used to treat anxiety and depression. Janeé Steele, a licensed professional counselor (LPC) and certified CBT therapist, says CBT can help anxious and depressed clients decrease their psychological distress and improve their ability to cope with life stressors. This can happen by teaching clients how to use CBT skills such as identifying and reappraising maladaptive thoughts and beliefs.

Steele, author of the forthcoming book Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing, says clients can also learn to apply CBT skills such as behavioral activation to positively affect their mood by increasing the amount of time they spend engaged in activities that provide a sense of pleasure or accomplishment. By teaching clients mindfulness strategies, such as deep breathing and relaxation techniques, counselors can help them with emotion regulation.

Some variations have been developed to tailor CBT to better meet the needs of certain mental health issues. For example, TF-CBT was developed in the 1990s to address the needs of children who had experienced sexual abuse, but today the scope has broadened, and clinicians can use TF-CBT to help children and adolescents recovering from all types of trauma. Christa Butler, an LPC who is certified in TF-CBT, says TF-CBT can help reduce the symptoms of trauma in children and teens and enhance their inner sense of safety. The modality, which includes parents and caregivers in the therapeutic process, is also effective in emotion regulation and building cognitive and social awareness skills, she adds.

Although CBT is an effective clinical approach for many mental health disorders, some mental health professionals argue that some of the techniques do not best address the needs of all clients, particularly those from marginalized communities. Practicing counselors are making cultural adaptations to the modality to better serve clients of color, and they are finding creative ways to combine other clinical techniques with CBT and TF-CBT to help adapt and modernize this approach to better address clients’ individual needs.

“The more we adapt CBT to suit the individualized needs of our clients, the more effective the treatment outcomes will be,” Teixeira says. “Any counseling theory and technique should first and foremost focus on the client as a unique individual and how counseling treatment can be best modified to produce successful results.”

Cultural adaptations

Steele, owner of Kalamazoo Cognitive and Behavioral Therapy PLLC, stresses the need for clinicians to culturally adapt CBT to better meet the needs of clients of color. Like all therapeutic approaches, CBT can’t be separated from the cultural context in which it was developed, Steele says. CBT “was developed with Eurocentric, individualistic assumptions that are not always suitable for clients from more collectivistic cultural groups,” she notes. And this may cause some clinicians to inadvertently overlook the environmental influences in a client’s life, she adds.

This can mean that there is the potential for clinicians who use CBT to “blame clients for problems that are primarily environmentally based, which can lead to an invalidation of their experiences,” Steele notes.

This can lead to negative outcomes. For example, she says that if the perspective and lived experience of people from marginalized backgrounds are not considered in therapy, they may decide to end treatment prematurely or they may experience a worsening of mental health symptoms.

Teixeira, an assistant professor in the Department of Counseling at Nova Southeastern University in Fort Lauderdale, Florida, also advises counselors to make cultural adaptations to CBT when working with clients who are vulnerable, underprivileged, disadvantaged or facing systemic discrimination. The adaptations should be made “to acknowledge that certain populations are not always in control of their environment and [that] certain groups of people have a major unfair disadvantage that directly impacts their thoughts, feelings and behaviors,” she says.

For clients who are dealing with racial trauma, Steele says cultural adaptations to CBT such as psychoeducation and culturally adapted cognitive restructuring can help them reduce their mental distress and build coping skills that foster their resilience in adverse situations. Steele discusses how to use these two cultural adaptations to treat a hypothetical client: a Black man in his mid-40s, who was the only Black male volunteer in a predominantly white organization. The client was having difficulty managing feelings of anxiety about fitting in at the organization. She says the client reported feeling worried and nervous when he tried to contribute his ideas in staff meetings, and he also experienced feeling dismissed and insecure when he was not considered for community assignments.

Steele found that using enhanced psychoeducation helped the client understand how social anxiety, which was the client’s presenting concern, works. For example, she talked to him about “stereotype threat,” a fear that people of color have about aligning themselves with negative stereotypes about their racial group, and how this threat may have contributed to his unease.

In this case example, the client felt an internal pressure to try to prove that he did not conform to the negative stereotype of Black men as inarticulate and only able to achieve in athletics, Steele explains. “This contributed to the self-focused attention aspect of his social anxiety and worsened the client’s performance, as his attention was often directed to perceived deficits in his use of language and [his] ability to communicate rather than the task at hand,” she notes, which often caused him to appear as though he could not concentrate or was forgetful.

“Intentionally situating problems in their cultural context in this way is omitted from traditional CBT,” Steele says. But the cultural context piece is critical in cases such as this one. Discussing stereotype threat in counseling allowed the client to better situate his problem within the cultural context and validate his lived experience as a racial being, she says.

Steele also adjusted how she approached cognitive restructuring with this client. “Traditionally, cognitive restructuring focuses on teaching clients to examine the rationality of their thinking through techniques such as Socratic questioning,” she notes. “Questioning clients’ experiences with race-related concerns, however, can be invalidating and may exacerbate their symptoms.”

Instead, she used Socratic questioning to examine the client’s negative self-thought and account for the impact of racial oppression in his life. “Adapted cognitive restructuring focuses on validating the painful emotions that arise in the face of these experiences, acknowledging that we live in a society where these painful experiences occur, and challenging negative thoughts about self that occur in response to these experiences rather than the experiences themselves,” she explains.

Working with this client, Steele asked questions to determine the thoughts he had that contributed to his anxiety and nervousness during staff meetings, such as “I sound too Black” or “I’m never going to fit in here.” She continued using Socratic questioning and asked culturally framed questions to help the client recognize and examine stereotypes that contributed to his negative thoughts about his self-worth and competence.

Using traditional CBT questioning, counselors may ask this client, “What evidence do you have to support the idea that you won’t fit in at work?” or “What’s another way to view the situation?” But this type of questioning can be insensitive to the client’s life and cultural context, and it could be perceived as a microaggression because it often requires people of color to prove their experiences with race, Steele says. Instead, she advises counselors to ask questions that consider the cultural context. For example, clinicians could ask, “What are the stereotypes that relate to being a Black man?” “When did you first encounter these stereotypes?” or “How do these stereotypes influence how you feel and what you think about the way people may perceive you?”

Steele reminds counselors to be careful when using CBT and avoid asking questions that might suggest the client’s discomfort about their experience is unreasonable or abnormal. “Microaggressions and questions that invalidate the client’s experience with race, ethnicity or culture can lead to ruptures in the therapeutic relationship or even worsen the client’s symptoms,” she notes. “They can also reinforce stigma associated with [the] receipt of mental health services and the perception that counseling is only for certain racial groups.”

Creative clinical approaches

When applying CBT and TF-CBT to other mental health issues, such as panic and trauma, the counselors interviewed for this article recommend incorporating creative techniques alongside these therapeutic approaches. Teixeira says using creative, individualized and unique CBT interventions such as spontaneous journal writing, gardening, coloring mandalas, and creating video blogs, vision boards and music playlists can help teach adults how to process and better manage difficult thoughts and emotions.

Grounding exercises are another creative CBT technique that Teixeira recommends counselors use with adult clients. These exercises use the five senses to help the client refocus their physical and emotional attention when they feel anxious, for example. “It allows the mind and body to take a break from the anxiety and panic it is currently experiencing by shifting the focus to more neutral and/or positive items that can temporarily change the client’s thoughts and feelings,” she explains.

Teixeira says counselors can ask clients to create a “grounding box” that can be used when they are experiencing panic or anxiety. The box should be filled with items that engage the five senses and provide the client comfort, she says. For example, the box could contain the following items:

• A ball that can be squeezed
• A beach shell that allows the client to hear the ocean
• A dried lavender flower to smell
• A pack of gum that the client can taste
• A funny or relaxing picture that the client can look at

Teixeira says this technique can be adapted to use with children and adolescents by having them fill it with items that bring them comfort, such as a small toy, fidget spinner, scented play dough, lollipops or a whistle.

Butler, a professional counseling issues specialist at the American Counseling Association and a registered play therapist supervisor, says TF-CBT can help children and teens process their thoughts and feelings about traumatic experiences, while providing them with a safe container to explore the impact of their experiences. She recommends counselors pair this approach with play therapy or play-based expressive therapy approaches, such as sand tray interventions and art-based activities.

The trauma narration process in TF-CBT can be “emotionally overwhelming” for children and teens who may be sharing the details of their trauma for the first time in therapy, Butler adds. So she advises counselors to incorporate age-appropriate games, such as flashcards, and expressive outlets, such as painting, to help make the therapeutic process more engaging while also providing a safe distance for clients to project their thoughts, feelings and emotions about lived traumatic experiences.

Counselors can also pair mindfulness-based techniques with TF-CBT. Butler and Teixeira suggest counselors use the activity of blowing bubbles to teach children about mindfulness. Clinicians can ask clients to breathe in and then slowly exhale as they blow the bubbles, which relaxes their body and mind.

When using games and art-based interventions, counselors must be sure to use tools that are culturally inclusive, Butler adds. This includes selecting miniatures, toys, dolls and images used in making collages that are representative of diversity and intersectionality. For example, counselors who use play therapy or work with children need to have a full spectrum of colors in their crayons, markers and pencils so clients can depict all different shades and tones of skin color in their drawings, Butler says. Counselors should also look for culturally diverse miniatures for use in sand tray therapy, she adds.

A staple approach

The counselors interviewed for this article say that CBT’s ability to treat a wide range of mental health disorders and its adaptability to fit clients’ needs are two reasons why the modality is likely to remain a staple in mental health. Teixeira also encourages new counselors not only to develop a mastery in understanding the main concepts of CBT, but also to engage in additional training for using CBT with special and vulnerable populations, which is important for the ethical use of the modality, she says.

Steele agrees that CBT “will continue to be the gold standard in behavioral care.” The emphasis on the empirical validation of treatments continues to be a priority within the profession, she says, “especially as it relates to increasing validation of the approach among culturally diverse groups.”

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For more ways to adapt cognitive behavior therapy (CBT) and cultivate an awareness for cultural diversity, check out the following resources:

• “Culturally adapted CBT with African Americans” (video) by Janeé Steele, 2022
• “The multidimensional model of broaching behavior” by Norma L. Day-Vines, Fallon Cluxton-Keller, Courtney Agorsor, Sarah Gubara and Nana Aba A. Otabil, Journal of Counseling & Development, 2020
• “Strategies for broaching the subjects of race, ethnicity and culture” by Norma L. Day-Vines, Fallon Cluxton-Keller, Courtney Agorsor and Sarah Gubara, Journal of Counseling & Development, 2021

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

Opinions expressed and statements made in articles appearing in Counseling Today do not necessarily represent the opinions of the editors or policies of the American Counseling Association.