Using CBT for Black Women

During the 1960s, Aaron Beck developed Cognitive Therapy, now synonymous with Cognitive Behavioral Therapy (CBT). Contemporary CBT is a widely used psychotherapeutic approach for different psychopathologies such as PTSD, anxiety, and depression, and I believe it to be effective across several clinical settings. 

I use several tools to assist in restructuring my maladaptive cognitions - most notably the use of mindfulness meditation and exposure - both of which are standard tools used in CBT sessions. Spiritual practices and operationalized goals have catalyzed my development, and I have seen them enhance the lives of others, too. As a black woman, it is also important that the therapeutic approaches I practice are suitable across cultural boundaries, such as CBT, which I believe can cater to the individual's worldview while still eliciting behavior change and emotional well-being. 

CBT used for Black Women with Anxiety 

The mental health epidemic concerning African American women is tremendous, with many of its roots being planted during slavery. Black women are “20% more likely than the general population to experience serious mental health problems” (Wallace et al., 2021, p.4). Many black women agree that anxiety is a ‘normal’ state of being for them amidst their desire to be perceived as strong and selfless (Liao et al., 2020). Tenets of strength and caregiving characterize the Strong Black Women Schema (SBW), and black women are socialized by external factors such as media, parents, and communities to accept this schema (Liao et al., 2020).  

Subsequently, black women are susceptible to experiencing maladaptive perfectionism, low self-compassion, and a lack of connectedness with others due to a fear of being perceived as ‘weak’ (Liao et al., 2020). Liao et al., (2020) remark that black women may endure higher rates of solitude and disconnection from others due to the pressure to maintain a facade of strength. 

A study done by Watson & Hunter (2015) explored the implications of the SBW schema on the perspectives black women have around receiving mental health counseling. The sample size consisted of 95 women from the ages 18 to 65, and the results found that African-American women may avoid mental health services to maintain their facade of strength. 

(Watson & Hunter, 2015) noted that adherence to the SBW schema is linked to adverse mental and emotional outcomes, including increased risk of depression and anxiety. Additionally, black women endorse somatic symptoms more than mood symptoms related to anxiety-related disorders (Watson & Hunter, 2015). Wallace et al., (2021) highlight that the prevalence of intense physical symptoms, particularly during panic attacks, is greater in black women than in other groups. By helping black women dismantle the expectations of the SBW schema and define the physical and mental symptoms they are experiencing, I believe we can help them return to a more holistic sense of self. 

Otte (2011) notes that CBT is the most empirically supported approach for the treatment of anxiety disorders. This form of psychotherapy utilizes several methods and approaches that can be individualized to the client and personalized to different cultural groups. In a meta-analysis done by Carpenter et al., (2017), the findings showed that participants who used CBT experienced more significant benefits for anxiety disorders than those in a placebo condition.  Clinically Important Features of CBT 

CBT uses various techniques to change thinking, mood, and behavior (Beck, 2021). I have learned of a range of treatment tools that can be utilized in sessions to address several maladaptive behaviors related to stress, anxiety, and cognitive distortions. I have found that cognitive restructuring, exposure, stress inoculation training, mindfulness-based techniques, and bibliotherapy work well to provide long-lasting results for our clients.

Cognitive Restructuring and the Cognitive Model 

Beck (2021) defines cognitive restructuring as analyzing and managing maladaptive thought patterns. It addresses automatic thoughts and dysfunctional beliefs that limit clients' ability to see their potential and take responsibility for their emotional behaviors. It utilizes several strategies to help clients consider alternative explanations for their beliefs. Examples I have found of cognitive restructuring techniques include thought recording, socratic questioning, and disputing. 

To identify how cognitive distortions alter our behavior, we can utilize Beck’s cognitive model, “which hypothesizes that people’s emotions, behaviors, and physiology are influenced by their perception of (internal and external) events'' (Beck, 2021, p.28). The cognitive model proposes that a situation or event precedes an automatic thought, triggering a behavior (Beck, 2021). Therefore I think psychological problems arise when one's cognitive distortions consistently elicit maladaptive behaviors. Concerning anxiety, Roemer (2002) found that “worriers believe their worry will help them prepare for, problem solve, or superstitiously avoid the negative events they fear” (p.57), often manifesting as maladaptive behaviors such as avoidance, procrastination, and excessive planning (Beck, 2014, p.16). 

In a study performed by Shikatani and Antony (2014), 56 adult participants with social anxiety were recruited for a study measuring the effects of cognitive restructuring on post-event processing (PEP). The participants were assigned to a control, cognitive restructuring, or mindfulness condition. In the cognitive restructuring condition, participants were educated about cognitive distortions and were taught how to identify and address their cognitions. The study's results showed that cognitive restructuring led to reduced self-reported anxiety from pre- to post-study. Some participants commented that the strategies used to challenge their maladaptive cognitions were so helpful that they would likely apply them in other situations in their everyday lives. 

I believe the desire many black women feel to be perfect and strong at all times may be a result of polarized thinking convincing them that anything other than ‘perfection’ is an implicit failure. As I see, using socratic questioning and thought recording can help black women see where their biases and behaviors prevent them from experiencing the fullness of the self. 

Exposure Therapy and Stress Inoculation Training 

Josefowitz et al., (2021) describe exposure as an experiment that challenges your client's fears and phobias and teaches them to replace maladaptive coping skills with healthier ones. As I’ve mentioned, many individuals with anxiety may engage in avoidance behaviors to avoid anxiety-provoking stimuli. The short-term consequence of avoidance may be a sense of relief. However, the long-term consequence is an increase in anxiety due to the continued avoidance of a non-dangerous situation (Josefowitz et al., 2021). 

A helpful supplement to exposure therapy is stress inoculation training (SIT), which teaches clients stress management techniques “based on the assumption that we can affect our ability to cope with stress by modifying our beliefs and self-statements about our performance in stressful situations” (Corey, 2017, p.294). In the second phase of SIT,  the therapist helps the client develop coping skills in a clinical setting and then pushes the client to practice these skills in vivo (Meichenbaum, 2007). Therefore, I think it may be a helpful precedent for exposure. 

In vivo exposure implies a direct interaction with anxiety or fear-provoking stimuli, and imaginal exposure involves the use of imagination to re-experience a stress-provoking situation. While the client is in contact with these stimuli, their goal is to give up their maladaptive safety behaviors and learn how to manage their anxiety without them. Though “anxiety is unpleasant, (it is) not dangerous” (Josefowitz et al., 2021, p.226). 

Virtual reality exposure (VRE) is a newer development. It is unique in its ability to immerse clients in a virtual environment consisting of their feared stimuli under the supervision of a mental health professional. In a study conducted by Loenen (2022), 817 participants diagnosed with an anxiety disorder participated in sixteen trials of VRE, and the results of the study showed that VRE-CBT is as effective as CBT in the treatment of anxiety disorders.

I believe exposure therapy may offer opportunities for black women with avoidance behavior to engage with environments they have been keeping away from, such as public speaking in front of an all-white audience, to help prepare them for giving a presentation at their job that lacks diversity. 

Mindfulness and Relaxation Tools

From Eastern traditions, mindfulness is best defined as being conscious and aware of the present reality without judgment (Roemer, 2002). Mindfulness encourages clients to settle into the present moment nonjudgmentally, and its utilization in clinical settings has been empirically proven to reduce symptoms of anxiety, with one study suggesting that mindfulness-based techniques have been proven effective in the reduction of anxiety. (Roemer, 2002). Similar to exposure, the present moment component of mindfulness alters avoidance behaviors that many anxious individuals may engage in habitually (Roemer, 2002). 

Several mindfulness techniques are used in the therapeutic setting, such as progressive muscle relaxation (PMR), deep breathing, and guided imagery. I believe PMR, the act of contracting muscles to achieve a state of relaxation, has the potential to be helpful in several settings. Toussaint et al., (2021) describe a study where thirty nursing students used PMR and found a significant reduction in stress post-utilization of the technique. In a separate study, deep breathing significantly decreased anxiety scores for participants trained in deep breathing exercises, and guided imagery showed increased self-forgiveness after seven five-minute guided imagery sessions. 

Woo (2009) conducted a study with 63 patients presenting with panic disorder or generalized anxiety disorder, in which participants were assigned to either an eight-week Mindfulness-Based Cognitive Therapy (MBCT) program or an eight-week Anxiety Education Program (APE). The study found that MBCT group members showed greater improvements in their anxiety score than ADE group members, concluding that MBCT can be effective in the reduction of anxiety symptoms.  

Progressive muscle relaxation and deep breathing practices are also beneficial when an individual may be experiencing intense physical symptoms, as do many black women with anxiety. 

Bibliotherapy 

Bibliotherapy involves using literature to promote mental health (Hynes, 2019, p.11). As I see it, providing our clients with helpful reading materials allows individuals to take responsibility for their education and reinforce concepts discussed during sessions. With that, I believe the therapist must provide the client with reliable sources and facilitate dialogue during sessions about the content the client has read. Hynes (2019) highlights that “the process of growth and healing is centered not as much in the act of reading as in the guided dialogue” (p.13). Ideally, the client can integrate what has been read into their daily life and apply it to the cognitive distortions and behaviors addressed during the therapeutic process.

In a pilot trial done by Sharma and Sood (2014), thirty-seven participants were given the book Train your brain, engage your heart, and transform your life, read over twelve weeks through a self-directed program. This study showed promising effects on decreasing perceived stress, increasing quality of life, and mindful attention through bibliotherapy. Their findings were consistent with other qualitative studies that found bibliotherapy can be useful for those looking to promote their sense of health and well-being (Sharma et al., 2014). 

For the black population, I believe bibliotherapy may help promote independence in their CBT journey. 

The Implementation of CBT 

Goals of CBT

CBT can be adjusted to fit the needs of each client (Beck, 2021). CBT explores the ways anxiety disorders are maintained by negative beliefs or maladaptive cognitions, followed by a biased perspective on the events that happen during anxiety-provoking situations (Marom & Hermesh, 2005). The overarching goal of CBT is to use different techniques to challenge distorted thinking and maladaptive behaviors in order to help our clients take greater responsibility for their mental health. Regarding cultural competence, Wallace (2021) mentions that CBT “meets the needs of multiethnic clients when the interventions are modified to enhance their congruence with the client's culture, context, and language” (p.43). 

CBT sessions must follow a structure that helps individuals leave each session with some degree of symptom relief. In the first part of the session, the client checks in about their emotions and any important notes from the previous week, then collaboratively sets an agenda for what will be accomplished in the session. The middle part of the session is used to discuss matters on the agenda, review and create new homework, and summarize the conversation we had during the session. Lastly, the therapist elicits feedback from the client to ensure that the process is effective and that trust is continuing to be built. (Beck, 2021). 

Challenging Maladaptive Cognitions with Faye 

To create a more cohesive explanation of application to my population, I will use the name Faye to refer to a black female client with anxiety. 

I would begin my relationship with Faye by attempting to understand her perspective of life through her cultural lens, including cultural stereotypes and expectations that may have impacted the adoption of the need to be a “strong black woman.” Throughout our time together, I would encourage Faye to relay how this schema has posed emotional or physical issues for her. With my awareness that somatic symptoms of anxiety are more prevalent in black women, I would watch out for cues that she is experiencing them and identify what the potential antecedents are to the onset of these symptoms. 

When I notice cognitive distortions, I will ensure that I present my observations in ways that align with the client's cultural lens. For example, if Faye expresses a ‘constant need to be strong, because if not she is worthless,’ I will have identified this as a polarizing distortion. A culturally sensitive way of addressing this may look like saying, “When you make statements like that, you are engaging in all or none thinking. You mentioned you bring your emotions to God, who loves you as you are. I would invite you to challenge those statements of ‘worthliness’ and replace them with self-affirmation statements, such as ‘I am doing enough by just being myself.” 

The Therapeutic Relationship 

As I’ve learned, CBT requires a sound therapeutic alliance that is egalitarian and fostered by empathy and positive regard. The therapeutic process is collaborative and requires the active participation of both parties. Watson (2015) states that many African Americans have a fear of being judged, so it is essential that the therapist takes on a nonjudgemental stance and builds rapport consistently throughout sessions. In addition, Beck (2021) mentions that CBT is educative and aims to teach clients to be their own ‘therapist,’ using the tools they have learned in the therapeutic process. 

Building a Relationship with Faye

Building constant rapport with Faye is going to be very important. This can look like recognizing her commitment to show up in a mental health office and providing well-timed self-disclosure in moments where she may feel isolated in their experience. Normalizing emotions is essential for women like Faye, particularly because these are usually suppressed or demonized. However, we will not stay in a state of normalization, but we will shift to eliciting change talk and engaging in tools that will help us create new behaviors. This may include recommending books to Faye, providing her with homework that will help her challenge her cognitions, and committing to exposure to situations that Faye usually avoids, such as speaking during job meetings and showing emotion in front of her children. 

The Client's Experience in Therapy

Throughout CBT, I believe clients should be able to develop a greater sense of self-efficacy and experience greater control in times of emotional distress. Many black women might perceive self-compassion as a weakness, as the SBW schema values prioritizing others' needs before one's own (Liao, 2020). Therefore, the therapeutic space should offer a retreat from constantly putting others' needs before oneself. Throughout the sessions, the client should experience an increase in hope, self-confidence, control and an improvement in mood and somatic symptoms (Beck, 2021). As I understand, clients should feel they have a say in their treatment plan and exemplify an ability to speak up if something is not working for them. 

Faye’s Experience in Therapy

For Faye, this may look like greeting her warmly whenever she enters the room and starting with a light-hearted conversation. The first few minutes can be rapport building, asking the client questions about their day and if they have anything exciting going on in their personal life. This constant building of rapport will allow Faye to build trust in me,  expanding outside her typical confidants, such as the church and the family unit. Providing positive reinforcement for the moments Faye honors her needs inside and outside therapy is essential to increase the overall frequency of these self-compassionate behaviors. 

Treatment Examples 

Faye is a 40-year-old black woman presenting with generalized anxiety disorder. She identifies as a Christian and has two kids. She describes herself as “the glue of the family” and “the one who keeps it together.” She works a corporate job and is the only black woman on her team. She mentions that “her anxiety keeps her safe because she is preparing for the worst-case scenario.” When stressed, she experiences headaches and shallow breath and avoids grocery shopping because it “makes her too nervous.” When she is not at work, she prefers to isolate herself in her room, reading her Bible because it is the only place that feels “safe.” Her identity as a “strong, black woman” is important to her, and she fears that she would be perceived as weak if she were to ask for a break. 

Maladaptive Perfectionism

1. Disputing: You mentioned that you don't take breaks because you will be perceived as weak if you do. What evidence is there for that? 

2. Progressive Muscle Relaxation: When you are going through your day and feel stressed, this technique may help your body relax.

Disputing helps Faye to identify her cognitive distortions, which in this case is polarization. Once we identify the maladaptive cognitions present, Faye and I can identify the emotions and behaviors connected to those cognitions and utilize the cognitive model to elicit behavior change. Finally, I provide Faye with information on Progressive Muscle Relaxation (PMR), which I have seen help alleviate symptoms of stress. 

Avoidance Behaviors 

1. Education: Often, when we avoid something to protect ourselves, it provides short-term relief, but in the long term, we never get to learn that we can handle it using new coping skills. 

2. Broaching: I can imagine working in an all-white environment comes with its challenges, perhaps even some racism. You may feel the pressure to ‘represent the black community well.’ 

3. Exposure: How would you feel about slowly building up to going to a grocery store again? We can begin with looking at pictures of a grocery store, then parking in the lot, eventually getting you inside. Eventually, you will learn that your anxiety is uncomfortable but not dangerous, and you can practice new coping skills. 

A part of my role as a therapist is to provide the client with information on what they may be experiencing and to not keep the client in the “dark.” Providing education also assures the client will have information to utilize outside of therapy. Broaching that race may play a significant role in her career will help the client recognize that talking about race-related issues in therapy is okay. Exposure therapy will help Faye replace her maladaptive safety behaviors with positive ones so she can come out of isolation and learn how to manage her anxiety in real life. 

Somatic Symptoms 

1. Bibliotherapy: You mentioned that when you are stressed, you experience headaches and shortness of breath, which are often manifestations of emotional symptoms we may have. I recommend the book The body keeps the score, which explores how our body tells us there may be something happening emotionally that we have not addressed yet. 

2. Deep Breathing: Deep breathing practices can be beneficial in times of stress. A few years back, I went to a conference, and a speaker noted that the Hebrew word for breath is ruach, which means breath of God. Perhaps you can visualize that during your breathing practices. 

Faye mentioned that she enjoys reading her bible, so I offered her a book to help her learn more about how emotions can show up physically. Bibliotherapy also helps clients have a sense of responsibility in their journey. Deep breathing, presented in a way that considers Faye's religious factors, may help alleviate some anxiety and help when her breath is shallow. 

Conclusion

I believe CBT is a useful theoretical approach in the treatment of anxiety, particularly for the black community. As a black woman myself who has experienced bouts of anxiety and worry, I have seen the benefits of implementing CBT tools into my daily routine, particularly in the way I communicate with myself and interact with the world around me. 

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