INFUSED APPROACH
Cognitive Behavioural Therapy (CBT)
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Anti-Oppressive Practice (AOP)
Limitations of CBT
While CBT is an intervention with many strengths, it also has several limitations that must be considered within a critical social work practice. The following section highlights some of the main limitations of CBT.
Individualizes and pathologizes service users’ problems
CBT has an individualistic focus; it sees problems as coming from an individual’s thoughts and corresponding behaviours, and ignores forms of structural oppression (Payne, 2016).
This method fails to see how an individual’s problems can stem from social interactions and behaviours and are often the result of unequal power dynamics and oppressive social structures. This is problematic and limiting because CBT does not address systemic issues as a source of an individual’s problems, nor does it provide an opportunity for CBT therapists to critically reflect on their own assumptions and social location in their relationship with the service user.
For example, CBT attempts to ‘restore’ individuals to ‘rational’ and ‘functional’ cognitive processes.
It does not acknowledge, however, that what is considered ‘rational’ or ‘functional’ has been defined by white, colonial understandings of mental health and ways of being (Howell & Vornka, 2012).
In this way, CBT both ignores and perpetuates sanism and Eurocentrism. In addition to working from a narrow understanding of mental health, CBT also pathologizes individuals’ mental health concerns.
By using CBT, “you can erase issues related to employment, housing, education, healthcare, substance use, colonialism, racism, ableism, cisheteropatriarhcy and make them about certain people with ‘disorders’ and ‘distortions’. CBT pathologizes behaviours, thoughts, and feelings based on one model or worldview that has a way to individualize all problems” (Joseph, 2020, as cited in Linton, 2020).
Conforms to a neoliberal ideology that reproduces inequality
CBT is a popular approach to mental health treatment because of its alignment with neoliberalism and the discourses of New Public Management [NPM].
Neoliberalism in the mental health and health care sectors manifests in lean health care strategies that value efficiency, standardization and cost containment. Michel Guilfoyle (2008) argues that CBT’s success can be attributed to the ease of integration with existing cultural and institutional power arrangements rather than its effectiveness.
CBT’s short-term therapy format is particularly appealing within neoliberal politics which value fiscal restraint in the mental health care sector.
Ameil Joseph, a professor and critical theorist at McMaster University, offers some insight into provincial and federal implementation of internet-based CBT (iCBT) stating,
“Online CBT can be a highly profitable way of claiming to provide mental health services without offering the depth and breadth of appropriate, required or necessary services and support for people” (Linton, 2020).
Further highlighting CBT’s alignment with neoliberal values of individualism and responsibility, Joseph continues, “CBT has a way of suggesting that both success and failure of the model is evidence of success–redirecting blame onto individuals or blaming external factors that CBT does not address. When the model fails, it’s because the person didn’t do the work” (Linton, 2020).
An AOP-Infused Approach?
So, how do we address the limitations of CBT using an Anti-Oppressive approach? Furthermore, are these two approaches even compatible?
CBT is severely lacking in a structural analysis of sociological factors and overarching systems of oppression that impact a person’s mental health and well-being. Utilizing an anti-oppressive approach in CBT treatment models may provide invaluable strategies and insight to address the structural underpinnings of service users’ mental health concerns.
However, it is worth noting that “the goal of therapy should never be to help people adjust to oppression” (carmencool, 2018). While CBT is used to develop skills and strategies to overcome challenges in one’s cognitive and behavioural processes, in the context of structural oppression, CBT from an AOP perspective does not endeavour to maintain oppression by providing superficial solutions to service users.
Rather, it seeks to understand the context that defines a service users’ social reality and address social action to change institutions so that social justice becomes available to all. As Salas et al. (2010) note,“Social work is most effective when the false dichotomy between working with individuals and working towards social change is reconciled and when social justice is addressed at all levels of practice” (p. 95).
Therefore, CBT–when grounded in a critically reflexive, non-judgmental, strength-based, and empowering philosophy that promotes equality within the therapeutic relationship and aims to understand the structural factors that contribute to one’s lived experience–can be an excellent fit for the social justice mission of social work (Brisebois & Gonzalez-Prendes, 2012).
Infusing an AOP lens into a CBT approach might address some of the limitations inherent to CBT.
The table below briefly reflects on five of AOP’s main practice principles and considers if/how these principles are present in conventional CBT approaches.
Based on the chart above, we will use a case study to demonstrate an AOP-infused CBT approach:
Case Study: José
A 35-year-old Latino man, José, has come to your clinic seeking therapy as a result of severe depression and anxiety stemming from an injury at work that caused him to be put on medical leave. José lives in a rural town in Ontario with a majority white demographic and works in agriculture. He has been at home for the last six months. His girlfriend is supportive but works long hours as a receptionist at a physiotherapist clinic. José spends his days alone and has stated that he often turns to alcohol to help the days pass by. He tells you that he has not been able to build many meaningful connections in his town which leaves him feeling isolated. José has also stated that he has little desire to return to work, and when you ask him about his thoughts on the situation, he constantly repeats, “I’m just a failure”.
Questions to Consider:
What does it mean to approach José’s case from an anti-oppressive lens?
What steps should you take?
A traditional CBT approach would work with José to restructure his thoughts around being a ‘failure’. One approach could be to use a thought record to help him look for evidence against this negative thought and move toward more balanced or alternative thinking. For example, this could look like asking José for instances when he thought he was successful in his career, with his family, or within his community. However, this neglects the larger structural issues that are impacting José and creating the conditions for his depression. A traditional CBT approach might help José develop strategies against negative thoughts, however, the true source of the problem remains unchallenged.
During further discussion with José, you decide to ask him what the source of his thinking stems from. He tells you that he had dreams of excelling in his career, starting a family, and becoming part of a tight-knit community by the time he turned 30 years old. He expresses that in the five years since living in the town, he has only managed to obtain minimum-wage jobs and often feels like an outcast in the community because of his race. He says that the increasing cost of living coupled with his low income have prevented him and his girlfriend from having children, as they are worried about being able to provide for a family. He also tells you that he is overwhelmed by the knowledge that he and his girlfriend are under significant financial stress that could be alleviated by his return to work. However, when you broach the subject of resuming his employment, José reveals to you that he feels uncomfortable returning because he is constantly berated and demeaned by his white supervisor and his white colleagues.
Questions to Consider:
How do poverty, racism, and precarious employment contribute to a service user’s mental health?
How do structural forms of oppression function in José’s life on a macro and micro scale?
What CBT interventions can be used to address these oppressions?
If you were to use CBT to teach him strategies to challenge these negative thoughts and encourage him to return to work with these new coping strategies, this could aid in maintaining an oppressive structure. This approach using CBT would only help José adapt to an oppressive system, instead of interrogating and challenging racism in his workplace and community. In addition to teaching service users CBT strategies for coping and managing negative thoughts and feelings, critical social workers also need to help service users access resources like community groups that offer practical support, to work with service users to find practical solutions to address racism in work and community settings by approaching management or a union, or connecting service users with advocacy groups who are doing work in the areas that are impacting them.
Below are potential guidelines to working with José’s case from an anti-oppressive framework:
Bring awareness to José’s positionality and the intersections of his social location.
Acknowledge the historical, social, political, and structural dimensions of oppression
Attempt to distinguish between problems that are environmental and those that stem from dysfunctional thoughts
Collaborate regarding the construction of treatment goals and planning a working alliance (that acknowledges power dynamics and works to dismantle them)
Co-construct goals to be accomplished through the relationship
Co-construct tasks to be fulfilled by each partner in the relationship
Build mutual trust and respect
Coping Strategies/Skill building
Identifying José’s strengths
Validating his experiences of oppression/discrimination
Engage in cognitive restructuring practices by externalizing structural forms of oppression that are impacting José’s mental health
Work together to create a list of tangible steps that can be taken to support José in securing sustainable employment and addressing racism in the workplace/community
Adapted from: Stepney (2006) cited in O’Neill (2017)
An AOP Infused Approach?
Working from an anti-oppressive framework means aiming to understand the full impact of structural oppressions and the context in which a service user develops negative thoughts and mental health concerns.
While it is beyond the scope of CBT to directly address structural issues of oppression, AOP can provide practical steps to create systemic change. Utilizing CBT with oppressed communities can create opportunities for strengths-based approaches to intervention and help service user’s build the skills for empowerment.
Cognitive restructuring, emotional processing, and behavioural interventions need to focus on the service user’s experiences of oppression, on useful thoughts, coping skills, and identification and incorporation of adaptive behaviours that work for the service user—not for an oppressive system. This is facilitated by a strong, collaborative therapeutic relationship, characterized by empowerment and validation strategies that help clients have a liberating, anti-oppressive CBT experience.
As critical social work practitioners, our goal is to empower and work with service users to challenge and overcome these oppressions. Utilizing anti-oppressive practice in cognitive behavioural therapy can provide insight into the larger structures that impact an individual and how these structures can be addressed using conventional approaches in social work.