Don’t let the perfect be the enemy of the good...Andrew Beck on Transcultural CBT
In this episode of Let’s Talk About CBT – Practice Matters, host Rachel Handley speaks with Andrew Beck, consultant clinical psychologist, CBT therapist, and author of Transcultural Cognitive Behavioural Therapy for Anxiety and Depression. Andrew is a leading expert in culturally adapted therapies and a former president of the BABCP. Together, they explore the importance of culture, language, ethnicity, and identity in therapy and how these factors influence mental health, therapy engagement and treatment outcomes.
Andrew shares his personal and professional journey into transcultural CBT and he and Rachel discuss practical strategies for therapists to approach conversations about culture and difference in therapy, as well as the evidence supporting culturally adapted approaches. Andrew encourages therapists to engage with these topics, step outside their comfort zones, and take a flexible and collaborative approach to transcultural CBT.
If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on Instagram, @babcppodcasts.bsky.social on BlueSky or email us at [email protected].
Resources & Further Reading
Transcultural Cognitive Behavioural Therapy for Anxiety and Depression: A Practical Guide by Andrew Beck
The Cognitive Behaviour Therapist Special Issue on Being an anti-racist CBT therapist
IAPT Black Asian and Minority Ethnic Service User Positive Practice Guide
Credits:
Music is Autmn Coffee by Bosnow from Uppbeat
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This podcast was edited by Steph Curnow
Transcript:
Rachel: Welcome to Let's Talk About CBT- Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients.
Today I'm going to be talking to Andrew Beck, consultant clinical psychologist and CBT therapist. Andrew is a former president of the BABCP and author of the influential book, Transcultural Cognitive Behavioural Therapy for Anxiety and Depression. He's also a leading expert nationally and internationally on culturally adapted therapies.
So we're so delighted to have you, Andrew. It's one of the great joys of hosting this podcast, having the opportunity to read and reread the work of world experts in different areas of CBT, like yourself, and to talk to them about their work and having dipped into your book a few years ago over the years, it's been wonderful to have an opportunity to read it from front to back as there’s such a rich, wide ranging and thought provoking and practical information in it. I'm also really curious, cause at first glance, not necessarily the obvious choice of a topic for a white British therapist to write. And I'm wondering how you got engaged in this work. What's motivated and informed your interest in it personally, professionally?
Andrew: Yep, it's a really good question, Rachel. And first, thanks for letting me know that it was a helpful book to you and something that was readable. It's one of those really difficult things about putting a book out there that you never know how it's landed and how it's landing, really. Because people pick it up, but you seldom hear from people about what it was like as a resource. I mean, how I came to be interested in it was through a couple of strands, really. One was quite personal, going right back to, I suppose like my early political life. I was born at the end of the 1960s. By the time I was 12, 13, the National Front who were kind of overtly racist political party were quite active in the area that I was growing up. And I think I was probably 13 when I first went on a kind of anti-Nazi league march and was listening to The Specials who were a band who really articulated the need to push back against that kind of growing tide of racism. And that was really formative for me as were some of the friendships and relationships I had during my teens and twenties, and being close to people who'd experienced discrimination at the sharp end. Really, as you say, I'm a kind of white English man, I'd never really experienced any kind of discrimination or hardship as a result of my characteristics, but politically I was interested in getting alongside people who had. So that was where it came from a kind of values point of view, I think, but in terms of how I ended up doing that as part of my job as well, is, so I was quite late to psychology. I graduated when I was around 25 and one of the first jobs I had was a research job in Nottingham, looking at how and why people used acute psychiatric beds. I was really lucky in that part of the team who were doing that work was a trainee psychiatrist called Swaran Singh, who's now Professor of Social Psychiatry in Warwick, but at the time he was just sort of finding his feet as a psychiatrist. And he said to me one day, have you ever noticed how nearly everybody who comes into these wards on a section of the Mental Health Act is a young black man? And I said, no, I hadn't noticed because, you know, I was a young white man. I didn't need to notice things like that. I didn't need to recognise those inequalities because they didn't really affect me, but Swaran as someone from a minoritised background had noticed. And what he was able to do was tack onto the study that we were doing, an additional study, looking at the rates of sectioning and who got sectioned and why. And with the statistical help of Tim Croudace, we wrote a paper that showed that young black men were massively disproportionately admitted under sections, despite the fact that the severity of their presenting problems was no greater than anyone else's. So that got me really interested in inequalities in mental health care. So I was really lucky that I had someone who opened my eyes to that really at a formative stage in my career. And then I spent three years as an academic, a research assistant, research associate. The professor in charge of my department told me that I'd never be a very good academic, but I'd probably be okay as a clinician. So then I applied for clinical psychology and began to practice clinical psychology in East London, where the patient group we were working with was diverse. So from the moment that I began to learn how to be a therapist, it was learning how to be a therapist with people from different backgrounds to myself. So that's how I became interested in that quite early on in my career, really.
Rachel: So it sounds like you found yourself in a time and place in your life where there are these movements going on around your natural interest and inclination to stand up against racism and discrimination. But then also these key figures that drew you in and were generous with their time and thinking and their experience to help you think about ways in which you could really enact that in your work.
Andrew: Yeah, that's absolutely right. I was so lucky in that, that there were a number of people who took the time to kind of help my thinking develop really. And that was generally people from minoritised backgrounds themselves who could see I probably had some kind of enthusiasm or interest and who sort of put the time and effort into bringing me along. And I'm really grateful for that really, I was very lucky to have those experiences.
Rachel: And it's evident from your own history of your involvement in this work. This isn't a new conversation. It's not something that we're arriving to just now in terms of a therapy community. However, the way in which we discuss these things often feels quite tentative and people are coming to it often quite new and without kind of fully formed ideas. One of the things that might be helpful to think about upfront as we're having this conversation is what kind of terminology we might use in this podcast and maybe more generally that is helpful, rather than alienating for folk as we talk about transcultural therapy.
Andrew: Yeah, that's a really good question, Rachel. And it’s one of those things that I think when I think back about how we had those discussions, in the kind of mid to late nineties, the language that we use then was very different to the language that I would use when I first started writing about this in publications and the language that we use now is different again. And it's a constantly evolving language. And I think that's great because as therapists, we know that the way we describe the world helps us understand the world and so refining our language is really helpful. But there's a downside to that, which is, I think worrying about getting the language right can be a little bit paralysing for people and people can be so worried about saying the wrong thing that they say nothing. And I think one of the helpful positions to take is that if people are trying to do the right thing, trying to talk about things from a position of good intent, but whose language isn't quite up to date, what I think I've learned over the years is not to kind of really overtly correct them, but to just use language that I find more palatable and see if that kind of rubs off to give people that different opportunity to talk in different language about these kind of issues, because I would rather people had a go and got it a bit wrong than didn't have a go at all.
But in terms of the language that we currently use, I mean, it's in a state of flux, I think, So, when I published the book Transcultural CBT, I used the term BME, Black and Minority Ethnic, because that was the most useful phrase around at the time. By the time it was published, that phrase was out of date and the preference was for Black Asian and Minority Ethnic. And so when we did the Positive Practice Guide, myself and Michelle, we used the term BAME because it seemed like the most useful, but we knew then that term was on its way to changing. And I think we even acknowledged that in the writing, that the language that we use at this moment in time will seem old fashioned by the time you read this almost. And so, the terms used now, that there's several that are competing in a way to become the definitive one. And so the terms people use, like from a minoritised community, is quite a useful one and why people prefer that to, say, being from a minority community, is that there's an idea that being minoritised is something that's done to you, to your community, it's about being excluded. But of course, that term has been flipped on its head by some academics in this field who prefer the term global majority. And why that's useful in some ways is it recognises that most people in the world are from a non-white background. And I think there are some settings where that's clearly quite useful to articulate an idea. But I always use what I call the mum test. And that's my mum is really bright, she left school at 15 and worked, when she did work, in a shop on the checkout until she was in her forties. And then through a friend of mine went into care work and was a really good care worker and worked with kids from diverse backgrounds. And I sometimes think the language that we use to talk about these things needs to make sense to my mum. Which is, you know, someone who's a frontline worker who gets on with doing the job and who wants to do the job, isn't discriminatory, but needs a language that they can make sense of. And so I always ask myself when we're thinking about these new terms, how would that land with my mum? Would she be able to make sense of it in order to do a better job by the people that she's supporting and looking after? So, I’m not entirely sure where I'm going with that other than to say that it's quite complicated and coming up with the terms that are going to be most useful is by no means an easy thing. And of course, it's not my role as a middle-aged white man to come up with them either, it’s sort of, I listen to what people are saying and prefer and kind of get alongside that when I can.
Rachel: I loved where you started there where you talked about defining our language helps us define our thinking, which is important in therapy, but it sounds like what you're saying is it's not a final statement, it's an iterative process. In therapy we define our thinking, we have Socratic dialogue to understand what we're thinking so that we can then test that out and change that thinking or modify that thinking if it's helpful and useful and helps us communicate to ourselves and others in different ways. So it sounds like if we inhibit ourselves from speaking about these issues, we inhibit ourselves from learning and changing.
Andrew: Yeah. And you've got to have that willingness to get it wrong. I've got it wrong so many times in my career, both as a therapist in the room, as a writer on this topic, you know, giving it a go means that at some point you're going to make mistakes, but you just fail again, but fail better next time.
Rachel: Yeah, I can identify with that, and I can also identify with the idea that language can really challenge us and hit us in different ways. I remember the first time I heard that phrase you mentioned, global majority. It really stopped me in my tracks for a moment because suddenly you realise the inherent comfort in being part of a majority and that was just a helpful moment to, you know, have a little mini tiny insight into something, a baby step along the way to developing my understanding.
Andrew: Yeah. That's a really nice example of just how a switch can go on.
Rachel: Hopefully folk will forgive us if we are clumsy in this podcast and we can use language that people find helpful and not destructive. And given all that you've already said, it seems blatantly obvious that factors such as culture, language, ethnicity, religion, these things that are important parts of our identity as human beings would impact on the way mental health problems manifest in individuals and society at large and how people engage with and benefit from therapy also. But we're always interested in the evidence here that, that seems self-evident, but what is the evidence that these factors are important in mental health and the application of CBT?
Andrew: I would say of the evidence that's out there, I'm probably on top of and able to articulate about a tenth of it, if that. So it's very much a kind of highly selective take from my point of view.
Rachel: 10 percent is pretty good, Andrew, we’ll go with that.
Andrew: We’ll go with that, it's a start. So emotional distress and what we might consider to be mental health difficulties occur in all cultures, in all contexts. People struggle with their feelings, with their experiences. But the frameworks within which they understand those can vary considerably, and the nature of those problems can vary too. So we know that in some communities at some points in time, certain kinds of distress will be greater, and that may be due to environment and what's going on, or it may be to do with how a particular community articulates and thinks about unusual experiences, or the things that are happening to that community at any one point in time. So all of our experiences are understood through the framework of our current culture. I can give an example of that from say panic, which is a fairly common problem that many people work with therapeutically. Now, whatever your cultural background, if you experience something as threatening, your fight or flight system will be activated and your heart will begin to beat faster amongst most other things. Now, if you're from a white Western background where we've had 30 or 40 years of really good public information about the risk of heart attacks and what to do if you have a heart attack, chances are you'll understand what's happened to you as a heart attack. This feels like a heart attack. This must be what a heart attack feels like. So then that, that burst of adrenaline is experienced as a potential heart attack and you'll act accordingly or kind of safety behaviour may be to call 999 or lie down on the floor or whatever seems sensible to you. But if you're from a culture that hasn't really experienced heart attacks, doesn't really talk about that as a kind of pressing health problem, but that may talk about particular kinds of supernatural forces that could act on the heart. When you get that burst of adrenaline and your heart starts to beat quicker, out of the blue, you'll interpret it through that lens. So you're still misinterpreting a bodily phenomena. So something about the underlying structure of what's going on is the same, but the phenomenology is different because the framework that you have for understanding is different. Does that kind of make sense?
Rachel: Yeah. So I understand the world's going to influence how I understand what's happening to me.
Andrew: Yeah. And then the thing that you do to fix it will vary. So if your belief is that's caused by a supernatural phenomena, the thing you do to make yourself safe would be probably to seek some kind of help that is supernatural in origin. Whereas if you believe it's a heart attack, you'll call 999. So it's your kind of, your subsequent behaviours are shaped by your cultural framework too.
Rachel: So the way these problems present, the way they manifest for individuals can be quite different based on the culture and how they respond. And what's the evidence that the needs of these different communities, minoritised communities, are met well or otherwise in our mental health services in this country?
Andrew: So we're really lucky in the UK and in England specifically that we've got the IAPT or NHS Talking Therapies data set. So that's unique, I think, in the world in giving us the ability to look at really large numbers of mental health consultations and see what happens. And we've known, from the IAPT data sets that in the early days of IAPT, so looking at the kind of new and pilot site, for example, people from minoritised backgrounds had as good an outcome as people from white backgrounds in therapy, probably because that team in the pilot site was multicultural in itself, had chosen to work in Newham, which was a famously multicultural area and had the kind of expertise to do that work. But we also know from that pilot is the access was lower for people from minoritised backgrounds. So some things were changed, including self-referral that enabled people from minoritised backgrounds to get better access. So we know that in some instances, at some times, access and outcomes can be as good for people from minoritised backgrounds, but if you look at the national picture in NHS Talking Therapies, we can see that both the access and the clinical outcomes have been worse for people from most, but not all minoritised backgrounds. So people from a Chinese background in Britain had as good a rate of access and outcomes as white service users right from the start, but compared to people from, say, a Bangladeshi or Pakistani background whose access rates were much lower and whose outcomes once in therapy were much lower. So we know that it's very uneven picture both between different teams and different ethnic groups. And that's the same for, look at, for example, psychosis services. And we know that you need to be much more unwell to get a service if you're from, for example, a black British background in psychosis services and the less likely to get kind of wraparound care and are more likely to be admitted still 30 years after Swaran and I's work highlighting this, still more likely to be admitted under the Mental Health Act.
I think there's a lot of evidence from within England and the wider United Kingdom, that there's still these gaps. But the good news is, over the past few years within NHS Talking Therapies, the gaps have closed and so you can see that, for example, if you're from a black British background, your access and outcomes are now as good as people from a white background when accessing NHS Talking Therapies. So it is possible to close the gap, but it needs resources and effort, but there's still a long way to go for some other communities, like, for example, the Bangladeshi and Pakistani communities, but the Indian community has really closed the gap and it's almost equitable now. We've still got a way to go.
Rachel: And what have the major initiatives been that have closed those gaps? What's changed, do you think?
Andrew: I think we're lucky in, in both SMIs, Serious Mental Health Services in the UK and in NHS Talking Therapies, in having had really outstanding leadership around this. And I know more about NHS Talking Therapy, so it's probably better I talk about that more than the SMI field, but the kind of leadership who set national strategy and policy, recognise these gaps and put resources into closing them by getting people the training that they needed, giving people the kind of feedback from the data sets that we've got about what was going on, by ensuring there were frameworks available to help improve services. So that's been a real success story over the past few years in NHS Talking Therapies. And I know that there are similar initiatives going on in the kind of serious mental illness field, for example. And one of the reasons that's been the case is that it’s sort of outstanding leadership within the psychiatric professions, actually, who've really done a lot of that work in the SMI field.
Where I think there's still a really big gap is in CAMHS. I think so little is known about whether children and young people from minoritised backgrounds get their mental health needs effectively met in CAMHS, because there aren't those kind of big data sets available that we've got in NHS Talking Therapies to monitor that closely, but small bits of research have shown that there are gaps but I'm not sure there's a national strategy to close them, really.
Rachel: So like the whole issue of discrimination more broadly in our culture, it’s a huge issue, no one can say job done, but there are encouraging signs that these gaps can be closed if we focus on them if there's good leadership and a real sort of sense of energy and motivation to address those issues.
Andrew: Yeah, absolutely. And one of the things I think has really helped as well is, if you look at workforce data, NHS Talking Therapies has a diverse workforce. So it's going to be much better placed to close those gaps than services, for example, traditionally clinical psychology services, which haven't been particularly diverse. I mean, that's changing slowly, but I do think one of the reasons for the success of NHS Talking Therapies, as well as the leadership, is that there's been a diverse workforce who've taken up those challenges and the same in SMI fields as well. I think, psychiatry has always been a very diverse field of medicine and that's really helped psychiatry to an SMI service to get the house in order.
Rachel: So bringing this all into the therapy room, if you like, you have a really wonderful, practical, helpful chapter in your book about how to discuss ethnicity and culture with individuals we work with in therapy. I guess I'm not alone in having some anxieties that sometimes hold me back from attempting to adequately broach these areas of difference in therapy. And I'm wondering from your work and your experience, what you think it is holds therapists back in having conversations around these issues.
Andrew: I think it's probably the same kind of thing that makes therapists avoidant of all sorts of things that would be helpful for their patients, like experiential learning and exposure and things like that. We're anxious about getting it wrong and because as cognitive behaviour therapists, we know that what we do when we're anxious about something is we avoid it, and we put a lot of effort into avoiding it. But I would say if people are a bit avoidant, do a bit applied practice and see what happens when you drop your avoidant behaviour a couple of times, and notice what happens to the therapeutic relationship, the engagement and how the session goes. And then you can compare, if I ask about these things and if I don't ask about these things, what difference do I notice and check it out experientially.
But actually what we know from asking patients- I was involved in a bit of small-scale research some years back, just ask patients in therapy, do you want your therapist to ask about your ethnic background? And these were all patients who are service users from a kind of minoritised background themselves, unanimously said, I want to be asked, and it would improve the therapeutic relationship. So we know that's what patients want, but if you're not sure, and it's understandable people might be a little bit avoidant, drop your avoidant behaviour, be a good cognitive behaviour therapist and see what happens.
Rachel: I think that’s really interesting what you said about it potentially improving the therapeutic relationship because I think that's possibly what often holds people back, they're worried about damaging the therapeutic relationship in some way if, as you said, they get it wrong and that can often drive that avoidance can’t it?. But actually the patients are saying, no, this is what we want.
Andrew: And you might get it a little bit wrong, but it's better than getting it totally wrong by not asking. And I suppose, what's that phrase? Don't let the, don't let the good be the enemy of the great or the great be the enemy of the good. Something like that. But you know, give it a go. Give it a go.
Rachel: And if we are to give it a go, if we are to, you know, try and get our mouths wrapped around some of these conversations in therapy. What is most helpful? What are the ways that you’ve found, or research and studies have found that there are helpful? You know, is it something we went to broach early on in therapy, or is it later on when we've got more of a trust built up, or do we need to ask permission to have these conversations, or is there anywhere in therapy it's particularly important to bring this up?
Andrew: Yeah, I think it's a bit layered. Early on, the first time you're in a room with someone, you want to establish that good working relationship using all those non-specific therapy skills of active listening, unconditional positive regard, non-verbal skills to put someone at ease to build a degree of trust. But then I would say within the first sort of one or two sessions, and often within session one, as someone's begun to relax into it, just a simple question like, is it okay if I ask a little bit about who's at home? Now that enables you to start to draw out a genogram. So I'd recommend a genogram, whether you're working in adult or child services, as a way to map who's at home. And then you could say something like, I would say because I'm white, I'd describe my ethnicity as white. How would you describe yours? How would other people in this genogram describe their background? And so you begin to add to the genogram a sort of a bit of cultural mapping on that as trust is developed. And I would say in the first session, you might just ask about broad ethnic categories and you might begin to explore a little bit as trust is a bit more apparent, something about, for example, faith background, migration histories. So things that are a little bit more of a challenge than just, you know, I describe myself as British South Asian, or I describe myself as Jamaican, into a bit more about how people identify the individual you're working with and some family members. And then once you've really developed a richer relationship of trust, you can go on to more challenging topics like experiences of discrimination or Islamophobia or the kind of aspects of marginalisation. So you're building trust over time and taking more risks in terms of what you talk about as that trust and that therapeutic relationship grows, that's the kind of rough approach I would take.
Rachel: It sounds like you're talking about early on really opening the door to those conversations and a nice sort of graduated approach to that. But I guess if the door is open, if people know that you're comfortable talking about those things, they can push the door open much wider if they want to at any point. You mentioned genograms, now a lot of therapists, particularly working in with children and in environments where we're thinking a lot about the system, the family system or wider system might be really familiar with using those. Some CBT therapists may never have used a genogram in their life. How would you describe that sort of simply as a tool?
Andrew: So I suppose a genogram is a bit of a family tree, really and it's just a way of representing who's who in somebody's life and typically with genograms, there's some sort of introductions to genograms on YouTube you could take a look at, but you use lines to represent relationships between people and there's a sort of format for doing that, how you would show a kind of romantic relationship, how you would show children and siblings, and then shapes to represent people's gender. Now that's an interesting one because, when genograms were developed, it was a square represented male, and circle represented female. But now the way that people talk about their identities become much more kind of multifaceted and complicated. And there's a whole bunch of additional genogram shapes to represent, for example, trans, nonbinary identities. There are ways of doing genograms to show gay relationships that's all easy to find on the tutorials that are out there. One of the things I would say around doing that is, don’t assume heterosexuality when you're doing genograms and assume that someone's relationship is someone of the opposite sex and so just ask a little bit about who are they in a relationship with, can you tell me a bit more about them and try not to make those assumptions. Because if you do make those assumptions about heterosexuality, it then closes down discussions about sexuality as well, which is quite important or gender identity. It's quite simple, but it's also quite complicated, but start simply and start with the kind of ABCs of genograms and then develop your practice from there.
Rachel: And it can be a lovely collaborative and pictorial tool that you can really share and get a lot of information out of. And as you're talking, it's reminding me of intersectionality in our identities and who we are and how actually a lot of what you talk about in your book on Transcultural Cognitive Therapy gives us hints and tips and clues as to how we might approach some of those other aspects of identity, like gender identity and other aspects that we often fumble around in therapy as therapists.
When it comes to assessment and formulation of presenting problems in CBT, most CBT therapists or people using CBT as part of their therapy, usually have a list of assessment areas, you know, a couple of decades in, I still have my kind of prompt sheet when I'm doing the assessment, cause I forget things routinely, you know, they might be thinking about presenting problems, predisposing issues, precipitating, perpetuating, maintaining factors, goals, aspects of personal and family history and things like that. Are there ways in which we might need to adapt our assessments to provide us with important information about culture and ethnicity that might usefully inform our formulations for therapy?
Andrew: Yeah, I think on the whole the things that people are already doing don't need much adaptation once you've started a discussion about difference, because those sort of predisposing, precipitating, maintaining factors, are there for most people's struggles, but what we include in those probably needs to be adapted. And I give one example of that, it's a topic that I didn't write enough about in the book, but that we wrote a little bit more about in the Positive Practice Guide, but that I've sort of tried to write about and think about more since, which is people's experiences of racism. And because the reason I didn't write about it in the book was that, you know, I'm a white man and I didn't need to have it forefront in my mind and it's only while I've been going out and doing training on this that, that people from minoritised backgrounds have pointed out that I needed to think more about it and do more about it in the therapy room. But if you think about experiences of racism, we know from the research that someone's from a minoritised background, or someone's from a LGBT background as well, for example, the more discrimination that you experience in your life, that's a cumulative risk factor for developing a mental health problem. So that experiences of racism can be a predisposing factor. But from our formulations, it might be that a particular incident of discrimination is the precipitating factor. So, it might be the thing that set off the thing that's got someone struggling and coming to see you. But actually, ongoing discrimination might actually be part of the maintaining factors. So those struggles that people have because of their characteristics can be predisposing, precipitating or maintaining. And one of the ways I sometimes formulate that is using a bit more a narrative formulation of why me, why now, why still, and so discrimination can fit into either of those kind of spheres really. So I think the basic stuff that everybody does well, still stands, it's still genuinely useful. And if you just add to that a kind of sensitivity to and willingness to think about people’s worldview, experiences, and the marginalisations. It just kind of enriches it really, rather than needing to reinvent it.
Rachel: And we think a lot in therapy, don't we, about being curious and asking people and not making assumptions about people's experience, which all of this really, you know, points towards and then some, you know, asking those questions of people and being willing to hear about their experience. But I'm wondering, is there a line to walk between burdening a person with educating you about their ethnicity and culture and how it might inform their problem and empowering them to tell you and actually just educating ourselves?
Andrew: It’s a great point, so I've been really influenced by systemic family therapy in the way that I've thought about adapting CBT. I got to do some systemic training early on in my career and really value the way that as a model, it was way ahead of CBT in its adaptation. But one of the things I think in systemic practice that they talk about is almost a relentless curiosity. I get the impression in some of the research or some of the practice literature, it's sort of relentlessly asking about someone's family life and dynamic. And I think that is potentially over intrusive. Actually, what you need to know about is just enough to help someone get better and if you want to learn about another culture, there’s loads of ways of doing that, that aren't in the therapy room. The therapy room is just for learning enough about that particular person and that particular moment in time to help them make some shifts. And the additional learning is what you do in your own time through books and films and getting involved in community associations and getting out into the world.
Rachel: And I know that I've had colleagues and friends and even trainees on programs I've been involved in running that have at times, because they've come from a minoritised background, have felt burdened in providing that sort of expert advice to their white middle class therapist friends. Is that something we need to be cognisant of as well do you think?
Andrew: Yeah I think that’s a really good point because if you think about the power structures within most mental health teams, it's usually people with my characteristics who are the most powerful, the best paid, the ones in the most senior positions, drawing on the expertise of people who are less powerful and less well paid within the organisation, who may not have the time and the capacity to educate everybody. And so I do think there's a sensitivity needed there that our colleagues and friends aren't resources to draw on. But if we are going to ask people's advice or thoughts or reflections, I think getting permission to ask is really useful. And one of the many things I've sort of taken from family therapy is not asking questions about something directly. So, to not say, can you tell me about how racism impacted on you when you were at school, for example, but to say, is it okay if at some point I ask about your experiences of racism at school and let me know when might be a good time? And so to shift the power dynamic away from you demanding a resource from someone, to checking if it's okay and giving them the choice about when that might take place and a choice not to do that at all. So I think that sort of shift in the way you might seek it out is useful.
But ofcourse there are people in our networks who would very much see that as part of their role to do that as well and part of their job. And I'm thinking specifically about chaplaincy services. So, if you're lucky, you’ll work in a trust that's got a multi faith, multiethnic chaplaincy service and my experience is generally they see their job as in part helping staff in the hospital or in the trust understand the communities that are served. So that might be a resource that's a more kind of reasonable one to draw on because they absolutely see that as what they're there for. Whereas a colleague who's another therapist doesn't come to work to do that.
Rachel: So again, some really fantastically practical ways to ask questions and who to ask them of as well that are really helpful there. You said that we just need to know enough to help folk. We don't need to keep going to be massively intrusive. So once we've established the problem presentation and informed ourselves around the kind of aspects we've spoken about, is it then just okay to roll straight ahead with the disorder specific evidence based models we have for the particular problem presentation? I'm thinking of, there was a quote in your book, Andrew, which hit me quite starkly when I read it. You said that there's no evidence to support the idea that because someone from a different culture meets the diagnostic criteria for a particular disorder, the problem can be formulated in the same way as it would be for a white service user in a Western context. That seemed like quite strong and potentially quite anxiety provoking statement for your average CBT therapist trained in the UK. I know the model, I've got to apply it. Can you say a bit more about that? And I think that example you gave about how the panic disorder, for example, might be experienced differently by an individual already started to suggest ways in which you may or may not apply some of the same strategies and approaches.
Andrew: Yeah, we've got to be really modest about the limits of our knowledge, I think. And there's a whole world of research about the cross-cultural applicability of diagnostic categories, first of all, but because as cognitive behaviour therapists, we're not tied to diagnostic categories that closely, but we are tied to disorder specific models. And there's lots of thinking about the degree to which these are useful or not across different cultures, because we've got to be honest about the fact that most of the diagnostic categories and disorder specific models were developed by white researchers from their work with white patients. However, we also are beginning to realise that many of the patterns that we see, you can see in other cultures, perhaps not all cultures at all times, but in some cultures at some times. So you wouldn't want to throw out the models that we've got. But you'd need to hold them lightly, and I think what I mean by that is to have a kind of modesty about the models that we offer to patients and say, well, if we think about it in these terms, what am I missing? What might we need to add for this to make sense. What bits don't fit your experiences? And so be prepared to, even when someone looks like a real kind of real barn door case of a particular model that we're keen on, confident with and think we're going to use, to be prepared to modify or even fully abandon that if the patient doesn't have a sense of it reflecting their own experiences and the patterns that they've noticed. Now that's true for working with white service users as well. That willingness to hold our ideas lightly is important, but it's even more important when we're taking a particular model across cultures or into different faith groups or people with very different worldviews and experiences. So start with what you know, I guess, would be my advice but hold it lightly because we do know there are really good trials of CBT for OCD from lots of different cultural groups that have been effective. Great work done in North African Muslim communities using OCD that's had some modification to take into account faith and spirituality but is largely like we recognise CBT for OCD. So we know that these models travel fairly well, but with that person in the room at that time, just be prepared to be a little bit flexible.
Rachel: You know we don't want to engage in a different kind of discrimination of not offering evidence-based treatments to people and assuming somehow that they're not going to be applicable. But I really liked that phrase, it's one my mum used to use a lot, hold things lightly. And it reminds me of that phrase we often use about CBT being collaborative empiricism, you know, this idea that we're finding out together and often I think when we adapt for difference of whatever sort, what we're doing is we're just refining our CBT to be better with all the people we work with.
Andrew: I think when we step into that willingness to be flexible, and I like that phrase, kind of really collaborative and really empirical, all of our CBT gets better, doesn't it? You know, that flexibility, that willingness to get alongside people's lives, just makes us better therapists in general.
Rachel: And I guess on that, you know, we've been thinking about how we discuss difference with individual clients. Is that only an issue when the person sitting in front of me is of a different cultural background or ethnicity or gender? Or is that something we should be thinking about with apparently very similar folk to ourselves?
Andrew: Yeah, it is, isn't it? I mean, one of the reasons that we might want to hold that in mind are things like socioeconomic difference. It can be really helpful when we're working with service users who are really poor, you know, who missed appointments because they don't have the bus fare to get there, who are struggling to pay their bills to say, I recognise I'm in a steady job in the NHS, and some of those struggles you're having financially are ones that I don't currently have. I wonder how I can get alongside you to better understand what that's like? And likewise, around issues around sexuality, I think it can be equally useful to acknowledge difference and similarity when we're working with service users. But of course, all of us will have different levels of comfort with self-disclosure as well. And of course, self-disclosure is not something we're obliged to do, but nor is it something we're forbidden to do in CBT. We, all of us will be a different way along a spectrum of how useful we find disclosure and I think as long as we can rationalise that and have checked in using supervision, that the level of self-disclosure we're using is in the best interest of patients, you know, that can also be a kind of useful tool. And if I could give an example of that from my own life, I've married into a Punjabi family. Now, I don't talk about that routinely with patients, but there are sometimes in therapy when it has been useful for me to let someone know that I've had that experience and that it's sort of enhanced the therapeutic relationship. There is a sort of benefit to a level of disclosure of difference or similarity. But I don't think anybody is obliged to bring that as a therapist.
Rachel: No. And presumably gives you lots of insights as you just live life with your family into the experiences people can have from multicultural backgrounds?
Andrew: Yeah, I mean, it's more giving me insights into how little I know, despite what I think I might know. It’s been a good lesson in cultural humility.
Rachel: So once we're then thinking about what we don't want to withhold CBT, we want to adapt, we want to hold it lightly, we want to do this curious and collaborative process. So how can we go about thinking about adapting CBT then without throwing the baby out with the bathwater or just entering a perpetual state of therapeutic drift? Do we have handrails? Are there best examples of how we can take a robust approach to adapting CBT in transcultural contexts?
Andrew: I think on the whole, the models you will have been trained in and used will be useful. And the thing that needs adding is the willingness to think about different phenomenology, and what I mean by that, is different views about what things mean and how they impact on people's lives. And that can take all sorts of forms, it can be around the degree to which and the importance of other family members thoughts, feelings and behaviours so something that's a little bit like a systemic approach to CBT. Because in some families, the beliefs and behaviours of others can be as important as the beliefs and behaviours of the person that you're working with. Ofcourse that can be true in white service users and their families too. But for some minoritised communities, it's really important to be able to hold that idea that the problem exists within a system and there's a kind of collectivist approach to thinking about it that you might not be used to with the more individualised CBT.
But other adaptations are, I mean, many of us from white backgrounds are from either sort of atheist, agnostic or fairly lightly religious worldviews. And I think being able to recognise that you'll be working with people who have very strong views about the world that are informed by faith, spirituality and the supernatural. And that's quite a different perspective on the world to the one that you might have. And just that willingness to get alongside that, to not see that as a sort of a faulty worldview that perhaps needs correcting or that can be safely ignored, but to just see it as one that a richer understanding of that will help you understand the dilemmas that people bring to therapy, or the stuckness they may find themselves having or why particular thoughts are especially abhorrent to them. And then I think lastly, it's just being willing to recognise that, as I said earlier, that those sort of predisposing and precipitating factors might be to do with discrimination of many kinds in a way that we're not trained to necessarily think about in mainstream CBT as usual. But that actually can be very readily incorporated into the models that we use. So they're the kind of, as you say, the handrails to bear in mind, really.
Rachel: And there are different models of adapting CBT, aren't there? So you speak in your book about culturally adapted CBT and culturally sensitive CBT. Could you say a little bit about how those might differ?
Andrew: Yeah. And it's one of those areas I keep changing my mind about, in the sort of five years, six years since I wrote it, it might even be longer now. So it's probably 10 years since I wrote it then, cause it takes a couple of years to get it out there into the world. What I think is that there are some examples of CBT that were, where researchers and clinicians from a particular ethnic or religious group took CBT and translated those ideas into a different language, and in a way that reflected the values and beliefs of their particular group. And then delivered CBT in that language with that framework and that's what I consider to be culturally adapted CBT. It's been done from the inside by people who are within a particular community, for people in that community. And we know that's effective and that works.
But in a UK setting, most typically you'll have therapists from any one of a number of backgrounds working with service users from any one of a number of backgrounds. And so that culturally adapted approach may be of limited use, and what you need is a kind of an approach that I call culturally sensitive or culturally responsive that enables you to flex your use of the model to take into account that the kind of whole experience of the person that you're working with, but that's very flexible and adaptive. So I suppose one of those approaches, culturally adapted, is for a particular community by a particular community. Culturally responsive or culturally sensitive has that kind of wider applicability and it's probably more useful in more settings in the UK.
Rachel: That's really helpful. And again, I know you've given examples of how that's been applied in PTSD, for example, in different settings and really usefully used. At risk of getting very esoteric and philosophic, are there any even more fundamental problems with the underlying assumptions of CBT that we need to engage in? For people out there that are thinking, well, you know, CBT largely formed in Western individualistic culture, the strong cultural norms or widely held assumptions about the locus of therapy being addressing the individual thinking and behaviours that are key in their maintenance. And that it is their responsibility to change that or within their power to address that, can that apply transculturally or are there other things we need to consider?
Andrew: That's a really tough question. I'm going to, I'm going to have a go at it, but I probably won't have a very good go at it so apologies in advance. I think, you know, the therapies that we provide, and it's as true of any other kind of therapy as it is of CBT assumes that, that come in, meet in a kind of, health services setting for 50 minutes a week and thinking about your difficulties and what you might do differently is a kind of universally understood way of overcoming problems. And of course, we know that a lot of the problems that people come with are to do with things that are outside of their immediate control, which may be about housing, poverty, discrimination, climate collapse is another area that people are increasingly interested in. So making that assumption that the responsibility for change can be wholly with one individual and that 50 minutes a week thinking about it is enough to empower them to do that is a bit naive, isn't it really? And that's probably one of the reasons why not everybody gets better in therapy, you know, even the best trials with the most straightforward cases, 30 percent of people show no improvement. Within NHS Talking Therapies, if a service is getting a 55 percent recovery rate, it's doing really well. And I think that is a little bit about all those other factors.
But I would say, and I really want to empower therapists around this, as a therapist, you can help someone have an impact on some of those other factors too. And that might be just as simple as someone who's in really substandard housing that's impacting on the health of themselves and their kids, in an unsafe neighbourhood whose mental and physical health is deteriorating as a result. You writing in a really clear and strongly worded letter to the housing authority about that can make a material difference to those processes. And you may not feel like you're particularly powerful sitting in a therapy room on your own, but a letter on headed noted paper that's sent to the right people and perhaps even copied to some other people can shift some of those other factors that aren't just about unhelpful behaviours or being over engaged with your thoughts. So actually, there's stuff that we can do as therapists that is effective. Now it's not to say that we ought to be social workers because we'd be poor social workers. We're not trained to be good social workers, but there are things that we can do that still might make a difference. And that includes things like liaising with the immigration services if someone's mental health is to do with uncertain immigration status and threat of being detained. Or referring them to someone who can do a benefits review if poverty is a big part of what they're struggling with. So there are things that we can do around the edges that might nudge things in the right direction, but I'm very much sympathetic to the idea that a lot of it is other things that takes political will to change in the long run.
Rachel: Yeah. And that is an encouraging idea that, you know, we do have potentially some power. We can use what power we have in the face of what we see, often feels like, you know, growing picture of discrimination and poverty, et cetera.
And I guess that kind of leads quite nicely to thinking about how this work can be personally challenging for us as therapists, because we can encounter shocking prejudice in the world as we're talking to our patients. We can also encounter shocking prejudice in ourselves as we do this work and that we are unaware of as unconscious biases that we bring that sometimes this work highlights to us in very stark ways. The mistakes we make in therapy can feel very high stakes, as we talked about, you know, not one even wanted to broach some of these conversations in case we get it wrong. If we're, whether we're recently trained or really experienced, it can still be hard to learn to adapt our practice or change our practice. So it strikes me that good supervision must be really important in this area. And I'm wondering what the role of supervision is in this work for the therapist.
Andrew: I'm really glad you highlighted that this work can be a challenge therapist in all sorts of ways, including just being exposed to how tough people's lives are. And because we're a bit used to that in terms of being exposed to say people's trauma history and their experiences of, I don't know, childhood sexual abuse, violence and neglect. We're a bit trained for that, but we're less well trained for exposure to people's experiences of discrimination. And that can take a toll on us. And I think it's, you know, talking to colleagues from minoritised backgrounds who I think find this particularly painful when they're working with service users whose experiences of discrimination mirror their own so much, but also, you know, therapists from white backgrounds can find it difficult to be exposed to this world of discrimination that they've maybe been able to ignore up until that point. And I think having a supervisor that you trust, is a really good starting point, but very few supervisors have been trained in working with this kind of material. And what I would say is if you've got a supervisor who isn’t that comfortable in having these kinds of discussions, it's better to be upfront about that and to recognise and say, I noticed that when I brought that, that seemed quite a difficult topic for you. I wonder if there's ways that we can work together to make this a more kind of useful topic. Because responsibility for supervision going well is both the supervisors and the supervisees, and it's okay for you to raise that with the supervisor if they're not managing it very well. But I do think supervision is important and supervisors can help you recognise vicarious trauma and when that may be impacting on you and to help you do something about that or reduce its impact. But I think it is important to find supervisors who are capable of having those discussions or to nudge them towards doing better if they're not. Probably particularly important if you're a therapist from a minoritised background yourself, and if you don't feel like you get that kind of support in supervision to look for other ways of developing kind of peer support networks around that kind of work that might help sustain you. So we've got a long way to go, I think.
Rachel: Yeah. Are there ways in which supervisors can access training or think differently, upskill that might help them in these areas?
Andrew: Yeah, we've done bits within BABCP before. So myself and Michelle Brooks both do some supervisory training on thinking about difference and diversity, both how to help supervisees do better in this work, but also specifically how to support supervisees from minoritised backgrounds. So, keep an eye out on the BABCP's CPD program. We sometimes run things at conference as well. There are few opportunities, I'm afraid, probably there's more these days within clinical psychology training because many of the courses now as part of their push to have more diverse trainees include some training for supervisors on that. So if you're clinical psychologist and you have trainees, you probably got a good route in there. But for many cognitive behaviour therapists, just watch what BABCP is offering.
Rachel: And I know from the clinical psychology world, there's lots of evidence emerging around both the negative impacts that people have had from poor, transcultural supervision, but also the positive effects that there can be when these things again are broached and made normal to speak about, that emotional processing is part of these things as part of supervision, as is a space in a non-shaming, non-blaming way to reflect on our own biases and assumptions that we come face to face with sometimes in this work.
Andrew: Yeah. And good supervision can really help with that, can't it, in a way that sort of supports and challenges.
Rachel: And you mentioned earlier on that an important aspect of culture for many people is their faith, their religious faith or their spirituality. And I think this is a huge topic and hopefully we'll do some further podcasts in this area, but it often isn't brought to the table explicitly in therapy. And you said one of the reasons might be because there may in the Western culture be sort of less strongly held or less commonly held faith beliefs. But I think even as therapists with faith, as I would identify, it can feel like a no-go area in therapy. Do you have thoughts about why we might be reluctant as CBT therapists to engage in conversations about faith?
Andrew: Yeah. Cause we certainly are reluctant, aren't we? And yet if you're working with someone with a faith background, your faith shapes the way you see the world. It shapes your values, your actions, what you consider a good life to be, the things that you will want to do more of and not want to do at all. And I think to miss this misses an important part of many people's identity. But I think the kind of origins of psychological therapies and yeah, going right back to Freud is a world where God was considered to be not that important anymore. And so it's not been built in to our kind
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