Culturally Responsive Cognitive Skills Guide
Goals:
1. Educate about the connection between thoughts, emotions, and behaviors.
2. Build insight into where thoughts fall on a continuum of helpful to unhelpful.
3. Identify thoughts that might benefit from cognitive restructuring.
4. Identify values-aligned cognitive coping skills to support the client when traditional cognitive restructuring may
risk invalidating the client’s experiences.
Cognitive skills are a common component of Ex-CBT. Their primary goal is to help youth recognize maladaptive thought patterns and support the development of more helpful ones. They include strategies such as thought identification, cognitive restructuring (i.e., identifying cognitive distortions or irrational thoughts, examining evidence for and against those thoughts, and adopting more balanced or helpful thoughts), and more general cognitive coping (e.g., developing simple coping thoughts to use when distressed, such as reminding oneself “I can do this!”). However, cognitive skills also have risks. Traditional cognitive restructuring helps clients recognize unhelpful or inaccurate thoughts driving anxious experiences and then reevaluate those thoughts using collaborative empiricism. A common assumption is that these anxious thoughts are “cognitive distortions,” meaning they are rooted in misinterpretations about how harmful, scary, or unhelpful situations are. However, clients sometimes have accurate interpretations of external stressors that drive distress. We can inadvertently invalidate the clients’ experiences if we incorrectly label something a cognitive distortion when it may, in fact, be a culturally normative, realistic, or adaptive thought. An inflexible classification of thoughts into categories (e.g., “irrational or rational,” “right or wrong,” “helpful or unhelpful”) also unintentionally perpetuates the idea of a rigid binary that may not be the most helpful approach. Instead, we can consider thoughts to be on a continuum. An additional risk is that cognitive restructuring of intrusive thoughts for individuals with OCD can create new rituals (e.g., needing to think a coping thought repeatedly in response to an intrusive worry). The greatest risk occurs if we try to restructure a largely logical or rational thought (e.g., trying to restructure a cognition about the safety of a situation that may, in fact, be unsafe). While clients sometimes hold truly distorted beliefs (e.g., overestimating how likely they are to be bitten by every dog they see), realistic external stressors also can be primary drivers of a child’s distressing thoughts (e.g., housing insecurity, neighborhood violence). We should not assume all “negative thoughts” are inherently irrational. Additionally, some clients’ anxious thoughts stem from past experiences or cultural beliefs, while for others, they do not. Striving to maintain an open, responsive, and curious approach to understanding our clients’ internal and external experiences is essential to ensuring we only apply cognitive techniques when appropriate. Like many things, it is complicated! There is no “one size fits all” approach. Cognitive skills can be powerfully effective when used well. We aim to provide guidance on how to apply cognitive skills responsively and collaboratively in a way that minimizes associated risks and is responsive to the clients’ culture and context. A key step in doing so is to be mindful of our own biases (we all have them!) Our personal upbringing, culture, and fears all shape how we interpret the world – including how we interpret our clients’ thoughts. Cognitive skills – most notably, cognitive restructuring – have historically been a major component of evidence-based treatment protocols for classic anxiety disorders. However, there has been emerging data over the past decade questioning the potential added utility of cognitive restructuring above and beyond the benefit associated with Ex-CBT alone. While there are certainly some youth who demonstrate clear cognitive distortions and overestimations of threat (e.g., feeling 100% certain that any dog will bite them if given the opportunity) that will benefit from cognitive restructuring, we do not recommend cognitive restructuring be employed as a universal strategy for youth with anxiety and related disorders. Rather, we encourage use of cognitive restructuring only when there is both: (1) clear evidence of cognitive distortions or maladaptive thought patterns, and (2) a hesitancy to engage with exposure practices driven by maladaptive thought patterns (e.g., a youth may need to learn information about true levels of risk to be willing to engage in an exposure practice). Another important reason that cognitive restructuring should be used carefully and sparingly is that it has the potential to invalidate the clients’ experiences by incorrectly labeling something a cognitive distortion that may in fact be a culturally normative or realistic or adaptive thought. However, cognitive coping skills other than cognitive restructuring (e.g., development of coping thoughts or affirmations) may be useful in helping clients cope with anxiety and chronic identity-related and environmental stressors. Throughout this work, we must work to be mindful of our own biases about what constitutes an irrational thought based on our own personal upbringing, culture, and fears. Using colleagues or supervisors to work through determining how irrational a client’s thought is can be a helpful strategy to support these reflections. While the principles below can be applied to any youth struggling with anxiety or OCD, they specifically focus on strategies for ensuring cognitive skills are delivered in a culturally responsive manner that acknowledges the connection between thoughts, feelings, and behaviors and supports clients to develop healthy thinking patterns while recognizing that many youth, especially those from marginalized or minoritized backgrounds, experience realistic fears and thought patterns that while distressing are not appropriate for traditional cognitive restructuring methods.
Note. This guide will not provide strategies for engaging in traditional cognitive restructuring as many excellent resources for doing so already exist (e.g., The Unified Protocol). Instead, this guide focuses on complementary strategies and including ones to utilize when traditional cognitive restructuring is not appropriate.
Guiding Principle #1
Increase client awareness of how thoughts influence emotions, physical sensations, and behaviors.
Intended Impact: Help the client see how their thinking patterns influence their emotions and behaviors, and how their thoughts may be influenced by their culture and context (e.g., are they beliefs that have been passed down through family?, are they internalized societal norms?). Collaboratively determining the effects of the client’s thinking patterns on their continued distress can help us decide which, if any, cognitive skills to utilize and how to effectively incorporate other treatment techniques.
Guiding Principle #2
Use a collaborative approach to evaluate how helpful or accurate a thought is and hold space for more than one thing to be “true.”
Intended Impact: Just because a thought leads to distress does not necessarily mean that it would benefit from classic traditional restructuring. For example, “my mom could be deported”, while distressing, may also be valid and would not benfit much from restructuring if this child’s mother is at risk of deportation. Determining which thought(s) can be targeted with cognitive restructuing – and which cannot - is a cruicial step for avoiding harm and encouraging healthy cognitive coping. The more clearly inaccurate or unhelpful a thought is, the more likely restructuring techniques are to be beneficial. Developing a collaborative understanding of cause and function of thoughts can generate more nuanced interpretations to support further cognitive work.
Guiding Principle #3
Cognitive restructuring can be adapted in subtle ways to reduce associated risks and support client progress in treatment; a curious, empathetic approach is essential to such work.
Intended Impact: Helping clients evaluate how helpful or accurate their thoughts are to generate alternative interpretations is often done through questions such as “How likely is it that X might occur? Has it ever happened before? Do you have evidence for that?” While this framing can be helpful when done in a genuinely curious manner, it risks invalidating the client’s valid experiences if asked with the intention of disproving the client’s experiences. For example, experiences of marginalization and trauma can lead youth to believe they are to blame for how they were treated. While such thoughts are unhelpful and will benefit from being targeted in treatment, these thoughts also may have real “evidence” to support their accuracy (e.g., a client telling themselves they are unlovable when they have experienced past neglect). Incorporating holistic understanding of the client’s cuture and context into cognitive skill delivery can help reduce client distress and encourage positive identity-development and self-efficacy.
Guiding Principle #4
Restructuring is just one cognitive technique. Other techniques that engage with thoughts, such as mindfulness and grounding techniques, should also be considered. This is especially true for youth with chronic worry and those with OCD who may get stuck in “thought loops” or “what if” spirals.
Intended Impact: Support youth to manage distressing thoughts and chronic worry by
creating distance from their thoughts, grounding them in the present moment, and “letting go” of the worries. Help youth learn that excessive worry may be a way to try to find control in an uncontrollable situation.
