Orienting Yourself to the RESPECT Toolkit
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Can I benefit from this toolkit?
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Are you a clinician who works with youth with Anxiety and OCD?
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Do you have basic training in Ex-CBT?
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Have you ever been uncertain about how to deliver Ex-CBT in a way that is responsive to your client's cultural or contextual background?
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If you answered yes to these three questions, this toolkit is for you.
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Isn't person-centered culturally responsive Ex-CBT just good quality Ex-CBT?
Yes and no. Good quality Ex-CBT does involve flexible delivery that considers an individual’s culture, context, and values.  Person-centered, culturally responsive Ex-CBT differs from traditionally taught Ex-CBT in its explicit focus on assessing and incorporating a client’s intersecting identities, experiences, contexts, and values into the treatment plan. Additionally, delivering person-centered, culturally responsive Ex-CBT involves intentionally considering the historical and current structural and systemic oppression of people with marginalized identities, and striving to recognize and address these challenges within therapy through transparent, open, and respectful communication, as well as advocating for the client’s needs.
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How was this toolkit developed?
The content of this toolkit was developed by combining insights from a rigorous review of previous treatment research, years of clinical experience working with and training clinicians to work with diverse populations, and many conversations with clinicians delivering services within specialty and community-based settings. We also interviewed youth clients and their caregivers and collaborated with a group of experts, including researchers and clinicians, to create a clinically useful guide. We will continue to utilize feedback from frontline clinicians and youth and families receiving services to refine this toolkit further.
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To provide us feedback, click here!
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I am newer to EX-CBT; this sounds like it could traumatize my client.
While the concept of exposure may seem counterintuitive, the process of exposure teaches youth that they can cope with situations that are anxiety provoking. Remember – the goal is NOT to get rid of the anxiety alarms that let them know when they are truly in danger (physically or emotionally). So, asking youth to do things like take public transportation alone in the evening, put themselves in a social situation in which they are likely to be discriminated against, let a poisonous spider crawl on them, or complete an independent task that is developmentally inappropriate, and may place them at risk, should never be part of exposure therapy. Also, it is important to remember that the physical symptoms caused by the “anxiety alarm” are not in and of themselves harmful. As for relaxation, we want youth to learn that they can cope on their own, and learn that their feared situations are truly safe. Exposure therapy can be empowering to clients by teaching them that they can tolerate distress and move towards their goals and values. See the READY toolkit for more exposure-specific resources and guides.
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I already know Ex-CBT. Shouldn’t I apply traditional Ex-CBT principles to anyone with Anxiety or OCD, regardless of their background? Can’t Anxiety and OCD manifest in anyone, regardless of their background?
While epidemiological research suggests that anxiety and OCD are prevalent across cultures, the symptoms and experiences of anxious distress may manifest, express, and persist differently across cultural and socioeconomic backgrounds. Uniform application of assessment and therapeutic approaches is reflective of a color- and culture-blind approach to mental health care (e.g., an anxiety disorder is an anxiety disorder, regardless of within whom it manifests); this runs the risk of overlooking real and valid cultural experiences that can greatly influence an individual's anxious experience, orientation to mental health care, and response to treatments. Incorporating a culturally responsive frame and employing techniques from person-centered care can facilitate the process of intervention technique selection to ensure it best matches the client’s needs and does not overlook cultural or contextual factors that may be critical to one’s unique clinical presentation.
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Should I expect to see guidelines for how to deliver Ex-CBT to different racial or ethnic backgrounds in this toolkit?
EVERYONE has a culture, identity, and context, which is relevant to experiences of mental health and help-seeking. This toolkit explicitly addresses client experiences related to their self-identified intersecting identities. Intersectionality considers how intersecting social identities create unique experiences related to relative oppression and privilege, which affect people’s beliefs about mental health and help-seeking.  We will not provide in-depth education on specific racial or ethnic groups and their associated cultural group practices/beliefs/histories, but instead will focus on cross-cutting cultural and contextual factors and person-centered strategies, to support clients in a holistic way. Interventions specific to clients from particular backgrounds are incredibly important, yet the ability to work with youth from many intersecting identities is necessary for increasing the quality of care within diverse community settings.
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Why does person-centered culturally responsive Ex-CBT specifically reference structural racism?
Structural racism, or oppression based on intersecting marginalized identities, has led and continues to lead to many of the inequities that exist for individuals with marginalized or minoritized identities when it comes to accessing and receiving quality mental health care. While all youth, regardless of background, can experience significant psychopathology, youth with marginalized identities are more likely to experience mental health difficulties related to their identities and social position (e.g., experiences of discrimination, poverty-related stress, immigration stressors, or community violence) and less likely to have access to quality, culturally responsive mental health care, as compared to youth with non-marginalized identities.
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How has structural racism influenced mental health treatment for youth with anxiety and OCD?
Ex-CBT was developed within a largely White, European, middle-class community and has traditionally focused on an individual's internal symptoms and white western understandings of healing, which often focus on the individual more than their family and community context. The cultural values of Ex-CBT may or may not align with the clients’ values and beliefs. These subsequent cultural assumptions are manifested in CBT through: 
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The model that the illness is situated inside the client instead of as a function of their environment
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The structure of weekly sessions
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Talk therapy rather than other forms of expression (movement, art, storytelling)
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Valuing enacting change over acceptance and persistence
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Self-disclosure over privacy
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Individualism over collectivism
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Social assertiveness over subtlety 
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Structural racism leads to policies and structures that make it harder for researchers and treatment developers from culturally diverse backgrounds to have their expertise valued. This has led to treatment and its development largely relying on the white western experience of mental health as the norm. While guiding definitions of evidence-based practice emphasize the importance of individual culture and context, Ex-CBT protocols rarely provide explicit guidance for how to do this, which can lead clinicians to overlook this critical aspect of care. However, Ex-CBT can still be helpful for youth of color and those from other minoritized backgrounds when culture and context are explicitly addressed. Clinicians must be aware of how the underlying values of Ex-CBT may or may not align with that of the client and discuss those topics with the client. 
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How can I as a clinician feasibly make change in a system that has perpetuated inequities?
The burden cannot and should not be on clinicians to solve the systemic and structural inequities that exist in the United States, both in the mental health system and outside of it. However, clinicians do have the ability to make meaningful change working one-on-one with their clients by providing the highest quality therapy services. A key part of doing this work sustainably is being continuously mindful to set achievable treatment goals, while naming the structural inequities unlikely to be solved in a clinical encounter and changed within their community. As clinicians, we must be aware of potential inequities and advocate for our clients on an individual, clinic, and policy level, to aid in reducing inequities in access to quality care. This can’t be done without prioritizing your own health and well-being and stepping away to do what you need to care for yourself. Of note, while most of the strategies in this toolkit aim to provide clinicians with clinical guidance, sustainable change will not be made without organizational commitment.
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What is the best way to engage with this toolkit?
This website is a living tool, for you to revisit over time. It is not meant to be a step-by-step treatment manual. We designed this website so that you can engage with the components that are most relevant to you and your clients, although we encourage you to review all of the content at least once. We have provided a wide array of formats (dialogues, vignettes, videos, etc.) to help make the material more digestible.  We want you to feel comfortable continuing to return to this website, knowing that the best learning is done through repetition and practice!
 
Content from this toolkit is likely to be most helpful to you if you also are able to build a community in doing this work. Therapy can be isolating. We encourage you to take what you learn or questions you have about strategies discussed in this toolkit to supervision or peer consultation. It is also important to be mindful that delving into culturally responsive work can be an emotional process. The best way to become more comfortable with using the strategies is to try them out and then reflect on how it went for you and your client.
 
It is a privilege to have the ability to work with youth and support them in achieving and maintaining emotional wellness. We hope this toolkit provides you with some structure and support along your journey in doing so.