Culturally Biased Therapy? Epistemic Violence and CBT (Part 1)

For his first and rather controversial blog of 2017, the president of the British Psychological Society (BPS), Peter Kinderman took a critical look at Cognitive Behavioural Therapy (CBT). Whilst acknowledging that the way that we make sense of the world has ‘profound implications’ for how we feel and behave and, referring to ‘acceptance and commitment therapy’ as a less individualist and pathologising ‘variant’ of CBT; Kinderman highlights in his blog, the serious limitations of focusing on people’s interpretations of events that are socially located and produced, to reduce psychological distress. He states:

‘CBT can rightly be criticized for adhering to an outdated and unscientific model of mental ‘illness’, for continuing to locate the blame for our distress inside our heads (rather than looking to social or even political root causes), and for sometimes implying both that people are responsible for “thinking errors” and that “positive thinking” can solve our problems’.

It was perplexing to see the above words create uproar. To me they did not go far enough. The individualism of CBT and its very real potential (to say the least), to lead to victim blaming and even re-traumatisation ought to be nothing new. Indeed, these are long standing critiques of CBT and, personal testimonies of people who have experienced the model as such are not hard to find. Many of us have had concerns over the uncritical dishing out of CBT, particularly to people of colour and other more marginalised groups, for years. This post is a first attempt at articulating some of these concerns.

What exactly is CBT, do we know?

CBT is reportedly a broad school of therapy said to include many different models (such as Mindfulness based approaches, Compassion Focussed Therapy, Acceptance and Commitment Therapy and many others) with various theoretical and empirical bases. In all fairness, I am no longer sure at all what is meant by CBT because of this rather ‘eclectic’ amalgam. The continuing difficulty in defining what ‘cognitions’ are, of course does not help. This is a serious problem. Without agreement on one of the two core elements of CBT, we cannot reliably delineate the model or establish inclusion and exclusion criteria.

Perhaps this explains why this church of therapy might appear to be expanding so rapidly. The power and legitimacy the model has acquired and its dominance within health systems is of course not incidental here. Given the above, and to be sure we are indeed talking about CBT… it makes sense to ground any critique on more traditional approaches. Approaches which nonetheless continue to shape the practice of CBT. No doubt the most influential of models and, which has arguably provided the blueprint for most other models is Beck’s (1979). The Beck’s institute defines the model as follow:

‘Cognitive Behavior Therapy (CBT) is a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems and teaching clients skills to modify dysfunctional thinking and behavior’

CBT from this model (and a plethora of others) is centred on addressing ‘dysfunctional thinking’ posited to be the cause of psychological distress and, to take (behavioural) steps to solve on-going difficulties maintained. Often, this is achieved through ‘behavioural experiments’ or internal dialogues/self-talks and reflection. The essence of CBT, as it was intended at least, is thus the identification and modification of thoughts and beliefs deemed maladaptive (though more recently, distance from distressing thoughts has been added as an alternative aim). It is highly contestable whether psychological models that do not have this basic (former) element actually constitute CBT.

CBT and empirical psychology more generally have been criticised for ‘disavowing’ the metaphysics and history of their objects of study, concepts and methodologies. These elements nonetheless remain, imbue the practice of CBT and, propogate a particular worldview. Worldview may be defined as the philosophy of individuals, groups or societies which encapsulate beliefs in relation to the nature of things, of being and of knowing. Worldviews influence how we interact and engage with the world around us. They are culturally located and, are tranferred through various means including, parenting, social interactions and educational institutions.

The silent assumptions of CBT

Critically, professional discourses and practices similarly transmit implicit assumptions related to the nature of human action, agency and wellbeing. CBT contains a number of such assumptions including: the division between the world (the objective) and us (our subjective reactions). The need for objective evidence to support our beliefs and related to that, the requirement to doubt and reject our subjective reality and lived experience, if it cannot be objectively backed-up. Added to this, is a heavy reliance on what is observable over what cannot be seen. And ultimately, beliefs that psychological distress can be overcome through reason so that the good and (psychologically) healthy life can be achieved by rethinking our thinking.

The epistemology of rationalism is often hailed as the hallmark of (white) European thought. Rationalism posits that reason is the ultimate source of knowledge and freedom. Rosen argues that two of the main forms of rationalism which have had the greatest influence on the theory are: discursive rationalism and pragmatic rationalism. The former identifies reason as the only means by which the self can emancipate itself from the world of senses and, asserts that human beings are motivated to reach their ideal self by the knowledge gained through rational reflections and considerations of the world. Pragmatic rationalism on the other hand, does not seek to achieve self-mastery by self-reflection but by taking rational actions aimed at changing one’s desires, impulses and urges.

According to that approach, all unwanted impulses can be overridden by repeated actions so that we may train ourselves through what we do, to be more rational and therefore exercise agency over both our subjective world and the world around us. CBT clearly embodies both approaches as illustrated for example, by the practice of challenging thoughts, ‘behavioural experiments’, rational self-talks or even therapists’ ambitions of  mastering ‘Socratic questioning’. However, it reproduces them silently. And, this requires attention. Many non-western worldviews do not uphold European rationalist ideals. African worldview obviously varies, nonetheless, many of its features have been held to demarcate it from the above.

‘A fundamental tenet of traditional African culture is that there is more to reality and to the realm of experience than that which is readily accessible through empirical inquiry, and that one can acquire an understanding of natural phenomena by appealing to experiences whose characterisations are not empirically confirmable but are nonetheless warrantably assertible’ (Brown, 2004).

African dominant ontology and view of reality are fundamentally different from Western rationalism and therefore clash with many of the assumptions of CBT. The centrality of notion that there is more that influences reality than is accessible through empirical enquiry, such as the spiritual or the ancestors, is core to a number of non-Western espistemologies and has been found not only in African worldviews but also in several indigenous, Asian and First Nations’ traditions. In addition to CBT indirectly problematising the validity of such worldviews and feeding into the superiority of European ideals, it may be charged with protecting oppressive systems in the ‘West’ by invalidating the lived experience of people of colour.

It is one thing to encourage people to seek objective evidence to help disprove the belief that everyone hates them but, quite another to ask people of colour to back up their belief that they are experiencing racism. Direct objective evidence of racism is rarely available. And it is precisely because of difficulties in objectively evidencing oppression that people living in racialised and in other bodies marked as Other, have had to develop ways to apprehend reality that are not dependent upon rationalism. Trusting our lived experience is a vital act of resistance and survival in a culture where objectivity is weaponised to dismiss experiences that are preverbal, embodied and often un/sub-conscious. In this context, invalidating our ways of knowing and navigating the world is not only potentially psychologically harmful; it is also a social act which negates racism and therefore reproduces white supremacy.

Epistemic violence

Epistemic violence is a term that has generally been used by postcolonial researchers to refer to the construction of the Other by Western thinkers and philosophers. According to Spivak (1988) ‘epistemic violence’ is the process by which non-Western methods or approaches to knowledge and worldviews are obstructed. Spivak posits that imperialist subjugation of non-Western understanding or the ‘Othering’ of the colonial subject’s mode of knowing/being and more generally, that of those who are at the bottom of social hierarchies, (whom she refers to as the ‘subaltern’) has been central to the colonial project. This dynamic represents attempts (varying in their success) at deleting the consciousness of the Other or to overwrite it with Western epistemologies.

Non-Western epistemologies have a long history of being dismissed as inadequate, ‘primitive’, naïve or otherwise inferior. Rationalist philosophers such as Hegel, Kant, Locke, and Descartes amongst many others indeed believed people of colour lacked agency, sophistication and that they were incapable of intellectual thought. In fact, many rationalists did not even consider Black people to be human beings.  Colonialism was based on this ideological framework. This is the history that the epistemology of CBT was built upon. Thus, it becomes problematic when it is practiced in some kind of ahistorical vacuum, particularly when people of colour are the clients whose worldviews or ways of knowing are so obliviously being ‘corrected’. This mirrors the social scepticism and denialism that continue to befall upon our lived experience.

In epistemic violence, the harm suffered in not physical and it may not even be direct. Nonetheless that violence has a subject, an object, and is perpetuated through subtle acts. The subject of violence in the case of CBT is the therapist, the object may or may or may not be the individual client in the room but it is in any event, people of colour, at least predominantly. There are various acts of epistemic violence to reflect upon: the invisibilisation of the epistemological origins of CBT, arguably removing choice and agency or again, the failure to challenge (Eurocentric) rationalism as the only/superior way to access truth. Consequently, each ‘therapeutic’ cognitive reframing attempt reproduces discourses establishing whose knowledge of the world is legitimate and valid and with it, misrepresentations and distortions of the Other.

Concluding thoughts

Whether the question of epistemic violence similarly applies to other models of therapy is of course an important one, to various degrees, it is likely arguable that it does. However, CBT is based on working directly on how people know and make sense of the world, on their worldviews, making it obviously more problematic in that regard. There is no denying that regardless of the model used, psychotherapy can be a violent and damaging experience. Epistemic violence highlights a different kind of harm. A violence which occurs beyond the individual, to groups designated as racial Others. Individuals may find various therapy models helpful whilst the assumptions underlying the same may actually, at group level, be problematic, reproduce discourses of inferiorisation and help maintain racism. Ironically, the reason so many people of colour experience psychological distress.

I am aware that some have attempted to or claim to use CBT in a culturally adapted manner. I remain sceptical. It is difficult to imagine how the necessary changes to the model could be made without shifting fundamental epistemic assumptions thus taking such practice out of the CBT school. Further, even if adaptations were feasible, this would arguably be equally problematic and not remove ethical considerations and questions. Most notably, why would people of colour continue to be supported by adapted models, or in other words, by models centred on others’ needs or experience of the world, on models’ not created for us?

A final point worth considering concerns the issue of effectiveness. Of course it is because of CBT’s record empirically (a record which is increasingly being challenged) that it has gained its dominance. On this point, it is important to remember that effectiveness is not a measure of violence. It is certainly not a measure of epistemic violence. An intervention which is experienced as violent may still yearn positive outcomes on individuals, if we look hard enough for them but, more to the point here, subject the Other to violence socially and discursively. A violence, I believe, which remains to be seriously reflected upon in the profession. Perhaps to that end, we could all do with this kind reminder: ‘The Master’s Tools Will Never Dismantle the Master’s House’ (Audre Lorde, 1979). Words which kept coming to my mind as I wrote this article.

References (not hyperlinked)

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Brown, L.M. (2004). Understanding and Ontology in Traditional African Thought in Brown, L.M. (ed.) African Philosophy: New and Traditional Perspectives. Oxford: Oxford University Press.

Thank you for reading.

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