2 - (SYM 23) Cultural Opportunities Within CBT Sessions: A Mixed Methods Approach

Clients from historically marginalized communities experience disparities in clinical outcomes (Owen et al., 2021; Drinane et al., 2022). To address inequities in care, researchers have focused on developing culturally adapted CBT interventions (Silveus et al., 2023), and training multiculturally oriented therapists (Davis et al., 2018). However, there is limited in-session data on how CBT therapists navigate or initiate opportunities to engage in cultural dialogue. We examined how therapists navigated cultural opportunities in 30 CBT sessions from community mental health settings. Using an archival dataset of 428 CBT sessions that contained (a) transcripts with conversations surrounding race, gender, and sexuality, and (b) session level behavioral codes for therapist empathy, collaboration, understanding, and interpersonal effectiveness, we calculated an average therapist common factors score from behavioral codes. We selected the 15 sessions that had the highest common factor scores, and the 15 sessions that had the lowest scores, and qualitatively coded these transcripts. 

Clients initiated conversations about cultural identities across the majority of sessions (73.3%), and at similar rates in sessions with low and high therapist common factor ratings. In instances where clients initiated cultural dialogue, therapists interventions often did not acknowledge cultural identities that clients discussed- only 31.8% of therapists acknowledged client cultural contexts. These rates were similar between sessions with low and high therapist common factor ratings. Therapists who initiated cultural dialogue did so by bringing up conversations from previous sessions about important cultural contexts in clients’ lives, as part of small talk, and by briefly discussing shared identities.

In sessions with high therapist common factor ratings, therapists responded to client initiation of cultural dialogue by focusing on thoughts, feelings, and behaviors associated with clients’ cultural contexts. Therapists used client disclosures as a way of deepening exploration of thoughts. Therapists who acknowledged clients’ cultural contexts validated client experiences, or used guided discovery to explore how the client made sense of their cultural context and presenting concerns. In sessions with low common factor ratings, therapists shifted the focus of conversation to different topics when clients talked about cultural contexts, or invalidated clients’ concerns surrounding prejudice and discrimination.