Overview Andreas, age 22, was completing his final year in college and was majoring in computer science. He had worked hard in order to prepare himself for a career in information technology, getting good grades with the hope of landing a job in a top company after graduation. He was the only son of a wealthy family. His father was a well-known lawyer in their average-size hometown and his mother was a cardiologist. Andreas had always received lots of attention from his parents, and they ensured that he got a good education and had everything he wanted. Andreas described his parents as being very strict and critical, requiring that he work hard and receive good grades in order to increase his chances of doing something valuable with his life. What triggered Andreas' s depression was an event that took place at the beginning of the semester. At the end of summer holidays, a renowned multinational information technology company launched a contest inviting all students in their final year of computer science to submit a project on an emerging topic. The prize for this contest was a well-paid 6-month internship with the company, which for Andreas would have been the perfect start to a fabulous career. Twenty internships were awarded among more than 200 students who submitted projects, and Andreas was not among them. This made him feel terrible, especially because he had told his parents about this opportunity because he was confident he would be selected. When he received the news about not having been accepted, he initially did not tell his parents about it or about the fact that he was so depressed, lying to them about not receiving the results each time they asked about it. As a result of being rejected for the award and lying to his parents, Andreas developed strong feelings of shame, guilt, and hopelessness, thinking that he would never be as he had been before. He saw himself as a failure both to himself and to his parents. He had tried to prove his worth by winning the internship, and now that opportunity was gone. Andreas came to therapy after what he described as the worst period of his life in which he felt deeply depressed and experienced suicidal ideation. However, he did not intend to commit suicide and did not make any attempt, stating that he was very afraid of these thoughts. When he came to therapy he had not been to class for more than 3 weeks, and in the previous month he had only gone from time to time in his better moments. In the past 3 weeks, however, the depression had gotten so intense that he barely got out of house. He spent his time sleeping, playing video games, and thinking intensely about his situation and the fact that he would not be able to complete his graduation thesis. In the initial session Andreas was introduced to the CBT model and behavioral activation, and in subsequent sessions he learned how to identify and dispute dysfunctional negative automatic thoughts. After the third session, Andreas started attending classes again and was able to study for winter exams, although he was very stressed about them. He also got up the courage to tell his parents that he had not received the award. He said that they were critical but did not dwell on it. In this fourth session the focus was on his deeper cognitions—the intermediate and core beliefs. I used Andreas' s thought records from the previous week to initiate further exploration of his thoughts using the downward arrow technique to access deeper beliefs. At the end of the session we developed a behavioral experiment to test the functionality of these beliefs. What follows is the transcript of the fourth session.

“It is not the external environment which influences you, it is what you tell yourself—your philosophy of life about that environment” (Ellis, 1962a). Also, the relationship between the past and the present is not a focus in REBT as it is in other forms of therapy. Rather, the focus is on what individuals are telling themselves in the present about the past events. As a result of this insight, Ellis modified his psychoanalytic techniques and methods of therapy on an empirical and theoretical basis.

Coordinated and concerted research, practice, and policy initiatives over the past several decades have established CBT as a “gold standard” treatment. However, evidence supporting the effectiveness and implementation of culturally sensitive CBT remains sparse. Although CBT effects appear to be robust across cultural groups, the minimal existing guidance on how to deliver culturally competent CBT represents a missed opportunity for reducing the burden of mental illness among ethnic minority groups. Additionally, the underrepresentation of ethnic minorities in the mental health services literature, the inconsistent methods used to study cultural competency, the limited empirical data on culturally competent CBT training and intervention, and the lack of a universal definition of cultural competency restrict the conclusions that can be drawn from the extant literature. To meet the needs of all prospective clients, the same effort, time, and funding that has been granted to studying CBT must be afforded to studying culturally competent CBT. Just as a task force was constituted to define evidence-based practice (APA Pres. Task Force Evid.-Based Pract. 2006), we as a field should define cultural competency. Just as Stuart & Lilienfeld (2007) posited that the “current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so” (p. 616), it is past time to shift our attention from addressing the question of whether cultural competency training is necessary to how we can sustainably train clinicians who are culturally sensitive and clinically effective. Just as there has been a proliferation of RCTs testing CBT, we need to rigorously test whether proposed models for providing culturally competent mental health care deliver the expected results. As we continue to advance this research agenda, there are many steps that can be taken simultaneously to reduce racial and ethnic disparities and promote mental health among ethnic minority groups. Institutions can work toward recruiting, supporting, and retaining ethnic minority researchers, clinicians, and trainees to diversify the mental health workforce. Advisors, mentors, and supervisors can initiate conversations with trainees about multicultural considerations in case conceptualization and treatment planning to model the importance of cultural competency and move toward more holistic mental health care. Clinicians can also be trained to use existing, culturally sensitive assessments and interventions with growing support, such as the cultural formulation interview (Sanchez et al. 2022). Additionally, trainees can use measurement-based care (Scott & Lewis 2015) to conduct case studies applying multicultural therapy models with their clients and testing whether doing so improves client outcomes. Psychology competencies have been operationalized as including values, knowledge, and skills (Falender et al. 2004). Remarkable advances have been made in both the field's value and knowledge of cultural competency. Our next step is translating that knowledge into skills that can benefit the diverse clients seeking our help.

INAL THOUGHTSGo to section... TOPABSTRACTINTRODUCTIONDEFINING CULTURAL COMPETENCETHE RATIONALE FOR CULTURALLY COMPETENT CAREDO COGNITIVE BEHAVIORAL THERAPIES WORK WITH ETHNIC MINORITIES?DOES CULTURAL TAILORING ENHANCE COGNITIVE BEHAVIORAL THERAPY OUTCOMES?CULTURAL COMPETENCY TRAINING OUTCOMESEVIDENCE-INFORMED MODELS OF CULTURAL SENSITIVITYFINAL THOUGHTS disclosure statement literature cited Coordinated and concerted research, practice, and policy initiatives over the past several decades have established CBT as a “gold standard” treatment. However, evidence supporting the effectiveness and implementation of culturally sensitive CBT remains sparse. Although CBT effects appear to be robust across cultural groups, the minimal existing guidance on how to deliver culturally competent CBT represents a missed opportunity for reducing the burden of mental illness among ethnic minority groups. Additionally, the underrepresentation of ethnic minorities in the mental health services literature, the inconsistent methods used to study cultural competency, the limited empirical data on culturally competent CBT training and intervention, and the lack of a universal definition of cultural competency restrict the conclusions that can be drawn from the extant literature. To meet the needs of all prospective clients, the same effort, time, and funding that has been granted to studying CBT must be afforded to studying culturally competent CBT. Just as a task force was constituted to define evidence-based practice (APA Pres. Task Force Evid.-Based Pract. 2006), we as a field should define cultural competency. Just as Stuart & Lilienfeld (2007) posited that the “current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so” (p. 616), it is past time to shift our attention from addressing the question of whether cultural competency training is necessary to how we can sustainably train clinicians who are culturally sensitive and clinically effective. Just as there has been a proliferation of RCTs testing CBT, we need to rigorously test whether proposed models for providing culturally competent mental health care deliver the expected results. As we continue to advance this research agenda, there are many steps that can be taken simultaneously to reduce racial and ethnic disparities and promote mental health among ethnic minority groups. Institutions can work toward recruiting, supporting, and retaining ethnic minority researchers, clinicians, and trainees to diversify the mental health workforce. Advisors, mentors, and supervisors can initiate conversations with trainees about multicultural considerations in case conceptualization and treatment planning to model the importance of cultural competency and move toward more holistic mental health care. Clinicians can also be trained to use existing, culturally sensitive assessments and interventions with growing support, such as the cultural formulation interview (Sanchez et al. 2022). Additionally, trainees can use measurement-based care (Scott & Lewis 2015) to conduct case studies applying multicultural therapy models with their clients and testing whether doing so improves client outcomes. Psychology competencies have been operationalized as including values, knowledge, and skills (Falender et al. 2004). Remarkable advances have been made in both the field's value and knowledge of cultural competency. Our next step is translating that knowledge into skills that can benefit the diverse clients seeking our help.

Despite requirements by the American Psychological Association (APA 2012) and the Psychological Clinical Science Accreditation System (PCSAS 2022) regarding training and education in multiculturalism, the shortage of clinicians trained in culturally competent care suggests that graduate programs in health service psychology may not be providing students with adequate training. Indeed, a recent study of current graduate students in clinical psychology PhD and PsyD programs in the United States found that while the majority of trainees (91.3%) have worked with clients of color, many have done so without adequate training in cultural humility and attending to the unique racial stressors that clients of color face (Galán et al. 2023). These findings underscore significant gaps between trainee needs and what they may actually receive from their respective programs. As a result, many students emerge from graduate programs feeling they are not prepared with the knowledge, awareness, and skills to provide culturally sensitive care. Underrepresentation of ethnic minorities in the mental health workforce may be disproportionately affected by this gap, with ethnic minority graduate students reporting less satisfaction with their training in multiculturalism than their White peers (Gregus et al. 2020). This means that many emerging clinicians, even when well-intended, may unintentionally contribute to the maintenance and widening of racial inequities in mental health access and service quality. Experienced clinicians express concerns as well. The inherent structure of CBTs and other manualized treatments has led clinicians to voice concerns about the cultural compatibility of EBTs (Addis et al. 1999, Palinkas et al. 2013). In addition, although quantitative and qualitative studies find that clinicians are generally satisfied with the cultural competency training that they received, specifically related to the topics of race and ethnicity, many believe that there were significant gaps with regard to their graduate training (Benuto et al. 2019, Green et al. 2009, Park et al. 2020b). To strengthen their cultural competence, psychology trainees have expressed a desire for more concrete and technical training, as well as training that is integrated across their coursework, clinical work, and research (Benuto et al. 2019, Gregus et al. 2020). Aligned with findings from reviews on cultural competency trainings, psychology trainees have reported that training increased their knowledge and awareness (Benuto et al. 2019).

Goal setting is very important in this theory. To motivate clients to engage in goal setting, the counselor may ask them to consider the advantages and disadvantages of working toward a particular goal. In essence, the process of goal setting is very collaborative in nature and enhances the therapeutic alliance. The goals will often focus on decreasing maladaptive and unhealthy behaviors through increasing clients' participation in positive or socially reinforcing activities, although tasks and goals will differ depending on the specific characteristics of the client and the treatment targets. For instance, clients who are experiencing anxiety disorders may benefit from interventions such as systematic desensitization, graduated exposure, and relaxation (Akin-Little, 2009; T. S. Watson & Gresham, 2013), whereas clients with externalizing disorders might benefit from positive reinforcement, positive attending, and planned ignoring (Flanagan, Allen, & Levine, 2015). These interventions are discussed later in the chapter. Clients with highly specific goals are likely to benefit from BT, but if clients present with vague or broad goals (e.g., “I don' t want to get so upset,” “I just want to be happy”), the counselor will work with them to help determine objective and measurable behavioral goals for change.

The metaphor of the three waves might not be the best way to conceptualize these differences in CBT. Waves come in an order, and new waves overtake previous waves, which recede back to the ocean unnoticed. The three waves of CBT did not occur in three different points in time; each has ancient roots in philosophy and psychology. Also, the first two waves have not run out of energy and fallen back into the undertow of science or clinical practice; they still exist and are going strong. A better metaphor would be three branches on an evolutionary bush, such as three groups of apes: gorillas, chimpanzees, and bonobos. Each model has common ancestors in psychology and philosophy and continues to evolve on its own. None of the models has driven the others into extinction.

CBT focuses on the knowledge and appraisal processes that are involved in excessive or insufficient emotional arousal. Disturbed emotional arousal or dysfunctional behaviors are hypothesized to occur because of some absent, erroneous, dysfunctional, incorrect, exaggerated, or extremely overevaluative appraisal of environmental threats or rigid reactions that one must behave in a certain way. CBT proposes that practitioners focus on both events and beliefs that are likely to arouse emotions. This emphasis on the information that people extract from the environment to ensure survival and adaptation is the key focus of CBT.

Exams: There will be 2 exams (midterm and final) which will be non-cumulative. The mid-termwill be during class time and the final will be during finals week. Each exam will count towards25% of the final grade (50% total). Absences on exam dates are not permitted so plan to be inattendance. Failure to attend an exam will result in a failing grade for that exam, unless officialdocumentation is submitted.Attendance and Participation: This course is very interactive. Attendance, class participationand homework assignments (will count towards 50% of the final grade). Here is the breakdown:Class attendance and participation = 10%, homework = 40%You can earn full points by attending the lectures and participating in class discussions,activities, small group work and completing homework. Class participation is a subjective grade.I realize that people have different levels of comfort with public speaking; however, I expecteveryone to stretch themselves and attempt to share their thoughts, comments and questions in arespectful and appropriate manner. Those of you who tend to dominate class discussions mayhave to stretch yourselves in the other direction.Course Format

CBT Homework & Reflection: Student will be responsible for completing homeworkassignments. These assignments are due BEFORE class to receive full credit. If you are absentfrom class and are unclear of what the assignment is, check-in with instructor/TA/classmateabout assignment details. You will still be responsible to turn in homework even if absent fromclass.

This course is very interactive. Attendance, class participation and homework assignments (will count towards 50% of the final grade). Here is the breakdown: Class attendance and participation = 10%, homework = 40% You can earn full points by attending the lectures and participating in class discussions, activities, small group work and completing homework. Class participation is a subjective grade. I realize that people have different levels of comfort with public speaking; however, I expect everyone to stretch themselves and attempt to share their thoughts, comments and questions in a respectful and appropriate manner. Those of you who tend to dominate class discussions may have to stretch yourselves in the other direction.  Course Format CBT Homework & Reflection: Student will be responsible for completing homework assignments. These assignments are due BEFORE class to receive full credit. If you are absent from class and are unclear of what the assignment is, check-in with instructor/TA/classmate about assignment details. You will still be responsible to turn in homework even if absent from class.

A critical review of the theoretical and conceptual underpinnings of Cognitive Behavioral Therapies (CBTs). Topics include the learning and cognitive foundations of, current scientific research supporting the use of CBT, and the practical application of CBT (such as relaxation, exposure techniques, cognitive approaches, emotional regulation) along with ethical considerations