Integrating Antioppressive Practice With Cognitive Behavioral Therapy
A Social Work Imperative to Address the Coronavirus Crisis
The coronavirus pandemic is exposing systemic inequities across North America, with racial and ethnic minority groups at higher risk for getting sick and dying from COVID-19, according to the Centers for Disease Control and Prevention (CDC). At a time when minorities and people of color face inadequate access to health care, overcrowded housing situations, pressure to work in high-risk settings, and toxic stress related to discrimination, there has never been a greater need for antioppressive practices (AOPs) to push for meaningful change.
AOPs aim to provide more sensitive and empowering services for marginalized groups while advocating to reduce power imbalances and social inequality (Dominelli, 1996; Mullaly, 2002). As the global mental health crisis caused by widespread pandemic-related anxiety mounts, and as suicide and drug overdose continue to be leading causes of death, there has never been a greater need for access to cognitive behavioral therapies (CBTs) to alleviate suffering and prevent loss of life.
Some social workers suggest AOP and evidence-based practices such as CBT are mutually exclusive and incompatible (Morgaine & Capous-Desyllas, 2014; Pollack, 2004). Others believe AOP and CBT can be applied together to meet the diverse and complex needs of clients (O’Neill, 2017; Rubin, 2020).
Despite these differing viewpoints, the integration of AOP and CBT in social work practice is not only possible but also imperative to supporting clients seeking help from social service organizations. This article outlines why these approaches must be combined and how they can be integrated to improve the quality of services provided to clients while meeting the ethical requirement of social workers to strive toward social change.
Integration in the Age of COVID-19
CBT is one of the most studied and evidence-informed therapeutic approaches, providing clients and counselors a framework to address an array of devastating challenges related to the pandemic. Worry and fear of catching the virus have been widespread, and CBT has been found to help people address health-related anxieties (Cooper et al., 2017). Many COVID-19 survivors will be left traumatized by their ICU experiences (Jee, 2020); CBT can diminish the debilitating effects of such trauma (Mendes et al., 2008).
Much of the population is experiencing overwhelming stress from being socially isolated for lengthy periods of time during government-sanctioned lockdowns, placing unprecedented pressure on families and community systems. These conditions have increased incidences of intimate partner violence (IPV) (Taub, 2020). CBT can reduce distress and trauma symptoms in survivors while improving self-esteem and problem solving in this group (Arroyo et al., 2017).
Rates of substance use have surged during the pandemic (Winstock et al., 2020), with the CDC reporting an increase in overdose deaths as people who use substances are left with limited access to safe drug supplies. CBT, combined with pharmacotherapy, is well established to aid in the addiction recovery process and prevent potentially lethal overdoses (Ray et al., 2020).
CBT can reduce hopelessness, suicidal ideation, and suicide attempts in diverse populations who are struggling with cumulative stress factors and limited options for problem solving (Brodsky et al., 2018; D’Anci et al., 2019). The list of afflictions CBT has been shown to alleviate is considerable and offers hope for many struggling with physical and mental health issues.
However, CBT has been critiqued for overemphasizing problems within the individual and minimizing the social, political, and economic factors that contribute to personal challenges (Guilfoyle, 2008; Pollack, 2004). Furthermore, social workers have expressed concerns about CBT being overly prescriptive (Baines, 2011), reductionist (Witkin, 1998), and “removing or reducing opportunities to be holistic or to pursue social justice” (Bates, 2011, p. 152).
Integrating CBT with AOP can create a structure to simultaneously address broader social problems and associated internal struggles. Clients concerned about or recovering from COVID-19 may request support with anxiety reduction and benefit from education on structural injustices that make certain groups more vulnerable to infection. This approach provides a method for encouraging change to empower people affected by unjust power dynamics.
Cognitive Change: Raising Critical Consciousness
Students forced to study at home during school closures may experience frustration and self-defeating thoughts due to restricted access to computers, the internet, academic guidance, and peer support. A number of mental health professionals have advanced critical CBT models for challenging internalized oppression and facilitating liberation (Barco, 2016; Dale & Saunders, 2018; Steele, 2020).
Adaptations of CBT have been proposed to emphasize the needs of specific ethno-cultural groups (Hinton & Patel, 2017; Naeem, 2019), integrate experiences of racism into assessment and formulation (Beck, 2019), and address the need for service change and community outreach (Beck & Naz, 2019). Cognitive modification involving critical awareness of societal influences can facilitate externalization of problems that clients may believe are located solely within themselves. Social workers can strive to avoid pathologizing normative responses to marginalization (Naeem, 2019) while providing fact-based education about anxiety and the risks of losing loved ones to COVID-19.
School counselors can support struggling students by teaching cognitive skills to strengthen focus while also working to secure the technology needed for families in poverty to succeed. In this framework, emotions such as anger and despair are validated as reasonable responses to unfair policies, thus connecting the personal to the political in individual counseling.
Behavior Change: Making It Happen
Exploring avenues to participate in virtual discussion groups related to advocacy and activism opens pathways to reduce isolation, find belonging, build community, and enhance pride in marginalized identities (Aldarondo, 2007; Naeem, 2019). Facilitating opportunities to participate in peer support or consumer/survivor initiatives can increase self-esteem while reducing the need for crisis services and hospitalizations in populations struggling with their mental health (McKee, 2005).
Engaging racialized and immigrant populations in community development initiatives, such as supporting local businesses to build an online presence, can also encourage a sense of belonging and citizenship. Supporting clients who have experienced IPV during lockdowns through developing crisis plans, referring to shelters, rehearsing assertiveness skills, connecting with support groups, and inspiring engagement in public demonstrations are behavioral interventions that can empower and connect personal experiences to systems of patriarchy.
Suicide Intervention: A Lifeline in Trying Times
More than health problems, homicide, and certainly more than COVID-19, youth across the United States are dying by their own hand. The pandemic is only adding stress on an already overburdened generation.
Isolation, anxiety, uncertainty, substance abuse, IPV, and economic difficulties associated with the pandemic are also factors that increase risk for suicide. Subsequently, according to the Centre for Suicide Prevention, suicide rates may increase during and after the pandemic. Due to intensified seclusion and unequal access to mental health services, rural and Indigenous populations are particularly at risk (Pollock et al., 2018). CBT, which is the most evidence-based psychosocial intervention for suicidal ideation and self-harm, can prevent suicide attempts and unnecessary loss of life when applied within the Zero Suicide model (Brodsky et al., 2018).
Comprehensive screening and assessment must include identification of triggers and warning signs related to the pandemic, such as fear induced by watching the news, grief related to losing a loved one to COVID-19, and anxiety when experiencing symptoms of benign illness.
Engaging with ethnic minority service users must occur alongside the assessment of experiences of racism, stigma, and discrimination (Beck, 2019). Integrating CBT with AOP at this stage creates opportunities for racialized clients to engage in open discussion about how their experiences of racism and prejudice may have contributed to thoughts of worthlessness and hopelessness.
CBT-based safety and crisis response planning also need to be adapted to mobilize coping skills, cultural strengths, and community supports that are now mostly available by phone, internet, and other socially distanced means. These brief interventions delivered online, in combination with dialectical behavior therapy skills, are effective in reducing suicide ideation, preventing posttreatment suicide attempts, decreasing hospitalizations and emergency department visits, and lowering risk of self-injurious acts (Brodsky et al., 2018).
Web-based therapy, which has created a lifeline for people living in remote regions, can save community social workers time and resources while still providing high-quality support to marginalized groups. CBT services offered by hospital social workers are also increasingly in demand to support inpatients who have been disconnected from supports due to restrictions on visitors.
Adapting CBT to culturally specific populations may reduce feelings of isolation and hopelessness associated with suicidality while acknowledging the cultural and colonial contexts that have contributed to mental health disparities (Hinton & Patel, 2017; Naeem, 2019).
Concerns that CBT limits the focus of social work practice to individual problems while ignoring forces such as racism, sexism, poverty, and other intersecting oppressions can be addressed through synergistic integration with antioppressive principles. Fears that CBT will replace professional judgment with prescriptive guidelines and standardization are unfounded (Bates, 2011). This path is guided by professional judgment and taken only in consultation with clients.
Participation in CBT is voluntary, not indicated for every issue, and should be undertaken only with adequate skill. However, concerns regarding CBT’s popularity as a reflection of power relations and neoliberal cost-containment pressures are rightfully problematized (Guilfoyle, 2008; O’Neill, 2017). CBT is not the answer to every problem people face, but rather is one of many therapeutic approaches that can address mental health issues prompted by the coronavirus crisis.
When implemented in the context of AOP, CBT offers clients and social workers another option to prevent harm and promote change during this challenging time.
— Amar Ghelani, MSW, RSW, is a registered social worker with the Centre for Addiction and Mental Health (CAMH) Forensic Early Intervention Service (FEIS) and PhD candidate with the Wilfrid Laurier Faculty of Social Work.
— Ashley Haywood, MSW, RSW, and Michelle English, MSW, RSW, are registered social workers with the CAMH FEIS program.
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