Therapist responsiveness to cultural contexts: A thematic analysis of CBT sessions in community care from a large-scale implementation effort

OBJECTIVES: We examined how community mental health therapists learning CBT as part of a large-scale implementation effort navigated conversations about cultural identities in sessions with behavioral ratings of high and low therapeutic alliance. METHODS: Using thematic analysis, we examined transcripts from 30 CBT community mental health sessions reflecting the highest and lowest alliance ratings from a set of 2,081 sessions. RESULTS: Therapists engaged in conversations about cultural identities spanning three themes across high and low alliance sessions: going into cultural opportunities, missing cultural opportunities, and cultural missteps. While some therapists leveraged opportunities to deepen exploration of cultural contexts and centered cultural contexts within CBT interventions, others missed cultural opportunities, and implemented CBT interventions centering individual thoughts and behaviors with limited connection to cultural contexts. Some therapists made assumptions about client cultural contexts, reinforced client biases, or pathologized client cultural contexts. CONCLUSION: Our results highlight how missed cultural opportunities and cultural missteps in sessions among therapists learning CBT can occur when therapists are demonstrating strong rapport-building skills. Given global implementation efforts to expand CBT access, cultural responsiveness failures may be replicated at scale in underserved communities when training does not center multicultural orientation in exploration of thoughts, feelings, and behaviors. CLINICAL OR METHODOLOGICAL SIGNIFICANCE OF THIS ARTICLE: : this study provides important qualitative context about how therapists approach conversations surrounding cultural identities within CBT. Our results provide concrete examples of how therapists may deepen dialogue surrounding cultural contexts, or inadvertently invalidate client experiences.