Social power: some implications for the theory and practice of cognitive behaviour therapy

Abstract

Practitioners of cognitive behaviour therapy (CBT), are faced by real dilemmas when having to take into account the consequences of unequal power relations in society. Whilst a perspective on social power is not new in psychology, its implications for therapeutic practice have yet to be fully worked out. The problem becomes most acute when clinicians have to confront the shortcomings of individually focused therapeutic models in, for example, inner city Community Mental Health Teams (CMHTs), where a majority of clients face real and corrosive adversities in their lives. Exploring the eects of juxtaposing the individually focused school of CBT (Beck, 1976) with one which explicitly focuses on power relations, e.g. in community psychology (Smail, 1997), is one way to shed light on these issues. Attention is drawn to core dierences in the perspectives, e.g. the main focus of CBT on idiosyncratic beliefs and the insistence of community psychology on the social structuring of such beliefs. Ways in which real adversity has been discussed within the CBT literature are outlined and a clari®ed view of the problem presented. A clinical case example is used to illustrate what a focus on social power could add to case formulation in practice. The aim of this process is to assist clinicians in practice to make the best use of the skills they have acquired within a theoretically coherent framework. 2716450. 1998, for that relating to ethnic minority groups; Gunnell, Peters et al., 1995, for evidence relating to deprivation; and Pilgrim and Rogers, 1994, for an overview). Research by Wilkinson (1996, cited in Donnison, 1998 demonstrates that chronic disadvantages confront those who are relatively impoverished. While frank poverty (in Third World countries, for example) is obviously damaging, relative poverty within any society (e.g. in Britain, where the gulf between auence and poverty is wide and widening) also matters, leading to gross inequalities in health and mental health status (see Donnison, 1998, for a summary of these issues).In view of this, accounts of therapeutic gains achieved as a result of psychological therapy as portrayed in the literature (studies of ecacy) are frequently at odds with reality as experienced in the inner city CMHT, (see Roth and Fonagy, 1996, p. 43). The issue is not simply that of there being a lack of research on the generalizability of interventions outside of the rare®ed requirements of randomized controlled trials, although this remains a serious problem. Rather, how are clinical psychologists to cope with the reality of disappointing outcomes (the limited eectiveness of their interventions) and the range and complexity of the problems clients experience, given that a sociological or political perspective is rarely prominent on the crowded curriculum of training courses? Unequipped with an analysis of unequal social power relations (see Hagan and Smail, 1997), the psychologist may blame poor outcomes on him/herself (as an ineective therapist), on the client (as unmotivated) or ( perha...

Integrating Social Justice into the Practice of CBFT: A Critical Look at Family Schemas

“…We suggest a number of interventions congruent with the practice of CBFT that therapists can use to disrupt problematic schemas. To this end, we echo Hagan and Donnison's (1999) recommendation that therapists should make explicit the ways in which social inequality contributes to emotional and relational problems. The interventions we suggest here are nonsequential, should be thought of as fluid, and be tailored to each situation.…”

“…He further argued that the success of CBT is enhanced by a “comfortable integration with existing cultural and institutional power arrangements” (p. 197). Early on, CBT was criticized for lacking attention to social adversity and offering no framework for addressing societal power dynamics (Hagan & Donnison, ). We believe these same critiques can be levied against cognitive behavioral family therapy (CBFT), as individual and relational cognitive behavioral approaches share many core assumptions and, as with CBT, there are no systematic guidelines for addressing societal power dynamics in CBFT.…”

“…While it is important to be more culturally sensitive by acknowledging the impact of cultural norms on the development of schemas, little if any attention has been paid to the effects of societal systems and power dynamics. According to Hagan and Donnison (, p. 130), “exploration of the client's childhood experiences, focusing explicitly on unequal social power relations, could assist in clarifying with the client the origins of his/her core beliefs.” This includes how inequity at the broadest and most intimate levels of society both affects and helps maintain schemas.…”

“You Didn’t Cause Racism, and You Have to Solve it Anyways”: Antiracist Adaptations to Dialectical Behavior Therapy (DBT) for White Therapists

“…This may include: identifying generational-transactions of trauma as a biological vulnerability, characterizing racism as a chronically invalidating environment, accounting for the transactional relationship between racism and the Black/African-American client's efforts to adapt and cope with racist invalidation, accurately labeling justified emotional reactions to racism and effective passivity in response to powerful, racist environments, distinguishing these adaptive behaviors from skill deficits and broader patterns of emotion dysregulation, and accounting for internalized racism as a form of selfinvalidation that results from the transaction between person and environment. Hagan and Donnison (1999) offer a compelling case for incorporating concepts of social power within the theory and practice of CBT. The authors make the following recommendations: reframing the difficulties of socially marginalized/oppressed clients as being in part over-determined by their social position and serving functions of survival in an unequal social world; changing the potentially pathologizing terminology of CBT; and changing the practice of therapeutic work to include problematizing the social world.…”

“…When imploring a client to scan their past and present for data that confirms it is possible to re-interpret a distressing belief, people who have suffered many forms of abuse, neglect, and oppression may find that disconfirming material is scarce. Alternatively, the therapist may find it more effective to focus explicitly on unequal power relations to assist the client in clarifying the origins of their beliefs (Hagan & Donnison, 1999).…”