Interventions that rely solely on change lack balance. This is especially true when working with minoritized individuals who have very real and justified pain stemming from systemic problems.
Limitations of Changed-Based Cognitive-Behavioral Therapies
Cognitive-behavioral therapies (CBTs) are often considered “gold standard” treatments for many mental health diagnoses given the evidence-base supporting their effectiveness. CBTs are historically change-oriented; they aim to directly alter an individual’s thoughts and behaviors that are conceptualized as contributing to and/or maintaining psychiatric morbidity. However, purely change-based approaches have limitations; for example, conceptualizations of psychiatric symptoms focus primarily on individual-level abnormality and do not effectively account for systemic problems (eg, racism) that would justifiably lead to distress for individuals impacted by those problems (eg, racial minoritized individuals); as such, these treatments risk invalidating the experiences of those who are minoritized, and relatedly are limited in their cultural responsiveness. This has prompted more recent work adapting CBTs to be more culturally responsive.1
Consider the following example—when working with a Black individual in treatment, they state the following:
“Seeing all these people who look like me being killed by the police scares me. I cannot go anywhere near police.”
A purely change-based cognitive approach (eg, cognitive therapy2) could identify this thought as distorted, and the clinician would work to change this thought. A clinician might respond with:
“I hear that others have been killed by police officers. Have you personally had your life threatened?”
This response is inherently invalidating, and neglects the impact of structural racism and its impact on Black experiences with law enforcement, as well as Black health.3,4
Similarly, a changed-based behavioral approach might consider use of exposure techniques to promote habitation5 and/or inhibitory learning6 in order to address this patient’s distress. Such an approach might actively encourage a Black individual to spend more time in the presence of law enforcement, which, in reality, could put them in danger. This approach is not only invalidating, but also ignores the objective risk involved and could lead to an increase in justified fear. Moreover, it fails to appreciate systemic racism and its contribution to both increased risk of arrest and murder of Black individuals by law enforcement.7
Now, let’s consider another example. A clinician is working with a transfeminine teen who presents with significant anxiety about using the bathroom at school. She limits her food and water intake and never uses the bathroom at school or in public due to fear of being bullied or harassed. This behavior has led to development of urinary tract infections. What might a change-based treatment target in this scenario? Perhaps a change-based clinician would conceptualize that avoidance maintains anxiety and contributes to physical health problems. Next, a clinician might target the avoidance behavior and related cognitions (ie, “I will be bullied if I use the bathroom at school”). Both approaches, again, invalidate the reality of transgender and gender-diverse lived experiences8 and fail to integrate knowledge regarding gender-diverse youths’ experience in school settings.
What Is Missing?
Interventions that rely solely on change are inherently lacking balance, and this is especially true when working with minoritized individuals who have very real and justified pain stemming from systemic problems. When only changing an individual’s cognitions and behavior, a clinician is communicating, even if inadvertently, “the problem lies within you.” This is invalidating and targets the wrong problem. Distress stemming from systemic issues must be addressed differently than problems stemming solely from ineffective thinking or behavior (eg, an individual with panic disorder who believes a fast heart signals a cardiac event).
More recent iterations of CBTs such as acceptance and commitment therapy (ACT)9 and dialectical behavior therapy (DBT)10 target this imbalance by integrating acceptance-based strategies. One of the most meaningful and therapeutic ways of communicating acceptance is by using validation—this is what has been missing. DBT, developed by psychologist Marsha Linehan, is arguably the first psychotherapy to operationalize validation. DBT offers 6 types, or levels, of validation. Each level has its own description, and clinicians are instructed to validate at the highest level possible. When working with minoritized individuals, this means clinicians validate systemic racism and oppression, anti-LGBTQ+ stigma, and socio-cultural-political factors that directly and indirectly compromise the health of minoritized individuals—this is imperative.
The Table lists each level of validation and its description.
V1. Staying awake and paying attention.
Perhaps the most invalidating experience is when others do not even pay attention, creating a sense of invisibility. This is particularly painful when the “other” is a mental health professional, someone whose job is to pay attention and offer help. Minoritized individuals and their experiences are very often ignored and consequently feel invisible. At this lowest level of validation, clinicians stay awake, pay attention, and demonstrate interest in patients.
V2. Accurately reflecting communication.
One of the easiest ways to validate someone’s experience is to reflect back to them what they report. This goes beyond solely acknowledging one’s existence and communicates directly to patients, “I acknowledge what you are saying.” This is especially important when working with minoritized individuals, particularly when they may have identities and lived experiences that differ from that of the clinician. For example, a queer Latinx patient reports experiencing both racism from within the queer community and anti-queer sentiments within the Latinx community. A V2 response might be, “Wow, yes, you are experiencing prejudice from both the Latinx and queer communities.”
V3. Articulating the unverbalized.
People who have experienced chronic invalidation of their experiences often develop, over time, decreased ability (or even inability) to trust their internal experiences. Likewise, this impacts ability to accurately communicate experiences to others including health care providers. In a seminal article, Linehan states: “Reading behavior accurately requires some familiarity by the therapist with the culture of the client.”11
For example, a Taiwanese woman in group therapy may report that another group member used a racial slur during a recent session. She then pauses and says nothing. Mindful of the increase in hate crimes perpetrated toward Asian individuals over the past few years, a clinician might respond by saying, “I imagine you might be feeling pretty scared about this, perhaps even angry.” Of course, clinicians may be inaccurate in their reflections, so they must also practice cultural humility, demonstrate willingness to be incorrect, and engage in repair (eg, apologize) and corrective action (eg, avoid making mistake again).
V4. Communicating behavior makes sense in terms of past circumstances.
A response can be valid in terms of historical causes and also invalid in terms of current antecedents. In working with LGBTQ+ patients in the New York City and Boston metropolitan areas, we often encounter individuals who have experienced chronic and pervasive invalidation and rejection based on LGBTQ+ identity in the past and are currently facing less rejection in their present lives. For instance, a gay male veteran who was forced to conceal his sexual orientation while serving in the military during “Don’t Ask, Don’t Tell,” shared that he was concealing his sexual orientation from his VA medical providers and fellow veterans for fear of losing VA benefits, which is not an accurate appraisal.
This clinical example encapsulates the construct of rejection sensitivity, which refers to both the emotion (eg, fear or anxiety) and cognition related to rejection based on a minoritized identity.12 Rejection sensitivity has also been demonstrated to predict anxiety and related disorders within LGBTQ+ populations.13 In supporting those who fear rejection on the basis of a minoritized identity, clinicians validate why it makes sense in terms of one’s learning history to expect rejection, which in turn can create opportunities for the individual to consider facts and engage in reality testing in the present.
V5. Communicating behavior makes sense in terms of current circumstances.
At this level of validation, the clinician communicates that experiences are completely reasonable given the current context. For example, it makes sense to be startled when fireworks go off. When considering how this level of validation applies to minoritized experiences, clinicians must be knowledgeable and name when ongoing and current events represent examples of systemic oppression and discrimination.
For example, when yet another Black individual is murdered by law enforcement, clinicians acknowledge this, name it as manifestation of systemic racism, and create space for patients to observe and describe their emotional reactions. Revisiting the aforementioned example, a clinician may respond by simply saying, “Of course you are scared. How could you feel any other way?” And, revisiting our example of a gender-diverse adolescent, clinicians must be aware of the ongoing and increasing legislation within the US which limits access to gender affirming health care and access to public spaces (eg, bathrooms) that are consistent with one’s identity.14 An effective clinician responds to concerns about being bullied by saying, “I completely understand why you would be afraid of using the restroom given the current climate.I think a lot of others in your shoes would avoid public restrooms.”
V6. Being radically genuine.
This highest level of validation means the clinician is a genuine person in the room with another person. At this level, clinicians respond with sincerity, treating patients like equals. For example, if a mother reports intense fear that her Black son will be harmed, a clinician might respond by saying, “I can only imagine what you are thinking and feeling right now, and you have to confront this everyday of your life. I would be beside myself, and I am so sorry this is something you even have to consider.”
It is important to note that verbal validation may be necessary but not sufficient. For example, if while walking out of grocery store, you see someone’s bag break, and their groceries spill everywhere, simply stating, “That must be so frustrating,” or “I would be so annoyed if that happened to me” and then walking away from them, while verbally validating, is functionally invalidating. Functional validation would entail offering help with groceries. In other words, functional validation is where one engages in action to perform a function that behaviorally and/or contextually demonstrates validation.
Let’s consider another example: perhaps a Native two-spirit individual reports that while entering the building to attend a therapy session, they observed another person saying racist and gender slurs and making racist gestures. Verbal validation might sound something like “I would be so angry to deal with racial slurs when you come in for therapy, and I can understand if you did not want to come back again.” Verbal validation is invalidation when it is accompanied by inaction when action is needed. Environments of care must be functionally validating for minoritized individuals, meaning that they should be free from oppressive experiences, include visual cues of affirmation and safety (eg, LGBTQ+ Pride flags/images), informational materials that depict minoritized individuals, and be staffed by those who are affirming and trained.
Are CBTs Bad? Do We Need to Reinvent the Wheel?
Of course not. And, to be clear, this article is not at all aimed at devaluing the utility of change-oriented approaches. These clearly have merit and can be effective. At the same time, validation can and should be incorporated, especially when patients experience invalidation of their identities and lived experiences on a daily basis. Additionally, as validation offers balance to change, patients may be more likely to receive and engage in change strategies when it is suggested/recommended by a clinician who communicates understanding of their truth. Of course, in order to do this effectively, clinicians are advised to learn about the contexts in which minoritized individuals live in order to use validation effectively. Such knowledge supports use of validation and enhances therapeutic interventions when working with minoritized patients.
Dr Sloan is the training director for VA Boston’s Clinical Psychology Internship Program and clinical associate professor of psychiatry at Boston University Chobanian & Avedisian School of Medicine. She is involved both locally and nationally in education, training, and consultation in sexual and gender minoritized (SGM) health. Dr Cohen is an assistant professor of medical psychology in psychiatry at Columbia University where he is active in the domains of education, clinical care, and research with a particular focus on the mental health of LGBTQ+ youth.Follow Dr Cohen on Twitter: @DrJeffCohen.
1. Iwamasa GY. Ethnic minority cultural adaptations of cognitive behavioral therapy. In: Wenzel A, ed. Handbook of Cognitive Behavioral Therapy: Applications, Vol. 2. American Psychological Association; 2021:823-842.
2. Beck AT, Weishaar M. Cognitive therapy. In: Corsini RJ, Wedding D, eds. Current Psychotherapies, 7th Ed. Thomson Brooks/Cole Publishing Co; 2005:238-268.
3. Bailey ZD, Feldman JM, Bassett MT. How structural racism works - racist policies as a root cause of U.S. racial health inequities. N Engl J Med. 2021;384(8):768-773.
4. Alang S, McAlpine D, McCreedy E, Hardeman R. Police brutality and black health: setting the agenda for public health scholars. Am J Public Health. 2017;107(5):662-665.
5. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychological Bulletin. 1986;99(1):20-35.
6. Craske MG, Treanor M, Conway CC, et al. Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther. 2014;58:10-23.
7. Criminal justice fact sheet. NAACP. Accessed June 19, 2023. https://naacp.org/resources/criminal-justice-fact-sheet
8. James SE, Herman JL, Rankin, et al. Executive Summary of the Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. 2016. Accessed June 19, 2023. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
9. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An experiential approach to behavior change. Guilford Press; 1999.
10. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press; 1993.
11. Linehan MM. Validation and psychotherapy. In: Bohart AC, Greenberg LS, eds. Empathy Reconsidered: New Directions in Psychotherapy. American Psychological Association; 1997:353-392.
12. Feinstein BA. The rejection sensitivity model as a framework for understanding sexual minority mental health. Arch Sex Behav. 2020;49(7):2247-2258.
13. Cohen JM, Feinstein BA, Rodriguez-Seijas C, et al. Rejection sensitivity as a transdiagnostic risk factor for internalizing psychopathology among gay and bisexual men. Psychol Sex Orientat Gend Divers. 2016;3(3):259-264.
14. Mapping attacks against LGBTQ rights in U.S. state legislatures. American Civil Liberties Union. Updated May2, 2023. Accessed April 23, 2023. https://www.aclu.org/legislative-attacks-on-lgbtq-rights