The Challenges of Offering Inclusive CBT
By: Geneviève Belleville
Since the early days of my training in clinical psychology, I have had the privilege of participating in numerous French-language CBT trainings delivered by experts who had themselves developed these approaches or trained directly with their founders. These interventions were firmly grounded in experimental research and supported by rigorous empirical evidence. Seeing their effectiveness in clinical practice, I felt I had acquired powerful tools for treating common mental health problems.
Around 2010, my interests shifted toward post-traumatic stress reactions. It was then that I became increasingly aware of the double-edged nature of CBT: its tremendous capacity to relieve suffering, but also, in certain contexts, its potential to reproduce, or even reinforce, the very conditions that contribute to the difficulties experienced by the people we hope to help.
A realization then influenced the direction of my work: In striving to apply treatment protocols in a standardized manner to preserve their rigour, we may inadvertently offer interventions that do not fit everyone, particularly those who may need them most. This is the paradox of the "one-size-fits-all" approach: what is intended to work for everyone often ends up serving no one especially well.
This paradox becomes especially apparent when working with trauma. Potentially traumatic events do not occur randomly, and their mental health consequences are not evenly distributed across society. Social determinants of health, including income, education, and access to services, influence both exposure to traumatic events and pathways to recovery. Added to this are the effects of systems of oppression, such as racism, homophobia, transphobia, ableism, and classism, which manifest through discrimination and historical trauma and shape psychological experiences. These realities invite us to move beyond a purely individual understanding of psychological difficulties.
Factors that we often attribute to personal characteristics, such as gender or perceived threat during a traumatic event, are rooted within broader social contexts. Gender roles, for example, help explain the higher prevalence of PTSD among women. Women's greater economic disadvantage, increased exposure to certain forms of violence, and socialization toward internalizing distress may help to explain these differences. Similarly, individuals from marginalized communities may perceive greater threat in situations that members of dominant groups consider safe because of repeated experiences of discrimination and violence, whether experienced directly or indirectly.
These observations raise an important question: How can we meaningfully integrate these realities into CBT practice?
I do not have a definitive answer. However, my research and clinical work over the past several years, conducted alongside dedicated students from diverse backgrounds, have highlighted several important directions. Meaningful integration appears to begin with awareness, followed by a gradual evolution of our clinical practices.
The words and models we choose are not neutral. By emphasizing individual thoughts and behaviours, CBT can unintentionally create the impression that psychological difficulties arise solely from characteristics within the person, overlooking the influence of broader social realities. Consider, for example, a survivor of sexual assault who thinks, "If I hadn't worn those clothes, this wouldn't have happened." In CBT, a thought such as this is often addressed to reduce self-blame. Yet the very existence of this belief reflects a broader social context in which victim-blaming myths continue to circulate. Placing beliefs within their broader social context helps us recognize that they are not simply individual cognitions, but are shaped by environments that make them both possible and believable.
The way interventions are delivered can also create unintended barriers. For example, CBT often relies heavily on written exercises, which may not suit everyone. Likewise, some therapeutic exercises contain implicit assumptions. One person with a mobility disability noted that an exposure exercise instructing clients to "walk alone at night" did not reflect their lived experience, whereas "go out alone at night" felt far more inclusive and relevant. A seemingly small change in wording can substantially increase the accessibility of an intervention.
Socioeconomic realities also influence what clients are realistically able to implement. Behavioural activation protocols, for example, often recommend activities such as dining at restaurants or taking dance classes, which may be financially inaccessible. Giving greater attention to free activities and becoming familiar with community resources opens additional possibilities. Although these resources are sometimes viewed as peripheral to therapy, they often provide essential opportunities for social connection, practical assistance, and emotional support.
Finally, cultural and spiritual frameworks shape how people understand psychological distress and recovery. Although CBT models are often presented as universal, they are rooted within Western culture and reflect its underlying values and assumptions. For some individuals, including immigrants, Indigenous peoples, and those from diverse religious traditions, these models may not align with their own understanding of suffering and healing. Applied too rigidly, CBT may create a disconnect or even a sense of invalidation. In contrast, a flexible, collaborative approach that seeks common ground between the underlying principles of CBT—the processes of change it seeks to promote—and the person's own beliefs allows for the co-construction of shared meaning.
Providing inclusive CBT does not require sacrificing scientific rigor. On the contrary, a substantial body of research demonstrates the effectiveness of CBT protocols delivered across diverse populations, including culturally adapted interventions. What is required are thoughtful adjustments to the language we use, the ways interventions are delivered, and our recognition of the broader contexts in which therapy occurs. The goal is not to dilute CBT, but to broaden its reach so that it truly serves the people it is intended to help.
