August 21, 2022 • 39 mins
In this interview, Dr. Trevor Hart discusses the need for CBT interventions that target sexual and gender minorities (SGM) and explains how they differ from standard psychotherapy. He addresses some of the critiques that are often shared about the CBT approach and shares his perspectives on the utility of goal-oriented models. Finally, he tells listeners what resources they can avail themselves of to learn more about SGM-affirming CBT.
GUEST BIO: Dr. Trevor Hart is the Director of the HIV Prevention Lab at the Toronto Metropolitan University, Department of Psychology. He is also a Research Chair in Gay and Bisexual Men’s Health with the Ontario HIV Treatment Network.Trevor Hart works to develop and test sex-positive, anti-oppressive HIV prevention interventions and psychotherapies for gay, bisexual and other men who have sex with men. His work is both community-based and clinical and relies on a health promotion framework.
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ABOUT THE CBT DIVE PODCAST
The CBT Dive is a video podcast that brings therapy skills to the real world. Each episode welcomes a new guest who wants to explore a challenging situation using the most common cognitive behavioural therapy tool: the thought record.
ABOUT HOST
Rahim Thawer is a queer, racialized social worker and psychotherapist based in Toronto. He's created The CBT Dive podcast to support folks who want to learn how to use a thought record and to demystify what therapy can look like.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
UNKNOWN (00:00):
Thank you.
SPEAKER_00 (00:00):
Welcome to the CBT Dive, a vodcast that goes into
the lives of real people withreal struggles.
Each episode welcomes a newguest who wants to explore a
challenging situation using themost common cognitive behavioral
therapy tool, the ThoughtRecord.
Your host, Raheem Thawar, is asocial worker and
(00:21):
psychotherapist based in Torontoand well-known for his work in
LGBTQ communities.
He's created the CBT Dive todiminish mystify what therapy
can look like, and shareintervention skills for
wellness.
We hope that each episode helpsyou along on your own journey
for insight and self-compassion.
SPEAKER_01 (00:42):
Hello, Dr.
Trevor Hart.
How are you today?
SPEAKER_02 (00:50):
I'm doing well.
How are you, Rahim?
SPEAKER_01 (00:54):
I am living the dream.
It's so good to see you.
Somebody from Toronto.
SPEAKER_02 (01:00):
Yeah, and I'm excited about your travels
across the world.
SPEAKER_01 (01:05):
Yeah, and I brought the CBT dive with me to
Johannesburg.
Before we get into it, you knowthat I have a lot of questions
for you.
I'm just going to share with ourlisteners a bit about you.
Dr.
Hart received his doctorate inclinical psychology from Temple
University.
After graduate school, hecompleted a postdoctoral
(01:26):
fellowship at Emory UniversitySchool of Medicine, through
which he received training atthe US Center for Disease
Control and Prevention.
He has received several awardsfor his advancements to research
and clinical work, includinginduction as a fellow of the
Canadian PsychologicalAssociation and as a fellow of
the Association of Behavioraland Cognitive Therapies.
(01:47):
Dr.
Trevor Hart is the director ofthe HIV Prevention Lab.
He holds a research chair in gayand bisexual men's health from
the Ontario HIV AIDS TreatmentNetwork.
Dr.
Hart is currently conductingmultiple studies, including a
test of new gay and queerfriendly therapies for social
anxiety for HIV negative gay andbisexual men, and a study
(02:09):
examining how biomedical HIVprevention, such as the use of
pre-exposure prophylaxis or PrEPis changing attitudes and sexual
health for gay and bisexualqueer men across three cities in
Canada.
He also has a private practicefocusing on CBT and other
evidence-based therapies relatedto sexual minority people in
(02:32):
Ontario.
Dr.
Trevor Hart, did I capture allof that okay?
Looks good to me.
So, I'd love to just tell theviewers, you know, I met Dr.
Hart when I was first working,like pre-MSW, like when I was
working at the Alliance forSouth Asian AIDS Prevention, and
(02:53):
that was in 2009.
So we're talking over a decadeago.
And Trevor has been kind enoughand supportive enough of my
career trajectory to invite meto be on all kinds of advisory
committees, And we've spokentogether at conferences and he's
(03:15):
always been very respectful andkind of supported me along in my
career.
So I'm excited to have him here.
So Trevor, I'd love for you totell me a bit about CBT.
What do you like about it orlove about it?
And in the therapy you do, whatkinds of CBT tools do you tend
(03:36):
to gravitate towards?
SPEAKER_02 (03:40):
Well, one of the things, I wasn't originally
trained in my undergrad to doCBT.
I was trained in a program thatreally didn't talk much about
it.
And so I was a bit surprisedabout all this CBT stuff.
And I had received some negativemessages about it too.
Oh, it's not real therapy.
(04:00):
It's a symptom management.
It's not going to help you withanything important.
It's just, you know, a surfacelevel thing.
And then I found out that whenworking, doing CBT, I had
patients that were gettingbetter.
I had patients that weregrateful.
We were having, making real lifechanges.
(04:21):
I remember being at a practicumwhere I was helping somebody
with one supervisor and thenswitch supervisors.
And then the supervisor waslike, why aren't you doing this,
that, and the other?
Your patient's not reallygetting better.
And I was like, yeah, they'renot.
And I'm like feeling reallyupset about it because I like
want to really help them.
They're really suffering from alot of anxiety and depression.
(04:46):
They were like, you know, haveyou considered using a CBT
approach?
And so what I did is Iintegrated that CBT into the
approach that I was alreadyusing.
And then I had that patient, gota lot better and then they were
doing a lot better.
And one of their comments to metoward the end was, I've really
appreciated all the work thatyou've done to help me to change
(05:08):
my life.
But if you don't mind me saying,why don't we start this earlier?
Because I felt like we were justkind of like just talking, just
talking about stuff, but notmaking any real changes in my
life before.
And I was like, so that was oneof my first experiences where I
was like, maybe the CBT stuff isactually pretty good.
(05:28):
And maybe that kind of strongman that's painted, you know,
about like, oh, it's surfacelevel is kind of not really
accurate.
Right.
You know, I really think thatthere is an increasing awareness
about the benefits of CBT andthat it's realistic.
It's realistic and it'seffective and it can help people
So many things.
(05:51):
Yeah.
SPEAKER_01 (06:05):
You started seeing people get better.
And at the end of sessions or atthe end of your time with
clients, they were thanking you.
I've had a similar experienceand I find it's part of it is,
you know, people really feellike something concrete is
getting done and somethingtangible.
And, you know, If you'retalking, that can be helpful,
(06:27):
but people don't leave withsomething concrete to reflect
on, right?
And so something like a thoughtrecord I find is really great.
I've heard people, they'll taketheir thought record and then
put it on their fridge orthey'll reflect on it from time
to time.
Are there specific CBT toolsthat you like or use?
(06:48):
And do you do them in a writtenformat or do you kind of, do
talk therapy in a way that'sinformed by CBT thinking?
SPEAKER_02 (06:59):
Yeah, I tend to do work that involves both talking
and writing it out.
I find that it's hard toremember when people say, oh, I
did think about it.
I'm like, tell me about what youthought.
It's usually kind of very ad hocand it can be very surface level
where it's like, I thought tomyself, I don't know, imagine I
(07:20):
was giving a presentation on avideo podcast to, you know, an
important member of ourcommunity and you want to do a
good job.
Imagine I was doing a thoughtrecord.
Oh, and I thought, well, youknow, I guess I'm going to flub
this up.
I'm not going to soundcompetent.
And then I do it in my head.
I might end up with somethinglike, you can do it.
(07:43):
Like just something that likeyou might hear from your
friends, right?
But if you do a full thoughtrecord, I think you can go a
little bit deeper thancheerleading.
And I think cheerleading isgood, by the way, but I think we
can do even more than that astherapists.
But I want to answer yourquestion about tools, too.
Do you want me to hold on for asec?
SPEAKER_01 (08:05):
No, I just wanted to say, when you said you can go
deeper beyond the cheerleading,I think I just want to point out
to people that the process ofcoming up with the negative
automatic thoughts and thendistilling them a bit has so
much depth to it.
And so it really counters thatidea that it's surface level
(08:29):
because when you're diggingwhat's underneath the automatic
thought, it does go deep.
But please go ahead.
Tell me about your favoritetools.
What do you like?
What do you hate?
SPEAKER_02 (08:40):
I don't think I hate too much, but I tend to use the
tools that are used in CBT.
CBT has got a lot of tools.
There's psychoeducation, whichis understanding your
psychology, your psychologicalstrengths and your challenges.
I think that's a good first stepis just to gain some insight as
to what do we know?
(09:00):
And CBT therapists are notafraid to say, hey, what do we
know from the researchliterature?
Like what things have we learnedas far as what caused a certain
problem or what makes itmaintain, but then also making
it come to life by talkingabout, hey, to what extent is
that true for you?
What's going on in your life orhow much does that jive with
(09:20):
your experience?
That's one tool.
Another tool is cognitiverestructuring, which is helping
to change the way that we thinkso that our thinking is more
rational, helpful, or alignedwith our values.
And I'd say that's a keycomponent of the thinking part
of CBT, changing the way wethink so that we can think in a
(09:41):
way that makes us feel better.
There's also behavioralexperiments or exposures, facing
difficult and anxiety-provokingsituations so we can do what we
want to do in life.
There's relaxation exercisesthat we can use when we're
feeling stressed or just havingnew ways to reduce our muscle
tension and our anxiety.
(10:01):
And then there's mindfulnessexercises like learning to live
in the moment and to understandour thoughts and feelings as
believing experiences likeanything else that we can
experience and not beoverwhelmed by our own thoughts.
So I'd say all of those thingswould be things that I think are
great tools and we've got greatevidence for them.
SPEAKER_01 (10:23):
Great.
I'm so glad you talked aboutboth psychoeducation and
mindfulness, because peoplesometimes will start therapy, in
my experience, and they'll say,I've received this diagnostic
label, right?
And I might say, do you knowwhat that means?
(10:43):
Or what does that mean to you?
And sometimes I'll say, itwasn't really explained to me.
I've just had it forever.
So a bit of psychoeducationabout like, when is this
diagnosis usually given?
What does it tend to mean?
What are the common symptoms?
How does it look in differentpeople?
What can it, how does itmanifest in your life?
What might it prevent you fromdoing?
Or why might something bedifficult?
(11:04):
Goes a really long way.
I'm glad you mentionedmindfulness because it's not
always talked about as beingpart of the package of CBT.
But for a lot of folks, youknow, we can only access our
rational mind or alternativeways of thinking once we're
grounded.
And so pairing that, you know,sometimes students I supervise
(11:26):
will say, when do I use thismindfulness business?
And I'm like, well, it couldeven be a good way to...
It could be something useful todo before you do a thought
record or before you get deepinto the thoughts, right?
Help ground somebody and helpreduce their level of anxiety.
I personally find behavioralexperiments very challenging to
(11:48):
do with my clients.
Dr.
Hart, do you have trouble withthose or any of the tools?
Or do you find, is there a toolthat you find clients have a lot
of trouble with?
SPEAKER_02 (12:02):
I think it's pretty random to me what folks will
have more trouble with or less.
I think some folks have troublegetting their mind around
cognitive restructuring, eitherbecause it's a little tough for
them to kind of figure out theirown thoughts.
They're not aware of theirthoughts or they find it a
little bit, for some folks, itcan be a little intellectually
(12:24):
challenging where it's like,what is it after what?
And then I have to do what?
Like there's a bunch of steps.
And for other folks, they're sointellectual that they get
wrapped up in their ownthoughts.
And I have to take them backdown to earth and be like, let's
talk about which thoughts arehelpful as opposed to having a
(12:44):
discussion about what thought ismore logical and what thought is
less logical and what does logicmean?
And you can go there if you'renot aware that your goal is
really to help the person andnot to have a really interesting
conversation.
For behavioral stuff, people areavoidant.
(13:05):
People don't come to see you forCBT usually because they're
feeling...
confident in their ability to dowhatever they want to do, right?
So they do this thing calledavoidance, where they avoid
doing the things that they wantto do.
They wanted to ask somebody outfor sex or for a date or to hang
(13:27):
out, but they avoided it.
They wanted to tell their bossthat they had some good ideas
that could change the way thatthey do things at work, but they
avoided it.
They wanted to speak up at ameeting, but they avoided it.
And so all these behavioralexperiments, those are all
things about going to do thethings you want to do, testing
(13:49):
out your thoughts.
So if you have a thought, no onecares about what I have to say
at work, and then that thoughtleads you to not acting, you can
use a behavioral experiment tosay, hey, how about I
intentionally say raise my handat that Zoom meeting or
in-person meeting and Iarticulate my point.
(14:11):
And will people just say nothingor will people say that's a good
point?
There's opportunities for peopleto learn about how they can
engage with the things that theywant to do.
They can feel strong andempowered.
SPEAKER_01 (14:26):
Okay.
I love that example.
You're making me want to trybehavioral experiments again.
Yeah.
I really like that you point outthat, you know, it's not
supposed to be easy.
People are coming to work onthings that they're avoiding or
having a hard time with.
I find that like that gives me,helps me access my own empathy
(14:52):
and working with clients.
Because I think it cansometimes, when you're lacking
motivation or you're afraid ofjudgment, sometimes, I think
it's stressful for the client toput themselves in a difficult
position, and sometimes it'sstressful for the therapist.
And as I'm thinking about it,I'm thinking, oh, I wonder if
it's my anxiety that gets in theway.
(15:13):
What if my client triessomething in a behavioral
experiment and it doesn't gotheir way?
And so it's like I'm catchingtheir anxiety.
It's contagious.
So I have to work on that.
Trevor, what is it about CBTthat makes it so popular?
It seems to be a common go-tofor a lot of people and
(15:34):
organizations.
You know, I've had students Isupervise that say, teach me
CBT.
And I'll say, okay, I'm happyto.
What interests you about it?
And they'll say, every jobdescription I've looked at says
I need to know how to do this.
So maybe you can shed some lighton why it's so widespread and so
popular, particularly in thenonprofit sector.
SPEAKER_02 (15:57):
Well, let me tell you, that was not the case when
you and I first met, whetherit's your first memory of me or
vice versa, that was not thecase.
I think things have changed inthe last 10 years and it's a
part of an ongoing change.
And the push is really towardsjust a pragmatic focus, like
(16:18):
just like we want people to getbetter.
We know that there's a varietyof therapies available and CBT
is not the only therapy that youcould use, but we also know that
CBT has a strong evidence basefor it saying, you know what,
it's, it's going to help.
It's going to help you with yourclients or patients, by the way,
(16:39):
use those terms interchangeably,the humans that we're trying to
help.
Yes.
So, uh, that it works,basically.
So at first, I think there wassome, even some resistance to
CBT, like, oh boy, it's surfacelevel because of psychodynamic
people thought that they weredoing very deep work or the more
(17:00):
humanistic people didn't likethat it was directive because it
meant that you weredisempowering the person and So
there was a lot of resistance,actually, and there still is
quite a bit of resistance in thefield against CBT.
But I have to say, I think whatpeople like at community-based
(17:21):
organizations is that they liketheir people getting better
quickly and that they care lessabout what theory and how much
the therapist likes the theoryand is sold by the theory.
What they care about is nottheory.
What they care about is, can weshow the government?
that we've helped 300 people getbetter in the past year that and
(17:45):
we can show like actually showthat it was not just they said
they really liked it and theylearned a lot but they said
SPEAKER_03 (17:53):
yeah
SPEAKER_02 (17:53):
i'm feeling better and now i'm able to function i'm
able to i'm able to uh get offof ODSP if they want to do so,
touch and go as to whetherthat's even a good idea in, you
know, in Ontario, you know,because of our disability
framework is very challenging towork with.
I'm able to get to work.
I'm able to enjoy my love lifeand my sex life.
(18:17):
And so I think that that's, Ithink it's really just the, that
many of the organizations thatwe work with, they don't care
about our theories.
What they want to know is whatgets people better.
And by the way, I want to tellyou, I'm not in the CBT camp.
I'm not in a camp.
I'm not a part of, I don'tfollow.
I'm not a Beckian or an Elysian.
(18:39):
We don't have that in the waythat I was trained.
What we have is evidence-based.
And I will tell you that if wefind that something else works
better than CBT, And we can showthat it works better than CBT.
I'm going to be pissed, but youknow what?
I'll be pissed.
I'll be pissed because I'm old.
And that means I have to learnnew stuff.
(18:59):
That is why.
Not because I think CBT is theway to go.
I just think right now it's gotthe strongest evidence base.
And I want to help my clientsthe best I can.
SPEAKER_01 (19:10):
Yeah.
No, that makes a lot of sense.
And I think you've known that,you know, I've been of two minds
about CBT.
I think it wasn't too many yearsago that I was quite critical of
it.
Do you remember that?
SPEAKER_02 (19:26):
I do.
And I remember us having aconversation.
I was like, what about CBT?
And you were just like, meh.
And I was like, okay.
I'm like, I don't know what tosay because I mean, so much of
it when we're trying to fellowtherapists, it's about your
readiness to accept messages andyour readiness.
And I was like, I don't knowwhat's my place to tell a fellow
therapist what to do.
(19:46):
Yeah.
But I've
SPEAKER_01 (19:49):
come some way.
I was
SPEAKER_02 (19:50):
surprised you came to me with the CBT dive.
I was like, okay.
SPEAKER_01 (19:55):
Yes.
SPEAKER_02 (19:57):
I was not expecting it.
I
SPEAKER_01 (19:59):
think we should pause there for a moment and
just delve into that if we can.
Okay.
I asked you to come on the showfor that very reason, I think,
because I've been at aconference where you've talked
about CBT and I've been like, Idon't think this is a great
idea.
I don't think this is great forclients.
I've had strong opinions likethat.
(20:21):
And I continue to be of twominds about CBT, you know, when
I'm like, I'm not sure it worksfor everybody.
But, you know, there's a fewthings that I've realized.
One is that CBT can be adapted.
to work for different people.
And two, it's easy to criticizesomething when you are
(20:47):
struggling with using ityourself.
And so that's an admission thatI didn't fully know how I could
use these tools.
And when I started to supervisestudents, I found by the time I
started to supervise students, Ihad taken two intense trainings
in CBT and they came in with alot of critiques about it.
(21:09):
And they would say, it's notclient-centered, it's not this,
it's not that, it's notanti-oppressive.
And I would say, well, I don'tknow that that's true.
I think any therapeutic modalitycan be done badly, right?
You could say, You could say,you know, psychodynamic free
association is client centeredbecause the client gets to do a
(21:33):
lot of the talking.
You could say CBT is clientcentered because a client picks
the goal.
You could say both of those arebad for somebody through some
other rationale.
So I said to my students, andI've come to learn this very
much.
You can critique something onceyou've learned how to do it and
you've attempted it, right?
(21:54):
You really need to try it withclients and see how it can fit
into your practice.
And I started the CBT divebecause I thought I really want
students of therapy, people whoare training in CBT, other
professionals, And folks who'vegone through some therapy to
(22:16):
just come to the podcast and seehow we work through things in a
very linear way.
I think that's one of myfavorite things is how you can
really isolate a problem andwork through it in a linear way.
So it feels like I've come to apoint in my career where I'm
(22:36):
appreciating a lot of the workyou've done for so many years,
Trevor.
So I just want to say thank youfor that.
SPEAKER_02 (22:45):
I'm honored, Rahim.
You're such a leader in thefield that it's, you know, I
knew you when you were kind ofat the earlier stages of your
career.
Yeah.
And then you're just, I see youas, you know, at the top of your
game and just a real contributorto our community.
(23:08):
Someone whose voice is so valuedand so appreciated.
And so, Rahim, I'm glad I couldcontribute in some way.
I mean, I think we're alllearning from each other in the
community, both the therapycommunity and also kind of the
sexual and gender minoritycommunity.
I think when we listen, we canalso listen to critiques, but
(23:33):
also hear where the critiquesare coming from.
Then we can improve our work,which is part of what I'm trying
to do is improve what CBT does.
SPEAKER_01 (23:42):
And having said that, so, We both do a lot of
work with LGBTQ communities orsexual and gender minorities.
And from what I understand, alot of your research and some of
the practices you've developedor drawn on are about using CBT
(24:03):
with LGBTQ communities.
Can you tell me a bit about whatthat work has entailed and why
is there even a need to adaptinterventions to make them, you
know, queer and trans-specificor queer and trans-aware or
queer and trans-competent.
You could see that I'm not evensure what the language is, but
there's a kind of adaptationthat people talk about.
(24:25):
Tell us a bit about it.
SPEAKER_02 (24:28):
I mean, CBT, while it's really effective, it hasn't
really been tested in thecontext of the things that many
of us would experience who aremembers of sexual and gender
minority communities, theLGBTQ2I community.
and all the other identitiesthat I haven't listed.
So it doesn't, CBT as done bycisgender straight people
(24:55):
probably isn't going to take alook at societal homophobia,
transphobia, heteronormativity,cisnormativity.
And these are all things that welive in as sexual and gender
minority people.
Like this is our context,whether we wanted it to be or
not.
And so what ends up happening iswe experience a lot of extra
(25:17):
stresses compared to people thatmight be a cisgender
heterosexual person.
People have, everyone hasstresses in their lives.
Everybody has potentiallyfinancial stresses or family
stresses or financial workstresses or other relationship
stresses or social problems.
But when you're a queer or transor other sexual or gender
(25:40):
minority person, you also haveto deal with being treated in
really derogatory ways as kidsand as adults, fear of being
rejected for who you are,literally like, should I tell
this person?
Should I not tell this person?
Do they know?
Are they going to treat mepoorly because I exist?
(26:01):
Or will they not treat me poorlybecause I exist?
Do I try to hide whether Iexist?
Dealing with heteronormative andcisnormative comments from our
family, like your own family oforigin that might have been a
place of support might actuallyalso be a place of great
oppression and concerns aboutwhere it's safe to be out.
(26:21):
So there's like a, I thinkthere's a profound need for
intervention that can beevidence-based but explicitly
anti-oppressive.
SPEAKER_01 (26:31):
Yeah.
So what does an affirmative CBTpractice look like?
And how does it differ fromstandard psychotherapy?
How does somebody know they'rebeing like LGBT affirming in
their practice?
SPEAKER_02 (26:50):
It's easier said than done, but it is also easily
done.
It just needs some thought.
The affirmative interventions,they're going to talk about the
things that people normally talkabout.
So let's say if you've gotsomebody who's coming to work
with you because they're havingpanic attacks, you might still
help that person with theirpanic attacks.
(27:11):
If they're depressed, you'restill gonna help that person
with depression, but you'd alsocan talk about stresses that we
experience in the community.
And sometimes those are calledthose minority stressors.
So the stressors of being a partof a minoritized group, and
we've talked about specificallykind of heteronormative and
(27:32):
cisnormative kind of stressors,but this could be true for all
forms of oppression, whetherit's racist stressors or sexist
stressors or classist stressorsor anti-immigration stressors or
anti-religion-based stressors.
So things that basically makeyou feel other than for doing
nothing wrong whatsoever justexisting as a person that had
(27:56):
your identities.
And so these affirmativeinterventions, they'll talk
about oppressive forces and forSTM people by helping STM
people, sexual and genderminority people, find ways to
live their lives.
Like for example, our sexualconfidence CBT program that
we're testing out at Ryersongoes beyond typical CBT for
(28:20):
addressing social anxietydisorders.
So usually social anxietydisorder, CBT, you would talk
about how you think aboutyourselves, face
anxiety-provoking situations,like asking somebody out for a
date or to hang out or going toa party, speaking up at a
meeting.
And all of this is great.
(28:41):
This is great.
But standard CBT therapistswon't think about asking about,
hey, you know what, here'sanother stressful situation.
How about what do you do whenyou hear homophobic comments on
the street?
What about a social anxietysituation called, I would like
to hold hands with my partnerwho does not appear to be of the
(29:04):
other gender?
right?
So, you know, like aheterosexual relationship, what
do I do when I'm holding handswith my gender diverse or trans
or same sex partner?
And they won't talk about gaysex.
They won't talk about trans sex.
They don't talk about, oh mygoodness, we have sex too,
because it's like veryuncomfortable to talk about sex.
(29:27):
Like that's inappropriate.
And that's, but sex is aninterpersonal situation where
people kind of need to beassertive if they want to be
able to give consent.
So in the standard CBT, theywouldn't talk about any of this
stuff, but in our sexualconfidence CBT program, we talk
a lot about it.
So it's still CBT, but it talksabout the stresses that we
(29:50):
experience in the community.
SPEAKER_01 (29:53):
Well, This is the first I'm hearing of this sexual
confidence CBT, and it soundsreally fascinating.
So perhaps you could share alink so listeners, I'll put it
in the show notes and listenerscan check it out.
It sounds really interesting.
So what I'm getting from youabout queer and trans affirming
(30:15):
or SGM affirming CBT is thatone, it really takes into
account like systemic issuespeople face, like kinds of
discrimination and validatesthat.
So we're not trying to change athought around, you know, I
experience homophobia and you'retrying to convert that into a
(30:37):
positive.
That's not what we're doing.
We're affirming people'sdifficult experiences in the
world.
And the other part of that is asthe as the affirming CBT
therapist, you're going toplaces, topics, issues in
somebody's life that have to dowith the subculture they live
(30:58):
in.
So things to do with sex andsexuality, the interpersonal
experience of being withsomebody else, dealing with
things like maybe internalizedstigma or homophobia, that kind
of thing.
That sounds really fascinating.
I'm also thinking, You know,what do you say to people who
(31:20):
might say that CBT is too shortterm or perhaps too surface
level to deal with things likeoppression, which is essentially
what you're talking about,right?
When you talk aboutdiscrimination people face, how
do you respond to that?
SPEAKER_02 (31:36):
Well, I mean, the first way is by saying, well,
but we are doing anti-oppressiveCBT, so I think it could happen.
Not only do I think it couldhappen, we're doing it, and
anecdotally, we're seeing somereally good outcomes, and we're
really happy about theimprovements that some of our
(31:58):
participants have been having.
You know, CBT can be reallyshort-term.
But it is not always.
I mean, there are very effectiveprograms that you could treat
insomnia in only two to foursessions.
That's really cool.
And although those short-termtherapies are amazing, CBT can
(32:18):
also be used to help people toprocess and move through past
traumatic experiences.
That doesn't sound surface levelto deal with social isolation,
to deal with feeling unlovable.
feeling unworthy as a person,feeling incompetent, feeling
(32:38):
like that you're less of aperson because you're a sexual
or gender minority person, orbecause of your experiences as a
racialized or indigenous person.
I don't consider any of thatstuff to be surface level.
I consider that stuff to be, inmy opinion, very deep.
And CBT doesn't need to beshort-term in order to be CBT.
(33:02):
I've seen some folks for asshort as two sessions, but I've
seen some other folks for longerthan two years, depending on
their needs.
You know, my goal, what'sdifferent in CBT versus some
other therapies, not alltherapies, but some other
therapies is that the CBTtherapist always has a goal to
help that person to becomeindependent and And to feel like
(33:26):
a whole person without meetingthe therapist, that the goal is
to get, they, that's a learningmodel in a way where you might
learn some new skills, buteventually you don't need to,
because you know, as much as thetherapist does and you're using
those skills, you're not just aknowledgeable in your head, but
you're using those skills tostrengthen yourself and to
(33:48):
empower yourself on the inside.
And so it, it, CBT does lean onthe side of shorter term
therapies, but what shorter termmeans for person A is going to
be really different than personB.
SPEAKER_01 (34:01):
Yeah, I really appreciate that.
And you know, when you firstwere talking about, you were
listing off some core beliefs,right?
Like I'm unworthy, I'munlovable.
I think CBT has done a reallygood job of distilling a lot of
common core beliefs.
And I think when people look atthose at a first glance, I think
(34:21):
that's what makes it seem likeit might be simplistic or
surface level.
But actually, I think this iswhere the psychoeducation comes
in, particularly around trauma,right?
Like when we look at havingdifficult experiences in the
world, those shift the ways wesee ourselves and the world.
They shift how we see the past,present, and future, right?
(34:46):
And it's in that context that wetalk about core beliefs.
So it absolutely can betrauma-informed or
trauma-focused.
Thank you for helping me clarifythat.
That is something I've alsowanted people to hear and to
acknowledge.
Trevor, what are the lastquestions I have for you?
(35:07):
Where can people learn to bemore affirming of sexual and
gender minorities in theirapproach to CBT?
Is there something they canread?
Are there trainings, I don'tknow, you provide?
Where can people learn moreabout this?
SPEAKER_02 (35:24):
Well, the fields could be a lot bigger than it
is, but for the people who arelistening, if you're listening,
we've got something for you.
So first of all, there is a bookcalled The Handbook of
Evidence-Based Mental HealthPractice with Sexual and Gender
Minorities by John Pachankis andStephen Safran, who are the
(35:45):
editors.
And it kind of reviews theliterature, but also gives some
examples of like, okay, here'show you do this thing.
Here's how you do that thing.
And so these folks are folks,the editors are folks that are
all about affirming andaffirmative practice in CBT with
(36:06):
a focus in on sexual and genderminority people.
I'd also say that like in theage of Google Scholar, you can
actually, a lot of people don'tknow about it.
They're like, what?
You mean I can look at all ofthe articles?
You can look at a lot ofscientific articles for free
just by going to Google Scholarand maybe there are other free
(36:28):
resources as well that are ofother companies.
But that's, I happen to use itfrequently and sometimes a lot
of the stuff is free.
And there are journals likecognitive and behavioral
practice where it's journalsthat have articles in it, but
they're written for us asclinicians, as therapists, as
(36:50):
counselors.
So it's like, okay, here's theproblem.
Let me walk you through it.
Let me tell you how we addressthis problem.
Here's how you can do it too.
So there are journals like thatas well.
And we do do some stuff at ourgay counseling training hub.
So we have something called,again, gay counseling training
(37:11):
hub.
I can send you the link for thatas well.
And what we do is we listen tothe needs of the community and
people tell us like, I want atraining on X, you know, or a
community organization wants toget a training on affirmative
CBT, or they want to gettraining on, can you just give
us some basics of working withLGBTQ2I people?
SPEAKER_01 (37:35):
Yeah.
SPEAKER_02 (37:36):
Great.
Or you want to learn how to domotivational interviewing, which
is another kind ofevidence-based counseling.
And you want to know how to dothat to help your clients to to
make important changes in theirlives, like kind of changes,
let's say, in their healthbehaviors or other aspects of
(37:56):
their life.
We offer all of that and it'sspecifically focused on gay, bi,
queer men.
But if you are seeking atraining that's kind of more
broad for sexual and genderminority folks, We're still into
it.
So we're not exclusivists.
We're just funded to do thiswork by our funder with Gay by
(38:17):
Queer Men.
But yeah, we'd be glad toprovide that training.
And that's a big part of wherethe field needs to go is to
training folks and helping folkswho want to help others.
SPEAKER_01 (38:28):
Great.
Dr.
Trevor Hart, thank you so muchfor being a guest on this show.
I'm really glad to have had you,and I look forward to running
into you at a conference againand talking shop, and maybe we
will co-present someday on CBTin sexual and gender minority
(38:49):
communities.
Thanks for being here.
SPEAKER_02 (38:51):
Thanks, Rahim.
It's always a pleasure to chatwith you.
SPEAKER_00 (38:57):
Thanks for tuning in to the CBT Dive.
Don't miss an episode.
Subscribe to our YouTube channelat thecbtdive.ca.
You can also listen on the gowherever you get your podcasts.
To follow Rahim on social media,check out ladyativan.com.
See you soon.
Thank you.
SPEAKER_00 (00:00):
Welcome to the CBT Dive, a vodcast that goes into
the lives of real people withreal struggles.
Each episode welcomes a newguest who wants to explore a
challenging situation using themost common cognitive behavioral
therapy tool, the ThoughtRecord.
Your host, Raheem Thawar, is asocial worker and
(00:21):
psychotherapist based in Torontoand well-known for his work in
LGBTQ communities.
He's created the CBT Dive todiminish mystify what therapy
can look like, and shareintervention skills for
wellness.
We hope that each episode helpsyou along on your own journey
for insight and self-compassion.
SPEAKER_01 (00:42):
Hello, Dr.
Trevor Hart.
How are you today?
SPEAKER_02 (00:50):
I'm doing well.
How are you, Rahim?
SPEAKER_01 (00:54):
I am living the dream.
It's so good to see you.
Somebody from Toronto.
SPEAKER_02 (01:00):
Yeah, and I'm excited about your travels
across the world.
SPEAKER_01 (01:05):
Yeah, and I brought the CBT dive with me to
Johannesburg.
Before we get into it, you knowthat I have a lot of questions
for you.
I'm just going to share with ourlisteners a bit about you.
Dr.
Hart received his doctorate inclinical psychology from Temple
University.
After graduate school, hecompleted a postdoctoral
(01:26):
fellowship at Emory UniversitySchool of Medicine, through
which he received training atthe US Center for Disease
Control and Prevention.
He has received several awardsfor his advancements to research
and clinical work, includinginduction as a fellow of the
Canadian PsychologicalAssociation and as a fellow of
the Association of Behavioraland Cognitive Therapies.
(01:47):
Dr.
Trevor Hart is the director ofthe HIV Prevention Lab.
He holds a research chair in gayand bisexual men's health from
the Ontario HIV AIDS TreatmentNetwork.
Dr.
Hart is currently conductingmultiple studies, including a
test of new gay and queerfriendly therapies for social
anxiety for HIV negative gay andbisexual men, and a study
(02:09):
examining how biomedical HIVprevention, such as the use of
pre-exposure prophylaxis or PrEPis changing attitudes and sexual
health for gay and bisexualqueer men across three cities in
Canada.
He also has a private practicefocusing on CBT and other
evidence-based therapies relatedto sexual minority people in
(02:32):
Ontario.
Dr.
Trevor Hart, did I capture allof that okay?
Looks good to me.
So, I'd love to just tell theviewers, you know, I met Dr.
Hart when I was first working,like pre-MSW, like when I was
working at the Alliance forSouth Asian AIDS Prevention, and
(02:53):
that was in 2009.
So we're talking over a decadeago.
And Trevor has been kind enoughand supportive enough of my
career trajectory to invite meto be on all kinds of advisory
committees, And we've spokentogether at conferences and he's
(03:15):
always been very respectful andkind of supported me along in my
career.
So I'm excited to have him here.
So Trevor, I'd love for you totell me a bit about CBT.
What do you like about it orlove about it?
And in the therapy you do, whatkinds of CBT tools do you tend
(03:36):
to gravitate towards?
SPEAKER_02 (03:40):
Well, one of the things, I wasn't originally
trained in my undergrad to doCBT.
I was trained in a program thatreally didn't talk much about
it.
And so I was a bit surprisedabout all this CBT stuff.
And I had received some negativemessages about it too.
Oh, it's not real therapy.
(04:00):
It's a symptom management.
It's not going to help you withanything important.
It's just, you know, a surfacelevel thing.
And then I found out that whenworking, doing CBT, I had
patients that were gettingbetter.
I had patients that weregrateful.
We were having, making real lifechanges.
(04:21):
I remember being at a practicumwhere I was helping somebody
with one supervisor and thenswitch supervisors.
And then the supervisor waslike, why aren't you doing this,
that, and the other?
Your patient's not reallygetting better.
And I was like, yeah, they'renot.
And I'm like feeling reallyupset about it because I like
want to really help them.
They're really suffering from alot of anxiety and depression.
(04:46):
They were like, you know, haveyou considered using a CBT
approach?
And so what I did is Iintegrated that CBT into the
approach that I was alreadyusing.
And then I had that patient, gota lot better and then they were
doing a lot better.
And one of their comments to metoward the end was, I've really
appreciated all the work thatyou've done to help me to change
(05:08):
my life.
But if you don't mind me saying,why don't we start this earlier?
Because I felt like we were justkind of like just talking, just
talking about stuff, but notmaking any real changes in my
life before.
And I was like, so that was oneof my first experiences where I
was like, maybe the CBT stuff isactually pretty good.
(05:28):
And maybe that kind of strongman that's painted, you know,
about like, oh, it's surfacelevel is kind of not really
accurate.
Right.
You know, I really think thatthere is an increasing awareness
about the benefits of CBT andthat it's realistic.
It's realistic and it'seffective and it can help people
So many things.
(05:51):
Yeah.
SPEAKER_01 (06:05):
You started seeing people get better.
And at the end of sessions or atthe end of your time with
clients, they were thanking you.
I've had a similar experienceand I find it's part of it is,
you know, people really feellike something concrete is
getting done and somethingtangible.
And, you know, If you'retalking, that can be helpful,
(06:27):
but people don't leave withsomething concrete to reflect
on, right?
And so something like a thoughtrecord I find is really great.
I've heard people, they'll taketheir thought record and then
put it on their fridge orthey'll reflect on it from time
to time.
Are there specific CBT toolsthat you like or use?
(06:48):
And do you do them in a writtenformat or do you kind of, do
talk therapy in a way that'sinformed by CBT thinking?
SPEAKER_02 (06:59):
Yeah, I tend to do work that involves both talking
and writing it out.
I find that it's hard toremember when people say, oh, I
did think about it.
I'm like, tell me about what youthought.
It's usually kind of very ad hocand it can be very surface level
where it's like, I thought tomyself, I don't know, imagine I
(07:20):
was giving a presentation on avideo podcast to, you know, an
important member of ourcommunity and you want to do a
good job.
Imagine I was doing a thoughtrecord.
Oh, and I thought, well, youknow, I guess I'm going to flub
this up.
I'm not going to soundcompetent.
And then I do it in my head.
I might end up with somethinglike, you can do it.
(07:43):
Like just something that likeyou might hear from your
friends, right?
But if you do a full thoughtrecord, I think you can go a
little bit deeper thancheerleading.
And I think cheerleading isgood, by the way, but I think we
can do even more than that astherapists.
But I want to answer yourquestion about tools, too.
Do you want me to hold on for asec?
SPEAKER_01 (08:05):
No, I just wanted to say, when you said you can go
deeper beyond the cheerleading,I think I just want to point out
to people that the process ofcoming up with the negative
automatic thoughts and thendistilling them a bit has so
much depth to it.
And so it really counters thatidea that it's surface level
(08:29):
because when you're diggingwhat's underneath the automatic
thought, it does go deep.
But please go ahead.
Tell me about your favoritetools.
What do you like?
What do you hate?
SPEAKER_02 (08:40):
I don't think I hate too much, but I tend to use the
tools that are used in CBT.
CBT has got a lot of tools.
There's psychoeducation, whichis understanding your
psychology, your psychologicalstrengths and your challenges.
I think that's a good first stepis just to gain some insight as
to what do we know?
(09:00):
And CBT therapists are notafraid to say, hey, what do we
know from the researchliterature?
Like what things have we learnedas far as what caused a certain
problem or what makes itmaintain, but then also making
it come to life by talkingabout, hey, to what extent is
that true for you?
What's going on in your life orhow much does that jive with
(09:20):
your experience?
That's one tool.
Another tool is cognitiverestructuring, which is helping
to change the way that we thinkso that our thinking is more
rational, helpful, or alignedwith our values.
And I'd say that's a keycomponent of the thinking part
of CBT, changing the way wethink so that we can think in a
(09:41):
way that makes us feel better.
There's also behavioralexperiments or exposures, facing
difficult and anxiety-provokingsituations so we can do what we
want to do in life.
There's relaxation exercisesthat we can use when we're
feeling stressed or just havingnew ways to reduce our muscle
tension and our anxiety.
(10:01):
And then there's mindfulnessexercises like learning to live
in the moment and to understandour thoughts and feelings as
believing experiences likeanything else that we can
experience and not beoverwhelmed by our own thoughts.
So I'd say all of those thingswould be things that I think are
great tools and we've got greatevidence for them.
SPEAKER_01 (10:23):
Great.
I'm so glad you talked aboutboth psychoeducation and
mindfulness, because peoplesometimes will start therapy, in
my experience, and they'll say,I've received this diagnostic
label, right?
And I might say, do you knowwhat that means?
(10:43):
Or what does that mean to you?
And sometimes I'll say, itwasn't really explained to me.
I've just had it forever.
So a bit of psychoeducationabout like, when is this
diagnosis usually given?
What does it tend to mean?
What are the common symptoms?
How does it look in differentpeople?
What can it, how does itmanifest in your life?
What might it prevent you fromdoing?
Or why might something bedifficult?
(11:04):
Goes a really long way.
I'm glad you mentionedmindfulness because it's not
always talked about as beingpart of the package of CBT.
But for a lot of folks, youknow, we can only access our
rational mind or alternativeways of thinking once we're
grounded.
And so pairing that, you know,sometimes students I supervise
(11:26):
will say, when do I use thismindfulness business?
And I'm like, well, it couldeven be a good way to...
It could be something useful todo before you do a thought
record or before you get deepinto the thoughts, right?
Help ground somebody and helpreduce their level of anxiety.
I personally find behavioralexperiments very challenging to
(11:48):
do with my clients.
Dr.
Hart, do you have trouble withthose or any of the tools?
Or do you find, is there a toolthat you find clients have a lot
of trouble with?
SPEAKER_02 (12:02):
I think it's pretty random to me what folks will
have more trouble with or less.
I think some folks have troublegetting their mind around
cognitive restructuring, eitherbecause it's a little tough for
them to kind of figure out theirown thoughts.
They're not aware of theirthoughts or they find it a
little bit, for some folks, itcan be a little intellectually
(12:24):
challenging where it's like,what is it after what?
And then I have to do what?
Like there's a bunch of steps.
And for other folks, they're sointellectual that they get
wrapped up in their ownthoughts.
And I have to take them backdown to earth and be like, let's
talk about which thoughts arehelpful as opposed to having a
(12:44):
discussion about what thought ismore logical and what thought is
less logical and what does logicmean?
And you can go there if you'renot aware that your goal is
really to help the person andnot to have a really interesting
conversation.
For behavioral stuff, people areavoidant.
(13:05):
People don't come to see you forCBT usually because they're
feeling...
confident in their ability to dowhatever they want to do, right?
So they do this thing calledavoidance, where they avoid
doing the things that they wantto do.
They wanted to ask somebody outfor sex or for a date or to hang
(13:27):
out, but they avoided it.
They wanted to tell their bossthat they had some good ideas
that could change the way thatthey do things at work, but they
avoided it.
They wanted to speak up at ameeting, but they avoided it.
And so all these behavioralexperiments, those are all
things about going to do thethings you want to do, testing
(13:49):
out your thoughts.
So if you have a thought, no onecares about what I have to say
at work, and then that thoughtleads you to not acting, you can
use a behavioral experiment tosay, hey, how about I
intentionally say raise my handat that Zoom meeting or
in-person meeting and Iarticulate my point.
(14:11):
And will people just say nothingor will people say that's a good
point?
There's opportunities for peopleto learn about how they can
engage with the things that theywant to do.
They can feel strong andempowered.
SPEAKER_01 (14:26):
Okay.
I love that example.
You're making me want to trybehavioral experiments again.
Yeah.
I really like that you point outthat, you know, it's not
supposed to be easy.
People are coming to work onthings that they're avoiding or
having a hard time with.
I find that like that gives me,helps me access my own empathy
(14:52):
and working with clients.
Because I think it cansometimes, when you're lacking
motivation or you're afraid ofjudgment, sometimes, I think
it's stressful for the client toput themselves in a difficult
position, and sometimes it'sstressful for the therapist.
And as I'm thinking about it,I'm thinking, oh, I wonder if
it's my anxiety that gets in theway.
(15:13):
What if my client triessomething in a behavioral
experiment and it doesn't gotheir way?
And so it's like I'm catchingtheir anxiety.
It's contagious.
So I have to work on that.
Trevor, what is it about CBTthat makes it so popular?
It seems to be a common go-tofor a lot of people and
(15:34):
organizations.
You know, I've had students Isupervise that say, teach me
CBT.
And I'll say, okay, I'm happyto.
What interests you about it?
And they'll say, every jobdescription I've looked at says
I need to know how to do this.
So maybe you can shed some lighton why it's so widespread and so
popular, particularly in thenonprofit sector.
SPEAKER_02 (15:57):
Well, let me tell you, that was not the case when
you and I first met, whetherit's your first memory of me or
vice versa, that was not thecase.
I think things have changed inthe last 10 years and it's a
part of an ongoing change.
And the push is really towardsjust a pragmatic focus, like
(16:18):
just like we want people to getbetter.
We know that there's a varietyof therapies available and CBT
is not the only therapy that youcould use, but we also know that
CBT has a strong evidence basefor it saying, you know what,
it's, it's going to help.
It's going to help you with yourclients or patients, by the way,
(16:39):
use those terms interchangeably,the humans that we're trying to
help.
Yes.
So, uh, that it works,basically.
So at first, I think there wassome, even some resistance to
CBT, like, oh boy, it's surfacelevel because of psychodynamic
people thought that they weredoing very deep work or the more
(17:00):
humanistic people didn't likethat it was directive because it
meant that you weredisempowering the person and So
there was a lot of resistance,actually, and there still is
quite a bit of resistance in thefield against CBT.
But I have to say, I think whatpeople like at community-based
(17:21):
organizations is that they liketheir people getting better
quickly and that they care lessabout what theory and how much
the therapist likes the theoryand is sold by the theory.
What they care about is nottheory.
What they care about is, can weshow the government?
that we've helped 300 people getbetter in the past year that and
(17:45):
we can show like actually showthat it was not just they said
they really liked it and theylearned a lot but they said
SPEAKER_03 (17:53):
yeah
SPEAKER_02 (17:53):
i'm feeling better and now i'm able to function i'm
able to i'm able to uh get offof ODSP if they want to do so,
touch and go as to whetherthat's even a good idea in, you
know, in Ontario, you know,because of our disability
framework is very challenging towork with.
I'm able to get to work.
I'm able to enjoy my love lifeand my sex life.
(18:17):
And so I think that that's, Ithink it's really just the, that
many of the organizations thatwe work with, they don't care
about our theories.
What they want to know is whatgets people better.
And by the way, I want to tellyou, I'm not in the CBT camp.
I'm not in a camp.
I'm not a part of, I don'tfollow.
I'm not a Beckian or an Elysian.
(18:39):
We don't have that in the waythat I was trained.
What we have is evidence-based.
And I will tell you that if wefind that something else works
better than CBT, And we can showthat it works better than CBT.
I'm going to be pissed, but youknow what?
I'll be pissed.
I'll be pissed because I'm old.
And that means I have to learnnew stuff.
(18:59):
That is why.
Not because I think CBT is theway to go.
I just think right now it's gotthe strongest evidence base.
And I want to help my clientsthe best I can.
SPEAKER_01 (19:10):
Yeah.
No, that makes a lot of sense.
And I think you've known that,you know, I've been of two minds
about CBT.
I think it wasn't too many yearsago that I was quite critical of
it.
Do you remember that?
SPEAKER_02 (19:26):
I do.
And I remember us having aconversation.
I was like, what about CBT?
And you were just like, meh.
And I was like, okay.
I'm like, I don't know what tosay because I mean, so much of
it when we're trying to fellowtherapists, it's about your
readiness to accept messages andyour readiness.
And I was like, I don't knowwhat's my place to tell a fellow
therapist what to do.
(19:46):
Yeah.
But I've
SPEAKER_01 (19:49):
come some way.
I was
SPEAKER_02 (19:50):
surprised you came to me with the CBT dive.
I was like, okay.
SPEAKER_01 (19:55):
Yes.
SPEAKER_02 (19:57):
I was not expecting it.
I
SPEAKER_01 (19:59):
think we should pause there for a moment and
just delve into that if we can.
Okay.
I asked you to come on the showfor that very reason, I think,
because I've been at aconference where you've talked
about CBT and I've been like, Idon't think this is a great
idea.
I don't think this is great forclients.
I've had strong opinions likethat.
(20:21):
And I continue to be of twominds about CBT, you know, when
I'm like, I'm not sure it worksfor everybody.
But, you know, there's a fewthings that I've realized.
One is that CBT can be adapted.
to work for different people.
And two, it's easy to criticizesomething when you are
(20:47):
struggling with using ityourself.
And so that's an admission thatI didn't fully know how I could
use these tools.
And when I started to supervisestudents, I found by the time I
started to supervise students, Ihad taken two intense trainings
in CBT and they came in with alot of critiques about it.
(21:09):
And they would say, it's notclient-centered, it's not this,
it's not that, it's notanti-oppressive.
And I would say, well, I don'tknow that that's true.
I think any therapeutic modalitycan be done badly, right?
You could say, You could say,you know, psychodynamic free
association is client centeredbecause the client gets to do a
(21:33):
lot of the talking.
You could say CBT is clientcentered because a client picks
the goal.
You could say both of those arebad for somebody through some
other rationale.
So I said to my students, andI've come to learn this very
much.
You can critique something onceyou've learned how to do it and
you've attempted it, right?
(21:54):
You really need to try it withclients and see how it can fit
into your practice.
And I started the CBT divebecause I thought I really want
students of therapy, people whoare training in CBT, other
professionals, And folks who'vegone through some therapy to
(22:16):
just come to the podcast and seehow we work through things in a
very linear way.
I think that's one of myfavorite things is how you can
really isolate a problem andwork through it in a linear way.
So it feels like I've come to apoint in my career where I'm
(22:36):
appreciating a lot of the workyou've done for so many years,
Trevor.
So I just want to say thank youfor that.
SPEAKER_02 (22:45):
I'm honored, Rahim.
You're such a leader in thefield that it's, you know, I
knew you when you were kind ofat the earlier stages of your
career.
Yeah.
And then you're just, I see youas, you know, at the top of your
game and just a real contributorto our community.
(23:08):
Someone whose voice is so valuedand so appreciated.
And so, Rahim, I'm glad I couldcontribute in some way.
I mean, I think we're alllearning from each other in the
community, both the therapycommunity and also kind of the
sexual and gender minoritycommunity.
I think when we listen, we canalso listen to critiques, but
(23:33):
also hear where the critiquesare coming from.
Then we can improve our work,which is part of what I'm trying
to do is improve what CBT does.
SPEAKER_01 (23:42):
And having said that, so, We both do a lot of
work with LGBTQ communities orsexual and gender minorities.
And from what I understand, alot of your research and some of
the practices you've developedor drawn on are about using CBT
(24:03):
with LGBTQ communities.
Can you tell me a bit about whatthat work has entailed and why
is there even a need to adaptinterventions to make them, you
know, queer and trans-specificor queer and trans-aware or
queer and trans-competent.
You could see that I'm not evensure what the language is, but
there's a kind of adaptationthat people talk about.
(24:25):
Tell us a bit about it.
SPEAKER_02 (24:28):
I mean, CBT, while it's really effective, it hasn't
really been tested in thecontext of the things that many
of us would experience who aremembers of sexual and gender
minority communities, theLGBTQ2I community.
and all the other identitiesthat I haven't listed.
So it doesn't, CBT as done bycisgender straight people
(24:55):
probably isn't going to take alook at societal homophobia,
transphobia, heteronormativity,cisnormativity.
And these are all things that welive in as sexual and gender
minority people.
Like this is our context,whether we wanted it to be or
not.
And so what ends up happening iswe experience a lot of extra
(25:17):
stresses compared to people thatmight be a cisgender
heterosexual person.
People have, everyone hasstresses in their lives.
Everybody has potentiallyfinancial stresses or family
stresses or financial workstresses or other relationship
stresses or social problems.
But when you're a queer or transor other sexual or gender
(25:40):
minority person, you also haveto deal with being treated in
really derogatory ways as kidsand as adults, fear of being
rejected for who you are,literally like, should I tell
this person?
Should I not tell this person?
Do they know?
Are they going to treat mepoorly because I exist?
(26:01):
Or will they not treat me poorlybecause I exist?
Do I try to hide whether Iexist?
Dealing with heteronormative andcisnormative comments from our
family, like your own family oforigin that might have been a
place of support might actuallyalso be a place of great
oppression and concerns aboutwhere it's safe to be out.
(26:21):
So there's like a, I thinkthere's a profound need for
intervention that can beevidence-based but explicitly
anti-oppressive.
SPEAKER_01 (26:31):
Yeah.
So what does an affirmative CBTpractice look like?
And how does it differ fromstandard psychotherapy?
How does somebody know they'rebeing like LGBT affirming in
their practice?
SPEAKER_02 (26:50):
It's easier said than done, but it is also easily
done.
It just needs some thought.
The affirmative interventions,they're going to talk about the
things that people normally talkabout.
So let's say if you've gotsomebody who's coming to work
with you because they're havingpanic attacks, you might still
help that person with theirpanic attacks.
(27:11):
If they're depressed, you'restill gonna help that person
with depression, but you'd alsocan talk about stresses that we
experience in the community.
And sometimes those are calledthose minority stressors.
So the stressors of being a partof a minoritized group, and
we've talked about specificallykind of heteronormative and
(27:32):
cisnormative kind of stressors,but this could be true for all
forms of oppression, whetherit's racist stressors or sexist
stressors or classist stressorsor anti-immigration stressors or
anti-religion-based stressors.
So things that basically makeyou feel other than for doing
nothing wrong whatsoever justexisting as a person that had
(27:56):
your identities.
And so these affirmativeinterventions, they'll talk
about oppressive forces and forSTM people by helping STM
people, sexual and genderminority people, find ways to
live their lives.
Like for example, our sexualconfidence CBT program that
we're testing out at Ryersongoes beyond typical CBT for
(28:20):
addressing social anxietydisorders.
So usually social anxietydisorder, CBT, you would talk
about how you think aboutyourselves, face
anxiety-provoking situations,like asking somebody out for a
date or to hang out or going toa party, speaking up at a
meeting.
And all of this is great.
(28:41):
This is great.
But standard CBT therapistswon't think about asking about,
hey, you know what, here'sanother stressful situation.
How about what do you do whenyou hear homophobic comments on
the street?
What about a social anxietysituation called, I would like
to hold hands with my partnerwho does not appear to be of the
(29:04):
other gender?
right?
So, you know, like aheterosexual relationship, what
do I do when I'm holding handswith my gender diverse or trans
or same sex partner?
And they won't talk about gaysex.
They won't talk about trans sex.
They don't talk about, oh mygoodness, we have sex too,
because it's like veryuncomfortable to talk about sex.
(29:27):
Like that's inappropriate.
And that's, but sex is aninterpersonal situation where
people kind of need to beassertive if they want to be
able to give consent.
So in the standard CBT, theywouldn't talk about any of this
stuff, but in our sexualconfidence CBT program, we talk
a lot about it.
So it's still CBT, but it talksabout the stresses that we
(29:50):
experience in the community.
SPEAKER_01 (29:53):
Well, This is the first I'm hearing of this sexual
confidence CBT, and it soundsreally fascinating.
So perhaps you could share alink so listeners, I'll put it
in the show notes and listenerscan check it out.
It sounds really interesting.
So what I'm getting from youabout queer and trans affirming
(30:15):
or SGM affirming CBT is thatone, it really takes into
account like systemic issuespeople face, like kinds of
discrimination and validatesthat.
So we're not trying to change athought around, you know, I
experience homophobia and you'retrying to convert that into a
(30:37):
positive.
That's not what we're doing.
We're affirming people'sdifficult experiences in the
world.
And the other part of that is asthe as the affirming CBT
therapist, you're going toplaces, topics, issues in
somebody's life that have to dowith the subculture they live
(30:58):
in.
So things to do with sex andsexuality, the interpersonal
experience of being withsomebody else, dealing with
things like maybe internalizedstigma or homophobia, that kind
of thing.
That sounds really fascinating.
I'm also thinking, You know,what do you say to people who
(31:20):
might say that CBT is too shortterm or perhaps too surface
level to deal with things likeoppression, which is essentially
what you're talking about,right?
When you talk aboutdiscrimination people face, how
do you respond to that?
SPEAKER_02 (31:36):
Well, I mean, the first way is by saying, well,
but we are doing anti-oppressiveCBT, so I think it could happen.
Not only do I think it couldhappen, we're doing it, and
anecdotally, we're seeing somereally good outcomes, and we're
really happy about theimprovements that some of our
(31:58):
participants have been having.
You know, CBT can be reallyshort-term.
But it is not always.
I mean, there are very effectiveprograms that you could treat
insomnia in only two to foursessions.
That's really cool.
And although those short-termtherapies are amazing, CBT can
(32:18):
also be used to help people toprocess and move through past
traumatic experiences.
That doesn't sound surface levelto deal with social isolation,
to deal with feeling unlovable.
feeling unworthy as a person,feeling incompetent, feeling
(32:38):
like that you're less of aperson because you're a sexual
or gender minority person, orbecause of your experiences as a
racialized or indigenous person.
I don't consider any of thatstuff to be surface level.
I consider that stuff to be, inmy opinion, very deep.
And CBT doesn't need to beshort-term in order to be CBT.
(33:02):
I've seen some folks for asshort as two sessions, but I've
seen some other folks for longerthan two years, depending on
their needs.
You know, my goal, what'sdifferent in CBT versus some
other therapies, not alltherapies, but some other
therapies is that the CBTtherapist always has a goal to
help that person to becomeindependent and And to feel like
(33:26):
a whole person without meetingthe therapist, that the goal is
to get, they, that's a learningmodel in a way where you might
learn some new skills, buteventually you don't need to,
because you know, as much as thetherapist does and you're using
those skills, you're not just aknowledgeable in your head, but
you're using those skills tostrengthen yourself and to
(33:48):
empower yourself on the inside.
And so it, it, CBT does lean onthe side of shorter term
therapies, but what shorter termmeans for person A is going to
be really different than personB.
SPEAKER_01 (34:01):
Yeah, I really appreciate that.
And you know, when you firstwere talking about, you were
listing off some core beliefs,right?
Like I'm unworthy, I'munlovable.
I think CBT has done a reallygood job of distilling a lot of
common core beliefs.
And I think when people look atthose at a first glance, I think
(34:21):
that's what makes it seem likeit might be simplistic or
surface level.
But actually, I think this iswhere the psychoeducation comes
in, particularly around trauma,right?
Like when we look at havingdifficult experiences in the
world, those shift the ways wesee ourselves and the world.
They shift how we see the past,present, and future, right?
(34:46):
And it's in that context that wetalk about core beliefs.
So it absolutely can betrauma-informed or
trauma-focused.
Thank you for helping me clarifythat.
That is something I've alsowanted people to hear and to
acknowledge.
Trevor, what are the lastquestions I have for you?
(35:07):
Where can people learn to bemore affirming of sexual and
gender minorities in theirapproach to CBT?
Is there something they canread?
Are there trainings, I don'tknow, you provide?
Where can people learn moreabout this?
SPEAKER_02 (35:24):
Well, the fields could be a lot bigger than it
is, but for the people who arelistening, if you're listening,
we've got something for you.
So first of all, there is a bookcalled The Handbook of
Evidence-Based Mental HealthPractice with Sexual and Gender
Minorities by John Pachankis andStephen Safran, who are the
(35:45):
editors.
And it kind of reviews theliterature, but also gives some
examples of like, okay, here'show you do this thing.
Here's how you do that thing.
And so these folks are folks,the editors are folks that are
all about affirming andaffirmative practice in CBT with
(36:06):
a focus in on sexual and genderminority people.
I'd also say that like in theage of Google Scholar, you can
actually, a lot of people don'tknow about it.
They're like, what?
You mean I can look at all ofthe articles?
You can look at a lot ofscientific articles for free
just by going to Google Scholarand maybe there are other free
(36:28):
resources as well that are ofother companies.
But that's, I happen to use itfrequently and sometimes a lot
of the stuff is free.
And there are journals likecognitive and behavioral
practice where it's journalsthat have articles in it, but
they're written for us asclinicians, as therapists, as
(36:50):
counselors.
So it's like, okay, here's theproblem.
Let me walk you through it.
Let me tell you how we addressthis problem.
Here's how you can do it too.
So there are journals like thatas well.
And we do do some stuff at ourgay counseling training hub.
So we have something called,again, gay counseling training
(37:11):
hub.
I can send you the link for thatas well.
And what we do is we listen tothe needs of the community and
people tell us like, I want atraining on X, you know, or a
community organization wants toget a training on affirmative
CBT, or they want to gettraining on, can you just give
us some basics of working withLGBTQ2I people?
SPEAKER_01 (37:35):
Yeah.
SPEAKER_02 (37:36):
Great.
Or you want to learn how to domotivational interviewing, which
is another kind ofevidence-based counseling.
And you want to know how to dothat to help your clients to to
make important changes in theirlives, like kind of changes,
let's say, in their healthbehaviors or other aspects of
(37:56):
their life.
We offer all of that and it'sspecifically focused on gay, bi,
queer men.
But if you are seeking atraining that's kind of more
broad for sexual and genderminority folks, We're still into
it.
So we're not exclusivists.
We're just funded to do thiswork by our funder with Gay by
(38:17):
Queer Men.
But yeah, we'd be glad toprovide that training.
And that's a big part of wherethe field needs to go is to
training folks and helping folkswho want to help others.
SPEAKER_01 (38:28):
Great.
Dr.
Trevor Hart, thank you so muchfor being a guest on this show.
I'm really glad to have had you,and I look forward to running
into you at a conference againand talking shop, and maybe we
will co-present someday on CBTin sexual and gender minority
(38:49):
communities.
Thanks for being here.
SPEAKER_02 (38:51):
Thanks, Rahim.
It's always a pleasure to chatwith you.
SPEAKER_00 (38:57):
Thanks for tuning in to the CBT Dive.
Don't miss an episode.
Subscribe to our YouTube channelat thecbtdive.ca.
You can also listen on the gowherever you get your podcasts.
To follow Rahim on social media,check out ladyativan.com.
See you soon.
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