International Journal for the Advancement of Counselling (2020) 42:217–233

https://doi.org/10.1007/s10447-020-09402-0

ORIGINAL ARTICLE

A CBT Approach to Internalized Racism

among African Americans

Janeé M. Steele 1

Published online: 20 May 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
This article presents a CBT approach to internalized racial oppression among African
American clients. Cognitive conceptualization and treatment planning using CBT are
illustrated through a case study, followed by a discussion on the generalizability of a
proposed cognitive model of internalized racism to other marginalized populations. The
article concludes with a discussion of further implications for practice, including those for
social justice advocacy.

Keywords Cognitive-behavioral therapy . African American . Internalized racism

Introduction

In spite of a growing amount of research documenting the deleterious effects of oppression on

marginalized groups (e.g., Thompson, 2002), there are few approaches within the counseling
literature to assist clinicians with countering its psychological effects (Hanna & Cardona,
2013). For counselors who work with African American clients, this is problematic as African
Americans experience higher levels of daily distress due to oppression, and in particular, racial
oppression (Carter, 2007). The purpose of this article was to consider a CBT approach to one
specific aspect of racial oppression, internalized racism, among African American clients.
The article begins with an overview of the version of CBT adopted as the organizing
framework for the approach. Next, existing research concerning CBT and its use with African
Americans is reviewed, as well as research documenting the relationship between internalized
racism and poor mental health outcomes among this population. A cognitive model of
internalized racism is then presented, followed by an illustration of cognitive conceptualization
and treatment planning using the model. Finally, the generalizability of the proposed cognitive

* Janeé M. Steele
janee.steele@mail.waldenu.edu

1
Core Faculty, School of Counseling, Walden University, 100 Washington Avenue South, Suite 900,
Minneapolis, MN 55401, USA
218 International Journal for the Advancement of Counselling (2020) 42:217–233

model of internalized racism to other marginalized populations is discussed, along with a

discussion of further implications for practice and social justice advocacy.

Cognitive Behavioral Therapy

CBT is a broad term used to describe theories of counseling that focus on the connection
between thoughts and reactions that may be emotional, behavioral, or physiological in nature
(Beck, 2011). The approach to CBT taken in this article is based on the work of Aaron T.
Beck, who first developed his approach in the early 1960s. CBT from Beck’s (2011)
perspective is grounded in the cognitive model, which posits that emotional, behavioral, and
physiological reactions are determined by perceptions of events rather than the events them-
selves. Awareness and modification of these perceptions, commonly referred to as automatic
thoughts, can help individuals alter negative shifts in their feelings, actions, and physiology.
As a form of therapy, then, CBT focuses on teaching clients to identify and challenge
dysfunctional thinking, and replace it with more rational and functional ways of thinking.
As a theory of personality development, CBT postulates that over time, but particularly
during childhood, life experiences lead to specific thoughts about oneself (Beck, 2011). These
thoughts are known as core beliefs. Negative core beliefs, in turn, lead to conditional
assumptions, or attitudes and rules that help individuals cope with the core beliefs. For
example, an individual who has the core belief “I’m not smart enough,” might have the
conditional assumption, “If I am not prepared I’ll look foolish, but if I anticipate and prepare
for everything, I will be ok.” This conditional assumption might then be followed by
dysfunctional coping strategies in line with the assumption, such as self-criticism, perfection-
ism, or avoidance of help-seeking.
Counseling from a CBT perspective typically begins with psychoeducation on the cognitive
model, followed by use of cognitive and behavioral strategies to help clients replace negative
automatic thoughts, modify core beliefs, and increase problem-solving skills. Treatment
planning during this process is based on the counselor’s cognitive conceptualization of the
client. According to Beck (2011), cognitive conceptualization can be viewed as a map that
depicts the relationship between the client’s core beliefs, conditional assumptions, and auto-
matic thoughts. This map consists of data describing the client’s relevant childhood experi-
ences, core beliefs, conditional assumptions, and coping strategies, as well as examples of how
such data are translated into negative automatic thinking and reactions in daily situations.
Because CBT from the Beck perspective relies heavily on the cognitive conceptualization of
each individual client, manualized approaches are typically not utilized in treatment. An
example of cognitive conceptualization is provided later in the article.

CBT with African Americans

A common criticism of CBT is that the Eurocentric worldview from which it was derived
limits its applicability to multicultural populations (Hays, 2009). Yet, according to Hays and
Iwamasa (2006), CBT shares basic tenets with multicultural counseling that actually make this
form of therapy particularly well-suited for individuals from culturally diverse backgrounds.
Some of these tenets include an emphasis on personal empowerment, attention to client
strengths and support systems, and affirmation of one’s own sense of identity.
International Journal for the Advancement of Counselling (2020) 42:217–233 219

In fact, although limited, some prior research has demonstrated the efficacy of CBT
with African American clients for a variety of disorders. In their review of evidence-based
treatments for ethnic minorities, for example, Huey and Polo (2008) presented research
that demonstrated the efficacy of CBT in the treatment of anxiety and posttraumatic stress
disorder among African American youth. Similar results were presented in a more recent
review of CBT with African American youth conducted by Wilson and Cottone (2013),
wherein the authors highlighted findings showing the effectiveness of CBT in managing
behavioral difficulties, anxiety, depression, PTSD, and suicidality. While the authors of
both reviews noted limitations in the research they explored, particularly in terms of small
sample and effect sizes, they nonetheless argued that CBT may be a useful tool in the
treatment of various clinical disorders among African Americans (Huey & Polo, 2008;
Wilson & Cottone, 2013).
To increase its effectiveness, Hall and Ibaraki (2016) suggest that CBT treatments for
people of color be adapted in consideration of a client’s cultural and sociocultural identities.
Hays (2009) offered several recommendations concerning the adaptation of CBT for use with
multicultural populations that apply to exploration of internalized racism among African
American clients. These recommendations included: (a) validating the client’s experience of
oppression; (b) helping clients make changes that minimize stressors, increase personal
resources, and build skills for more effective interactions with the social environment; and
(c) creating a list of culturally-related strengths and supports in the process of cognitive
restructuring (Hays, 2009, pp. 357–358). The counselor’s cultural competence is critical
during this process, particularly in terms of the counselor’s knowledge of the African
American community’s historical experience with racial oppression in the United States
(Bailey, Williams, & Favors, 2014).
In terms of cognitive conceptualization, cultural adaptions of CBT should also give
consideration to the unique sociocultural influences on cognition and behavior among
African Americans (Hall & Ibaraki, 2016). This includes consideration of attitudes,
beliefs, norms, roles, and self-definitions within the African American community, as
well as implicit messages and cultural scripts about African Americans received from
society (Hall & Ibaraki, 2016). Rather than focusing largely on the role of individual
childhood experiences in the development of the client’s core beliefs and assumptions,
counselors practicing a culturally adapted form of CBT should also be intentional in
exploring the influence of racial stereotypes and biases on the client’s worldview and
sense of self. This might include gathering information by: (a) looking for common
themes, (b) direct questioning, (c) suggesting hypothesized rules, attitudes, or assump-
tions the client might ascribe to, and (d) using the downward arrow technique, wherein
the counselor asks clients the meaning they would ascribe to themselves were an
automatic thought true (Beck, 2011).
Strategies found to be effective when examining internalized oppression with other
cultural groups such as the word-completion task, the implicit association test, and the
lexical decision-priming task may also be of benefit (David & Okazaki, 2010). These
strategies, wherein the presence of implicit negative attitudes are explored through
activities such as completing missing parts of words after specific priming terms are
used to activate cultural knowledge schema or associating specific images or words with
certain stereotypes, may be particularly beneficial as an assessment of the extent to
which clients may ascribe to internalized racist beliefs, allowing for greater exactness in
case conceptualization and treatment planning.
220 International Journal for the Advancement of Counselling (2020) 42:217–233

Internalized Racism

For the purpose of this article, internalized racism is defined as a negative view of self based
on the perceived inferiority of one’s own culture or race (Graham et al., 2016; Hipolito-
Delgado, 2010; Lipsky, 1977). Essentially, internalized racism describes the self-hatred and
self-alienation that comes from (a) accepting negative racial/ethnic stereotypes about one’s
self, and (b) accepting beliefs about the superiority of the beauty, language, and cultural norms
and traditions of White people (Bailey, Chung, Williams, Singh, & Terrell, 2011). Throughout
the counseling literature, several scholars have spoken to this phenomenon among African
Americans, both conceptually (e.g., Bailey et al., 2014; Speight, 2007; Watts-Jones, 2002;
Williams & Williams-Morris, 2000) and empirically (e.g., Brown & Segrist, 2016; Maxwell,
Brevard, Abrams, & Belgrave, 2015; Parham & Helms, 1985; Szymanski & Gupta, 2009;
Szymanski & Obiri, 2011; Wester, Vogel, Wei, & McLain, 2006). For example, in her
discussion of within-group healing for people of African descent, Dee Watts-Jones (2002)
conceptualized internalized racism as “an experience of self-degradation, and alienation; one
that promotes the assumptive base of our inferiority” (p. 592). She went on to say:
Internalized racism involves two levels of shame: the shame associated with our
African-ness, as a result of slavery and racism, and the shame of being shamed.
Identifying the initial shame as a response to the trauma assists in externalizing the
shame, and generating compassion toward ourselves for the shame we experience. To
heal from the initial shaming, people of African descent need to let go of the secondary
shame, which means freeing ourselves to talk more openly about the initial shaming.
The secondary shame is what binds us to the primary shame, by keeping it secret, quiet.
The secondary shame is about being victimized. (Watts-Jones, 2002, p. 593)
Implicit in Watts-Jones’s (2002) discussion of internalized racism is a cognitive model wherein
maladaptive thinking (i.e., the shame associated with being of African descent) leads to
negative psychological (i.e., self-degradation and self-alienation) and behavioral (i.e., secrecy)
responses that have a negative impact on overall wellbeing and health. Maladaptive thinking
and negative psychological and behavioral response components are also evident in the
conceptualization of internalized racism proposed by Bailey et al. (2014), who identified four
dimensions of the construct: “(1) belief in a biased representation of history; (2) alteration of
one’s physical appearance; (3) internalization of negative stereotypes about African Americans;
and (4) changing one’s hair texture and style to fit a more European aesthetic” (p. 145). Within
these dimensions, maladaptive thinking is reflected in the Eurocentric view of history, while
internalization of negative stereotypes and alteration of one’s appearance and hair texture to
reflect White ideals of beauty are the resulting negative psychological and behavioral responses.
Empirically, several studies have linked internalized racism to poor mental health outcomes
among African Americans, including skin color dissatisfaction (Maxwell et al., 2015), low
self-esteem (Parham & Helms, 1985), low career aspirations (Brown & Segrist, 2016), and
various forms of psychological distress (Szymanski & Gupta, 2009; Wester et al., 2006).
Graham et al.’s (2016) recent study of 173 self-identified Black university students, for
example, explored the association between anxiety and internalized racism as measured by
the Self-Hatred subscale of the Cross Racial Identity Scale (Worrell, Vandiver, Cross, &
Fhagen-Smith, 2004). Results revealed statistically significant bivariate correlations between
internalized racism (r = .53, p < .001) and anxious arousal, as well as between internalized
racism and generalized anxiety symptoms (r = .38, p < .001). Furthermore, when explored as a
International Journal for the Advancement of Counselling (2020) 42:217–233 221

mediating variable, internalized racism was found to fully mediate the effect of racism
experienced over the past year for both anxious arousal (R2 = .25, F = 28.82, p < .001) and
generalized anxiety (R2 = .13, F = 12.54, p < .001); that is, when internalized racism was
accounted for, the relationship between past-year racist experiences and anxious arousal and
generalized anxiety became statistically non-significant.
In another recent study, Mouzon and McLean (2017) explored the association between the
frequency of depressive symptoms, serious psychological distress, and internalized oppression
as measured by the six-item Stereotypes Scale (Jackson et al., 2004). Data for this study were
obtained using secondary data from the 2001–2003 National Survey of American Life (Jackson
et al., 2004). Results again confirmed the relationship between internalized racism and poor
mental health, with ordinary least squares regression analyses revealing internalized racism as a
statistically significant predictor of depressive symptoms (ß = .25, p < .001) and serious
psychological distress (ß = .15, p < .001) within the multi-ethnic sample of 4573 African
Americans, U.S.-born Black Caribbean Americans, and foreign-born Caribbean Blacks.

Cognitive Developmental Model of Internalized Racism in African

Americans

As described earlier, CBT relies heavily on the cognitive conceptualization of each individual
client; however, the basic cognitive model of any clinical issue remains constant. Figure 1 portrays
a cognitive developmental model of internalized racism similar to cognitive models of other
clinical issues, such as the model of substance abuse presented by Beck, Liese, and Najavits
(2005). This model depicts cognitive processes that occur once internalized racist beliefs are
activated, as well as contextual factors that influence the development and maintenance of these
beliefs. Traditionally, life events, especially those that occur during early childhood, are explored
as the primary antecedents to the development of core beliefs; however, in this culturally adapted
model, societal influences that contribute to the development of negative cognitions are also given
unique consideration, with particular attention given to historic and contemporary societal
structures that perpetuate messages of White superiority and Black inferiority.
While the historical legacy of the African American community extends far beyond the
introduction of African slave labor in the North American colonies, in the United States,
slavery represents the apex of this messaging, which was later replicated through black codes
and segregation, and is today seen in contemporary laws, policies, and ideologies that continue
to position African Americans at the margins of society (Bailey et al., 2014). The paragraphs
below offer a brief explanation of just a few of these influences. This is followed by a
demonstration of case conceptualization and treatment planning based on the proposed
cognitive model using a case example client named Jasmine.

Slavery

African laborers were first brought to the British colonies in 1619; however, formalized
slavery was not institutionalized until the start of the eighteenth century (Smedley, 1999).
During this time, laws and statutes were gradually introduced to deny Africans basic freedoms
such as the right to bear arms, hold property, vote, buy, sell, congregate, travel without
permission, receive education, serve in militias, and even the right to legally marry (interracial
or otherwise) and parent. The eventual effect of these laws was the creation of an established
222 International Journal for the Advancement of Counselling (2020) 42:217–233

Fig. 1 Cognitive developmental model of internalized racism. Contextualized from Beck, Liese, & Najavits
(2005)

class of slave labor, necessary for continued English conquest and colonization. As justifica-
tion, the English adopted an ideology of White supremacy that depicted African religion and
customs as savagery, demonized African skin-color and phenotypes, and idealized White
beauty, language, and cultural norms (Smedley, 1999).
Using legitimizing myths, this ideology provided moral and intellectual support for slavery
by ascribing natural causes and personal blame to Africans for their state of oppression
(Sidanius, 1993). Slaves were portrayed as ignorant and docile heathen, in need of saving
by the White race. While initially devised as a justification for the degradation and systematic
torture of Africans during slavery, the societal and psychological effects of this ideology
continue to be observed today through ongoing asymmetric power relations and internalized
feelings of inferiority among African Americans (Bailey et al., 2014).

Black Codes

Black codes were laws that were passed subsequent to the end of the Civil War primarily in
southern states in order to limit the access of freed Blacks to voting, education, and equal
International Journal for the Advancement of Counselling (2020) 42:217–233 223

treatment under the law. Black codes were also enacted in some northern states, such as
Illinois, Michigan, Ohio, and New York, in order to discourage Blacks from moving to these
states (Bailey et al., 2014). Relying on legitimizing myths that portrayed Blacks as criminal
and hostile, these laws had the effect of producing labor conditions similar to those experi-
enced during slavery.
For example, many of the laws limited the types of property Blacks could own, upheld strict
vagrancy and labor contract rules, and implemented anti-enticement measures designed to
punish individuals who offered higher wages to Black laborers already under contract
(History.com Editors, 2019). In Mississippi, one Black code even prevented Whites from
selling, lending, or giving Blacks or bi-racial individuals firearms, knives, ammunition, or
liquor, punishable by a fine of $50 (a significant figure at the time) and 30 days imprisonment.
While these laws have technically been abolished, their legacy lives on. This is evidenced,
for example, by sentencing laws that result in racially disparate crime statistics wherein in spite
of being a numeric minority in the overall population, 7.7% of Black men between the ages of
25 to 54 are imprisoned, compared to only 1.6% of White men (Nittle, 2019).

Segregation

Segregation refers to the legalized restriction of access to opportunities and services based on
some aspect of one’s social identity (Clark, Chein, & Cook, 2004). In the United States,
segregation became institutionalized as a result of the 1896 Supreme Court decision in the
Plessy v. Ferguson case, which upheld the doctrine of “separate but equal” (Bailey et al.,
2014). Under this doctrine, African Americans experienced segregation in the areas of
education, housing, transportation, healthcare, and use of public facilities, which for almost
60 years contributed to disparate social outcomes such as high disease and mortality rates, poor
housing, and substandard access to education (Clark et al., 2004).
One of the most significant outcomes of segregation, however, was the profoundly negative
affect it had on the psychosocial development of African American children. Based on the
famous doll studies conducted by psychologists Kenneth and Maime Clark (Clark et al., 2004)
(which ultimately helped to overturn the separate but equal doctrine in the Brown v. Board of
Education of Topeka case), it was determined that segregation caused African American
children to develop a sense of inferiority and personal humiliation that often led to self-
hatred and rejection of other African Americans. These reactions often continued throughout
childhood and into adulthood, resulting in a host of symptoms including aggression toward
either members of their own group or members of the dominant group, withdrawal, rigid
conformity to prevailing White middle-class values, defeatism, low aspirations, depression,
and anxiety (Clark et al., 2004).

Colorblind Racial Attitudes

Colorblind racial attitudes describe one of many concepts used to characterize newer, less
overt forms of racial attitudes (Neville, Worthington, & Spanierman, 2001). Defined simply as
the belief that race should not and does not matter, colorblind racial attitudes, while seemingly
innocuous, ignore the roles that race and racism have in people’s lives. Recently, Neville,
Awad, Brooks, Flores, and Bluemel (2013) identified four specific types of colorblind racial
attitudes: (a) race, (b) blatant racial issues, (c) institutional racism, and (d) White privilege.
According to those authors, these attitudes represent expressions of ultramodern racism among
224 International Journal for the Advancement of Counselling (2020) 42:217–233

White Americans and internalized racism among people of color, and add to the previously
existing number of legitimizing myths that serve to justify the racial status quo. Among
African Americans, colorblind racial attitudes also contribute to poor mental health outcomes.
A study conducted by Barr and Neville (2014), for example, found that higher levels of
colorblind racial attitudes, combined with a higher frequency of mainstream socialization
messages (provided by parents), resulted in negative mental health scores among young Black
adults. Moreover, by diminishing race, colorblind racial attitudes also ignore the role positive
racial identity development has as a protective factor against internalized racism.

Microaggressions

Microaggressions are subtle, often unintentional, put-downs that reflect prejudiced or discrim-
inatory messages about minority groups (Sue & Sue, 2016). They can be verbal or delivered
through an organization’s physical environment, and can even be the result of good intentions.
For example, many African Americans are often confronted with slights such as “You speak
so well,” from well-meaning colleagues or admirers. While meant as a compliment, this
microaggression reflects a societal perception of African Americans as generally unintelligent
or inarticulate, and identifies the person to whom the compliment was directed as an exception.
Essentially, microaggressions communicate unconscious biases and beliefs that either: (a)
suggest the individuals targeted by microaggressions do not belong, or (b) invalidate the
experiences of targeted groups. Having low diversity in the workplace, for instance, commu-
nicates the message that certain individuals do not belong or can only go so far, while
colorblind messages such as “I don’t see race” and “Everyone has the same opportunity”
suggest that African Americans and other oppressed groups experience poor social outcomes
due to their own inadequacies, and discriminatory social systems have little or no part to play.
Research shows that individuals who experience microaggressions are at an increased risk
for anxiety and other forms of psychological distress. A recent study of Black university
students, for example, found that racial microaggressions are positively associated with anxiety
symptoms (Liao, Weng, & West, 2016), while another study of Black, Latina/o, Asian, and
multiracial participants found that a higher cumulative experience with racial microaggressions
is a statistically significant predictor of depressive symptoms and of how positively or
negatively one views the world (Nadal, Griffin, Wong, Hamit, & Rasmus, 2014). Of note,
the study also found that Black and Latina/o participants experienced more inferiority-related
microaggressions than Asian participants, and Black participants experienced more
criminality-related microaggressions than both Asian and Latina/o participants, reflecting the
legitimizing myths discussed above.

Media

Popular media contributes to the development of internalized racism among African Ameri-
cans, primarily through the proliferation of stereotypes that reinforce legitimizing myths and
portray African Americans as undeserving and to blame for their social status (Prilleltensky &
Gonick, 1996). Stereotypes are beliefs about the personal attributes of a group of people that
are sometimes overgeneralized, inaccurate, and resistant to new information (Myers, 2005, p.
333). These stereotypes may be broad, such as the stereotype that African Americans are lazy,
or they may be unique to the intersection of multiple social identities. African American
women, for example, are often subjected to several common stereotypes in the media, namely:
International Journal for the Advancement of Counselling (2020) 42:217–233 225

(a) the ‘mammy’ stereotype, in which African American women are depicted as “the faithful,
obedient domestic servant,” (b) the ‘Jezebel’ stereotype, which represents African American
women as sexually deviant, and (c) the ‘Sapphire’ stereotype, in which Black women are
viewed as hostile and nagging (Collins, 2009, p. 80). Not only do these stereotypes contribute
to self-rejecting beliefs among African American women, but they also have the effect of
helping to maintain oppressive societal structures. This occurs by symbolizing the ideal
relationship of Black women to White men, rationalizing widespread sexual assault by White
men against Black women, and placing blame on the Black woman for emasculating her Black
male partner and causing the economic and social turmoil in the Black family (Collins, 2009).
As stated, the factors described above are just a few of the many societal influences that
provide the context for the development of internalized racism among African Americans. As
depicted in Fig. 1, these influences, along with individual childhood experiences, affect the
beliefs African Americans develop about themselves, other people, and their world, as well as
the assumptions and rules they establish to guide their behavior in light of these beliefs (Beck,
2011). Once developed, beliefs and assumptions specific to the racially stereotyped messages
received from society are reinforced through interpersonal interactions that strengthen the
sense of inferiority, shame, and powerlessness experienced within this group. Resulting race-
related beliefs and continued exposure to racist interpersonal interactions, in turn, act as an
additional lens through which everyday situations are interpreted. Corresponding emotional,
behavioral, and physiological reactions result in the reinforcement of dominant societal beliefs,
which, in fact, is a definitional aspect of internalized racism (Bivens, 1995).

Case Study

This case study illustrates the model of internalized racism outlined above. It involves Jasmine,
a 33-year-old African American woman nearing completion of her doctorate degree in
anthropology at a predominately White university. Jasmine is the only African American in
her cohort of seven students, and often feels isolated from her peers and professors. At school,
she is discouraged from exploring her interests in Black cultural studies with the explanation
that she would be more successful if she first developed a mainstream research agenda and
later added a specialization in Black cultural studies after gaining a tenured professorship.
When she does attempt to explore topics such as Black feminism or hip-hop culture in
classes, she typically knows more than the instructor and is met with awkward stares by her
classmates. At her job as a museum tour guide, Jasmine frequently experiences interpersonal
clashes with other staff and her supervisor who accuse her of being “sassy,” standoffish, and
difficult to talk to. Jasmine’s supervisor has reprimanded her twice over the past 6 months,
leaving Jasmine feeling confused and angry due to what she perceives as being punished for
being Black.
At the start of counseling, Jasmine described her primary concerns as worry about the
future and difficulty expressing her feelings. She endorsed several symptoms of depression
including sadness, irritability, poor concentration, binge/emotional eating, and a lack of
energy. She also described herself as lonely, and reported avoiding most of her classmates
and co-workers. Jasmine has very few social outlets, as she had moved far from her hometown
and family to attend her PhD program. Although she spends most of her time alone in her
apartment, she has difficulty concentrating on her schoolwork and has started to experience a
decline in her academic performance. Jasmine was having an especially difficult time
226 International Journal for the Advancement of Counselling (2020) 42:217–233

completing a research proposal for her dissertation seminar, and reported feeling extremely
anxious about selecting the “right” topic. She doubted that her interests were substantial, and
questioned if she was intelligent enough to write a dissertation and complete her degree.

Cognitive Conceptualization

The cognitive conceptualization that provides the basis for CBT with Jasmine is diagramed in
Fig. 2 (see Beck, 2011). Growing up, Jasmine was the only child of a single mother who was
very vocal about the importance of being independent and strong. Jasmine was discouraged
from crying or showing outward signs of hurt or frustration, and was regularly cautioned
against appearing weak in public.
In effect, Jasmine was socialized to conform to the Superwoman Image, a stereotype in
which African American women are portrayed as capable of having and doing it all, also
known as the Strong Black Woman Schema (Abrams, Maxwell, Pope, & Belgrave, 2014). In
this phenomenon, Black women are ascribed qualities such as unyielding strength, responsi-
bility, and self-sacrifice, reflecting implicit obligations to (a) “suppress fear and weakness,
showcase strength, resist being vulnerable or dependent…and succeed despite limited re-
sources,” (b) “assume multiple roles such as financial providers and caregivers and possess

Fig. 2 Jasmine’s cognitive conceptualization diagram (contextualized from Beck, 2011)

International Journal for the Advancement of Counselling (2020) 42:217–233 227

the ability to independently support their families,” and (c) “suffer quietly as they work to meet
the expectations of their families, jobs, and larger society” (Abrams et al., 2014, pp. 503–504).
As a result of her upbringing, Jasmine developed core beliefs reflecting difference, vulner-
ability, and a sense of not being good enough. These beliefs were reinforced in her school
environment as a child, where Jasmine and other African American students were subjected to
low expectations from teachers and were noticeably absent from advanced classes. Eventually,
these experiences led to the development of internalized race-related beliefs that African
American students are not as smart or as capable as their White counterparts—beliefs now
reinforced by cues in her current school and work environments; namely, the passive stance
taken by peers when Jasmine’s ideas are devalued or undermined in classes, the lack of
mentoring and advising received from faculty, the absence of Black perspectives in course
curricula (e.g., lack of textbooks written by African American scholars), and stereotyped
accusations from co-workers of being hostile and difficult to work with.
In response to her beliefs, Jasmine developed several conditional assumptions including, “If
I work hard, I’ll be accepted,” “If I make a mistake, terrible things will happen,” and “If I share
how I feel, I’ll be rejected.” While personal to Jasmine’s unique human experience, the
assumption “If I work hard, I’ll be accepted” also reflects a broader aspect of internalized
oppression, namely, belief in a just world, or the belief that “people get what they deserve”
(Prilleltensky & Gonick, 1996, p. 134).
Jasmine has attempted to make sense of the difficulties in her doctoral program by believing
that conforming to the prevailing cultural norms and expectations of the professors in her
department and choosing the “right” dissertation topic will earn acceptance from her peers,
instructor, and those in her discipline. This assumption also reflects another aspect of inter-
nalized oppression, obedience to authority, wherein “compliance with the dominant social
order is typical even if the social order proves to be oppressive to the self, family or one’s own
community” (Prilleltensky & Gonick, 1996, p. 134). In Jasmine’s case, obedience to authority
contributes to her desire to select a research topic that meets her faculty’s standards, in spite of
the conflict with her personal goal of conducting research that would ultimately add value to
the African American community. Ultimately, Jasmine’s assumption that working hard will
earn her acceptance will likely only have the effect of furthering the status quo by silencing
Black voices and undermining Black success and power (Joseph & Williams, 2008).
Jasmine’s other conditional assumptions, “If I make a mistake, terrible things will happen”
and “If I share how I feel, I’ll be rejected” also reflect a combination of childhood and social
influences. The explicit messages she received from her mother about being strong and not
allowing herself to be perceived as weak carried with them implicit messages about severe
consequences for doing so, including rejection from those she cares about. Fears of being hurt
or embarrassed by being vulnerable were heightened in classroom settings where she was
hyper-visible as the only African American student (Stone et al., 2018). As a coping strategy,
Jasmine often deferred to White students and then later criticized herself for not being “Black
enough,” both manifestations of internalized racism (Joseph & Williams, 2008).
As shown in Fig. 2, the underlying cognitions described above are reflected in the
automatic thoughts that occur during situations wherein Jasmine’s core and race-related beliefs
are activated. In situation 1, for example, Jasmine’s automatic thoughts “No one ever
understands my research ideas. I probably won’t even complete my dissertation,” exemplify
the internalization of messages about her intellectual inferiority and resulting feelings of
hopelessness, anxiety, and sadness. Likewise, the automatic thoughts occurring in situations
2 and 3 (“I should just leave, I don’t fit in” and “I can’t tell my mother how I feel, she’ll find
228 International Journal for the Advancement of Counselling (2020) 42:217–233

out that I am weak”) also exemplify Jasmine’s underlying maladaptive beliefs. Believing that
she is different from those at her job has left Jasmine feeling angry, anxious, and embarrassed,
emotions Bivens (2005) argued leave African Americans too scattered to explore the effects of
racism and internalized racism in their environments. The sense of vulnerability she feels in the
relationship with her mother worsens her sense of isolation; further diminishing Jasmine’s
ability to challenge the racism in her environment.

Treatment Planning

The model of internalized racism shown in Fig. 1 and the conceptualization described above
(shown in Fig. 2) provide a guide for treatment planning during counseling with Jasmine. The
primary goal in CBT is to help clients increase awareness of, challenge, and modify their
negative thoughts and beliefs. This goal is actually quite similar to broader empowerment
goals, which focus on consciousness-raising and claiming one’s voice and power in a system
of oppression. With this in mind, goals in Jasmine’s case would be to: (a) identify the cycle of
internalized racism affecting her current difficulties; (b) articulate an individualized set of
values not based on imposed Eurocentric ideals and standards; and (c) increase Jasmine’s
sense of power in making decisions relating to her educational and research goals, especially
when they conflict with the dominant racial group.
According to Bivens (1995), internalized racism is a system of oppression that “undermines
the power of people of color and teaches us to fear our own power and difference” (p. 1). The
cognitive model of internalized racism suggests how counselors can intervene to challenge this
oppression and achieve the goals described above. As shown in Fig. 1, internalized racism is a
cyclical force that ultimately results in attitudes and behaviors that reinforce the status quo. For
example, the activating event in situation 1 for Jasmine eventually led her to avoid work on her
dissertation proposal, reinforcing dominant beliefs that African Americans are intellectually
inferior, in this case, less able to develop and maintain a rigorous research agenda.
A first step to intervening in the cycle might be broaching the role of internalized racism in
Jasmine’s current difficulties. According to Day-Vines et al. (2007), broaching is defined as,
“a consistent and ongoing attitude of openness with a genuine commitment by the counselor to
continually invite the client to explore issues of diversity” (p. 402). A culturally congruent
example of broaching in Jasmine’s case might include first acknowledging the difficulties she
is experiencing as one of only a few African Americans in her program and the toll it has taken
on her emotionally and psychologically, and then intentionally examining the potential roles
racism and corresponding internalized racism have within these difficulties.
After broaching the topics of race and internalized racism, the next step would be to assess
Jasmine’s readiness to confront and challenge aspects of her personal internalized racism. This
can be accomplished using the advantages-disadvantages analysis technique (Beck, 2011),
wherein the counselor would guide Jasmine in exploring the advantages and disadvantages in
adopting more culturally congruent and self-defined standards and approaches to decision-
making. Once Jasmine’s beliefs that the advantages of resisting internalized racism outweigh
its disadvantages, counseling would then focus on increasing Jasmine’s awareness of her
automatic thoughts in situations at school and work, and teaching her to challenge and modify
these thoughts using interventions such as Socratic questioning and keeping thought records to
help identify and challenge habitual themes (Beck, 2011). This might be coupled with
behavioral strategies that promote consciousness-raising such as bibliotherapy or participation
in campus or community organizations that affirm her Black identity.
International Journal for the Advancement of Counselling (2020) 42:217–233 229

To reduce the occurrence of negative automatic thinking in daily situations, later interven-
tions in counseling for Jasmine might focus on direct modification of her core and race-related
beliefs. According to Beck (2011), core beliefs are often very deeply held and may be more
amenable to modification once clients have learned that it is in fact possible to modify more
superficial cognitions like automatic thoughts. Therefore, after Jasmine has become skilled at
identifying negative automatic thoughts and their corresponding emotional, behavioral, or
physiological reactions, modification of her core beliefs can begin by utilizing the cognitive
conceptualization diagram to help Jasmine conduct a historical review of her core and race-
related beliefs, including when and how these beliefs developed, evidence that the beliefs are
true, evidence that the beliefs may be untrue, and alternative explanations for the beliefs. A
final step in this process would be to help Jasmine identify new and more functional core and
race-related beliefs, and then engage in an ongoing process of examining evidence for and
against these beliefs.

Discussion

The purpose of this article was to present a way to examine internalized racism in African
American clients using CBT. To this end, a cognitive developmental model of internalized racism
was presented, and then illustrated using a case example. In this model, early life experiences and
social influences are given equal importance in terms of their influence on the development of
core beliefs and conditional assumptions, and connections between exposure to interpersonal
interactions that reinforce messages of inferiority, shame, and powerlessness, and the ultimate
development of negative cognitions and reactions. Identified social influences that have a direct
impact on the development of self-rejection and sense of powerlessness characteristic of internal-
ized racism included slavery, Black codes, colorblind racial attitudes, microaggressions, and the
media. However, colorism (Chavez-Dueñas, Adames, & Organista, 2014; Organista, 2009),
modern racism (McConahay, 1986), aversive racism (Gaertner & Dovidio, 1986), and institu-
tional racism (Jones, 1997), are just some of the many other types of racial oppression that affect
African Americans that also could have been included in this discussion.
While the model presented in this article is specific to internalized racism among African
Americans, it holds broader applicability to individuals of African descent from across the
diaspora, as well as individuals who experience other forms of oppression such as ableism,
sexism, and heterosexism. With sexism, for example, gender role expectations are socialized
through many of the same media and organizational-based means as ideals concerning race, and
also result in specific gender-related beliefs that negatively influence automatic thinking in daily
situations. While sexism historically has not had the same societal impacts as racism, it too has
nevertheless negatively influenced the mental health and human development of its target of
oppression. Moreover, all forms of oppression are characterized by “verbal or emotional abuse,
where the target individual is subjected to degrading language and portrayed as useless, inferior,
incapable, lazy, unlovable, stupid, and a litany of other demeaning adjectives” (Prilleltensky &
Gonick, 1996, p. 135). Adaptation of the current model of internalized racism for use with other
oppressed groups would, therefore, only necessitate an understanding of the specific cultural
scripts and history of oppression relevant to that population.
While this article focused on internalized racial oppression, no form of oppression can be
separated from its ultimate purpose of domination through control over goods, lands, and
resources (Bulhan, 1985). The complete end of oppression, including its negative human
230 International Journal for the Advancement of Counselling (2020) 42:217–233

development affects, therefore, cannot be obtained without greater societal equality, which can
only occur through political and social change. In the counseling literature, social justice
advocacy has been described as the means through which this is accomplished (e.g., Lewis,
Arnold, House, & Toporek, 2003; Ratts, 2009). One definition of social justice advocacy is
“professional practice, research, or scholarship intended to identify and intervene in social
policies and practices that have a negative impact on the mental health of clients who are
marginalized on the basis of their social status” (Steele, 2008, pp. 75–76). Marginalized groups
refer to populations who are systemically excluded from social, economic, cultural, or political
life. Marginalized groups are different than other groups that may be discriminated against, but
whose circumstances are not widely affected by institutionalized policies and practices; for
example, children who experience bullying or individuals dealing with obesity. This distinction
is significant, as while these problems and others like them have significant impacts on the
climates of our communities, they differ from social justice concerns in that they are not the
result of system-wide policies that selectively affect certain groups according to their demo-
graphic characteristics.
Specific competencies have been developed to help define the knowledge, attitudes, and
skills necessary for counselors to facilitate change within social and political contexts. The 43
advocacy competencies developed by the American Counseling Association (Lewis et al.,
2009), for example, identify ways in which counselors can intervene with or on behalf of
clients on micro to macro levels within six different domains (i.e., client/student empower-
ment, client/student advocacy, community collaboration, systems advocacy, public informa-
tion, and social/political advocacy).
The case conceptualization and treatment planning approach described in this article has
direct implications for the domains identified within the advocacy competencies, particularly
within the client/student empowerment domain. This domain focuses on helping clients
understand their lives in context, and the implementation of empowerment strategies during
direct counseling. Specific competencies include (1) Identifying strengths and resources of
clients and students, (2) Identifying the social, political, economic, and cultural factors that
affect the client/student, (3) Recognizing the signs indicating that an individual’s behaviors
and concerns reflect responses to systemic or internalized oppression, (4) Helping the indi-
vidual identify the external barriers that affect his or her development, (5) Training clients in
self-advocacy skills, (6) Helping clients develop self-advocacy action plans, and (7) Assisting
clients in carrying out action plans.
The cognitive conceptualization and treatment plan in the case study provided suggest
several ways in which these competencies can be incorporated into counseling with this client,
Jasmine. Knowledge of the social influences that contribute to internalized racism among
African Americans increases the counselor’s ability to recognize signs of this oppression and
identify barriers affecting her development. Moreover, the cognitive modification and behav-
ioral interventions included in the treatment plan can be broadened to focus on increasing
Jasmine’s self-advocacy skills and developing and carrying out a specific action plan to
address her difficulties at school and work.

Conclusion

This article presented a theory-based approach to internalized racism among African American
clients. While the basis of this approach is grounded in the literature, empirical research is
International Journal for the Advancement of Counselling (2020) 42:217–233 231

needed to determine the validity of the proposed model. Research is also needed to determine
how various factors may influence the counseling relationship during this process; for
example, the impact of cross-racial counseling dynamics, counselor racial identity develop-
ment, and client racial identity development. Nevertheless, this article addresses a significant
gap in the counseling literature; that is, the lack of specific approaches to assist clinicians with
countering the psychological effects of oppression (Hanna & Cardona, 2013). CBT as
described herein has the potential to not only address the negative psychological effects of
internalized racism, as documented by existing research, but may also serve as a launching
point for broader social justice advocacy efforts, helping to reduce the effects of racism in
society at large.

Compliance with Ethical Standards

Conflict of Interest The author declares she has no conflict of interest.

References

Abrams, J. A., Maxwell, M., Pope, M., & Belgrave, F. Z. (2014). Grace of a lady and the grit of a warrior:
Deepening our understanding of the strong black woman Schema. Psychology of Women Quarterly, 38(4),
503–518.
Bailey, T.-K. M., Chung, Y. B., Williams, W. S., Singh, A. A., & Terrell, H. K. (2011). Development and
validation of the internalized racial oppression scale for black individuals. Journal of Counseling
Psychology, 58(4), 481–593.
Bailey, T.-K. M., Williams, W. S., & Favors, B. (2014). Internalized racial oppression in the African American
community. In E. J. R. David (Ed.), Internalized oppression: The psychology of marginalized groups (pp.
137–162). New York, NY: Springer Publishing Company, Inc..
Barr, S. C., & Neville, H. A. (2014). Racial socialization, color-blind racial ideology, and mental health among
black college students: An examination of an ecological model. Journal of Black Psychology, 40(2), 138–
165.
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York, NY: Guilford.
Beck, J. S., Liese, B. S., & Najavits, L. M. (2005). Cognitive therapy. In R. J. Frances, S. I. Miller, & A. H. Mack
(Eds.), Clinical textbook of addictive disorders (3rd ed., pp. 474–501). New York, NY: Guilford Press.
Bivens, D. K. (2005). What is internalized racism? Flipping the Script: White Privilege and Community Building,
1, 43–51.
Bivens, D. (1995). Internalized racism: A definition. Retrieved from https://www.racialequitytools.
org/resourcefiles/bivens.pdf
Brown, D. L., & Segrist, D. (2016). African American career aspirations: Examining the relative influence of
internalized racism. Journal of Career Development, 43(2), 177–189.
Bulhan, H. A. (1985). Black Americans and psychopathology: An overview of research and theory.
Psychotherapy: Theory, Research, Practice, Training, 22(2S), 370–378.
Carter, R. T. (2007). Racism and psychological emotional injury: Recognizing and assessing race-based
traumatic stress. The Counseling Psychologist, 35(1), 13–105.
Chavez-Dueñas, N. Y., Adames, H. Y., & Organista, K. C. (2014). Skin-color prejudice and within-group racial
discrimination: Historical and current impact on Latino/a populations. Hispanic Journal of Behavioral
Sciences, 36(1), 3–26.
Clark, K. B., Chein, I., & Cook, S. W. (2004). The effects of segregation and the consequences of desegregation:
A (September 1952) social science statement in the Brown v. Board of Education of Topeka supreme court
case. American Psychologist, 59(6), 495–501.
Collins, P. H. (2009). Black feminist thought. New York, NY: Routledge.
David, E. J. R., & Okazaki, S. (2010). Activation and automaticity of colonial mentality. Journal of Applied
Social Psychology, 40(4), 850–887.
Day-Vines, N. L, Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake K., Douglass, M. J. (2007).
Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling &
Development, 85(4), 401–409.
232 International Journal for the Advancement of Counselling (2020) 42:217–233

Gaertner, S. L., & Dovidio, J. (1986). The aversive form of racism. In J. Dovidio & S. L. Gaertner (Eds.),
Prejudice, discrimination, and racism (pp. 61–89). San Diego, CA: Academic Press.
Graham, J. R., West, L. M., Martinez, J., & Roemer, L. (2016). The mediating role of internalized racism in the
relationship between racist experiences and anxiety symptoms in a black American sample. Cultural
Diversity and Ethnic Minority Psychology, 22(3), 369–376.
Hall, G. C. N., & Ibaraki, A. Y. (2016). Multicultural issues in cognitive-behavioral therapy: Cultural adaptations
and goodness of fit. In C. M. Nezu & A. M. Nezu (Eds.), The Oxford handbook of cognitive and behavioral
therapies (2nd ed., pp. 465–481). New York, NY: Oxford University Press.
Hanna, F. J., & Cardona, B. (2013). Multicultural counseling beyond the relationship: Expanding the repertoire
with techniques. Journal of Counseling and Development, 91(3), 349–357.
Hays, P. A. (2009). Integrating evidence-based practice, cognitive-behavior therapy, and multicultural therapy:
Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40(4), 354–
360.
Hays, P. A., & Iwamasa, G. Y. (2006). Culturally responsive cognitive-behavioral therapy: Assessment, practice,
and supervision. Washington, DC: American Psychological Association.
Hipolito-Delgado, C. P. (2010). Exploring the etiology of ethnic self-hatred: Internalized racism in Chicana/o and
Latina/o college students. Journal of College Student Development, 51(3), 319–331.
History.com Editors. (2019, June 6) . Black codes Retrieved from https://www.history.com/topics/black-
history/black-codes
Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of
Clinical Child and Adolescent Psychology, 37(1), 262–301.
Jackson, J. S., Neighbors, H. W., Nesse, R. M., Trierweiler, S. J., & Torres, M. (2004). Methodological
innovations in the National Survey of American life. International Journal of Methods in Psychiatric
Research, 13(4), 289–298.
Jones, J. (1997). Prejudice and racism (2nd ed.). New York, NY: McGraw-Hill.
Joseph, V., & Williams, T. O. (2008). The struggle to find courage, strength, and confidence to fight internalized
racism and internalized dominance. Democracy and Education, 17(2), 67–73.
Lewis, J., Arnold, M., House, R., & Toporek, R. (2003). ACA advocacy competencies. Retrieved from
http://www.counseling.org/Resources
Liao, K. Y.-H., Weng, C.-Y., & West, L. M. (2016). Social connectedness and intolerance of uncertainty as
moderators between racial microaggressions and anxiety among black individuals. Journal of Counseling
Psychology, 63, 240–246.
Lipsky, S. (1977). Internalized oppression. Black Re-Emergence, 2, 5–10.
Maxwell, M., Brevard, J., Abrams, J., & Belgrave, F. (2015). What’s color got to do with it? Skin color, skin
color satisfaction, racial identity, and internalized racism among African American college students. Journal
of Black Psychology, 41(5), 438–461.
McConahay, J. B. (1986). Modem racism, ambivalence, and the modem racism scale. In J. F. Dovidio & S. L.
Gaertner (Eds.), Prejudice, discrimination, and racism (pp. 91–125). Orlando, FL: Academic Press.
Mouzon, D. M., & McLean, J. S. (2017). Internalized racism and mental health among African-Americans, US-
born Caribbean blacks, and foreign-born Caribbean blacks. Ethnicity & Health, 22(1), 36–48.
Myers, D. (2005). Social psychology (8th ed.). Boston, MA: McGraw Hill.
Nadal, K. L., Griffin, K. E., Wong, Y., Hamit, S., & Rasmus, M. (2014). The impact of racial aggressions on
mental health: Counseling implications for clients of color. Journal of Counseling & Development, 92, 57–
66.
Neville, H. A., Awad, G. H., Brooks, J. E., Flores, M. P., & Bluemel, J. (2013). Color-blind racial ideology:
Theory, training, and measurement implications in psychology. American Psychologist, 68(6), 455–466.
Neville, H. A., Worthington, R., & L, & Spanierman, L. B. (2001). Race, power, and multicultural counseling
psychology: Understanding white privilege and color blind racial attitudes. In J. G. Ponterotto, J. M. Casas,
L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 257–288).
Thousand Oaks, CA: Sage.
Nittle, N. K. (2019, February 18). The black codes and why they matter today: The black codes still impacting
policing and prison in the 21st century. In ThoughtCo Retrieved from https://www.thoughtco.com/the-black-
codes-4125744.
Organista, K. C. (2009). Latino clinical perspective on Montalvo’s ethnoracial gap in clinical practice with
Latinos. Clinical Social Work Journal, 37, 287–293.
Parham, T., & Helms, J. (1985). Attitudes of racial identity and self-esteem of black students: An exploratory
investigation. Journal of College Student Personnel, 26(2), 143–147.
Prilleltensky, I., & Gonick, L. (1996). Polities change, oppression remains: On the psychology and polities of
oppression. Political Psychology, 17(1), 127–148.
International Journal for the Advancement of Counselling (2020) 42:217–233 233

Ratts, M. J. (2009). Social justice counseling: Toward the development of a fifth force among counseling
paradigms. Journal of Humanistic Counseling, Education, and Development, 48(2), 160–172.
Sidanius, J. (1993). The psychology of group conflict and the dynamics of oppression: A social dominance
perspective. In S Iyengar ; W. J. McGuire (Eds.), Explorations in political psychology (pp. 183-219).
Smedley, A. (1999). Race in North America: Origin and evolution of a worldview (2nd ed.). Boulder, CO:
Westview Press.
Speight, S. L. (2007). Internalized racism: One more piece to the puzzle. The Counseling Psychologist, 35(1),
126–134.
Steele, J. M. (2008). Preparing counselors to advocate for social justice: A liberation model. Counselor
Education and Supervision, 48(2), 74–85.
Stone, S., Saucer, C., Bailey, M., Garba, R., Hurst, A., Jackson, S. M., Krueger, N., & Cokley, K. (2018).
Learning while black: A culturally informed model of the imposter phenomenon for black graduate students.
Journal of Black Psychology, 44(6), 491–531.
Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse (7th ed.). Hoboken, NJ: John Wiley & Sons,
Inc..
Szymanski, D. M., & Gupta, A. (2009). Examining the relationship between multiple internalized oppressions
and African American lesbian, gay, bisexual, and questioning persons’ self-esteem and psychological
distress. Journal of Counseling Psychology, 56(1), 110–118.
Szymanski, D. M., & Obiri, O. (2011). Do religious coping styles moderate or mediate the external and
internalized racism-distress links? The Counseling Psychologist, 39(3), 438–462.
Thompson, V. L. S. (2002). Racism: Perceptions of distress among African American. Community Mental
Health Journal, 38(2), 111–118.
Watts-Jones, D. (2002). Healing internalized racism: The role of a within-group sanctuary among people of
African descent. Family Process, 41(4), 591–601.
Wester, S. R., Vogel, D. L., Wei, M., & McLain, R. (2006). African American men, gender role conflict, and
psychological distress: The role of racial identity. Journal of Counseling & Development, 84(4), 419–429.
Williams, D. R., & Williams-Morris, R. (2000). Racism and mental health: The African American experience.
Ethnicity & Health, 5(3/4), 243–268.
Wilson, C. J., & Cottone, R. R. (2013). Using cognitive behavior therapy in clinical work with African American
children and adolescents: A review of the literature. Journal of Multicultural Counseling and Development,
41(3), 130–143.
Worrell, F. C., Vandiver, B. J., Cross Jr., W. E., & Fhagen-Smith, P. E. (2004). Reliability and structural validity
of Cross racial identity scale scores in a sample of African American adults. Journal of Black Psychology,
30(4), 489–505.

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