Authors’ Note: Additional research by these authors can be found in the Trauma Research Institute newsletter. Subscribe by contacting Constance Dalenberg, Ph.D., at [email protected].
Imagine that you are working with a client of a different racial background than your own. Should the topic of race be specifically addressed? If it is addressed, how do you go about starting this conversation, and more importantly, how might your therapeutic choices impact the relationship and treatment outcomes?
Why Race Matters
The ethnic minority populations in the United States are rapidly growing in relative magnitude, accounting for at least 30% of the U.S. population according to the U.S. Census Bureau (2013). Despite this changing demographic of potential clients, mental health professionals are still predominantly Caucasian, with only 10% of them being classified as non-White currently (American Psychological Association, 2014). Therefore, many of the ethnic minorities seeking mental health services will encounter a clinician who is of a different ethnic background. As this population continues to grow, it is important for those in the field of psychology to examine how differences in race affect the working relationship between therapist and client, and how providers can best accommodate this expanding group of clients.
Race and Psychopathology
Minority status in the U.S. may place some individuals at risk for certain mental health disorders or may change the typical presentation of these disorders (U.S. Department of Health and Human Services, 2001). A variety of factors affect the rate at which symptoms and disorders manifest in a specific population, such as genetics (Park et al., 2004) and cultural practices (e.g., the tendency for some cultures to provide spiritual explanations for physical or psychological symptoms; Curtis & Davis, 1999; Griffiths, Richards, McCann, & Jesse, 2006). Additionally, racial and ethnic minorities have often faced the stress of discrimination or racism which can be linked to psychological trauma, depression, anxiety, and suicidality (Bryant-Davis & Ocampo, 2005; Crawford, Nur, McKenzie, & Tyrer, 2005; McKenzie, Serfaty, & Crawford, 2003; Schraufhagel, Wagner, Miranda, & Ron-Byrne, 2006).
Despite evidence that ethnic minorities may experience higher rates of stressors and exposure to high magnitude stressors and traumatic events, the non-Caucasian population of the U.S is actually less likely to seek treatment than their Caucasian counterparts (Burgess, Ding, Hargreaves, Van Ryn, & Phelan, 2008). Research has suggested that this may be the product of a social stigma against seeking services in many cultures, the fear of exposure of personal information to outsiders, the experience of misuse of information by authorities, and lower likelihood of access to culture-friendly explanations of available treatments (Corrigan, 2004; Carter, 2007; Gary, 2005).
Does Race Affect Treatment?
Even when ethnic minorities do seek services, there is evidence that they are more likely to drop-out and that they often receive poorer quality treatment (Burgess et al., 2008; Clark, 2004; McGuire & Miranda, 2008).
Why might this be?
Clark (2004) suggests that this is likely because there is an unequal amount of research addressing the specific needs and pathologies most common in various racial and ethnic minorities in comparison to those more common in Caucasian groups. As graduate students, we have read numerous articles and chapters on the differences in expectations and treatment needs of varying cultures to serve Clark’s end of adequate knowledge of varying culture-specific pathologies.
Our point here however, is slightly different. Our position is that the problem is not as simple as noting that the typical Caucasian therapist is not an expert in the minority client’s culture and should become one, but instead that neither the therapist nor client may be comfortable acknowledging the impact of the therapist’s inevitable lack of expertise in some cultures. We know that most of the ethnic minorities that do seek treatment are being paired with a provider who is of a different ethnic or racial background.
How do minority clients experience the Caucasian therapist? What critiques do they have about the way the therapist is raising or not raising the topic?
Perceptions of Ethnic Minority Clients
In a recent study at the Trauma Research Institute, located at Alliant International University, San Diego, CA, Work, Estrellado, Rosenberg, Cropper, and Dalenberg (2014) selected 35 African American and 15 Hispanic clients who had completed at least three months of individual psychotherapy related to trauma with a Caucasian therapist. The clients were selected from a larger number of participants (N=360) who took part in the San Diego Countertransference Study (Dalenberg, 2000) and constituted all Caucasian-Hispanic or Caucasian-African American pairings. All of these clients took part in an extensive interview addressing their positive and negative views of their therapy experiences.
Of these clients, 82% indicated that a problem in communication occurred between the client and the therapist that they believed (now) had to do with race or cultural differences.
According to Work et al. (2014), two major themes were identified:
(1) The first centered around the absence of discussion of race in the therapeutic dialogue. Thirty-six percent of the participants indicated that their Caucasian therapist never mentioned race at all. An additional 46% stated that such conversations were rare. In the perception of the clients, the therapist typically appeared uncomfortable discussing race-related issues. Sixty percent rated their therapist below 5 on a 9 point scale in their level of comfort in discussions of race and culture.
(2) The second theme related to perception of therapist intensity when the issue of race was raised. Some clients reported that their therapist’s discomfort appeared to manifest in excessive interest in cultural detail or an expectation that the client show expertise in their cultural group. Eighty-two percent indicated that when race was discussed, their therapist appeared to become more intensely interested in them. Only 28% reported that their therapist handled the issue of race well (7 to 9, on a 9 point scale).
Empirical Support for Similar Trends During Race Discussions
Previous studies on cross-racial therapeutic dyads have also noted client dissatisfaction (e.g., Chang & Berk, 2009) and lack of sensitivity with how the topic of race was addressed by the therapist (e.g., Thompson & Alexander, 2006). Other studies have focused on the discomfort reported from the Caucasian therapists’ point of view when addressing racial differences in therapy (e.g., Knox, Burkard, Johnson, Suzuki, & Ponterotto, 2003). Work et al. (2014) extends these findings to discussions of race during trauma psychotherapy and concentrates on how a range of therapeutic needs may be missed when Caucasian therapists over-focus or disengage from race-related discussions.
Developing a More Effective Way to Address Race-Related Issues
What steps can be taken by the therapist to make this process more effective and conducive to treatment?
1. Address the topic of race as potentially relevant to therapeutic issues and discussion
Many clinicians are reluctant to bring up racial issues in psychotherapy. However, therapists who discuss and demonstrate a competency for race-related issues can provide an experience for ethnic minority clients may be quite liberating (Wade, 2005). Facilitation of an open conversation early in therapy about the client’s expectations and goals will help to inform the therapist, provide an opportunity to address any potential resistance or concerns, and minimize the power differential. We would recommend that this conversation specifically address the possible benefits and obstacles created by a cross-racial pairing of therapist and client, and the need to bring race into the therapeutic discussion when it feels relevant. Opening the topic with an acknowledgment of the inevitable lack of expertise of each member of the dyad on living in the culture of the other also provides a safer path for client correction of therapist or suggestion of alternative interpretations of behaviors.
2. Acknowledge difficulty verbally expressing racial similarities/differences
When the topic of race is discussed in therapy, it may be difficult for the client to put into words those factors that are different or similar to that of their therapist. It is also possible that there are cultural rules about symptom or belief expression that would have an effect on the therapy course (e.g., Japanese clients’ reluctance to discuss symptoms associated with PTSD; Friedman, Schnurr, Sengupta, Holmes, & Ashcraft, 2004). In working with a client of a differing ethnicity or culture, we recommend discussion of the invisibility of culture to those who live within it, so that both therapist and client are encouraged to discuss the possibility that a communication difficulty or difference in point of view may have a cultural basis.
3. Consider acknowledging racial privilege
Along with addressing the topic of race, clinicians who are Caucasian should consider when it might be therapeutically appropriate to acknowledge their own racial experiences. The “colorblind approach,” while well-meaning, may not always work. To deny their own experience as racial beings is not only unrealistic, but it can quickly become a barrier to treatment. Therapist acknowledgement of some of the privilege they may have experienced as a member of their White racial group may provide opportunity for a powerful therapeutic moment (Utsey, Gernat, & Hammar, 2005).
4. Find opportunities to increase sensitivity to racial and cultural stereotypes
While multicultural competency largely aims to educate clinicians on how populations are different and on the possible stereotypes that may arise, a therapist will not be aware of all the stereotypes that occur. However, while in therapy, the clinician should aim to provide a safe environment to explore these stereotypes at the client’s pace. The focus here should be less on having the discussion of shared knowledge of stereotypes, and more on showing the client the therapist’s awareness that such stereotypes exist and may impact the client’s life.
5. Improve clinician training
In 2002, the APA Task Force released Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists. In recent years, the majority of therapist training programs have undertaken some required multicultural competency component; however, the recommended content of these courses differs broadly. Normalizing apprehension with engaging in discussions of race and utilizing activities such as role-plays and experiential exercises may have practical implications and prove helpful. As Work et al. (2014) posits, therapists are uncomfortable in situations involving racial differences, and may benefit from help in formulating acceptable phrasing when first raising the issue of race in a cross-racial therapeutic dyad.
6. Enhance community outreach efforts
There is a need for graduate programs to increase outreach efforts within the community. This would not only allow therapists to gain experience working with diverse populations, but it would also facilitate the development of a more positive, accurate perspective on culturally-informed mental health services. Community mental health facilities are at the forefront of providing more accessible care in an effort to lessen social exclusion and provide services for diverse populations. Greater emphasis needs to be placed on the inclusion of clinicians-in-training in these efforts.
There is a tendency for Caucasian therapists working with African American or Latino clients to either disengage from the topic of race or demonstrate excessive interest in cultural differences during trauma psychotherapy.
Rather than concentrating their energy exclusively on becoming an expert in a particular client’s culture, therapists should aim to promote a safe environment to openly acknowledge disparities and address mutual discomfort regarding racial differences.
Cite This Article
Work, G. B., Cropper, R., & Dalenberg, C. (2014, November). Talking about race in trauma psychotherapy. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/talking-about-race-in-trauma-psychotherapy
American Psychological Association. (2002). Guidelines on Multicultural Education , Organizational Change for Psychologists.
American Psychological Association. (2014). Health disparities and mental/behavioral health. Retrieved from: http://www.apa.org/about/gr/issues/workforce/disparity.aspx
Bryant-Davis, T., & Ocampo, C. (2005). The trauma of racism: Implications for counseling, research, and education. The Counseling Psychologist, 33(4), 574-578. doi:10.1177/0011000005276581
Burgess, D.J., Ding, Y., Hargreaves, M., Van Ryn, M., & Phelan, S. (2008). The association between perceived discrimination and underutilization of needed medical health care in a multi-ethnic community sample. Journal of Health Care for the Poor and Underserved, 19(3), 894-911. doi:10.1353/hpu.0.0063
Carter, R. T. (2007). Racism and Psychological and Emotional Injury: Recognizing and Assessing Race-Based Traumatic Stress. The Counseling Psychologist, 35(1), 13-105.
Chang, D. F., & Berk, A. (2009). Making cross-racial therapy work: A phenomenological study of clients’ experiences of cross-racial therapy. Journal of Counseling Psychology, 56(4), 521–536. doi:10.1037/a0016905
Clark, E. J. (2004). Health disparities: Social workers helping communities move from statistics to solutions. Retrieved from: http://www.socialworkers.org/pressroom/2004/040804b.asp
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi:10.1037/0003-066X.59.7.614
Crawford, M. J., Nur, U. U., McKenzie, K. K., & Tyrer, P. P. (2005). Suicidal ideation and suicide attempts among ethnic minority groups in England: Results of a national household survey. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 35(9), 1369-1377. doi:10.1017/S0033291705005556
Curtis, R.C., & Davis, K.M. (1999). Spirituality and multimodal therapy: A practical approach to incorporating spirituality in counseling. Counseling and Values, 43(3), 199-210. doi:10.1002/j.2161-007X.1999.tb00143.x
Dalenberg, C. (2000). Countertransference and the treatment of trauma. Washington, DC: American Psychological Association.
Friedman, M. J., Schnurr, P. P., Sengupta, A., Holmes, T., & Ashcraft, M. (2004). The Hawaii Vietnam Veterans Project: Is minority status a risk factor for Posttraumatic Stress Disorder? Journal of Nervous and Mental Disease, 192(1), 42–50. doi:10.1097/01.nmd.0000105999.57129.ee
Gary, F. A. (2005). Stigma: Barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing, 26(10), 979-999. doi:10.1080/01612840500280638
Griffiths, R.R., Richards, W.A., McCann, U., & Jesse, R. (2006). Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance. Psychopharmacology, 187, 268-283. doi:10.1007/s00213-006-0457-5
Knox, S., Burkard, A. W., Johnson, A. J., Suzuki, L. a., & Ponterotto, J. G. (2003). African American and European American therapists’ experiences of addressing race in cross-racial psychotherapy dyads. Journal of Counseling Psychology, 50(4), 466–481. doi:10.1037/0022-0220.127.116.116
McGuire, T.G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities of mental health: Policy implications. Health Affairs, 27(2), 393-403. doi:10.1377/hlthaff.27.2.393
McKenzie, K., Serfaty, M., & Crawford, M. (2003). Suicide in ethnic minority groups. The British Journal of Psychiatry, 183, 100-101. doi:10.1192/bjp.02.667
Park, S. H., Kim, B. I., Yun, J. W., Kim, J. W., Park, D. I., Cho, Y. K.,…Kim, S.W. (2004). Insulin resistance and C-reactive protein as independent risk factors for non-alcoholic fatty liver disease in non-obese Asian men. Journal of Gastroenterology and Hepatology, 19(6), 694-698.
Schraufhagel, T.J, Wagner, A.W., Miranda, J., & Ron-Byrne, P.P. (2006). Treating minority patients with depression and anxiety: What does the evidence tell us? FOCUS-The Journal of Lifelong Learning in Psychiatry, 6(4), 517-527.
Thompson, V. L. S., & Alexander, H. (2006). Therapists’ race and African American clients’ reactions to therapy. Psychotherapy (Chicago, Ill.), 43(1), 99–110. doi:10.1037/0033-318.104.22.168
United States Census Bureau. (2013, June 13). Asians fastest-growing race or ethnic group in 2012, Census Bureau reports. Retrieved from: https://www.census.gov/newsroom/release s/archives/population/cb13-112.html
U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: Author. Retrieved from http://www.surgeongeneral.gov/library/reports/
Utsey, S. O., Gernat, C. A., & Hammar, L. (2005). Examining white counselor trainees’ reactions to racial issues in counseling and supervision dyads. The Counseling Psychologist, 33(4), 449–478. doi:10.1177/0011000004269058
Wade, J. C. (2005). The issue of race in counseling psychology. The Counseling Psychologist, 33(4), 538–546. Retrieved from http://0-search.ebscohost.com.library.alliant.edu/login.aspx?direct=true&db=psyh&AN=2005-06432-008&site=ehost-live&scope=site
Work, G. B., Estrellado, J., Rosenberg, M., Cropper, R., & Dalenberg, C. (2014). Ethnic minority perceptions of addressing racial issues in psychotherapy. [Manuscript in preparation.]