- White clinicians can learn how to effectively treat Black patients with culture-centered approaches.
- Implicit biases make it easier for white clinicians to associate Black patients with negative attributes.
- Systems of oppression contribute to Black patients’ psychological distress and resilience.
Are you a white mental health provider seeking culture-centered care for Black patients?
Asking yourself why you want to be in the practice of providing Black patients with greater care is always a good place to start. Knowing the source of your motivation will likely tell you whether it originates from an internal desire (i.e., being authentically moved to address your cultural understanding gaps with humility and intentionality), an external desire (i.e., concern for how you’re viewed and experienced by others) or some combination of the two.
Earnest self-examination is critical in determining how committed you are to doing the oftentimes uncomfortable work of confronting systemic racism and the implicit and explicit biases that you have about Black people. For some white clinicians, this may include the acknowledgment of a specific meta-stereotype (i.e., a stereotype that members of one group have about how they are stereotypically viewed by members of another group). Previous research supports the contention that many white people are concerned about appearing racist(Devine & Monteith, 2013; Dunton & Fazio, 1997; Greenwald et al., 1998) and might experience a sense of threat when they believe their racial attitudes are being evaluated (Steele, 1997).
Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions unconsciously (Dovidio et al., 2005). People's implicit associations do not necessarily match their stated beliefs and may not indicate positions individuals would explicitly endorse. On the other hand, explicit biases are conscious preferences for or aversions to a person or group. Both biases can occur at the same time and may even serve to reinforce each other. While explicit bias is commonly assessed by classic self-report measures, implicit bias is not, given the inherent challenge of identifying that which is not consciously known to someone.
The most popular way implicit bias has been assessed is through the use of the Implicit Association Test (IAT),which measures the relative ease with which people make associations between target categories (e.g., white faces and Black faces) and evaluations (e.g., pleasant words and unpleasant words; Greenwald et al., 1998). Suppose one is quicker to associate pleasant words with white faces than with Black faces, and slower to associate unpleasant words with white faces than with Black faces. In that case, the test will report that you have a slight, moderate, or strong preference for white faces over Black faces or some similar language. The IAT has shown that approximately 70 percent of individuals implicitly prefer whites over Blacks (Sabin et al., 2009 & Nosek et al., 2002).
Implicit biases are also flexible, and given the complexity and plasticity of the human brain, the implicit associations that emerge can be gradually unlearned through empirically validated de-biasing techniques (e.g., exposure to counter-stereotypical images, mindfulness, and intergroup contact with diverse racial groups of equal status; Kirwin Institute, 2023). One study of note used virtual reality to show a longer-lasting effect (i.e., the decrease in bias was immediate and lasted at least one week after the end of one exposure) in reducing implicit bias when white participants virtually embodied a Black virtual body (Banakou et al., 2016).
Real-World Consequences of Implicit Bias
Implicit bias can have serious real-world consequences in the form of racial disparities in health care between whites and Blacks. It has been widely documented that the racial disparities in the treatment of cardiovascular disease(Smedley et al., 2003) are alarming with whites up to two times as likely to receive treatment for thrombolytic therapy for myocardial infarction than Blacks (Petersen et al., 2002; Allison et al., 1996; Canto et al., 2000; Weitzman et al., 1997; Taylor et al., 1998).
In what is believed to be the first study to assess implicit associations concerning mental health diagnosis, compliance, and treatment in medical students and psychiatric physicians, the study found that participants had a greater probability of associating Black faces with psychotic disorders (rather than mood disorders), noncompliance (rather than compliance), and antipsychotic medications (rather than antidepressant medications). Additionally, white participants who endorsed a higher level of training most strongly predicted the association of Black faces with psychotic disorders, even after adjusting for participant age (Londono et al., 2021).
So, how can white clinicians work more effectively with Black patients after making efforts to become consciously aware of their implicit biases? They can start by identifying their worldview. Worldviews are socially constructed beliefs about ourselves and others that are formed by cultural and sociopolitical factors that determine how we think, feel, and behave.
Clinicians who can identify both their own and their patients’ worldviews will be starting on a path toward cultural humility that has the power to improve empathic capacity and insight into Black patients’ lived experiences, goals, and presenting issues that are often connected to their endurance of unequal social, economic, legal, and political power in mainstream society based on their phenotype (Leong, 2008).
Sue’s (1978) worldview model shows that beliefs are formed at the intersection of the locus of control (e.g., internal and external) and the locus of responsibility (e.g., internal and external) and that white, middle-class clinicians typically have the dominant worldview in American society (e.g., IC-IR). It suggests that they have control over their destiny and are responsible for their successes and failures, but are also more predisposed to misinterpret the behavior of a Black patient with an IC-ER worldview (i.e., a belief in their agency to influence events if given the opportunity, but also realistically perceive external barriers, such as racism, to operationalizing their desires). White clinicians may view them as passive with scarce ego strength when it may be attributable to racial oppression (Sue, 1978).
A multidimensional model of cultural competence (Sue, 2001) in counseling/therapy was developed
in an effort to integrate three important features associated with effective multicultural counseling: (a) the need to consider specific cultural group worldviews associated with race, gender, sexual orientation, and so on; (b) components of cultural competence (e.g., awareness of attitudes/beliefs, knowledge, and skills); and (c) foci of cultural competence (e.g., societal, organizational, professional, and individual) so that there is a systematic identification of the sources to which interventions may be applied (Sue, 2012, p. 52 ).
Case Vignette (*This is not an actual patient)
Janice* is a 42-year-old Black woman who lives with her husband and two children and holds a senior-level executive position at a well-known technology firm. She grew up in a low-income, predominantly Black neighborhood with three siblings and two parents who worked hard at their blue-collar jobs to make ends meet. Janice remarked how much she appreciated her parents’ sacrifices, but often lamented being left at home to care for her brothers and sister while her parents worked.
Janice self-referred for weekly individual therapy in January of 2019 for increased anxiety symptoms (i.e., excessive worry, irritability, and difficulty concentrating) that she mostly attributed to longstanding impostor syndrome that has significantly affected her self-esteem at work. Janice occasionally consumes alcohol and doesn’t smoke or use illicit drugs.
By taking a culture-centered approach, clinicians will first consider the larger sociopolitical context at play before choosing to reconcile Janice’s impostor syndrome by challenging her maladaptive thoughts and behaviors, focusing on her past as a way to foster insight into the here and now, or using some other traditional counseling approach.
While impostor syndrome is not solely the dominion of Black people, their experience with it is distinct given the historical exclusion of Black people through social norms and legislation that places them in the estranged and subordinate position of the outgroup, which ultimately engenders the internalization of racism. So, some of the patient’s dysregulatory affect is not about her “not being enough” but, rather, a proportionate and natural reaction to systems of oppression that have defined her as “not enough.”
White clinicians have the power to make cultural competence more than just a buzzword by recognizing their own implicit biases and worldviews, incorporating culture-centered counseling approaches in their practices, and empathically working towards a greater understanding of not only the challenges (e.g., systemic racism and disproportionate emotional responsiveness) that their Black patients face but also their enduring resilience to such adversity.
Devine PG, Monteith, MJ. The role of discrepancy-associated affect in prejudice reduction. In: Mackie, DM, Hamilton, DL, eds. Affect, Cognition, and Stereotyping: Interactive Processes in Group Perception. Academic Press; 2013:317–344.
Dunton BC, Fazio, RH. An individual difference measure of motivation to control prejudiced reactions. Personality and Social Psychology Bulletin. 1997;23(3):316–326.
Greenwald AG, McGhee DE, Schwartz, JL. Measuring Individual Differences in Implicit Cognition: The Implicit Association Test. Journal of Personality and Social Psychology. 1998;74(6):1464–1480.
Steele, CM. A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist. 1997;52(6):613.
Dovidio JF, Gaertner SL, Pearson AR. On the Nature of Prejudice: The Psychological Foundations of Hate. In: Sternberg RJ, ed. The Psychology of Hate. American Psychological Association; 2005:211–234.
Sabin JA, Nosek BA, Greenwald AG, et al. Physicians' Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender. Journal of Health Care for the Poor and Underserved. 2009;20(3):896–913.
Nosek, BA, Banaji MR, Greenwald AG. Harvesting implicit group attitudes and beliefs from a demonstration website. Group Dynamics. 2002;6(1):101–115.
Implicit Bias Module Series. Kirwan Institute for the Study of Race and Ethnicity. Accessed June 11, 2023.
Banakou D, Hanumanthu, PD, Slater M. Virtual Embodiment of White People in a Black Virtual Body Leads to a Sustained Reduction in Their Implicit Bias. Front. Hum. Neurosci. 2016;(10):601.
Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US); 2003.
Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Med Care. 2002;40(1 Suppl):I86–I96.
Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM. Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction. J Gen Intern Med. 1996;11(12):736–743.
Canto JG, Allison JJ, Kiefe CI, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N Engl J Med. 2000;342(15):1094–1100.
Weitzman S, Cooper L, Chambless L, et al. Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol. 1997;79(6):722–726.
Taylor HA Jr, Canto JG, Sanderson B, Rogers WJ, Hilbe J. Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators. Am J Cardiol. 1998;82(9):1019–1023.
Londono Tobon A, Flores JM, Taylor JH, et al. Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations. Acad Psychiatry. 2021;45(1):23–33.
Leong, F T. Encyclopedia of Counseling. Vol. 4. SAGE Publications, Inc.; 2008.
Sue DW. Worldviews and Counseling. Personnel and Guidance Journal. 1978;(56):458–162.
Sue, DW. Multidimensional facets of cultural competence. The Counseling Psychologist. 2001;29(6):790–821.
Sue DW, Sue D. Counseling the Culturally Diverse: Theory and Practice (6th ed.). John Wiley & Sons, Inc.; 2012.