Culturally Incompetent Therapy: When Therapists Do Harm
Sometimes clients have to educate their therapists about race.
Posted Feb 02, 2014
Racial battle fatigue
Hello Dr. Williams,
I greatly appreciate your blog posts about racism among mental healthcare. When I read them I felt like someone open the blinds.
Currently, I am experiencing trouble with my therapist, and I am in need of advice. I brought up about my experiences with racism, and it was the only time in any form of psychological treatment that I mentioned it. It was a hard thing to bring up and it puts me in vulnerable position because of how my community treats racism and their post-racist mentality. He responded to my distress about my experience of racism by saying we can work on "my perception" to keep things in control and kept derailing away from the topic of racism saying he wants to “keep things controlled.” I cried because I feared this was going to happen... Part of me expected it, but I thought I was being negative, so to see this happen anyway and the one time I brought up racism while feeling vulnerable made me cry.
I tried to explain to him why I was upset, but he cut me off and concluded that I have a chemical imbalance in my brain. At the end of therapy I tried to explain it to him again. He rolled his eyes and said, "I mean if you want to 'fight' [racism]. . ." (using finger quotation on the word "fight"). At my next appointment I found out that he wrote all this in my records. He wrote about my views on racism as he saw it: oversensitive, chemical imbalance, etc.
It worries me because my insurance only covers the therapists and social workers in that clinic, and the notes written down about me from one therapist/social worker is what every mental health professional in that clinic reads before they meet me. It heavily influences on how they treat me. So this prejudgment about me plus this post-racist mentality has caused more microaggressions, dismissal, and pathologization.
Do you have any advice on how I can handle this situation, what is written about me, how to prevent it in the future and how to respond the kind of behavior my therapist exhibits?
It can be hard to communicate about racism
The first thing I want to say is that this situation should never have happened. Even if a client tells me that he saw Elvis in Central Park, I am not going to roll my eyes or use air quotes. To me this is an indication of your therapist’s own internal biases. That he said, we need to “keep things controlled” illustrates his own insecurity over being able to professionally manage your distress. And the way he refers to the problem as your "perception" insensitively communicates disbelief over your report. I want you to know that I believe you.
This racial disconnect is a tough problem and potentially tricky issue. White people in our culture are socialized not to see themselves as racial beings, and thus experience themselves as non-racial. Therefore it can be difficult to understand the perspective of ethnic minority clients, who typically live and struggle with racism on a regular basis. Racism is something we must fight to maintain our dignity, sanity, and self-esteem, so this struggle falls squarely within the realm of mental health. Fighting the deleterious effects of racism can lead to what scholars have termed “racial battle fatigue" — which leads to the same kinds of anxiety traumatized soldiers expereince when returning home from war.
Pointing out racist behavior to an offender is usually not a useful strategy, as people are quick to become defensive when called out, and no one wants to be considered a racist. And, as you pointed out, therapists are seen by many (and themselves) as objective, progressive and open-minded, so they may become dismissively closed off from the possibility they may be part of the problem. Although most new therapists are emerging from training programs with at least some basic multicultural education, there is a whole generation of practitioners who were never exposed to any multicultural training at all.
I posed the question you asked to my classroom of doctoral students in my Clinical Psychopathology course. We had just completed a segment on the mental health effects of racism, and I thought it would be useful to brainstorm this problem. They broke into groups of two and came up with several excellent suggestions.
First, I should point out that there was a broad consensus that you, as the aggressed-upon client, should stop seeing this therapist and find someone else who can actually intervene therapeutically. I agree with this suggestion, since the therapist described above is only making you worse by doing the very thing that others have done, resulting in so much emotional pain. I would not worry too much about what your therapist wrote in the chart. Any good therapist will want to hear your perspective before drawing any important conclusions about you.
What you can do when your therapist is culturally incompetent
However, finding another therapist is not always easy or possible, especially depending on where you live, your resources, and insurance options. If you must continue with this person, here are a few suggestions.
(1) Do your best to share how your therapist’s response made you feel. Let him know that you feel marginalized and invalidated because he didn’t take the time to understand your experience. You might even write out your thoughts in advance to help you organize your thoughts while in session.
(2) Ask the therapist if he knows what it feels like to be discriminated against. And if so, ask him how it would feel if he had that experience dismissed by important people in his life.
(3) Trick him into hearing the experience by describing the event without framing it as racism, and let him pathologize the experience rather than his attribution of it.
(4) Suggest he take a cultural competency course so he can better relate to his minority clients. I actually offer a webinar on this topic every other month, so that’s one easy possibility.
(5) Offer him research literature about cultural differences and how racism can affect mental health outcomes. See below for some suggestions.
What a culturally competent therapist would have done
Here is what the therapist should have done – or at least what I would have done if you had shared your experience with me:
- Ask questions to more fully understand the problem
- Reflect back the essence of what to you said to ensure you felt heard and understood
- Validate the experience and your distressed feelings about it
- Discuss some of the mental health consequences of racism to help put your symptoms into perspective
- Discuss coping mechanisms for dealing with racism
- Problem solve surrounding the issue
- Strengthen self-esteem to better enable you to manage future (unfortunate but inevitable) experiences of racism
I am fairly behavioral in my approach, and other therapeutic traditions may have some equally effective means of helping without being as directive. I would also likely share some of my own experiences of racism to help normalize the experience, my feelings about those experiences, and my feelings about your experience. However, there are many therapists who don’t share much about their own feelings and experiences, but who can still be helpful if appropriately trained.
Thanks for sharing and keep up the good fight.
Cokley, K., Hall-Clark, B., & Hicks, D. (2011). Ethnic minority-majority status and mental health: The mediating role of perceived discrimination. Journal of Mental Health Counseling, 33(3), 243-263.
Constantine, M. G. (2007). Racial Microaggressions Against African American Clients in Cross-Racial Counseling Relationships. Journal of Counseling Psychology, 54 (1), 1-16.
Smith, W. A., Allen, W. R., & Danley, L. L. (2007). Assume the Position . . . You Fit the Description: College Students Experiences and Racial Battle Fatigue Among African American Male College Students. American Behavioral Scientist, 51, 551-578.
Soto, J. A., Dawson-Andoh, N. A., & BeLue, R. (2011). The relationship between perceived discrimination and Generalized Anxiety Disorder among African Americans, Afro Caribbeans, and non-Hispanic Whites. Journal of Anxiety Disorders, 25(2), 258-65.
Sue, D. W., et al. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271-286.
Sue, S., Zane, N., Nagayama Hall, G.C., & Berger, L. K. (2009). The Case for Cultural Competency in Psychotherapeutic Interventions. Annu Rev Psychol., 60, 525–548.