African Americans
and Psychotherapy

Race in the Therapeutic Relationship

Little has been written about race and ethnicity in the therapeutic relationship. Some suggest that less attention has been paid to this issue because patients and therapists of color are themselves underrepresented. According to this perspective, the dynamics of race and ethnicity are understudied because most therapists are not familiar with the clinical issues presented by such clients.

However, this rationale treats race and ethnicity as if they were qualities possessed only by people of color and ignores the fact that all patients have a race and an ethnicity, including the (typically) European American therapist and the African American client. This reminds me of the puzzled looks on the faces of my White psychology students when asked to complete a questionnaire about ethnic identity. Many students had no idea how to answer questions about their ethnic identity. One benefit of majority White status in the US is the privilege of forgetting that one belongs to an ethnic group at all.

Cultural Mistrust

African Americans have a greater distrust of the medical establishment in general, and many believe medical institutions hold racist attitudes. This goes all the way back to historical abuses of slaves by White doctors for medical experimentation; Blacks could neither consent or refuse to participate because of their low social status and were frequently victimized, even to the point of being used as examples of surgical techniques for medical students. Events such as the Tuskegee Syphilis study, confirmed the need for suspicion in the minds of many. Correspondingly, African Americans are reluctant to participate in medical research and are even today underrepresented in many medical treatment studies.

Cultural mistrust is linked to the underuse of vital mental health care services, leaving many without needed care. Black Americans may fear mistreatment, being hospitalized involuntarily, or being used as research "guinea pigs." Black people who regularly encounter prejudice may develop what has been termed "healthy paranoia" — a cultural response style based on experiences of racism and oppression in White society. Concern about being judged or improperly diagnosed may lead many African Americans to exercise excessive caution or avoidance of mental health care altogether. This reaction has lead some clinicians to over diagnose paranoia in suspicious Black patients, perpetuating the cycle.

Therapist Factors

As much as psychologists hate to admit it, prospective Black patients are right to be cautious. Ethnic and racial stereotypes often affect therapeutic relationship, and not always to the client's benefit. The therapist's reaction to the patient can be complicated by unacknowledged prejudice, stereotypes, and feelings of guilt. An honest discussion of ethnic and racial factors in the therapeutic relationship can increase trust and mutual understanding, leading to a more rapid unfolding of core issues. However, many therapists are unsure how to approach racial differences, and may prefer a "colorblind" approach.

Colorblindness Is Not the Answer

A colorblind approach merely relieves the therapist of his or her obligation to address racial differences and difficulties.

Colorblindness is actually a form of racism. A colorblind approach allows the denial of uncomfortable racial and cultural differences. "Blind" means not being able to see things, and it's been said that wanting to be "blind" to color or race means wanting to ignore race or pretend its social and historical effects don't exist. It ignores the experience of being stigmatized by society and represents an empathetic failure on the part of the therapist.

Many White therapists I have encountered have minimized the importance of acknowledging cultural issues in the therapeutic setting, ascribing to the doctrine of colorblindness. One colleague told me, "There is no scientific difference in the way Blacks and Whites habituate to stimuli," reducing the substance of treatment to brain chemicals and conditioning theory. This approach fails to account for the very real differences in experiences and expectancies of Black Americans. Colorblindness merely relieves the therapist of his or her obligation to address racial differences and difficulties.

The Black Patient and White Therapist

Undoubtedly, psychotherapy with a culturally different patient provides more opportunities for empathic stumbling blocks. Minority patients may be sensitized to racial insults, resulting in negative attitudes toward the therapist. Additionally, Black clients often evoke more complicated reactions from the therapist than White clients since stereotypes of Blacks make them easier targets for therapists' projections.

I once observed the assessment of a Black patient by a senior therapist who was White. The patient was nervous, talking excessively, fidgeting, and getting in and out of his seat. At one point, the therapist said "down boy," to calm the patient, which the patient (rightly) felt was degrading. The patient's offense was interpreted by the therapist as a sign of defensiveness which would therefore make him a poor candidate for psychotherapy, and the patient was denied treatment (Terwilliger et al., 2013). The therapist failed to understand the depth of insult embedded in the remark, as the term "boy" has been used historically to demean African American males.

The Dilemma of the Black Professional

When disadvantaged minorities present for treatment, it is not hard for a White therapist to understand difficulties that may be linked to low income, lack of education, crime-infested communities, and single parenthood. However, Black professionals seeking treatment can be challenging for White therapists who may not understand all the layers of difficulty such patients experience. Social psychology research has shown us that majority group members often attribute minority success to luck, racial hiring policies, or other external factors, while attributing failures to laziness, stupidity, or negative character traits.

A Black person's performance may be evaluated in a negative or hypercritical fashion, involving intolerance for even small mistakes, and a tendency toward denying professionals of color respect or the presumption of competence. Also called "the qualification question," this response involves the suspicion that all professionals of color achieved such status because of affirmative action policies and not because of merit. One example that comes to mind is a situation in my workplace where there was a communication error between the members of our research team due to recent staff turnover. Deemed my mistake, I was reprimanded by my supervisor who questioned my competence by wondering aloud whether I had actually graduated from MIT (my undergraduate alma matter). Black professionals may struggle with the stress of these attitudes in the workplace, yet be unable to effectively communicate their concerns to a therapist out of concern (rightly or wrongly) that a White therapist may share the same views.