Racism: A Challenge for the Therapeutic Dyad

A patient’s race and zip code influence health care delivery more than any other variables. Mental health care disparities faced by members of racial-ethnic minority groups, Medlock et al. (1) contend, include “inequities in access, symptom severity, diagnosis, and treatment,” as well as in treatment outcome. Removing the socioeconomic barriers to access does not level the health care playing field. Data on the significant effects of racial bias in mental health care delivery are overwhelming, too wide-ranging and copious to enumerate. In her riveting analysis, The Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century, legal scholar Dorothy Roberts writes, “Race is not a biological category that naturally produces health disparities because of genetic differences…[but] a political category that has staggering biological consequences because of the impact of social inequality on people’s health” (2).

The effects of racism permeate all levels of our health care system, regardless of the arena of medicine or psychiatry being practiced (3). Racism manifests in many forms, from individual discriminatory acts, to structural barriers, to beliefs based on unconscious ideas. We in the helping professions wish we were exempt. As mental health clinicians, we aspire to offer our patients, through treatment, an opportunity to achieve fuller and healthier lives—as Freud said, at work and play—but our own unconscious scripts guide us too. Unconscious racism in the form of derogatory unconscious race fantasies about Blackness restrict our view when we least expect it (4). Are Black patients with psychiatric illness really more dangerous than white counterparts and more likely to need involuntarily commitment (5)? Is a psychotic Black male patient more likely to have schizophrenia than bipolar disorder (6)? Why are the therapists’ response rates to patients’ call for treatment slower if the callers are perceived to be Black (7)? Why are Black patients who experience anxiety disorder or depression less likely to receive care that adheres to established guidelines (8)? Why are young Black males perceived as older, more mature, and more dangerous than white age-matched counterparts (9)?

Unconscious racism, what we now call implicit bias, affects the practice of psychotherapy on many levels (1, 10). Racial bias influences whom we see in our offices or clinics and with whom we are comfortable in the consultation room. Bias affects how we diagnose and who makes it to our office to receive a diagnosis. It influences whether we recommend medication, which medications we prescribe, and in what doses. It affects our research protocols, including who and what is the priority of scientific study. It affects whom we deem appropriate for psychotherapy and who we think has the ego resources to benefit. It influences how we see race in the transference or in the supervisory relationship—or whether we are blind to it as an entry point for treatment. In all of these cases, racialized thinking can be explored and understood psychologically and can be a subject of inquiry.

Even if we manage to initiate therapy, the literature teaches us that trust is a fundamental obstacle affecting interracial treatments (11). It can be gained through effort from both sides of the dyad. Still, we are haunted by the ghosts from the Tuskegee experiments and the Sims gynecological procedures, two examples of unethical medical practices cited in Harriet Washington’s startling book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present (12), a work that barely scratches the surface in the long history of racist medical practices. This history is painstakingly detailed further in Byrd and Clayton’s encyclopedic compilation An American Health Dilemma: Race, Medicine, and Health Care in the United States (1900–2000) (13). Centuries of racist medical practice dating back to slavery dwell in the collective unconscious among people of color, perpetuating the cultural paranoia that obstructs care and trust.

The stress of racial discrimination exacts a biological toll on Black and brown bodies, thereby adversely affecting overall health, argues Yale historian Carolyn Roberts (14). Experiencing discrimination is associated with stress and self-reports of ill health (15). Accordingly, if patients from minority groups are matched with providers who do not acknowledge the realities of discrimination nor the challenges of living in a racialized society, the quality of care suffers (16). Studies document higher patient dropout rates for interracial therapy dyads (17). Clinician education; cultural sensitivity; and understanding of “racial or ethnic identity, cultural values, cultural mistrust, [and] therapist cultural competence and worldview…may moderate the [potentially limiting] impact of racial differences” (18).

In the practice of psychotherapy, understanding how the psychodynamics of race, racism, and discrimination are encoded in the derogatory unconscious fantasies held about Black people in our culture can open a multiplicity of rich entry points for interpreting transference and countertransference. The fragmenting toll that discrimination can take, whether manifested as physical symptoms, depression, or anger, can be one reason a patient might seek medical care, including psychotherapy. A patient whose racial trauma, for example, causes fractures in the sense of self may find racial trauma superimposed on or fundamental to a sense of brokenness, badness, or inferiority. In these cases, connection and identification in the transference with a therapist of color, if artfully explored, can be fruitful and healing to the patient. Exploration and analysis of racialized transference dynamics can also uncover damaging effects when racial trauma coincides with key developmental nodal points in childhood or adolescence.

Reports of racial violence in the media disproportionately affect patients of color, triggering anxiety and reviving trauma for which psychotherapy can be an important supportive intervention. In 2018, Lancet published a study by David Williams’s group at Harvard examining mental health reports of African Americans and data on shootings of unarmed Black men in the United States (19). Data correlation revealed that every time an unarmed Black American was shot, the mental health of African Americans in that state was adversely affected for 3 months. Could these findings guide research on what an appropriate community intervention might look like? Consider that over 2,000 Black Lives Matter demonstrations shook the country this summer in response to what, in effect, was a lynching of George Floyd by Minneapolis police and to the deaths of 300 African Americans per year that have been attributed to police shootings. The people involved in the demonstrations crossed race, class, gender, and national boundaries, and in my office almost every patient I saw contemplated the question, Do Black lives matter? Race, as a transference variable, can be a powerful entry point to explore deeper conflicts around vulnerability and early trauma that transcend the specific racial composition of the therapeutic dyad.

In my experience as an educator, well-trained and well-meaning therapists are often mystified about how to talk about race and how to recognize the way racism infiltrates psychotherapy. Historically, this subject has not been covered in clinical training programs or supervisions. It has not been addressed in clinicians’ personal therapies or analyses. As a result, it is easy for therapists and patients alike to become unknowing victims of an enactment. In our private offices, it is also easy to settle into our privilege of blindness to the effects of disenfranchisement.

For white psychotherapists who are not comfortable exploring issues of race, this is treacherous territory. Anxiety inhibits their ability to deepen the treatment and threatens the working therapeutic alliance. Therefore, greater clinician training and self-study are needed. For white patients questioning parental or family attitudes around race, psychotherapy can provide a space to maneuver the conflict-laden terrain so as to retain the parental and familial love but excise and renounce a family member’s racist attitudes. Race can also permeate the transference as a connector to other conflicts. For example, for a white patient whose life narrative reveals a privileged social position coupled with parental emotional neglect, the fantasy of the Black female therapist as caregiver or maternal object or as a displacement from a beloved nanny might activate in the transference the pain around narcissistic failures in the patient’s family of origin. These are but a few examples of the ways race can permeate treatment; the possibilities are endless because all of us are affected in multitudinous ways by living in a racist society.

White therapists are often intrigued and surprised to find that they have not recognized the racial dynamics in same-race (white therapist, white patient) therapies; training and supervision never afforded them the tools to make better sense of these issues in treatment. Latent references to race often hide important entries to deeper conflicts as well. Even if the transference is not directly interpreted, therapists can develop an understanding of the ways race affects the therapeutic relationship and treatment compliance. Young trainees want educational programs to address these issues because their patient population is increasingly diverse and multicultural and because racism, in our culture, is all around us. And, yes, some “racist thinking” can be amenable to psychotherapeutic treatment. It is always illuminating after teaching on this topic to receive calls from therapists who now are beginning to hear and see issues of race emerge in treatment.

Racism robs our nation of rising to a greater humanity at all levels. We need racial equity and racial justice in the streets, in the courtrooms, in the classrooms, and yes, in our health care system. That space is given for commentary on the subject in the American Journal of Psychotherapy advances discussion about racism within the mainstream educational conversation. Hopefully, space will be given in future issues to bring scholarly focus to this clinical work and research. But change, as psychoanalytic theory teaches us, comes from within before it comes from without. Psychotherapy and psychoanalysis offer an opportunity for that personal change on both sides of the therapeutic dyad.