by Janice Hawkins, Ph.D., LMSW
Being an Afro-Caribbean American social worker, I have always found it personally difficult to be receptive to therapy. I am by no means exempt from the vicissitudes of life and have entered therapy several times with varying degrees of success. I always start with good intentions, but I am the ultimate resistant client with attitude and too much information. As a black woman, I learned early that authority figures generally could not be trusted. I learned to distract them from focusing on my issues with my sense of humor and an outgoing attitude. I knew instinctively that it was important to look okay so “they” left me alone.
Growing up in a household with Afro-Caribbean parents, I was brought up to neither share confidences nor admit emotional pain to outsiders. The personal disclosure and behavioral changes that therapists typically suggest were often embarrassing and totally unimaginable to me even from a cultural point of view. Most women from my background would rather “handle their own business” than seek outside help from a stranger. It was considered an embarrassment to one’s family and upbringing to admit that any issue is so severe that only a “head doctor” could help.
As a social worker for a city agency, I was called in by a coordinator of a teen mother program to interview a teenage mother. According to the coordinator (who was Black American) and the social worker (who was Latino), there was “something wrong” with the girl. She would not carry through on instructions although she was a pleasant quiet girl who never said “no.” When I spoke to her, I recognized that as the youngest member of her household, she could not make decisions. Her grandmother would have to be consulted, as she was the family matriarch. Despite the teen mother’s age (18) and her motherhood, she was still considered a child in her culture (Guyana) and behaved as such. The program coordinator remained resistant, stating she had to change because “she is in America now.” Disclosing personal problems to a counselor (“stranger”) could not only be seen as a sign of weakness, but also as leaking family secrets. Personal matters that cause pain or discomfort are only discussed with family members and very close friends. As an indirect result, parents and other extended family members exert considerable influence on important decisions, such as career choices and choice of marriage partners, assuming an unusually strong role in structuring and directing response to stress and stressful situations.
Culture and ethnicity have been well documented as key factors in the psychotherapeutic process. Even if therapists are aware of the variations of African diasporic cultures, they can mistakenly think that individuals from those cultures prefer to be called “African American.” The term “African American” is commonly used to refer to individuals who share historical ties to the west coast of Africa, and to experiences of slavery. African Americans are diverse with respect to appearance, religious affiliation, socioeconomic status, sexual orientation, cultural expressions, family composition, and geographical origin. But black people from the Caribbean, South and Central America, and Canada speak different languages and/or different versions of English and may consider themselves to be black but not African American because of vastly different historical and cultural experiences (Liggan & Kay, 1999).
Generally speaking, in family systems of African descendants, family members assist each other with child care, finances, emotional support, housing, counsel, and so forth, particularly in times of trouble or stress. Families are considered to extend to non-blood related relatives, such as neighbors, babysitters, friends, ministers, ministers’ spouses, and church family, with ties as well as bio-family members (Evans & Davies, 1996).
Standard Therapeutic Beliefs About Counseling and Family
Cultural consideration must be part of the therapy, as cultural issues will emerge under pressure of the process. The lack of knowledge of a particular client’s culture and family dynamics could delay or harm the therapeutic process. A client’s behavior that is labeled resistant may simply be a lack of recognition of the client’s world view. Part of our job as social workers is to understand the client’s world to the degree that we see their behavior for what it is.
Many standard therapeutic paradigms discourage developing a personal relationship with a client, because of the possibility of transference of feelings from the therapist to the client and vice versa (NASW Code of Ethics, Sec. 1.06c). This approach to therapy appears to be based on an assumption that all people, regardless of race, ethnicity, or culture, develop along uniform psychological dimensions and respond in similar ways to interactions. This assumes that there are no cultural biases in outcome between dissimilar analysts and clients.
The lack of understanding of a culturally different client’s values and motivations, or the assumption that they are the same as one’s own, can be a chief cause of resistance in the client (Comas-Diaz & Jacobsen, 1991). Studies of treatment outcomes seem to substantiate an assumption that therapy is often ineffective with black clients because their self identified view is crisis-oriented and non-introspective, valuing environmental change rather than personal change, independence, and self-actualization (Liggan &Kay, 1999).
In many cases, when clients come to the attention of government agencies and are judicially mandated to therapy or other programs, it is easy to forget they neither asked for nor wanted help. Part of the initial negotiation becomes to convince them that they need help and that we are the ones to give it. As humans who are also clinicians, we tend to see—based on our training and personal viewpoints—what we expect to see and behave toward other people as though they are the people we expect them to be. We project a mental model on the client and may behave in a way that is appropriate for our internal model, but inappropriate to the reality (Hughes & Kerr, 2000). In interracial or intra-cultural therapy, our internal preconceptions about the client can be devastating to the therapeutic relationship.
It is not possible to discuss intercultural and/or interracial therapy situations without discussing racism. Racial discrimination is a phenomenon that African Americans experience in both blatant and subtle ways almost daily. Counseling is no exception to this phenomenon, despite the well-meaning intentions and efforts of therapists who believe they would never deliberately act in such a manner toward their clients. Even when therapists receive extensive multicultural training, racism can still be manifested unconsciously in the counseling process (Constantine 2007).
Social scientists describe it as the “illusion of color blindness,” in which a therapist may assume that the black patient’s culture is the same as that of the therapist’s own culture, disregarding the importance the patient’s blackness has for him or her. This can also ignore the impact of the therapist’s culture on the patient, detracting from the patient’s sense of the social realities of his or her experiences (Liggan & Kay, 1999). A less obvious form of racism, known as aversive racism, is characterized by the harboring of unconscious negative racial feelings and beliefs toward people of color, despite the fact that the person may perceive him- or herself as egalitarian, fair, and nonracist. Aversive racism is expressed via subtle, commonplace exchanges that somehow convey insulting or demeaning messages to people of color (Constantine, 2007).
It is vitally important that therapists who work with African Americans be self-aware. In addition to taking courses to learn about the African American experience, therapists should identify any sources of uncertainty, discomfort, anxiety, bias, or cultural baggage that they might have (Comas-Diaz & Jacobsen, 1991).
African Americans are very cautious about seeking mental health services. Historically, those individuals who sought services were pathologized, overmedicated, given long-term and inpatient treatment rather than outpatient treatment, and were exposed to insensitive therapists who did not believe African Americans could benefit from verbal therapy. When African Americans obtain assistance and meet with a white therapist, they are often fearful that these therapists will be biased, use stereotypes, minimize the clients’ experiences of discrimination, and not understand cultural traditions (Comas-Diaz & Jacobsen, 1991)
Today, non-Hispanic whites make up approximately 90% of mental health providers in the United States, whereas racial and ethnic minorities are projected to make up 40% of the U.S. population by 2025 (Ida, 2007). Regardless of race, 40% of clients attend one session and drop out, and the remainder typically end therapy after four or five meetings. African Americans drop out at rates higher than 40% (Liggan & Kay, 1999).
It is important for social workers to connect with clients on the basis of the client’s reality rather than the social worker’s agenda. When the social worker connects with the client’s perceptions in the beginning of the counseling process, the social worker might lessen client resistance. Also important is to have mutually agreed-upon goals. It’s all too easy for social workers to establish a goal for the client that the client either isn’t aware of or doesn’t agree with (Shallcross, 2010).
Most current training programs do not integrate exploration of therapists’ attitudes regarding race, class, and [their] personal bias/discrimination into the curriculum. If future therapists had to examine and confront their views regarding racism and discrimination early on in their training, and reflect on evidence about how such attitudes affect the development of the therapeutic alliance and client outcomes, training programs might generate practitioners more in tune with the realities and perspectives of minority clients. Initiatives to make training programs more accessible to non-white populations and increase diversity within the mental health field can provide a long term solution to facilitating dialogue about techniques to best establish trust and understanding between therapists and clients from different racial and ethnic backgrounds (Cabral & Smith, 2011).
Cabral, R., & Smith, T. (2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions and outcomes. Journal of Counseling Psychology, DOI: 10.1037/a0025266.
Comas-Diaz, L, & Jacobsen, F. (1991). Ethnocultural transference and countertransference in the therapeutic dyad. American Journal of Orthopsychiatry, 61 (3), 392-402.
Constantine, M. G. (2007). Racial microagressions against African American clients in cross-racial counseling relationships. Journal of Counseling Psychology, 54 (1), 1-16.
Evans, H., & Davies, R. (1996). Overview issues in child socialization in the Caribbean. In Caribbean families: Diversity among ethnic groups, ed. J. L. Roopnarine and J. Brown. Greenwich, CT: Ablex.
Hughes, P. & Kerr, I. (2000). Transference and countertransference in communication between doctor and patient. Advances in Psychiatric Treatment, 6, 57–64.
Ida, D. J. (2007). Cultural competency and recovery within diverse populations. Psychiatric Rehabilitation, 31 (1), 49-53.
Liggan, D., & Kay, J. (1999). Race in the room: Issues in the dynamic psychotherapy of African Americans. Transcultural Psychiatry, 36 (2), 195–209.
Shallcross, L. (2010). Managing resistant clients. Counseling Today, February 14 2010.
Janice Hawkins, Ph.D., LMSW, earned her master’s degree in social work administration at Columbia University and her Ph.D. in public policy and administration from Walden University. Janice gained extensive experience during her tenure at ACS through several administrative roles, including direct casework on high-risk cases, development of training for staff, and assisting in creating ACS’ first federal cost allocation plan. She lectures nationally on child abuse and neglect, ethical social work practice, and recognizing the importance of spirituality and ethnicity in social work intervention. She is a former recipient of National Association Social Workers, Black History Month Outstanding African American Social Worker, 2009/2011.