Two years ago, I saw a posting on a listserv I am a member of requesting a “mid-40’s, transgender female, Taiwanese-American Therapist.” This request was so specific that I had a hard time envisioning how many people could actually respond as an appropriate fit. Requests that are exceedingly demographically specific seem increasingly common to me. Patients sometimes come to me, in fact, because I am a Latino male, and they feel that I will best understand them. There is a reality that there are certain commonalities within the Latino community that I know well. It is also true that there is a wealth of diversity within the Latino population and my “Latino-ness” is different from theirs.
On the surface, it makes sense: people want a therapist that they feel that they can relate to and who will understand them. But this is more than that. I believe that it represents a larger problem, which is the difficulty that people who belong to dominant cultural groups have in talking about difference with sophistication and awareness. Patients of color are more concerned about whether or not their white therapist will believe them and honor their experience as real. (For practical purposes, I will talk only about race/ethnicity in this article, but the concepts are broadly applicable).
I believe that the abundance of particularly demographic-specific therapist requests represents a failure on the part of psychotherapy as a field and of individual psychotherapists, especially those that are part of a dominant group (such as being White, male, cisgendered, or heterosexual) to address cultural identities. We are failing our patients.
The psychoanalyst Kimberlyn Leary once said that therapy is an environment in which we can talk about our sexual fantasies toward our mother and murderous rage toward our father, yet race and culture are often too taboo to bring up. When one is a member of the dominant culture, it is easy to be unaware of realities that others face. There are a number of reactions that a white therapist can have when a person of color discusses racism. Those experiences can be overlooked, misunderstood, minimized, or defended against. Alternatively, the white therapist goes into a hyperactive mode of trying to save the patient, by appointing themselves as the patient’s advocate (implying powerlessness) or directing the patient toward action which I call “Dances with Wolves Syndrome.”
Patients need to know that what they feel and experience is important. People of color are often hesitant to discuss experiences of racism with white people. Amongst other people of color, these discussions may occur frequently. There is a feeling of acceptance and mutuality. There is a feeling that one need not go to great lengths to make themselves understood and that not only will the other person understand, they will be able to relate to the experience and offer affirmation and kinship. People of Color may feel that it is too dangerous, with the danger being rejection, to bring up these issues with white people, including (or maybe especially) their white therapist.
I was co-leading a therapy group for “high-risk sex offenders” mandated to treatment with another therapist, a white middle-class man. During one session, a young African-American male from west Oakland, who had just been released from San Quentin, was talking about a family gathering after a church service. He asked my co-leader if he went to church. My co-leader became anxious and refused to answer. It was dismissive, defensive, and off-putting. The patient needed some minor self-disclosure to establish trust and engage with someone that he knew was very different. The therapist missed an opportunity to discuss race, class, religion, and family and the influence that they have had on this young man. The patient received the message: “I am not like you. I am different and better.”
There are several things that therapists can do. Just as with topics related to intense feelings of hatred or eroticism, we need to help the patient articulate an experience that is difficult for them to consciously name or discuss. We need to:
- Listen carefully to subtle content related to race. These may be invitations to talk more about a topic, or may be tests to see whether a not a therapist is able to discuss race. By bringing something more explicitly into the conversation, and/or consciousness, we are saying that we encourage and welcome such discussion. Alternatively, when we do not “take the bait,” we send a powerful message to patients that “those things” cannot be talked about.
- Listen carefully to the absence of comments about race when it seems appropriate. As therapists, we are trained just as much to listen to what is not said as much as what is said. When a patient tells a story in which race is quite relevant, or it seems relevant to us, it is important to note that the patient did not bring it up. There are many interventions that can be made here. If you feel that the patient is defensive and externalizing, the therapist can simply introduce the topic gently. If there is good rapport, a process-interpretation or comment may be appropriate: “When you were telling me what happened, I thought that perhaps security may have harassed you because you are Black, but I notice that you did not even mention that aspect of the story. I wonder if it does not feel safe to discuss that with me.”
- Use countertransference. Sometimes we may feel an inclination or desire to talk about race in a given moment, but may be overcome with fear of concern that it would be inappropriate, offensive, or upsetting to the patient. That feeling is co-created in the intersubjective experience of the patient-therapist dyad. It may actually be a communication not only of the therapist’s own discomfort in talking about race, but may also suggest that the patient feels unsafe in discussing it and needs our help it bringing it into their consciousness.
- Be curious and humble. Being culturally sensitive and aware is not about knowing everything about other cultures and their values. It’s certainly not about going to Gay Pride one year or the 14 days you spent in Hanoi 2 years ago. It’s far more about an openness and receptivity. It’s about being willing to listen and hear without necessarily putting people into a category or a box. All you really need to be able to do is listen attentively and with respect and try to understand. That also means that sometimes you have to tolerate the patient’s hatred for your privilege, whether that is identified as your race, class, sexual orientation, or anything else.
While many people will likely continue to search for therapists who match important parts of their own cultural identities, it is essential that we create a safer space to discuss challenging and sometimes uncomfortable issues. It often involves taking the initiative to non-defensively bring the topic to the forefront and face our own discomforts to help the patient explore something incredibly important. Perhaps it is idealistic, but I think reading more requests like, “ISO a good therapist” would be nice.