Racism can – and often does – show up in therapy.

It may be a BIPOC (Black, Indigenous, and People Of Color) patient dealing with racially based trauma. It could be a white patient unwittingly expressing racial prejudice. It may happen as a therapist’s internal response to a patient that manifests his or her own subconscious racial bias.

“I’ve often struggled to bring up race and racism when working with therapists who are not Black,” writes Sojourner Ahebee in Rewire. “I’ve noticed a pattern of writing off Black people’s experiences with racism as an overreaction. And the labor of having to withhold salient aspects of one’s identity as a Black person in therapy is stressful in and of itself.”

In whatever form the subject of racism surfaces, therapists must determine whether they should address it and, if so, how.

Race-Based Biases and Treating BIPOC Patients

For many African Americans, the resistance to revealing oneself to a therapist runs deep. The roots of this discomfort is described by the non-profit Boris Lawrence Henson Foundation:

“African-Americans are the least likely population to seek treatment. We were taught to hold our problems close to the vest out of fear of being labeled and further demonized as inapt, weak, and/or inadequate. African-Americans also have a history of being misdiagnosed, so there is mistrust associated with therapy.”

All therapists, being human, have ingrained attitudes that may cause unintended discrimination.

“A quarter-century ago, social psychologist Anthony Greenwald of the University of Washington developed a test that exposed an uncomfortable aspect of the human mind: People have deep-seated biases of which they are completely unaware. And these hidden attitudes –  known as implicit bias – influence the way we act toward each other, often with unintended discriminatory consequences,” according to an article on PBS.com. “Today, implicit bias is widely understood to be a cause of unintended discrimination that leads to racial, ethnic, socioeconomic and other inequalities.”

Recognizing inherent biases, therapists can show up for their BIPOC clients and provide support in ways that do not worsen racially based pain.

Creating a safer therapy space for BIPOC clients can happen in a variety of ways:

1. Educate yourself on issues of oppression – OUTSIDE of the therapy room.

The therapy room needs to be a safe space for Black clients. If you depend on your clients to teach you about oppression, you are shifting the focus away from the client’s needs and onto your own.

“Do not expect your Black colleagues, mentors, friends, or family to explain the history of racism and institutionalized bias to you. This is known as emotional labor because it puts an exhausting burden on an already oppressed group. Put in the effort to educate yourself,” writes therapist Annette Miller in Medium.

2. Recognize and address ways that you may be committing microaggressions.

A microaggression is a subtle, often unintentional, form of bias, that whether or not they are intentional, can denigrate BIPOC patients. “Microaggressions can be communicated verbally or nonverbally, intentionally or unintentionally,” writes Priscilla G. Wilson in Counseling Today.  “Cultural awareness and introspection are two tools that can help counselors become cognizant of microaggressions and address slights that may occur in the counseling relationship.”

3. Make clear to your BIPOC clients that you recognize the impact of racial trauma.

In a Zencare blog post, Dr. Melba Sullivan, a New York City psychologist, recommends validating how a client interprets a situation, considering systemic racism, acknowledging the client’s pain, and teaching self-compassion.

Telling patients that you “don’t see color” can be detrimental to the therapy session as it may “prevent therapists from noticing how race actually affects a client’s lived experiences; it allows therapists to ignore racial trauma, and/or be dismissive of a client’s reality,” according to the Zencare blog.

Further, according to an article by Dr. Jessica Jackson in Mental Health Match, “telling a client that you do not see color is essentially telling them that you do not see the totality of who they are. It is not polite, it not good etiquette, it is not a compliment.”

Therapists should acknowledge “the pain and possibility that race mattered in the interaction,” says Dr. Sullivan in the Zencare blog.

4. Express your awareness of differences and your commitment to inclusivity.

Simple actions and meaningful inclusion practices can help Black clients feel more supported in the therapy room. We talked about how inclusivity can be used to help LGBTQ clients in a previous GeneSight blog post.

“Culturally responsive therapy requires … empathy to truly understand and conceptualize how the client’s social identities interact and influence the client’s perception of their distress,” Dr. Jackson writes in Mental Health Match.

5. Self-disclose mindfully.

Sharing information about your family life or your true reactions to a client’s experience of racism and oppression can build stronger bonds between you and your client. But it also can shift the conversation away from the patient and onto you.

According to the Society for Psychotherapy, Dr. Richard Schwartz urges therapists to use the acronym WAIT (Why Am I Telling?) before disclosing personal information in a therapy session.

The Open Colleges blog provides additional guiding principles for therapists to consider after asking themselves WAIT: Be brief, use ‘I’ Statements, think about your client’s values, and consider the impact of what you’re about to disclose.

6. Acknowledge this work is hard and keep doing it anyway.

“As hard as it is to hear a client say, ‘you just don’t understand me,’ continuing to invest the time and energy into understanding their own privilege and experiences can help non-POC therapists and how they provide treatment,” Dr. David Dove, a Providence-based psychologist tells the Zencare blog.

When Patients Express Race-Based Prejudice During Counseling

It may be an awkward moment when a patient says something racially insensitive during therapy.

“As much as we want to protect the therapeutic relationship, we can’t pretend that we therapists aren’t shaped by our own cultural identities, just like our clients are, and that this doesn’t affect what happens in the therapy room,” says POC Anatasia Kim, PhD in Psychotherapy Networker. “After all, if we uttered something our clients perceived as offensive, wouldn’t we want them to speak up?”

Dr. Kim tells the story of a client named Rebecca, a 17-year-old white girl from an affluent school, whom she liked and had worked with for a while. The girl entered Dr. Kim’s office in a frenzy and moaned about how she didn’t have a shot at the colleges she wanted because of the competition. Then she singled out one high-achieving girl with impressive scores and activities, and blurted that because the girl was black, she’d get in. The patient complained about how unfair that was.

As the patient continued to rant, Dr. Kim deliberated whether or not to say something. She decided that, since she’d been troubled by what the patient said, it would be constructive to speak the truth of her experience, in as mindful a way as she could.

Before she spoke, she asked herself a series of questions:

“What is my goal in the conversation?”

As a therapist, the focus needs to be on showing up for your client in ways that focus on their healing journey.

“Are there barriers standing in my way?”

Sensitive topics can make a client uncomfortable. Be sure to determine whether the risks are deliberate and thoughtful.

“How am I going to anchor myself during the conversation?”

Staying grounded in your professional and personal values, even if the client has a difficult reaction, will keep you from letting your potential emotions to get out of hand.

“Okay, so how do I bring it up? What do I say?”

Dr. Kim suggests reflecting and affirming the client’s experiences and feelings before presenting the sensitive information.

In Dr. Kim’s situation, bringing up the statement that bothered her led to a productive, reflective discussion about prejudice.

“Not all clients will be as open and receptive as Rebecca, and not all therapists will choose to speak up in every instance,” she says. “But when we decide to say something – with goals, barriers, and anchors in mind – the possibility that it will enrich our relationships is boundless.”

Therapists Can Be Part of the Solution

People from marginalized groups carry a burden that impacts their lives in multiple ways. “Racial violence and discrimination are woven into the fabric of the United

States. The way policies and laws are implemented. The weaponization of Whiteness and privilege. Disparities in education and health care. The horrible and senseless killings of Black people throughout our nation’s history and into the present day,” according to an article by Lindsey Phillips in Counseling Today.

The burden of racial inequity impacts the mental health of Black Americans. It’s a threat to personhood and can lead to a sense of powerlessness. Therapists have skills in building trust and rapport that can be used in therapy, and potentially can impact how the system of oppression operates.

According to Phillips, “counselors play an important role in helping Black Americans cope with and heal from racial stress and trauma, but they can do more. Namely, they can also take steps toward changing an unjust and racist system that powerfully and negatively affects the mental health of Black Americans.”

If you’d like to learn more about unconscious bias and racial discrimination in mental health, read these GeneSight blog posts:

• https://genesight.com/blog/healthcare-provider/is-unconscious-bias-impacting-your-treatment-of-black-patients/
• https://genesight.com/blog/healthcare-provider/racism-discrimination-and-mental-health/