Can transcultural therapy address the issues of racism within psychotherapy?

Current worldwide race relations are not at their best right now. In a study published last year in the American Journal of Public Health, it found that African Americans are almost three times more likely than white people to be killed by the police. Indigenous Americans are also almost three times as likely to suffer such a fate, while Hispanic men are twice as likely. Whilst this is happening in the US, in Myanmar, the Rohingya people are being ethnically cleansed from their homeland by Buddhist aggressors. And meanwhile, in the UK anti-Muslim hate crimes have increased fivefold since the London Bridge attacks in June this year. These examples are just a tiny fraction of the dis-ease that is dominating the world, and provide the perfect backdrop to ask questions about racism within psychotherapy.

It is naïve to assume that the therapeutic relationship somehow can be excluded from the racial tensions in the world; just as the client’s relationships can be played out in the therapy room (transference), why wouldn’t worldwide interpersonal relationships penetrate the therapeutic process?

When we look at the current mental health system, people from black[1] and ethnic minority groups living in the UK are more likely to:

• Be diagnosed with mental health problems
• Be diagnosed and admitted to hospital
• Experience a poor outcome from treatment
• Disengage from mainstream mental health services, leading to social exclusion and a deterioration in their mental health. 

This demonstrates clearly that mainstream mental health services are failing to understand and/or provide services that are acceptable and accessible to black and ethnic minority British communities and meet their cultural needs. These differences can be explained by factors, such as poverty and institutional racism, and highlight that mainstream approaches to counselling and psychotherapy might be so bound up by European assumptions about human nature, that they become irrelevant to people from non-European cultures. Perhaps the influence of slavery, colonialism, and oppression on the development of psychotherapy has been underplayed within the therapy world considering it evolved during the late 19th century when racism was the norm.

For example, racist attitudes were not easily changed after the slavery abolition act was passed in 1833 and, even amongst the well-educated, these ignorant beliefs were difficult to abolish, as reflected in the following quote by Charles Darwin:

'At some future period, not very distant as measured by centuries, the civilised races of man will almost certainly exterminate, and replace the savage races throughout the world. At the same time the anthropomorphous apes… will no doubt be exterminated. The break between man and his nearest allies will then be wider, for it will intervene between man in a more civilised state, as we may hope, even than the Caucasian, and some ape as low as a baboon, instead of as now between the negro or the Australian and the gorilla.'

(Darwin, 1874 in “The descent of man” p.178)

Sigmund Freud’s work was very much influenced by this kind of literature, and later Jung addressed American therapists in the 1920s, with the following; “the American black has what he calls probably a whole historical layer less” (cited by Thomas and Sillen,1972).

During the second world war, doctors and psychoanalyst refugees who were mainly of Jewish origin were a testament to this kind of racism when the British Medical Association opposed their entry to Britain, when fleeing Germany (Littlewood and Lipsedge, 1989). In time psychoanalysis became a private paying contract between the therapist and the patient, which allowed race to be ignored and ignored social contexts in favour of intrapsychic factors. This experience of the Jewish psychoanalysts became a kind of “ethnic cleansing” where they inversely repeated their past experiences so they became the oppressors by developing a therapy which ignored race.

The question for me, is how do we address racism and cultural bias in the therapy world so that it isn’t re-enacted within the therapeutic relationship? As Littlewood and Kareem (1998) rightly suggest, the history of psychotherapy should not be underestimated. For example, how might a black or person of colour feel when confronted with a European/white therapist and European style of therapy? What emotions does it generate for the client to know that they are faced with their historical oppressors, and with whom they may associate a past of colonialism, slavery, and oppression? How is it to be in a relationship which is therapeutic by nature, but stands as a contradiction historically?

Cultural awareness training is the key to raising awareness of these issues and improving counselling competence (Wade and Berstein,1991). I believe as psychotherapists, it is important to explore one’s own prejudices, assumptions, and issues regarding race and racism (Thomas, 1998) so that our cultural story does not unconsciously spill into the therapy room and prompt clients to disengage from counselling services. Therefore, it is important to have the opportunity to explore and work through our pre-transference in a safe and non-judgemental environment before we engage in the therapeutic relationship. Curry (1964) described pre-transference as fantasies and values ascribed to white and black therapists towards the other race.

Thomas (1998) gives an example of the pre-transference being acted out within the therapy room when he recalls an incident with a white child psychotherapist, who said that she could no longer give black dolls to her black children for play work. After exploration, it became evident that she viewed the black dolls as inferior to white dolls and hence could not give the children something inferior to play with. She wanted to protect the black children from their blackness and protect herself from her whiteness. Some therapists may believe that they must protect their black clients from the race issue, as well as themselves.

We must never lose sight of the economic and social interests being served and mediated by covert and overt racism inside and outside the therapy room. If therapists ignore race or don’t deal with it adequately, there is a danger of the therapist and client re-enacting historical racist dynamics, and for the therapist to misjudge ‘political’ resistance as ‘therapeutic’ resistance.

Transcultural therapy addresses this political resistance and challenges the dormant racism within psychotherapy and has been described by McKenzie-Mavinga as:

'An understanding and reflection of diverse and intercultural experiences. In this approach, consideration is given to origins and belief systems that mirror and influence identity, personal experience and the social impact of oppressions, within the therapeutic relationship'

(The Handbook of Transcultural Counselling and Psychotherapy, 2011, p30)

Therefore, transcultural therapy is not about a ‘type’ of therapy for black and ethnic minority people, but is about:

• Becoming aware of our own culture, assumptions, prejudices, and stereotypes
• Working through the pre-transference
• Learning about diverse cultures and their histories.
• Understanding the historical implications of race and racism within counselling and psychotherapy
• Learning about slavery, colonialism, and oppression
• Exploring the impact of oppression and race on the unconscious process,
• Exploring the dynamics of culture, race, and ethnic difference in the therapeutic relationship
• Reviewing our own practice and considering what is multi-culturally therapeutic

The impact of oppression and racism is far reaching for all cultures, past and present; and, it is essential for everyone to have a safe place to explore and heal from the trauma that has been carried by generations.

[1] Throughout this article, I have interchangeably used the terms ‘black’, ‘ethnic minorities’, ‘people of colour’, in the political sense with its origins in the anti-racist and civil rights movements. Whilst the term ‘black’ originally only referred to people of African and Caribbean descent, the word has come to encompass both Asian and Arab people, seeing commonalities in their shared oppression.

Resources

Curry, A. (1964) ‘Myth, Transference and the Black Psychotherapist’. International Review of Psychoanalysis, 45

Darwin, C. (1874) The Descent of Man. Penguin Classics (republished 2004).

Littlewood, R. and Kareem, J. (1998) Intercultural Therapy. Oxford, Blackwell.

Littlewood, R. and Lipsedge, M. (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry, 2nd revised edn. London: Unwin Hyman (originally published 1982)

McKenzie-Mavinga, I (2011) in The Handbook for Transcultural Counselling and Psychotherapy. Eds Colin Lago. Open University Press.

Thomas A. (1998) The stresses of being a counsellor trainer. In H. Johns (ed.) Balancing Acts: Studies in Counselling Training. London: Routledge.

Thomas, A. and Sillen, S. (1972) Racism and Psychiatry. New York: Brunner/Mazel.

Wade, P. and Berstein, B. L. (1991) ‘Cultural Sensitivity Training and Counsellors’ Race: effects on black female clients’ perceptions and attrition’. Journal of Counselling Psychology, 38, 9-15.