Sensitive Clinicians and Ethnically Diverse Clients
When dealing with a patient who comes from an ethnically diverse background, there are many factors that a sensitive clinician has to take into consideration. A person’s ethnic background largely shapes how they go about constructing their world. Therefore, understanding the dynamics of that culture is an important tool in understanding the unique experience of your client. Interestingly, however, a central factor in conducting therapy with ethnically diverse clients is understanding how one’s own (the clinician’s) ethnic identity is perceived in the room. When conducting treatment, a clinician may avoid addressing the obvious differences that exist between herself and the client, fearing that doing so will create some divide or barrier. Instead, the clinician may try to bridge the divide between client and therapist by identifying the ways in which the two are similar, despite their differences. This appears to be a common route taken by new clinicians, especially when attempting to build an alliance with younger clients. There are several dangers in approaching the therapeutic relationship in this way, as perceived similarities harbor the potential for conflict. A client may feel a lack of validation by the therapist if told that their experiences are similar. The marginalization and oppression felt by many minorities is not something that has a counterpart in the life of a privileged, white therapist. If the clinician is a woman, though she most likely has experienced marginalization and oppression due to sexism, it is unlikely that drawing this parallel will make her client feel more validated. Instead, the client may feel as though something about her identity, about her unique experience and struggles, has been “taken away” and grossly misunderstood.
If bridging gaps causes a divide, why do clinicians seek to find common ground? Part of the answer may involve the social privilege of the therapist, of which both the clinician and client are aware. This may lead to a sense of guilt or shame in the therapist leading to a denial of the difference and a focus upon perceived similarities. Therefore, it is important for the clinician to be aware of the differences that do exist between the client and herself and for her to not be ashamed of her position. This will allow her to examine what the differences mean to her client, how her client’s world is constructing. For example, one white, female clinician, during the course of her training, had an adolescent black male as a client. When he asked her if she was Jewish (him being Catholic), she revealed that she was but that Jewish people believe in God, like Christians. This was her attempt to strengthen the alliance between herself and her client. However, she may have benefited more by asking what her being Jewish would mean to him.
Understanding the client’s construction of their world is also important when it comes to assembling a psychodynamic case formulation of their presenting problems. As psychodynamic theory was largely conceptualized in a European and Western framework, applying it to other dynamics may result in misinterpretation or misapplication. For example, applying the theory to an extended Hispanic family may pose problems. In such an instance, a child may be raised by a mother, siblings, aunts, and grandparents. Clearly, the family dynamics of such a household would differ substantially from the nuclear families of Western society. Application of the conception of the Oedipus complex to such a situation requires some finesse. The traditional conception involves a struggle between the child, the mother, and the father. In a situation where other primary caregivers are included, the triad may become more complicated. This is an interesting idea that requires much more thought than can be achieved in a short essay. However, it is important to begin thinking about these unique dynamics.
A final consideration in dealing with ethnically diverse clients is being aware and mindful of unique expressions of mental illness that may be common to a particular culture. For example, the Puerto Rican expression of depression, especially in Puerto Rican women, is markedly different from the symptomology presented by in Western, Anglo culture and typified by the DSM. Rather than presenting with loss of interest or pleasure in daily activities and hopelessness that typifies a Western conceptualization of depression, Puerto Rican women come to therapy with a variety of somatic complaints, including tension, headaches, and muscle fatigue. In each case, the client may view some part of the self as being damaged due to the internalization of some critical love object (McWilliams). Yet, the expression is dissimilar. Puerto Rican women are discouraged from engaging in any assertive behaviors, including the honest expression of emotions. As a result, rather than expressing despair, hopelessness, or a sense of damage, Puerto Rican women’s emotions manifest somatically, and sensitive clinician should be aware of these unique presentations.
It is critical that the culturally sensitive clinician working with an ethnically diverse patient examines the cultural differences that exist between himself and the patient. The examination of how cultural and racial differences affect the therapeutic dynamic minimizes potential cultural misunderstandings, helps to elucidate the patient’s cultural perception of mental illness and mental health treatment, and allows for the uncovering of the therapist’s own biases and ethnocentric related countertransferences. But how does this really play out in reality, within the context of the therapeutic setting?
Avoiding the discussion of cultural and racial differences can be like ignoring the proverbial elephant in the room. The intrinsic power differential that exists between a patient and therapist comes with the territory of the profession, but this differential can be compounded by racial and ethnic differences, especially if the therapist is a member of the dominant culture. Therefore, it is essential for the therapist to convey a willingness to address the relevance of these differences by initiating this difficult conversation if the patient has not done so. Obviously, the sensitive clinician should not shove the issue down the throat of the patient, but he should at the very least communicate a sense of availability to the issue so that the patient feels comfortable broaching the subject.
The nature of psychodynamic psychotherapy training is such that we are taught to believe in certain universal truths regarding human development, attachment, psychopathology, etc. While there exists a high degree of scientific credibility to pyschodynamic theory, we also have to acknowledge that the theory is heavily steeped in Western beliefs and values, and that most of our theoretical notions are based off of samples/phenomena/observations of Western people made by Western psychologists. Consequently, patients with diverse backgrounds who come to psychotherapy may be misunderstood because of the enthnocentric lens from which they are viewed.
Psychodynamic theory, for instance, tends to regard the origin of paranoia as a result of persecutory, critical, suspicious parenting. However, when considering ethnic and racial factors, one can see how paranoia may actually be an adaptive defense of historically persecuted people (e.g., African Americans) in response to aversive environmental demands, not poor parenting. In fact, African American parents may actually instill certain paranoid qualities (e.g., suspiciousness) in their children—qualities that are completely adaptive to survival in hostile and racist environments. This illustrates the importance for clinicians not to exclusively rely on psychodynamic conceptualizations without considering the patient’s cultural and racial framework.