Providers in minority groups remain underrepresented in the field of psychology, meaning that individuals in minority groups will most likely see a non-minority therapist when they seek psychological help. How do we, as clinicians, make a safe space for service members to discuss their experiences of racism in a therapeutic capacity?
Invite your patient to talk about how they have experienced the impacts of race. Clinicians are in a position of power within the therapeutic relationship and in the military, and this power can be further amplified by rank differences between patient and provider. Minority patients may be reluctant to talk about race and racial discrimination for a number of reasons, including fears that the therapist will be offended or defensive, the therapist will see them as a stereotype rather than an individual, their experiences will not be taken seriously, or the therapist would not be able to understand or empathize with their experience. When you initiate the conversation, you create an opening for the patient to discuss these issues. I typically start by asking, “What is your perspective on this from the standpoint of a Black person?” or “How do you think your experiences have been impacted by your gender and your identity as a Mexican American?” I find that it’s more productive to ask these questions directly than to attempt to discuss race and racial inequities in a more circumspect manner. When you listen and follow your patient’s lead as they share their experiences and feelings, you convey interest and empathy, a genuine desire to understand your patient’s perspective and respect for how much or how little they feel comfortable disclosing.
Invite your patient to talk about how your racial identity may impact the therapeutic relationship. Ask about any concerns or beliefs your patient may have about your capacity to understand their experiences as a minority service member. Minority group members may have had a bad experience, owing to racial or other disparities in health care, or with a provider in the past and this may influence the rate at which trust is established in therapy. I may ask something like, “What is it like for you to discuss this with a white female psychologist?” Be prepared to listen and acknowledge and validate any concerns expressed when your patient responds with honesty. If you find yourself feeling defensive, take a deep breath and remain focused on understanding the patient’s account, listen and remain open to what you’re learning. If you find yourself struggling with reconciling your role as a therapist with current events and new awareness, or with your past beliefs and assumptions about yourself and others, consultation, supervision and/or therapy are available to aid in your self-reflection and growth. Thoroughly exploring our own privilege wherever it may exist may lead to a better understanding of the disparities between our personal experiences and those of our patients.
Avoid seeing pathology to excess. Seeing pathology to excess in patients can lead to unnecessary and inaccurate diagnoses which can have life-altering implications, especially in a military setting. It’s important to take into account the patient’s worldview – for example, racial/ethnic minorities may have family relationships that, from your external perspective seem enmeshed at first glance, but are in fact culturally normative. Individuals who persistently face discrimination because of their ethnicity or race may develop healthy cultural paranoia as a coping response. They may express feelings (anger, sadness, pain, etc.) to a greater degree than what seems proportional to the situation due to the cumulative effects of racism and racial discrimination.
Don’t inappropriately avoid diagnosis. It’s also important to recognize that in some areas of medicine, providers fail to diagnose existing conditions more frequently in minorities than their white counterparts. Inaccurate beliefs persist among some medical students and residents that biological differences exist between Black and white patients that make Black patients less susceptible to pain. These explicit beliefs, as well as implicit biases, can contribute to a discrepancy in the medical treatment of pain such that Black patients may receive less medication for pain symptoms than white patients with similar presenting problems and pain ratings. Additionally, minorities are often less likely than white patients to receive preventative health care for a number of conditions, even when controlling for socio-economic status and health insurance coverage. This is largely due to the current inequities in health care as well as the transgenerational trauma that stems from the historic abuse of persons of color by medical professionals, which is often structurally based.
Get a bio-psycho-social history. Medical conditions can have a complex and interactive relationship with mental health and previous experiences of substandard medical care may impact a patient’s willingness to trust and engage in therapy so we, as mental health clinicians, must ensure our case conceptualization accounts for this multitude of factors. Minority group members are subjected to the stress of systemic racism, as well as the long-term impacts of historical discrimination. Due to multiple and often inter-related factors, they are at higher risk for developing depression, anxiety, hypertension, diabetes and cardiovascular disease, all of which impact and/or are impacted by mental health. Ensure that you’ve familiarized yourself with the patient’s personal experiences, medical diagnostic and treatment history, and familial and cultural backgrounds. Consider this information, perhaps in consultation with a colleague, before finalizing a diagnosis.
Author’s note. Initially, I was afraid to start conversations about race with my patients. I was afraid of saying the wrong thing, being offensive, and that they wouldn’t come back to therapy. What I found over time, though, was that most of my patients appreciated the opportunity to openly discuss this with me, and it led to more meaningful and productive therapy sessions. I often see a notable change in patients’ non-verbal communication when I invite race into the room; they seem relieved. Many of my colleagues report similar reactions in their minority patients when they begin to address race in therapy. If, like me, you’re a white provider working with a minority service member, race is already in the room. Directly inviting your patients to share their racial experiences and perspectives signals that therapy is a space where the service member can be more fully authentic, ‘heard,’ and understood, which can be an incredibly powerful and healing experience.
Lt. Cmdr. Pollman-Turner is an active duty clinical psychologist in the United States Navy. She has a master’s degree and a doctorate in clinical psychology and is currently filling the role of Operational Stress Control and Readiness (OSCAR) psychologist with Fifth Marine Regiment.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.