Ninety percent of the patients who seek treatment from Atlanta clinical psychologist Jennifer Kelly, PhD, are referred by a doctor, insurer or attorney. When they first come to her office, some are surprised to see she is African American. A few times, they have mistaken her white office manager for the clinician, thinking Kelly is "the help," she says. Others have been openly hostile: Early in her career, she recalls one patient refusing to work with her because she was black. "That’s a hurtful thing because it has nothing to do with your education and training, level of experience or the content of your character. It’s all about what you look like," Kelly says.
Erlanger Turner, PhD, a clinical psychologist in Houston and an assistant professor at the University of Houston–Downtown, faces a different brand of bigotry: ageism. He gets pushback from some of the parents of his young clients, who doubt his ability to treat their children. "I can’t control my physical appearance—I look much younger than I am, but I don’t think that should discount my competence and my experience," Turner says.
A psychologist with a less visible diversity status may face a different set of challenges. Lindsey Buckman, PsyD, a lesbian psychologist practicing in Phoenix, says that "most people assume everybody is heterosexual…and people say things when they feel like you are similar that they wouldn’t say if it was obvious that you are different."
While no formal surveys have measured the scope of the issue, anecdotally many psychologists report they have experienced discrimination from clients based on race, ethnicity, age, religion, sexual orientation or disability status. Many also regularly hear clients express prejudice about other groups during treatment. Bigotry directed at the practitioner can weaken the therapeutic alliance, while intolerance of other groups can negatively affect a client’s personal relationships, says Buckman.
Yet most practitioners receive little to no formal training for handling prejudice during treatment. Psychology programs often offer a single diversity course, says Huberta Jackson-Lowman, PhD, president of the Association of Black Psychologists (ABPsi).
"Unfortunately, in many institutions, this is still essentially a sidebar. You may have one lecture, one workshop, one training that people go to, and they assume that makes them culturally competent," she says. "We don’t talk a lot about these grayer areas, and how to navigate those in terms of our ethical responsibilities, but also in terms of our own safety," says Buckman. The only formal training she received during graduate school was when her supervisor helped her cope with sexual harassment from a client, and that "wasn’t even really training, it was essentially just crisis management," she says.
The result is that practitioners must learn how to handle prejudice from clients on the job, relying on supervision when possible to address individual cases.
"We don’t know exactly what to do in the room because this has not been part of our conscious collective thought process as a discipline, in terms of how we teach, train and supervise clinicians, and how we work ourselves," says Theopia Jackson, PhD, chair of the clinical psychology degree program at Saybrook University in Oakland, California, and president-elect of ABPsi. "So, we have to do our own science around what works and what doesn’t."
How to handle hostility
Jackson and other psychologists offer the following advice for confronting a bigoted or otherwise insulting patient:
Be aware of your own internalized biases. Reflecting on their own social, cultural and political perspectives means practitioners are less likely to be caught off guard by something a client says. "It’s important for psychologists to be aware of what a client’s biases and prejudices are bringing up for them internally, so as not to project that onto the client—it’s important to really understand what’s happening," says Kathleen Brown, PhD, a licensed clinical psychologist and APA fellow.
For Kelly, the Atlanta-based clinical psychologist, this means she’s careful not to assume that resistant clients are treating her disrespectfully because she’s African American. Sometimes her clients, who are referred for pre-surgical evaluation and treatment, are difficult or even hostile because their psychological intervention was mandated.
Foster an open dialogue about diversity and identity issues. "The benefit of having that conversation, even though it can be scary or uncomfortable to bring it up in the room, is that it prevents it from festering or interfering with your ability to provide high-quality care to the client," says Illinois-based clinical psychologist Robyn Gobin, PhD, who has experienced ageism from patients. She responds to ageist remarks by exploring what specific concerns the client has regarding her age (like Turner, she looks young). If she’s met with criticism, she tries to remain receptive, understanding that the client is vulnerable and any hostility the client expresses reflects concern for his or her own well-being. By being open and frank from the start, she shows her clients the appropriate way to confront their biases in therapy.
Of course, practitioners approach these conversations differently. If a client makes a prejudiced remark about another group, Buckman says labeling the comment as "offensive" shifts the attention from the client onto her. "It doesn’t get to the core of what’s going on with them. In the long run, exploring a way to shift how the client interacts with the ‘other’ is probably more valuable than standing up for a group in the moment."
Be straightforward. Kelly takes a direct approach—she often calls out biased comments in the moment—but does so in a lively manner that confronts the statement while accepting the patient. "If I don’t call out the microaggressions, they become a distraction and prevent me from helping the client manage with their medical condition," she says. "It may not be how other people would approach it, but it’s what works for me."
Consider silence. Whereas some clinicians prefer to respond to prejudiced remarks directly, others find silence to be a powerful therapeutic tool. "Silence can be used extremely effectively," says Brown. "It allows the person to sit with the uncomfortable space, because what it does is bring up a patient’s anxiety." She says learned biases are comfortable for many people, but sitting quietly with those beliefs can start to raise questions about their validity. In that sense, silence can open up space for further dialogue and exploration.
Tie your response to theory. When he experiences a bigoted statement, trauma psychologist Tyson Bailey, PsyD, says that he points to his training in dialectical behavior therapy, which helps provide the client with a framework for confronting their biases. He says patients voice stereotypes as a way of trying to simplify or understand other identity groups. Bailey responds by explaining to the client how judgments can heighten emotion and make it harder to think clearly, using this as a segue to begin a focused exploration of the judgment.
"It’s tough because sometimes I need to sit with someone who holds a different view than I do," he says. "I want to help people grow and recognize where bias is present, but I don’t believe it’s our job to change their views. It can be a problem if you lose the client in service of your own agenda."
Bailey says he’s had mixed success in tackling these issues during treatment. The conversations go poorly when he gets caught up in his own beliefs and his focus shifts away from the client. But when he’s stayed present, he finds there has often been a deepening of the therapeutic relationship; for many of his clients, it may be the first time they’ve had a safe space to explore the roots of their biases.
Determine when to revisit the issue. Practitioners may want to further explore intolerant remarks when they are relevant to the patient’s treatment. For example, when one of Buckman’s clients frequently made racist and homophobic remarks, she encouraged her to consider what was driving that behavior, and how it might be affecting the client’s relationships.
Brown says she handles prejudice the same way as she would other unconscious beliefs. "My job is to help the person understand what’s underneath that belief, how they came to develop that belief and whether they choose to change that belief, if it’s creating stress in any way."
Seek support. Regardless of the approach a psychologist uses to address bigotry, a key step is for him or her to seek support from supervisors or colleagues. "Repeatedly facing offensive remarks is painful, and it does chip away at you quietly if you try to hold all these experiences inside," says Gobin. "I think the most important thing someone can do is to share what they’ve experienced." Consulting with peers and supervisors not only provides social support, but also offers a forum to brainstorm and troubleshoot potential responses.
Be cautious. Above all, clinicians should always feel safe before speaking up, understanding that power dynamics and privilege play a role in the therapeutic relationship. "It’s my job to hold whatever the client brings in the room, and that does mean some of the bigoted language," says Jackson. "However, it doesn’t mean that I have to be a punching bag. At no point does being a good therapist mean that you have to be abused in the moment."
More attention needed
Looking forward, most practitioners agree that conversations about bias and prejudice need to first take place within the institutions of psychology before change can be expected at the therapist-client level. Jackson-Lowman, the ABPsi president, says this involves setting clear standards around types of interactions that are unacceptable—among colleagues, trainees, supervisors and clients.
"It’s not much different from the conversations that are beginning to occur around sexual harassment. These things have been going on forever, but there has to be some kind of watershed moment," she says. "Once people feel that there is enough support and they experience a sense of safety, we can begin to vocalize what our experiences have been, insist on the need to make changes and start holding people accountable for their behavior."
Diversity Within African American, Female Therapists: Variability in Clients’ Expectations and Assumptions About the Therapist
Kelly, J.F., & Greene, B.
The International Journal of Critical Pedagogy, 2011
The Heat of the Moment in Treatment: Mindful Management of Difficult Clients
Norton Professional Books, 2013
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