Discussions of social determinants of behavioral health (SDBH) are often limited to data. While statistics are extremely valuable to understand the impact of institutional and systemic forces across racial and economic lines, SDBH conversations regularly exclude practical means to raise the cultural competence and humility of non-Hispanic White (NHW) behavioral healthcare providers. In 2017, NHW behavioral healthcare providers in the United States composed the majority of therapeutic counselors at 61.9% of the workforce (United States Census Bureau Public Use Microdata Sample; 2017) (Data USA; Counselors; 2017). In 2015, 86% of psychologists were NHW. (Christidis, Lin, Stamm; How Diverse is the Psychology Workforce?; 2018). Despite the majority presence of NHW behavioral healthcare providers, there are few available and concrete means to improve cultural awareness and avoid damaging the therapeutic alliance between NHW providers and BIPOC (Black, Indigenous, people of color) participants. The contained content on racial microaggressions and approaches to apology for cultural missteps will help fill this gap in opportunities for professional growth.
Research demonstrate how the “racial match” of a behavioral healthcare provider and their participants is “associated with increased utilization, favorable treatment outcomes (i.e., global assessment scores, substance use reduction), lower treatment dropout, and greater satisfaction” as well as “a generally higher level of importance of cultural elements for ethnic minority clients compared with White clients.” (Meyer and Zane; The Influence of Race and Ethnicity in Clients’ Experiences of Mental Health Treatment; 2013) Similar research is present in the realm of physical healthcare, where increased engagement in physical health treatments has resulted from pairing African-American patients to African-American doctors when compared to African-American patients working with NHW doctors. (Alsan, Garrick, Graziani; Does Diversity Matter for Health? Experimental Evidence from Oakland; 2018). Reasons deeper than racial and ethnic identification in the behavioral healthcare dyad explain this increased engagement between racially and ethnically matched participants and providers. For NHW providers, treatment of their BIPOC participants and patients can be disrupted through diminished patient-centered behavior, visit length, and even pace of speech (Van Ryn; Avoiding Unintended Bias; 2016). BIPOC participants and participants that belong to other minority groups cite deficiencies in providers’ cultural competency as an inhibitor to the therapeutic alliance (Chang and Berk; Making cross-racial therapy work: A phenomenological study of clients’ experiences of cross-racial therapy; 2010). Since the therapeutic alliance is key to participants’ engagement in behavioral healthcare treatment (Allan, Cook, Carson, et al.; Patient-Provider Therapeutic Alliance Contributes to Patient Activation in Community Mental Health Clinics; 2017), NHW providers have an obligation to adjust their practice to include racial and ethnic awareness along with cultural competency and humility for the sake of their professional efficacy. Additionally, the aforementioned research suggests that NHW providers have a disadvantage when serving BIPOC participants, which is a challenge that requires professional development to overcome.
One effective path to reduce potential barriers between NHW behavioral healthcare providers and BIPOC participants is to raise awareness around microaggressions. Microaggressions are defined as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color.” (Sue et al.; Racial Microaggressions in Everyday Life Implications for Clinical Practice; 2007) Microaggressions are often both unintentional and undetected when an NHW behavioral healthcare provider perpetrates them. For example, the phrase “America is a melting pot,” a phrase commonly used by NHW persons as proof of the United States’ inclusivity to all people, indicates that a BIPOC participant should “Assimilate/acculturate to the dominant culture.” (Sue et al.; Racial Microaggressions in Everyday Life Implications for Clinical Practice; 2007) D.W. Sue et al. also explains how a denial of race’s role in the therapeutic dyad, e.g. a provider stating that, “Race does not affect the way I [the provider] treat you [the participant],” sends the message that a participant’s “racial/ethnic experience is not important” (Sue et al.; Racial Microaggressions in Everyday Life Implications for Clinical Practice; 2007).
NHW behavioral healthcare providers may experience doubt or resistance to examples of microaggressions, especially when the phrases are intended to communicate support. Supervision and further training can help process such emotions. Left unaddressed, this cultural resistance (which is in essence a conscious confrontation with unconscious implicit bias) may result in further damaged rapport with BIPOC participants and ultimately reinforce the racial health disparities and SDBH that we seek to dismantle.
When microaggressions or other cultural missteps do occur, the therapeutic alliance can be repaired as soon as reasonably possible through a systematic approach to apology outlined by cultural sociologist Karen Cerulo.
Cerulo’s approach to apology is:
- Put yourself in the role of the victim and say what you would want to hear.
- Address the victim, admit guilt, and ask for forgiveness.
- Offer restitution or correction, if possible.
- Apologize for your actions or words and not because you were misunderstood.
While avoiding the following, i.e. do not:
- Make excuses or rationalize your behavior.
- Blame others—especially the victim.
- Dwell on your problems or hardships.
- Minimize the harm caused by your words or actions” (Cerulo; The Anatomy of an Apology; 2017) (Cerulo, Ruan; Apologies of the Rich and Famous: Cultural, Cognitive, and Social Explanations of Why W Explanations of Why We Care and Why We and Why We Forgive; 2014).
This format for apology incorporates other studies on effective apologizing to “prioritize the ‘object’ of the offense and the negative impact of the offender’s sin. That focus triggers central cultural scripts of compassion and sympathy” (Cerulo, Ruan; Apologies of the Rich and Famous: Cultural, Cognitive, and Social Explanations of Why W Explanations of Why We Care and Why We and Why We Forgive; 2014).
To roleplay said approach, in the past I made the microaggression of overemphasizing congratulations for a BIPOC participant’s educational achievement. “You have a high school diploma,” I said to a participant, a bit too graciously while completing a routine intake form inside of Bayside State Prison in New Jersey. “That’s good. That’s really, really good.” I sensed the participant’s shift toward reticence after my statement. At the next reasonable opportunity, I would have done well to repair rapport with the participant and say, “I feel I wronged you. I said too many congratulations when it came to your education, and I thought that was unkind and belittling. I’m sorry. Is there anything I can do to make it up to you?” I would then await the participant’s response and proceed accordingly. Unfortunately, I did not take this approach to correction after my microaggression. I knew I had erred in that moment, yet I did not have the tools to correct course before the participant lost contact with our services after their release from prison.
At their most fundamental, these two practical approaches to improving service delivery are rooted in a perspectival shift. As an NHW behavioral healthcare provider, I have to actively cultivate a shift in what I may consciously or unconsciously believe is correct, based on my own cultural and implicit biases. Asking “Where are you from?” or “Where were you born?” may be more than my curiosity; it can imply that a participant is “not American,” (Sue et al.; Racial Microaggressions in Everyday Life Implications for Clinical Practice; 2007) an implication I would not have considered without cultural competency training. This intentional shift must also occur when confronting the effects of Covid-19 on BIPOC communities in the United States. When speaking with BIPOC participants, NHW behavioral healthcare providers must maintain awareness that the ability to socially distance is itself a privilege, as BIPOC participants may have family, friends, or may themselves be: essential workers, as essential workers in the United States are a significant percentage BIPOC (McNicholas, Poydock; Who are Essential Workers?; 2020); “generally less able to work from home”; “more likely to live in densely populated areas”; and/or “reside in multigenerational or multifamily households” (Li, Rhoades; Racial Disparities in COVID-19; 2020). We must also be aware of the effect of the current sociopolitical moment on the BIPOC participants we serve, remembering that when “an unarmed Black American was shot [by police], the mental health of African Americans in that state was adversely affected for 3 months” (Stout; Racism: A Challenge for the Therapeutic Dyad; 2020) (Bor, Venkataramani, Williams, et al.; Police Killings and Their Spillover Effects on the Mental Health of Black Americans: A Population-Based, Quasi-Experimental Study; 2018).
NHW behavioral healthcare providers can utilize these detailed approaches to strengthen the therapeutic alliance with their BIPOC participants. NHW providers can do so now by learning about and avoiding microaggressions; implementing evidence-based strategies for apologizing to participants after cultural missteps; and applying these perspectival shifts to engage Covid-19’s effects on BIPOC communities and participants as well as the impact of the United States’ sociopolitical climate. More concrete strategies are needed to help NSW providers work alongside BIPOC participants and communities. The discussion of SDBH can thereby be given a greater depth, a depth beyond data, that incorporates interventions to improve NSW behavioral healthcare providers’ efficacy.
Corey Kuebler is pursuing an MSW and MPH at Rutgers University. He currently works as a Habilitation Counselor/Case Manager with Rutgers University Behavioral Health Care’s Intensive Recovery Treatment Support Program. He can be reached at (732) 434-8217 and at email@example.com.