Clinical Reflections on the Impact of Race and Racism on the Counselor/Client Relationship

This article was prepared in collaboration with an interracial group of mental health providers practicing in a variety of public and private mental health settings. Each clinician has completed the PISAB Undoing Racism Workshop and does anti-racist organizing in their various settings.

In July 2006 the American Psychiatric Association Board of Trustees approved a Resolution against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health. This resolution was prepared by the Committee of Black Psychiatrists of the Council of Minority Mental Health and Health Disparities and states in part that:

“Racism and racial discrimination adversely affect mental health by diminishing the victim’s self-image, confidence and optimal mental functioning.” “Racism also renders the perpetrator unprepared for the 21st century society that is becoming increasingly multicultural and global.”

“The APA and its members should be mindful of the existence and impact of racism and racial discrimination in the lives of patients and their families, in clinical encounters, and in the development of mental health services.”

We understand that mental health theories, practice models and service delivery systems are constructed in the context of white Western norms and values. Therefore, racist power structures that exist in societal institutions, including health and mental health care, contribute to the structural racism affecting people of color, and especially poor people of color who are often seen in public mental health settings. In order to provide culturally competent, anti-racist mental health services clinicians and supervisors need the following:

Knowledge about the history of race and racism, and their manifestations, understanding of white skin privilege and how it advantages and empowers white clinicians and contributes to a power differential between white clinicians and clients of color, and familiarity with racial identity development theories developed by various and clinical and counseling psychology theorists. Many of these are anchored in the pioneering work of Cross and Helms. Two other important areas of knowledge are Sue’s work on racial micro aggressions and Leary’s work on Post Traumatic Slave Syndrome. It is also important to understand the relationship among race/culture and class, gender, sexual orientation, class, age, religion/spirituality and various forms of structural oppression.

Self-awareness about our racial/cultural identity and our experience of racism is necessary. Clinicians of color and white clinicians must know their assumptions, values, vulnerabilities, privilege and power around race, and understand the dynamics and implications of internalized racial superiority and internalized racial inferiority for the therapeutic relationship.

Understanding the client in terms of their specific specific experience of race, culture, class, racism and other forms of social oppression; including an understanding of how white skin privilege affects white clients and their families. A holistic understanding of clients includes the interaction of their psychological and interpersonal issues, their social identities and their experience of racism and other oppressions. In order to understand the client the clinician should include questions about race and culture, its import and impact in assessments with all clients -white and clients of color; and routinely explore the impact of race and racism in all treatment planning, development of therapeutic alliances, and in supervision and case conferences.

Recognizing manifestations of racism in mental health is also essential. Gail Golden in her article “Retooling Mental Health Models for Racial Relevance” examines ways in which “most mental health theories have failed to incorporate an analysis of societal oppression into their understanding of human behavior.” Accordingly, this failure has disadvantaged members of marginalized groups by measuring their behavior against what has been established as “Eurocentric and privileged notions of normal.” This perpetuates a “diagnosis industry that inaccurately characterizes people of color from a perspective of deficits and pathologies. Resultantly, people of color are as misunderstood and “damaged by the Mental Health System as they are by every other system in this country.”

The following examples from the work of the contributing authors illustrate the positive outcomes of incorporating Anti-racist approaches in clinical practice.

Sandra Bernabei shared the following feedback illustrating some of the dynamics that emerge in the therapeutic relationship between white therapists and client of color:

“I have been in therapy in the past, but working with you was the first time I felt really understood in a social context larger than my immediate personal life.  Balancing my personal stuff alongside the larger social justice issues I care about will be an ongoing challenge, but I thank you for helping me to build a framework for this.”

Jonathan McLean described an African American male therapist’s work with a Latina who initially resisted been seen by a Hispanic male therapist. The careful exploration of her underlying feelings facilitated the uncovering of internalized stereotypes about Hispanic males and subsequent establishment of a productive therapeutic alliance with this client.

Jordan Margolis described the difficulty a young white male therapist had engaging an older African American man in family therapy:

The client, the father in the family, commented as he walked with the therapist from the waiting room, “where are you taking me – the gas chamber? Recalling that the client had recently been released from prison, the therapist stated, “I may be white but I’m not a prison guard.”

The client seemed to sit down comfortably, and asked “Really? Are you so sure about that? One thing you have to understand is that I naturally put up a wall.” “Well,” said the therapist, “I won’t try to change your mind.”

The therapist did not acknowledge to himself his defensive position. Since he did not know how to move the conversation forward, he asked a general question about the client’s experience as a Black man without directly addressing the feelings and interaction in the room. The client obliged the therapist with an intellectual response that also maintained the barrier between them. He did not continue the therapy beyond the first few sessions.

It was not until several years later, after the therapist attended an Undoing Racism Workshop and began to read and have dialogues about race, power and ethnic identity, that he understood more clearly the elephant in the treatment room that was not addressed in the work with this African American family. For example, the therapist had an increased understanding of the cumulative impact of structural racism on the client, the client’s understandable mistrust of an unknown white male therapist, whose presence embodied white privilege and white power in society, the therapist’s discomfort with his white skin privilege and the therapist’s lack of experience having authentic cross-racial conversation about race and racism. In the engagement process, the therapist might have opened a dialogue by validating the client’s concern about how he would be treated by a white man, and stating that the therapist was aware of the unequal resources and opportunities available to white and Black people in the society. This opening could have made space for the client to bring himself more fully into the therapeutic encounter.

As we strive to provide anti-racist mental health treatment, there are a number of questions we might ask ourselves:

What norms and values do we use as markers of good mental health? Do we place a high value on individuated separation from family, competiveness and the importance of acquiring material goods? Do we undervalue strong connections to family and community, cooperativeness and the importance of relational and spiritual resources?

Additional questions we can ask ourselves were posed by Gail Golden in the previously cited article:

How might African Americans deal with their anger towards a white person in a mental health setting? What is socially sanctioned and what is not? Do our diagnostic categories help or hurt people? Are they flexible enough or elastic enough to incorporate experiences of oppression? When making assessments, are we able to identify the resilience and assets of people who are not like ourselves?


Our discussion suggests clinicians can improve their clinical practice and mental health outcomes with all clients by increasing their knowledge about race and racism, self-awareness, understanding of clients and recognition of manifestations of racism in mental health. Here are three avenues for continued learning and development:

  • The People’s Institute’s Undoing Racism Workshopcontact and schedules can be found on the internet at
  • Training and case consultation for workers and supervisors on addressing race, culture and racism in mental health treatment contact: JBFCS Anti-racism & Multicultural Consultation and Training Service:
  • Introductory continuing education workshop around the nature and impact of white identity, white culture, white privilege. For white practitioners and practitioners of color in multiracial settings or in communities of color Contact: The Center for the Study of White American Culture Bonnie Cushing/Jeff Hitchcock (

We also suggest next steps for expanding our models of mental health treatment:

  • In treatment settings collect data on the meaning and impact of race/culture and racism as ascertained in assessment, treatment, development of therapeutic alliances, supervision and case conferences. Aggregate the data by race/ culture and review for outcomes.
  • As Gail Golden suggests, in the article cited previously, “develop asset-based models which incorporate curiosity and respect about the survival skills which whole communities have had to mobilize in order to confront genocidal affronts to their being.”
  • Review and discuss emerging research on the contribution of gross wealth disparity to mental health problems (WHO report – see the Guardian London, 3/11/09). Wealth disparity is another manifestation of structural racism. People who are white and poor are not poor because they are white (PISAB Undoing Racism Workshop core trainer) whereas many poor people of color are poor because of structural racial inequities in the society.

Joan Adams, LCSW, is Founder and Senior Consultant of the Anti-racism and Multicultural Consultation and Training Service of JBFCS; she is also a private psychotherapist and trainer. Sandra Bernabei, LCSW is a Founding Member of the AntiRacist Alliance, community organizer, and a private practitioner. Bonnie Cushing, LCSW. Gail Golden, EdD, LCSW, is Clinical Director of VCS Inc, in New City, New York. Jeff Hitchcock, MS, MBA, is Executive Director of the Center for the Study of White American Culture, Inc. Natania Kremer, LMSW, MSEd, is Director, Early Childhood Support Services at JBFCS Child Development Center. Jonathan McLean, LMSW, JBFCS; Steering Committee Member, PISAB Men of Color Group. Jordan Margolis, LCSW, is a Mental Health Consultant, Clinical Consultation Program of JBFCS.


Cross, W., (1971) The Negro to Black Conversion Experience; DeGruy Leary, J., (2005) Post Traumatic Slave Syndrome: America’s Legacy of Enduring Injury and Healing, Uptone Press;

Golden, G. (2004) Retooling Mental Health Models for Racial Relevance;

Helms, J. (1993) Black and White Racial Identity: Theory, Research and Practice, Praeger;

Sue, D. (2007) Racial Micro aggressions in Everyday Life: Implications for Clinical Practice, American Psychologist, Vol. 62, No.4, pp 271- 286

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