Noted Panelists Discuss the Impact of Race and Racism on the Mental Health Professions and on the Therapeutic Alliance

Moderator’s Note: I had the pleasure of assembling a panel to address the impact of race and racism on the mental health professions. All of the panelists had participated in the Undoing Racism Workshop training offered by the People’s Institute for Survival and Beyond and were familiar with its framework for analyzing the realities of racism in contemporary America. The panel members, all of whom work in New York City, included: Robert Abramovitz, MD, psychiatrist, Distinguished Lecturer, Hunter College School of Social Work; Kalima De Suze, MSW, social worker, feminist, and anti-oppression community organizer; Billy Jones, MD, psychiatrist, Clinical Professor of Psychiatry, New York Medical College and former Commissioner of the New York City Department of Mental Health; Julie List, LCSW, social worker, Director of The Harry Blumenfeld Pelham Counseling Center, Jewish Board of Family and Children’s Services; Alan Siskind, PhD, social worker, adjunct faculty, Hunter College School of Social Work, private practitioner, former CEO of the Jewish Board of Family and Children’s Services and Co-Convener of the First Monday Anti-Racism Collaborative; and Peter Yee, LMSW social worker, Assistant Executive Director, Hamilton Madison House, a settlement house that provides a range of services, including mental health.

Peter Beitchman: Of course, we can’t separate the mental health professions from the clients we serve so let’s begin with what we know about the impact of racism on our clients.

Robert Abramovitz: The impact of racism on clients of color is pervasive, affecting all aspects of their experience and development. So often the experience of racism has been internalized so that clients don’t give voice to the experience that they’ve had. In fact, if a client came to treatment angry, and declared that his or her problems were attributed to racism, we know that years ago they would have gotten some sort of diagnosis of paranoia.

Alan Siskind: It’s the imprinting that occurs from pervasive and repetitive experience and then how all subsequent cognitive and emotional experience gets filtered through that imprinted response. The result is that people of color often develop a belief system that their repetitive negative experience with the environment are their fault and that “there’s something wrong with me.” White people also have their perceptions of people of color and their participation in racist systems reinforce in the same way.

Julie List: We’ve learned that one of the examples of how the constant experience of racism gets internalized is that in communities of color there’s a lot of concern about the shade of one’s skin. In families where some members are darker, they feel that they’re treated less fairly in their own family.

Robert Abramovitz: In fact, I just heard a talk by an African American woman who plays in the WNBA. She talked about how her father sent her such strong messages because he felt she was too dark and too tall. Her entire self-image revolved around her father’s attitude towards her, including his internalized racism.

Peter Beitchman: What happens when clients bring this internalization, mostly unconscious, into the treatment relationship?

Julie List: When clients who have internalized racism come into treatment—especially poor clients of color with no job, often no decent housing or health care—they’re feeling powerless. In addition, there’s a hierarchy in the therapeutic relationship. The white therapist has the power by virtue of color, education or class. Clients will react to the same experience inside the therapy room that they experience outside the therapy room, unless the clinician has the proper training and awareness. I think if you don’t acknowledge this difference between the clinician and the client in treatment, and the client continues to act on the basis of the internalization of superiority and inferiority, then the treatment is a lie. If not a lie, then it is certainly inauthentic.

Alan Siskind: What makes this so complicated, of course, is that the client is coming in with a presenting issue and it’s so easy for the clinician to not consider the impact of something like internalized racism or the experience of being oppressed and acknowledge it in the assessment and in helping the client address the problem. We as professionals have to think about the impact of racism on all aspects of our clients’ lives as challenging as that may be. And we must to be aware of our own agendas. For white therapists the agenda is often the therapist’s guilt and other distortions of perception that come from their own internalized feelings of racial superiority. The guilt can get in the way of really hearing and understanding the client.

Kalima De Suze: Yes, I’ve seen that guilt, where therapists over-identify with structural racism and the therapeutic relationship becomes patronizing. That kind of false solidarity with people is just as damaging.

Alan Siskind: Assessment is complicated, even more complicated when you acknowledge the role of racism in both the client’s and therapist’s (white or of color) lives.

Billy Jones: My first analyst was white and as an African American medical resident in psychiatry I recognized a lot of difference between me and him: his color, certainly his power, education and class. Yes, the client rarely brings those differences out in treatment but it’s important for the therapist to help bring them out. Through a number of life experiences I returned to analysis years later and this time with a black analyst. And while there weren’t a lot of differences I did feel freer with the back analyst if only because he understood my language, like when I referred to my grandmother as Big Mama, which I’d have to explain to the white analyst but which instantly communicated an image to the black analyst.

Peter Beitchman: Peter, how do you see this playing out in the mental health services provided in the Asian community?

Peter Yee: My experience is quite different. We’ve been exploring the issues of racism and difference to empower clients. In the Asian Community the culture is so different. New immigrants come to treatment only as a last resort. In fact, the Chinese culture believes “the more pain you endure the more virtuous you are.” The idea of empowerment is a new concept. So when someone comes for help it is to address something very concrete. We tell our clinicians and doctors to prominently display their credentials, which are respected; an equal therapeutic alliance based on acknowledging difference is a foreign idea. The racism that is felt is the racism against our community as a whole—the lack of resources, long waiting lists, and gaps in services. For example, there is no supervised mental health housing for people who speak Chinese or Korean.

Billy Jones: So what we’re saying is there are different manifestations of racism in mental health services: in the relationship between those who treat the client and within the system of funding and the structure of services. Basically, when I was at the City Department of Mental Health, for a host of reasons, we could not start with assessing need in various communities, we had to start with the given and then try to add a little bit new. Redirecting resources and meeting needs is very difficult and it shows itself racially and ethnically.

Alan Siskind: There’s no question about the systemic racism in terms of how resources get assigned. There is always more need than resources. And limits on funding become a place where policy makers can hide so they don’t have to deal with how racism plays out in the allocation of resources. Ideally, our mental health system should be organized to ensure that all communities are getting what they need; and if that’s not being done, which I think is the case or if it can’t be done, let’s be honest and acknowledge it. The worst thing is to pretend that our system is meeting the needs for mental health services universally.

Peter Beitchman: How does that kind of systemic or institutional racism play out at the provider agency level?

Julie List: This is where white privilege comes in. When you think about it, the people at the table making diagnoses and treatment plans for people of color are usually white. And the therapist, regardless of color is usually reporting to a supervisor who may be white, and there are often white people in charge above them on the management team and on the board level. Our institutions, which are founded on racism, leave our clients at the very bottom before they even open their mouths. That is why the anti-racism movement has to take place from the top down as well as from the bottom up. It has to be integrated into our work on an ongoing basis. We need to diversify people in supervisory positions who are making the diagnoses and the treatment plans. The upper echelons of our agencies need to have members who represent the clients we see in the city. I think that this is one way to begin to change the way things have always been.

Kalima De Suze: I think there are also some basic problems with the constructs of our therapeutic models. As an African-American, anti-racist feminist, when I’m working with a therapist, black or white, and I say something like marriage is not for me, if the psychodynamic construct the therapist is using points to “oh-oh, she’s got daddy issues,” that construct just doesn’t acknowledge who I am. That therapist simply won’t hear or understand me. That kind of therapy would just drive me further away from myself. So it’s not just having people of color in leadership positions or more therapists of color, it has to be people who have an analysis and clear understanding of racism to begin to make change. One of these important changes is for clinicians to recognize the need to explore client material that move beyond traditional psychodynamic constructs.

Robert Abramovitz: In the anti-racist training we learned about gatekeeping, which I understood to mean the control of access to concrete services. But what I now understand is that having the Western psychodynamic model and the clinician hearing you and translating what you’re saying through that model is a profound example of gatekeeping on a deeper level. The model directs us to internal dynamics, rather than the life you’ve lived, a totally different mindset.

Alan Siskind: And it’s our clients’ life experience, including the impact of race, class, ethnicity and gender that impact on both me as the therapist and my client. I agree we just can’t understand this if our lens is clouded by a purely psychodynamic lens. Our assessment tools need to be psychosocially broad enough to include the impact of race, oppression, gender, as well as biology. As we think about race, ethnicity and culture we need to consider that there is often as much diversity within groups as there is between groups, as is true, for example, in the myriad of Latino communities.

Billy Jones: When we talk about our therapeutic model it’s so ironic to me because there’s been a huge swing from the more analytic dynamic approach to the biological. And in that swing, we’re missing exactly what we’ve been talking about: the understanding of race, culture and class that had begun to get into the mainstream now, in psychiatry, we’re skipping over these things.

Peter Beitchman: Is there a therapeutic model that incorporates an understanding of racism and the related “isms?”

Robert Abramovitz: I think, although it’s imperfect, looking at the client from a trauma perspective holds some real promise. It holds that life experience affects biology. It starts from the perspective that adverse life experiences are the source of problems, although it recognizes that there are protective factors that promote coping and adaptation. The trauma model, at least as it’s being conceptualized in government-funded studies, stops short in labeling “racism” as a crucial life experience, preferring “culture” as a euphemism and it doesn’t readily make a connection between the adversity caused by racism and mental health problems, but it is a promising perspective to do so.

Alan Siskind: I agree about the utility of a trauma approach. Virtually 100% of our poor clients of color have trauma from racism sometimes with a small “t” sometimes with a large “T.” And the trauma approach gives you understanding of the imprinting and impact of the accumulated experience. What’s missing and what’s needed is an integrated therapeutic model that explicitly includes racism. For now we have lots of individual thinkers – Robert Carter for example – who write important articles about racism and mental health. I think there will be an integrated paradigm, hopefully in the nor too distant future.

Kalima De Suze: And I hope that in addition to creating constructs around the effects of racism, the emerging therapeutic model will incorporate an element of political consciousness as part of the clinical work. We know that when your consciousness is raised you begin to understand the racism in so many systems, you feel empowered and feel that you can advocate for change. You feel less powerless.

Peter Beitchman: In the absence of a fully formed therapeutic model how do we incorporate race-sensitive practice into our agencies?

Julie List: I agree that the first step is to have the analysis. We’re so fortunate to have the People’s Institute Undoing Racism training. Implementing the understanding is challenging and, I admit, uneven. You have to have agency leadership behind the effort, as I do. You have to make it part of everyday discussion at the agency – in the record room, in the lunchroom, and talking about it in supervision, both individual and group. We meet every other week to talk about race and racism in our clinic, how these issues come up in our work and in our lives. As a supervisor, I listen for it all the time and if no one brings it up, I do. Some people are resistant: they say, “I didn’t become a social worker to talk about social justice.” That’s when you say, “but it’s a deep clinical issue; we have to look at racism to understand what your clients’ lives are like.”

Robert Abramovitz: To maintain this effort there has to be a clear message from the highest levels of the agency that legitimates giving voice to these issues. If it isn’t legitimized the effort won’t succeed.

Peter Beitchman: What about the education we receive to become mental health professionals? We’ve heard Billy talk about the lack of opportunity in psychiatry training programs to address issues of race and racism; what about social work education?

Kalima De Suze: In my experience talking to social work colleagues, I hear over and over that there is resistance to incorporate an understanding of race and racism into the curriculum, even to discuss it in class. At the Undoing Racism trainings most, nearly all of the social workers say they haven’t had the conversation about race before and certainly, not in their social work education.

Alan Siskind: In a social work class I taught recently, a student was describing the hostility of a group of clients she had been assigned to at her first meeting with them. There were lots of ideas about where the hostility may have come from, but no one suggested that racial difference between the student and group members might have played a role (and it’s a racially and ethnically mixed class). It’s another example of how hard it is to address the racism and how many places there are to hide when you don’t want to deal with it.

Kalima De Suze: I think another contributing piece to the lack of attention to race and racism in social work education is that many of the faculty are not equipped to have those conversations or handle the emotions that inevitably come up. Professors need an analysis of racism; they need to be comfortable with addressing it, so that they are better prepared to have the conversations and help the students understand the manifestations of racism and how it maintains the status quo. Then they can stress the need for change, not just personal change, but social change.

Peter Beitchman: So are social change and social justice part of our agenda in addition to developing a therapeutic model that incorporates an understanding of racism?

Alan Siskind: Yes, mental health professionals have to understand social justice is an integral part the service we’re providing. You have to introduce this to clinicians in a sophisticated way; you can’t just say it’s important. You have to demonstrate how clinically it has enormous import. Treatment can’t take place without caring about the need for our clients to live in a just context. Injustice corrupts the very essence of self. This is true for those behave unjustly as well.

Kalima De Suze: I’m thinking about the social work Code of Ethics, how it demands self-determination, social justice, collective action. The Code insists we not only help the person we’re working with, but also challenge the systems and conditions that contribute to the client’s condition in the first place. It’s about challenging the root causes; no matter how much you help, if the conditions still exist, the clients and new clients are going to keep coming back!

Robert Abramovitz: When clinicians say social justice is not my issue to me that’s a manifestation of how many ways people can hide and it’s a way to split off in their own mind what’s going on around them. Again, it’s the trauma paradigm that helps understand that some of the worst adversities occur when the social contract is broken and nobody cares.

Alan Siskind: And what happens when the clinician doesn’t stay with the “ouch” of the violation? How can there be any therapeutic repair if that violation is not addressed?

Kalima De Suze: In Judith Herman’s trauma model, the last phase of healing and recovery is activism. Why can’t part of our role as mental health professionals in helping our clients heal be referring them to advocacy organizations that are working for change in those areas that the client has been working on in the healing process?

Peter Beitchman: Peter, how would the social justice agenda play out in the Asian community?

Peter Yee: It’s interesting; people will march and be active to advocate for children’s services or senior services but not for mental health. Remember how in mental health the helping, especially for first generation immigrants, is so concrete. We can’t even get a community advisory board formed to support mental health services. If you’re a second generation Asian-American maybe you will begin to see the importance of social justice and advocacy. But there’s a strong bias even in the new generation against political action and advocacy, given the experience in many of the Asian countries of origin where politics was so constricted. I hope that as new generations emerge—and in New York City we now have three Asian-American elected officials—that more of the community will be involved in advocacy.

Peter Beitchman: We’ve been talking about bringing systemic change to our own mental health agencies, and granted other systems need to change as well. But, can we possibly be effective in changing other systems as well?

Alan Siskind: It’s more than a challenge. Take the social security system for example. I don’t know in my lifetime if I’ll have a chance to change it, but I can certainly care about and explore with my clients the problems they confront in that system. It’s clinically important to care about these issues and understand them to actively engage our clients in addressing their life issues. I think it’s also one of the ways to get to race issues more easily because it’s right there in their lives.

Robert Abramovitz: It’s true that when you see all of those intractable systems out there infused with racism it becomes a case of “the higher the consciousness the lower the morale.” You can feel pretty overwhelmed and frustrated. But I agree our clients’ experiences with other systems is also a chance to have the conversation with our clients so they understand that the way we work “in here” is not the way other people work in those other systems. The conversation gives you a frame of reference to be able to address the racism. In fact, it’s not only an opportunity, it’s also our responsibility.

Alan Siskind: Yes, it’s an opportunity, responsibility and mission.

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