Black History Month and Beyond: Cultural Competency for White Therapists

Black History Month is an annual U.S. celebration of the pioneers, trailblazers, and activists past and present in the Black* community.  Embraced officially since 1976, this month provides the perfect backdrop for discussions on the importance of continued education in cultural competence. 

Accepting That Racism Will Occur In Session

Working with someone from a different background than your own is going to happen in your career as a therapist. When you add differences of ethnicity and culture, there will be mistakes made in the therapy room, simply due to a lack of lived experience. Working with someone who is ethnically and culturally different than you are will increase instances of transference, countertransference, and projection. These situations are bound to cause therapeutic ruptures that, if not dealt with appropriately, will ruin the therapeutic alliance and cause harm to your patient.

Therapy is meant to be a safe space for a patient to work on wholeness and create integration with all parts of themselves, because they feel seen and heard. When a therapist trusts the validity of their patient’s experience, this allows the patient to walk away knowing that their full humanity has been witnessed.

But when a therapist who is white or light-skinned works with a Black or minority patient: addressing concerns around racism, understanding how these traumas affect the patient, AND understanding how stereotyping and racism enter the therapy room are key to providing good care.

Despite the best intentions of most therapists, the therapeutic relationship is not immune to racism. Non-minority therapists must accept that systemic racism has caused them to lack certain awareness regarding the experiences of their Black patients. They must also accept that they will do things, say things, and react in ways that will increase the experience of racism with their Black patients. Acceptance does not mean that you embrace racism, or have malicious intent. It means that you own your lack of awareness, and strive to better your understanding for the sake of your patient’s health.

Once acceptance occurs, a therapist can truly increase their knowledge of how to work with Black patients, because they have already let the patient know that they will believe them when they say that something isn’t right.

Common Mistakes Therapists Make

Through cultural competency training, you will increase your knowledge, and learn how to minimize common mistakes therapists make when working with Black patients. You will learn a variety of common themes to incorporate, or avoid, in order to provide appropriate treatment.

These are some common mistakes that you can become aware of, some tips on how to avoid them, and my approach:

• Adopting the approach of colorblindness.

A therapist may take a colorblind approach to treatment, stating “I don’t see color” or “I see everyone equally.” This ideology assumes that in order to end discrimination, we should not acknowledge an individual’s race, culture, or ethnicity. Unfortunately, colorblindness is actually a form of racism, because it denies the societal and historical effects of racism. A therapist’s use of a colorblind approach does not protect their Black patients. Instead, it allows the therapist to be relieved of addressing racial differences and difficulties.

Therefore, the therapist should not ignore race, culture, and ethnicity. You must check-in with your patient regularly to learn if their feelings are connected to discrimination. You must acknowledge your own difference and disclose your own ignorance as well.

My Work:

At the end of the first few sessions I ask my patients, “Are you feeling comfortable working with me, as we are from different cultural [and/or gender] backgrounds? It’s okay to say if you don’t. I will gladly help you find a clinician who aligns better with your lived experience.”

Throughout treatment I ask if the patient felt an experience they’ve described was discriminatory. For example** I had a Black patient describe to me the critical and harsh treatment he received from his boss, and how differently his boss treated his peers. Knowing that he worked in a predominantly white field I asked, “Do you get the feeling that your boss treats you differently because you are Black?” This question allowed my patient to discuss how he felt he was being unfairly targeted because he was Black. It validated his feelings and gave him permission to openly talk about his experience without needing to edit, or skirt around, what the real problem was.

Lastly, I check-in with my patient when political or news outlets highlight experiences of discrimination and racism in the news. I inquire as to their initial reactions, their current state, and what support they may need.

• Not accepting the experience of race-based trauma.

When you have not been subjected to the minority experience it may never occur to you that racism could be traumatic. The environment experienced by Black people includes poor societal support, systemic low socioeconomic status, governmental discrimination, and various levels of stigmatization. Daily and generationally, racism can cause feelings of fear, panic, despair, anguish, hostility, distrust, and paranoia: all common symptoms of PTSD. When a therapist does not take note of this in session, they create treatment plans that do not align with the needs of their patient.

Therefore, when a Black patient describes experiences of racism, it is important to accept their experience and work with them through a trauma-informed lens. Utilize theories such as The Minority Stress Model and Historical Trauma.

My Work:

During intake, I inquire if there are any experiences with discrimination in the patient’s background, or their family background, that stick out the most and have caused them to create a worldview. I also inquire if this worldview has been helpful in keeping them safe (as I do not assume that all worldviews are pathological).

When developing a treatment plan, I ask what support they need around discrimination, including: 

• Creating awareness with their partner if they are in a biracial relationship.

• Referrals to programs that increase support from the Black community (such as the NAACP or Black Lives Matter).

• Creating a plan of action to address discrimination in the workplace with their HR department.

Throughout treatment I utilize Narrative Therapy, Art Therapy, and trauma informed approaches to validate their experience as a victim and survivor.

• Making racists remarks.

Because we don’t know what we don’t know, even therapists who receive extensive cultural competency training will make racist remarks toward their patients. We may unknowingly use terms and phrases that have large cultural impacts of racism, that we did not believe to be racist. A therapist might attempt to build rapport with a Black patient by saying, “Your name is so unique and lovely.” This statement actually implies that their patient is “other,” and that a name which may be typical in their cultural background is in the “majority,” different. Despite the positive intention, this situation may make a Black patient feel segregated from their therapist.

We may also reinforce stereotypes we were unaware were stereotypes. Telling your Black patient “You just need to work harder to succeed,” uncritically accepts the stereotype that Black people are lazy. It ignores social forces and other barriers that actually take success away from Black people.

Therefore, it is important to check-in with your patient. If you find your patient skipping sessions, ask if anything occurred in previous sessions that caused them discomfort. Increasing dialogue around your potential mistakes lets the patient know that your sole focus is to help them.

My Work:

I check-in with my patient if it appears that they’ve reacted to a comment or phrase I used, saying “I noticed your reaction of [insert reaction] to my comment. Tell me, did I just discriminate against you?” If their response is yes, then we process this and I apologize. I let them know I will attempt to be more aware, and I document this interaction thoroughly in my notes. I also consult with colleagues, especially colleagues of color, to create further understanding of what occurred and how to prevent further harming my patient.

• Having the patient educate the therapist.

Black patients often have to educate their white therapists regarding cultural norms and standards. These long explanations of backstory not only change the subject from the original issue the patient was presenting, it also take precious time away from session, time that was meant to benefit the patient.

Therefore it is important to learn about the cultural differences between you and your Black patients independently. Learning about the strengths and barriers of their community will strengthen the therapeutic alliance, and increase the effectiveness of treatment.

My Work:

Black patients are often told to seek help from their pastor, not a therapist. It may have taken great effort to make the decision to see me. Knowing this, I will ask my Black patients who their support systems are, and if there are any people they wish to include in therapy, like their pastor. If they do identify that they want to include their pastor, I allow room for sessions where their pastor can attend and, if necessary, I have consultations with their pastor. This is, of course, once the appropriate release of information paperwork is signed.

I accept that some treatment, like boundary setting, may look different to my Black patients who come from a kinship collectivism mindset. If this is the case, I do not teach “traditional” boundary setting skills, as it only sets my Black patients up for failure. Instead we utilize tools that are appropriate for them.

• Assuming all Black people have the same experiences.

As a therapist begins to learn more about the culture and experiences of their Black patients, they may make the mistake of assuming everything they’ve learned applies to every one of their Black patients. This takes away from the individual experience of each patient, and ignores intersectionality. A Black patient who is also Latinx will have a different experience with the Black community than someone whose parents both identify as Black, especially if the patient appears more brown than black-skinned. A Black patient who is also homosexual may have hurtful experiences with the church and identify their faith as individual instead of as a collective religious experience.

Therefore it is important to never assume. Ask questions of your patient’s experience, and utilize other cultural competency understandings. This will allow you to treat the individual as a whole. Learn about intersectionality so that you do not unfairly project the experiences of an entire cultural background onto one individual.

My Work:

I allow my patients to identify for me what they consider discrimination and stigmatization. I do not assume that the experience of one Black patient is the same as another. I always keep a curious mind to explore with my patients.

I learn about other cultures, groups, and familial backgrounds in order to bring up the various experiences of intersectionality. I keep firm the knowledge that my patient is not just their race or ethnicity or gender or sexuality or ability. I do not identify them by their mental or medical disorder. I always allow the patient to tell me what parts of themselves need highlighting in session, and what parts they aren’t ready to explore.

Cultural Competency Education

There are still many licensing boards who do not mandate cultural competency education. This is a huge disadvantage for both therapists and patients. We*** as white therapists must increase our cultural competency, even if it’s not mandated. Learning how to better serve a variety of people will help you to better serve the populations you already have a niche for, as it gives you more language and treatment modalities to use.

Here are a few cultural competency resources that may be beneficial to incorporate in your practice:

• “Improving Cultural Competency for Behavioral Health Professionals” from Think Cultural Health

• “Cross-Cultural Competency” from Canvas Network

• “Cultural Competency Training” from DiversityEdu

• “Cross Cultural CE Courses” from CE4Less

• “Improving Cultural Competence” from AATBS Training

• “Cultural Competency Resources” from Community Health Association of Mountain Plains States

Black History Month is the perfect time to increase our understanding of Black people and Black culture in order to holistically support and treat our Black patients. If we don’t educate ourselves, we are at risk of perpetuating the trauma our patients sought treatment for in the first place. Ultimately, the therapeutic process is about feeling seen. When you feel your therapist “gets you,” the treatment works. 

Did you learn anything about working with Black patients? Where do you get your cultural competency training? Let me know in the comment section below!

*Additional Awareness: I have made the choice to use the identifier “Black,” instead of “African American”, as the number of Black people in the U.S. who have limited-to-no origins in Africa continues to increase. This term is more inclusive of people from the Caribbean, Latin America, or Europe who are also black or brown skinned. Additionally, this term has a generational connotation, as more young people embrace it as an identifier.
That being said, the term “Black” has been known to subconsciously distance the individual from the history of slavery in America as Americans have been taught about the history of individuals forced into slavery from Africa. This distancing from the history can be seen as discriminating. Though historically individuals from the Caribbean and Latin American were also forced into slavery for sugar plantations, this isn’t common knowledge for most Americans. Additionally, it may cause friction as individuals of an older generation utilize the identifier African American.
Therefore, as a therapist, when deciding which identifier is appropriate, it is best to ask your patient. If your patient chooses to use African American, then utilize this language in session.

**Additional Awareness: My patient has given me explicit permission to utilize his experience as an example for this article for learning purposes. All other examples are generalized.

***Additional Awareness: I include myself as a white therapist because although I am half-Filipino, I am passing for white, was raised by a white father, and raised in a predominantly white community for a large portion of my upbringing.

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