When and How Do Therapists Raise Issues of Race and Racism in Session

Background: It is well documented that racism exacerbates mental health problems and worsens prognosis and functioning. A growing body of research highlights the need to treat racism as traumatic, including the effects of ongoing exposure to racial stress and microaggression. Yet, training on how to raise issues of race or treat the effects of racism are not generally part of educational training, although this may have changed some since June 2020. In this study, we are interested how psychotherapists engage with clients around issues of race and racism, and any recent changes in their practice.

Methods: Psychotherapists were recruited through professional listservs. Ten focus groups were conducted, two hours each. The first half included all participants, and in the second half, psychotherapists were divided into affinity groups by racial identity: Black/BIPOC/African American and White/European American. Responses to seven open-ended questions were recorded, transcribed, and explored with thematic analysis. Participants were asked how they characterize their relationships with clients of color, broach topics of race and racism during session, assess and treat the effects of racism, and any changes in their practices since June 2020.

Results: Responses were categorized into subthemes and by racial identity of respondent, client described, and affinity group. Preliminary analysis suggests that therapists vary in whether or not they raise race during the intake or organically during the sessions, with White therapists deferring more to clients and less likely to mention race with White clients. Black therapists describe an influx of clients of color since June 2020 and increased comfort bringing their full selves into session. Most therapists agreed that racism is traumatic but have different experiences of what clients bring to session. No therapists are using racism-focused assessment tools, and few describe familiarity with them. In affinity groups, Black therapists generally share appreciation for the affinity group; while White therapists appreciate being able to learn from Black participants, while noting their own selective sharing and concern about unintentional harm.

Conclusions/Implications: Based on focus group discussion, practice appears to lag behind research, especially as study participants volunteered to participate, and thus were likely more comfortable and invested in antiracist practice than a wider population of therapists. These findings highlight the need for more racially diverse therapists and the need to increase cultural competence and humility training, knowledge, and skill among White therapists in particular, who currently make up the majority of therapists, on how to raise issues of race and racism in session and create more safety for clients of color to share about their experience. There is also support for the development of tools and diagnostic categories that include racism more explicitly and incorporating these into practice. Among the outgrowths of this and related research may be the creation of a therapist or agency checklist or self-assessment for best practice with diverse clients.