Confronting Racism in the Therapy Room

The therapist-patient relationship is a unique one. It is at once exquisitely intimate, and yet also ruled by boundaries. A therapist is single-mindedly dedicated to healing, even when a patient might be uncooperative, hurtful, or belligerent. But like all inter-personal relationships, belief systems and implicit biases are at play, and sometimes the therapeutic relationship cannot be sustained because prejudice – from either person – gets in the way of effective treatment.

This is a challenge faced commonly by both patients and therapists of minority communities. Shawn Blue, Psy.D, a staff psychologist at the Student Personal Counseling Center and clinical assistant professor in the Department of Psychiatry and Human Behavior at Jefferson, has long navigated the balance of advocating for mental health care for the BIPOC community, and prioritizing her own well-being when faced by both micro- and macro-aggressions, from colleagues and patients.

Being the Only One Means Advocating and Educating

“In many positions I have held, I have been the only Black person in the room,” says Dr. Blue. “I take that representation very seriously, and I have always dedicated a lot of energy to being a role model, an advocate, and to creating spaces, whether it is town halls or support groups, for our BIPOC students. I’m also very aware of the privilege that comes with being a faculty member, and use that to stand up for and mentor other BIPOC in my department, whether they hold administrative positions or are rising faculty.”

Dr. Blue knows how important it is for her community to see her occupy space in a field that is dominated, like many medical fields, by straight white men. “There is a long history of mistrust that BIPOC, and particularly Black people have toward the medical establishment in general,” she explains. “Historically, Black patients have been misdiagnosed at higher rates than white patients, and the Black community has been exploited by the government and the medical community in the name of discovery and advancement.”

This mistrust prevents individuals from seeking care, and is exacerbated by a stigma towards mental health that pervades society in general, but is perpetuated uniquely in the Black community by a survival mentality. “Black people have faced centuries of systemic oppression and racial injustice,” Dr. Blue says thoughtfully. “And even though that adversity has taken a significant toll on mental health, we have survived, so it is sometimes seen as a weakness to get help or treatment.”

Religion and the powerful community found in the church and other places of worship also often dissuade Black people from seeking mental health care. “Many of us are told to talk to our pastor or ‘pray it out’,” says Dr. Blue. “In fact, many Black people think that pastoral counseling and therapy are the same.  Although this approach is shifting and churches are attempting to address mental health needs, there still remains a stigma regarding seeking mental health treatment.” As part of her advocacy efforts, Dr. Blue promotes awareness about mental health in churches, and tries to educate on the importance of psychological counseling and debunk the stigma around medications.

Being the Only One Also Means Dealing with Micro- and Macro- Aggressions

As much energy that Dr. Blue puts into advocating within her own community, she pours the same into confronting prejudices, slights, and othering in spaces where she is the minority, which includes the work place and the therapy room.

“I think the question that a lot of Black people have to deal with at work, especially when most of the people around you don’t look like you is – what amount of Blackness is acceptable?’’ she says. “And it impacts everything, from the way I wear my hair, to how I talk, to how I approach people.” Dr. Blue says she often finds herself “masking" or code-switching, that is, adopting an appearance or behavior that is very different to how she would exist outside the work place, in order to manage the conflict of existing in a rigid culturally defined space of what society deems as appropriate.

Last month, in the wake of the death of George Floyd, and the uprisings against police brutality of Black people, Dr. Blue wrote about the trauma of overt and violent racism, but also of the harm of micro-aggressions and more subtle racist prejudices. “It is exhausting to navigate that on a daily basis, especially in the work place,” she says. “They may seem small things – like the other day, my title was omitted on a call, but that didn’t happen to any of my white colleagues. And it made me think ‘Is it because of my race? Was it just a mistake?’ I have to decide in those situations whether to just walk away, or to use my emotional labor to call it out.”

Facing Prejudice in the Therapeutic Space

It is trickier when these interactions happen with patients. “As a therapist, my goal is to support the person in bettering themselves,” explains Dr. Blue. “It is not my responsibility to change their view on an issue, like race. If they have views that are not affirming to my own, I have to hold that conflict in a separate space in my head, and check in with myself after a session to see what it brought up for me.”

Though it has not happened during her ten years at Jefferson, Dr. Blue has faced outright hostility from patients because of her race. “One person just couldn’t get past my race and it created so much distrust, it was not possible for them to accept and approve my treatment,” she says. “Ultimately, in those kinds of rare situations, it isn’t healthy for me to be a part of that therapeutic relationship anymore, and I recommend the patient see someone else.”

In times like now when race is at the forefront of natural conversation, it often comes up during a session. “For my BIPOC students and clients, it’s so important to have that space to talk about how the events around them are affecting their mental health,” says Dr. Blue. “With my white patients, some are very open to talking about it and expressing support, others kind of tip-toe around the issue, and some may have differing opinions. But most of the time, even if we disagree, it doesn’t get in the way of treatment. And in cases where the patient wants to specifically work on race issues, there has been progress or a positive impact of therapy.”

Whatever the situation, Dr. Blue never forgets that in the therapeutic setting, it is always about the patient. “As therapists, we have to maintain that privacy and boundary, and I have to make sure that I take care of myself outside the therapy room to make sure I’m not projecting or bringing my own challenges to a session,” she says. “It might mean that I have to practice more self-care, check in with my own therapist, and connect with my peers, especially fellow colleagues of color, to get that validation on what my experience was and how I handled it.”

Looking Forward – More Representation and Equity

Reflecting on the lack of Black people in the roles of psychiatrists and therapists, Dr. Blue says with a pause, “Sometimes I think, is it 2020? We haven’t progressed much, honestly.” She does see a shift in the attitude and openness around mental health in the Black community, especially amongst Black women. “I think there has been a surge of energy and empowerment surrounding Black women,” she says hopefully, “and there is more willingness to embrace self-care. I don’t see as much of a shift for Black men, who are particularly vulnerable to violence and brutality at the hands of law enforcement.”

Dr. Blue hopes that with initiatives like National Minority Mental Health Month, which was started in honor of Black mental health advocate Bebe Moore Campbell, more awareness will be drawn to the unique mental health issues faced by BIPOC communities, and education and destigmatization of mental health will encourage individuals in these communities to pursue support and treatment.

“I want more equity for Black people and communities of color in the mental health space,” she says. “It shouldn’t be so hard to find good and safe therapy, and until we can encourage more BIPOC to join the mental health profession, it has to be mandated that all therapists have multicultural and anti-racist training. Our license says that we protect our patients’ wellbeing, and part of that is making sure that we can adequately help, and do no harm.”