Does the race of my therapist matter?
According to Maslow, safety is an innate need which humans will stop at nothing to attain. Physiological safety embodies food, water, warmth, rest and security. One rung above this, on Maslow’s hierarchy, is the need for psychological safety, which encapsulates the need to belong and the need to be loved. But, what does any of this have to do with choosing a therapist? The goal of therapy, in most cases, is self-actualization. Yet, a client does not generally make their choice of therapist based on the pinnacle of that iconic pyramid. In most cases, a client will choose their therapist based on a feeling of support and belongingness. Are we a good fit based on the categories we share (ethnicity, race, gender expression, sexual orientation, socioeconomic status, hair texture, marital status, Mac vs. PC)? In this post, we will delve into the thought processes inherent in choosing a therapist. Specifically, we’ll answer the question: “Does the race of my therapist matter?”
Do we make assumptions about identity?
If one were to see a photo of me and identify my brown skin, dark red dreadlocks, 5’11” plus-sized stature, tortoiseshell glasses frames, and wide smile, one may assume that I am a soulful Black woman who may lead a sedentary lifestyle who appears to be warm. The next step in the game of assumptions would be to ascribe meaning to the identities ascertained. “This soulful, sedentary and warm Black woman can probably relate to my racial trauma, and has, no doubt, experienced size bias. Thus, were I to choose her as my therapist, it is likely that I wouldn’t have to educate her about my lived experiences. She would get it!” And just like that, the assumption has morphed into a presumption nurtured by the illusion that a similar cultural background makes us safe.
Does it matter if my therapist is similar to me?
Google search trends for the keywords “Black therapist” peaked at 100% on August 10, 2021, up from 36% in August of 2020, and 10% in August of 2010 (Google Trends, n.d.). This data is particularly noteworthy in light of the historic and traumatic context of systemic racism woven into the fabric of medicine, which has fostered a mistrust of healthcare systems and impacted help seeking behaviors among Black Americans. Although denounced as erroneous pseudoscience early in the 20th century, the effects of biological racism still exist today as evidenced by a relatively recent study by Hoffman, et al. (2016) published in the National Academy of Sciences. This study asked participants (n= 220, White medical students and White resident physicians) to rate the extent to which 15 biological differences between Blacks and Whites were true or untrue based on a six-point Likert* scale. For example, “Blacks’ skin is thicker than Whites’” or “Blacks’ nerve endings are less sensitive than Whites’.” Participants were then asked to rate the level of pain for Black vs. White patients and later offer treatment recommendations. The results of this study showed that participants who endorsed false beliefs about the biological differences between Blacks and Whites demonstrated significant racial bias (p = 0.002) in assessment of pain perception and pain management (Hoffman, 2016).
When we take these results into consideration, particularly the striking fact that these data were obtained just 5 years ago, it is understandable that a prospective Black client would harbor conscious or subconscious suspicion of a White therapist and be inclined to seek the security of sameness and shared experience with a Black therapist. Yet, if we go back to the soulful, sedentary and warm Black woman in paragraph 2, and peel apart the layers of assumptions, we find that she is a Caribbean immigrant who is a strong swimmer and an avid cyclist. She is neither sedentary nor soulful and has more experience with colorism than racism. Would she be a better fit for a Black American client simply because she is Black?
Kimberlé Crenshaw may have an answer for us. By coining the term “intersectionality” 32 years ago, this pioneering scholar and critical race theorist blew apart the construct of categories. Her theory of intersecting social identities not only points out overlapping systems of oppression, domination and discrimination towards marginalized groups, it also calls attention to the glaring reality that identity can neither be assumed nor presumed. This means that even with full disclosure of lived personal experiences, two persons with similar identities may STILL not identify with one another. Shared identity cannot predict therapeutic alliance nor clinical efficacy. “Therapist of opposite race” effects can still be felt, even if you picked a therapist based on race and assumptions about their culture to match yours.
What does the literature say?
Chinese American siblings Derald and Stanley Sue, world renown clinical psychologists, prolific authors and staunch supporters for multicultural counseling and psychotherapy, have long advocated for culturally diverse clients to be treated by culturally diverse therapists. The premise of their hypothesis is that therapeutic outcomes will be improved when therapists understand clients better and clients feel better understood (Sue & Sue 2012).
However, a systematic review of the literature on the multicultural practice of psychotherapy by Raja (2016) warns against the default presumption that therapist-client similarities provide an asset to therapeutic work. In fact, Raja proposes that there is danger in focusing on the psychotherapeutic impact of therapist-client differences, while ignoring the potential ethical dilemma associated with therapist-client similarities. Raja (2016) focused his review on two propositions: (1) demographic matching between therapists and clients will yield better psychotherapeutic outcomes for clients, and (2) clients prefer therapists who are similar to them on demographic factors relevant to their self-identity.
The data show notable therapeutic benefits for demographically matched therapist-client dyads attributable to increased empathy and decreased judgment. For example, it was found that Latino adolescents matched with Latino therapists experienced decreased substance use compared to Latino adolescents matched with White therapists (Raja, 2016). Yet, within the same review it was also found that Japanese American and White social workers reported increased feelings of over-vulnerability, over-identification and over-investment with same-race clients. The meta-analysis of data from this review, representing 50-80 studies on racial/ethnic matching, indicated little to no treatment benefit from racial/ethnic matching (Raja, 2016).
So, after all this, does the race of my therapist matter?
Answering this question as a therapist, I would shout “no”! Do not choose a therapist based on an assumption of shared identities. Choose a therapist who challenges you and is skilled enough to discern the whimper of true pain amidst the scream of anger. However, were I to answer this question as a client (therapists need therapy too!), I would have to admit that I would lean towards choosing a therapist of the same race, regardless of scope of expertise.
So where does that leave us?
Maslow’s theory of behavioral motivation suggests that humans will meet the lower level needs of physiological safety before the higher level needs for self-actualization. Only you can determine which need takes precedence for your mental health. Perhaps your next google search will yield a therapist who can satisfy both ends of the pyramid simultaneously. Perhaps she will have dark red dreadlocks.
Fact Check:
- Choosing a therapist whose gender and/or race is similar to yours may increase your level of comfort and feelings of safety.
- The therapeutic alliance should be a safe space, however, if it is always comfortable, very little work is being done.
- Selecting a therapist based on a preference for similarities in race and other identities will increase the risk of hazardous transference (redirection of emotions originally felt in childhood, from client to therapist) and countertransference (the emotional reaction of the therapist to the client).
- The person you most identify with may not be the person who would provide the most effective therapeutic intervention or advice for you.
- Your belief in a therapeutic alliance matters a great deal more than race or color. If YOU believe that healing will happen, then healing WILL happen. You will make sure of it.
References:
Google Trends. n.d. Retrieved from https://trends.google.com/trends/explore? date=all&geo=US&q=black%20therapist
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296–4301.
Raja, A. (2016). Ethical Considerations for Therapists Working With Demographically Similar Clients. Ethics & Behavior, 26(8), 678–687.
Sue, D. W., & Sue, D. (2012). Counseling the culturally diverse: Theory and practice (6th ed.). Wiley.
*Likert scale: a rating system designed to measure the strength of an attitude normally ranging from strongly disagree to strongly agree