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How does shared racial identity between client and therapist impact the success of treatment?

Introduction

In this project, I decided to focus on the impact of having a shared racial identity in therapist-client relationships and, specifically, whether or not it made therapy more effective and succesful. I already knew from personal experience that finding a therapist of color- whether you’re looking for one or not- is very difficult- at least in Portland, Oregon, where I live. And while I’ve been able to have successful experiences with a white therapist, I’ve become increasingly aware through both research or friends that this experience is far from universal among people of color. Overall, people of color are more often subject to misdiagnosis and ignorance from treatment providers than white people are. As a result, I started to consider what we could do to fix this. Obviously, training therapists to avoid racial bias and understand other cultures is important, but it clearly hasn’t been enough to level out these inequalities. It was really only as I started to look more into the complaints that people of color had about their experiences with white therapists that I began to wonder if the lack of diversity among mental health professionals was much more intertwined with these disparities than researchers have been giving it credit for.

My goal for this project is to have my viewers become more aware of these disparities in treatment and of the actual value of increasing representation in the field of mental health. A lot of the time, it feels like people talk about diversity, but fail to acknowledge the real impact of representation. In this case, it seems very clear to me that increasing representation among mental health professionals is not just diversity for the sake of being diverse, but for the sake of reliable and effective treatment for all people.

Oregon’s Workforce Statistics

With 87.1% of our population being white, it’s no surprise that the percentage of white psychologists in Oregon is similarly large at 87.8%. The issue is, however, that other races are not nearly as well represented.

This table is a representation of Oregon’s mental health workforce statistics as of 2019. While there is a lot to take in, there are some rather striking trends in the data. For instance, there are almost no Native American/Native Alaskan providers, and there is a significant difference between Oregon’s Hispanic/Latino population (13.1%) and what percentage they account for as providers (4%). Racial minorities seem to suffer from underepresentation among mental health professionals as a whole.

Racial Inequalities in Mental Healthcare

In addition to the lack of proportional race representation, there is also a large disparity in the ways that ethnic minorities are treated when seeking mental health treatment.

First of all, I find it important to acknowledge that I found very few studies or statistics on ethnic minorities outside of the African American and Latino communities in my research. This hole in the data I was able to collect is important to keep in mind as I go through the information that I was able to find. I believe that it also further emphasizes the fact that not enough research is being done on this topic. That said, the statistics that have been published on White, Black, and Latino patients are still very significant and troublesome on their own, despite their limited representation of other ethnicities.

According to the American Psychiatric Association, African Americans are “less likely to receive guideline-consistent care,” “less frequently included in research,” and “more likely to use emergency rooms or primary care (rather than mental health specialists)” when seeking mental healthcare. This source also reported that African American patients are more likely to be diagnosed with schizophrenia than bipolar disorder when compared to white patients exhibiting the same symptoms. In terms of the therapy sessions themselves, “one study found that physicians were 23% more verbally dominant, and engaged in 33% less patient-centered communication with African American patients than with white patients.” Additionally, while discussing potential barriers for African Americans seeking mental health treatment, the report stated that stigma around mental illness, a sense of distrust for the healthcare system, and the lack of ethnic and racial diversity among providers were three of the most probable deterrents. 

In a 2008, Thomas G. McGuire, a Professor of Health Economics at Harvard Medical School, and Jeanne Miranda, a Professor in the Department of Psychiatry and Biobehavioral Sciences at UCLA, published a study in the National Library of Medicine. McGuire and Miranda reported that, while African Americans had lower rates of lifetime major depression than White Americans living in similar areas, major depression rates in the past year were similar across both groups, “indicating a more persistent illness.” Black Americans were also “more likely to rate their depression as very severe and disabling.” Similarly, the report added that both Black and Hispanic Americans report a lower risk of having psychiatric disorders than White Americans, but found that those who are ill have more persistent disorders.

When summarizing their findings, McGuire and Miranda stated that “disparities exist in access to and use of mental health services for ethnic minority individuals” and that “during the past decade, efforts to eliminate these disparities have not been successful in primary care or specialty psychiatric services.” They indicated that one of the most important factors in addresing mental health disparities is “increasing the proportion of racial minority providers,” stating that “a federal commitment to the outreach and educational support necessary to build a truly diverse mental health workforce is a critical policy recommendation for decreasing disparities in mental health care,” as well as improving minority patients’ lack of trust for the healthcare system. 

Common Approaches to the Issue

There are several approaches to the issue of diversity in mental health care. Despite there being a plethora of evidence arguing against it, one of the most common schools of thought is the ‘colorblind’ approach, which maintains that culture and race should be ignored in order to give the most effective and equal care, and that these aspects of one’s identity are not factors in mental health. The idea is essentially to ignore race and culture entirely when providing treatment. Another popular approach is to acknowledge that race should not be ignored entirely in treatment, and instead push for current therapists to be better trained in cultural competency, arguring that, with sufficient training, outcomes will be improved. 

However, neither of these approaches account for the fact that no amount of training can compare to real life experience or fully address power dynamics caused by racism. In the end, the client is still often put in a position where they must educate their therapist and validate the severity of their own traumas. This makes the therapy process even more difficult by forcing the client to be even more vulnerable in order to recieve help- at a time when they’re already struggling. Most importantly, as we saw in the earlier reports, these efforts still haven’t been enough to improve therapy outcomes to a level that is equal to those for white or majority culture clients. The disparities still exist, and they are significant.

So How Can Shared Race Impact the Success of a Therapist-Client Relationship?

While studies and statistics are important, it is just as important to look at the more analytical side of this issue to understand how race affects therapy, especially in order to determine how important a shared racial identity between client and therapist actually is for treatment to be effective. For this, I took to interviewing Dr. Cynthia Fowler, a black psychiatrist operating in Portland, Oregon. When asked on her thoughts on how important it is for a client to find a therpist of their own ethnicity, she told me that it really depends on the client. While it’s entirely possible to have a successful therapy relationship without the client and therapist being the same race, for many people of color seeking therapy, it’s key.

While discussing the colorblind approach to mental health treatment, Dr. Fowler explained that it’s pretty much the way we’ve been delivering mental health care all along. When diagnosing patients, “there’s really not much consideration about culture or ethnicity or race,” she told me, “we’ve been treating people as if we’re kind of all the same.” And yet, Fowler pointed out that people of color are still “more likely to get the most severe treatment and heavier medication, as well as more severe diagnoses.” As a result, she finds the idea that we can treat everyone the same by not talking about race very “short-sided.” 

According to Dr. Fowler, race can indeed be major factor in one’s mental health, as racism, in particular, can be a significant stressor and exacerbate mental illness. One problem she has with the current design of cultural competency training is that racism is not often considered despite being a major factor in both the mental health of people of color and their trust within a therapist-client relationship. After all, racism and invalidation in therapy are some of the most common reasons people of color are more likely to quit treatment before their white counterparts. A therapist-client relationship “is about the relationship,” Fowler insists. “You’re talking about intimate issues that people don’t normally discuss when they’re out with other people, so [having a therapist of the same ethnicity] can help to establish trust and allow people to open up.” 

Conclusion/Reponse

At the end of our interview, I asked Dr. Fowler what she thought was responsible for the disproportionate representation in Oregon’s mental health professionals and what we should change in order to begin addressing the issue. She recognized stigma within communities of color related to mental health as a major factor in deterring people of color away from pursuing psychiatry, just as it often deters them from seeking treatment. Furthermore, Fowler pointed out the fact that Oregon only has one medical school and doesn’t produce a lot of physicians in the first place. However, schools are almost entirely focused on testing, which tends to be biased away from racial minorities.

One of the most important changes schools can make to increase diversity is shifting the way that they choose which students they’re going to train away from just testing. Fowler also indicated that funding people to train through “providing not loans, but actual grants” can make a huge impact in the accesability of school for people of color.

But as people that have very little input on those types of decisions, there are still ways we help support this cause. We can spread awareness about racial inequalities in the mental healthcare system and about the value of representation among providers. In our everyday lives, we can decrease stigma within our communities and encourage our friends and family to open up and seek treatment when they might need it. That is how we can do our part advocate for the next genertion of therapists to be more diverse, and in doing so, we will be chipping away at the disparities within our healthcare system and creating a new institution that is able to provide the most successful treatment for everyone.

Questions/Feedback

Now that you’ve read about the studies, statistics, and professional opinions, it’s your turn to join the conversation. What did you think of the information and conclusions presented here? Did you learn anything new or surprising? If you’re part of a racial minority, can you relate to these concerns?

Works Consulted

Thank you for taking the time to read through my project! I hope that you found it interesting and are a little more aware of the world around you than you were before reading through it.

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COMMENTS: 2
  1. April 26, 2020 by Isabell

    Hi Patina, I really like this presentation and I’m happy to see this topic explained in such an amazing way. I really liked the graphs you showed and how they are incorporated into your argument as well as the information you learned from talking to Dr. Fowler. I didn’t know the different approaches therapists take to race and how strongly they differ from each other. I think it’s really interesting but also very problematic on how those are the two are the most popular approaches, and there definitely needs to be a change where culture, experiences, and race are taken into account in a way that helps the patient receive more personally shaped treatment.

  2. April 27, 2020 by Sierra Martin

    Hey Patina! Great job. I found your topic to be super interesting and unique– as somebody who’s never had a therapist themselves, I had never even thought about how the racial identity of a therapist might be important for the patient’s sense of connection. It definitely makes sense, though; when you’re part of a marginalized group, it’s totally understandable that you’d want to explore that marginalization with somebody who experiences/empathizes with what you’re going through. Accordingly, I agree that the lack of POCs in mental health professions is a major issue. Great work!

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