Staying The Course:
Psychotherapy In The African-American Community

By Janis Sanchez-Hucles

African-Americans are appropriately cautious about seeking mental health services. Historically, those individuals who sought services were pathologized, overmedicated, given long-term and inpatient treatment, rather than outpatient treatment, and were exposed to insensitive therapists who did not believe African-Americans could benefit from verbal therapy. Like other potential clients, black individuals fear that if they seek formal mental-health assistance they will be labeled “crazy” or blamed for their problems. Unlike other patients, African-Americans are also reluctant to seek services because of a longstanding tradition that dirty laundry should not be aired to others, and that they must solve their problems on their own.

When African-Americans obtain assistance and meet with a white therapist they are often fearful that these therapists will be biased, use stereotypes, minimize the clients’ experiences of discrimination and not understand black cultural traditions. Even if a black client has a black therapist, the client may rightly fear that the therapist may be unable to relate to the client due to differences in education, class or life experiences.

The reality of providing mental-health care is stark: The first session a clinician spends with a client may be the last. Managed care and limited insurance benefits often make psychotherapy focused and short-term. Regardless of race, 40 percent of clients attend one session and drop out, while the remainder typically conclude therapy after four or five meetings. African-Americans drop out at rates higher than 40 percent. All too often therapists today do not understand the issues that are unique to African-Americans and the special dynamics that these clients bring to a first session of therapy.

As more African-Americans seek therapy, service providers are challenged to offer culturally competent services to all clients. In my more than 20 years of providing clinical services and supervision, colleagues and students from both majority and minority groups have expressed confusion and perplexity about how to treat African-Americans, and how to conduct the kind of successful first session that increases the chances that the client will return.

What, others have asked me, should I do so that I don’t scare clients away in a first session? Should I talk about racial differences? How can I talk about differences without alienating a client? I am afraid that if I bring up race my clients will think that I am prejudiced. Perhaps I should just avoid working with clients different from me; it’s simply too difficult.

Overcoming Distrust

Nevertheless, research tell us that almost all counselors can become culturally competent, and that well-trained therapists are capable of providing quality services to virtually all clients. While an African-American therapist may, in some cases, develop a faster rapport with a black client, there is no reason to believe that therapists who do not match their clients in race and other demographic areas cannot provide excellent services.

When colleagues and students ask if they can determine a client’s racial identity by appearance, I strongly let them know that they can’t and that they should not try to do so. The term African-American refers to individuals who share a historical tie to the west coast of Africa, and to experiences of slavery, indentured servitude, discrimination and traditions of resiliency. But at the same time, African-Americans are heterogeneous with respect to appearance, ethnic identity, religious affiliation, socioeconomic status, sexual orientation, cultural expressions, family composition and geographical origin.

Nor is the African-American community monolithic in terms of language. Black individuals residing in the Caribbean, South and Central America and Canada speak different languages, while individuals from the Caribbean and outside the United States may consider themselves to be black but not African-American because of vastly different historical and cultural experiences. Indeed, some Caribbeans and individuals from Africa are offended if they are mistaken for African-Americans.

Given the high numbers of multiracial individuals in this country, therapists are wise to refrain from guessing or assuming any client’s ethnic identity. We show respect for our clients by asking them about their ethnic background and how they self-identify.

What African-American clients need in a first session is a culturally competent therapist. Service providers need to ensure that clients are treated with respect from their first office contact. Clients can be put at ease when they enter a waiting room and find familiar magazines, books, toys, art and music.

African-American clients are also usually very sensitive to protocol issues. They expect to be addressed by the title of Mr., Ms., Mrs. or Dr., and will use titles with their therapist. African-American clients also expect therapists to spend some time with small talk before jumping into a session. These clients often don’t care about how much we know until they have a sense of how much we care about getting to know them as individuals. We also need to be aware that these clients need to keep the conversation real and genuine. Therapists who try to convey distance and neutrality instead of a warm interest are likely to lose African-American clients after one session.

It is vitally important that therapists who work with African-Americans be self-aware. In addition to taking courses to learn about the African-American experience, therapists should identify any sources of uncertainty, discomfort, anxiety, bias or cultural baggage that they might have. Therapists can learn about potential bias or blind spots by being supervised by culturally competent colleagues. For example, many white therapists know about discrimination but are unaware of their white privilege. They take for granted that they are not typically pulled over by police or followed around stores, or stared at with fear simply because of their race.

An Alliance Based On Rapport

Therapists need to be able to have difficult dialogues with African-American clients on issues of race, discrimination, gender, sexual orientation, religion or any other possible area of difference. Although race continues to be a taboo subject both in and outside of therapy rooms, in order to have a successful first session with African-Americans, therapists must not be afraid to raise the topic of race or to talk comfortably about racial issues and differences. Many African-American clients have very well developed senses of non-verbal communication. Therapists who are unaware of their own non-verbal signals of discomfort can alienate clients.

Therapists need to be able to do “perspective taking”: that is, how might I look at the world differently or respond to this situation if I were black? How are my cultural and political beliefs shaped by my family and my personal experiences? To what extent have I been assuming that my values or the values of the majority culture are correct and normative for all individuals?

African-American clients are not likely to return for therapy unless a strong working alliance is developed in the first session. It is important for therapists to give clients an overview of what will occur in the first session and to invite the clients’ active participation. We typically can tell if we are successfully connecting with our clients when they seem to be actively engaged and interested by virtue of both verbal and non-verbal behaviors. Therapists can show familiarity with black culture in their appropriate use of materials from the African-American artistic, literary and performing-arts traditions.

Because none of us can be experts on all cultures, there may be occasions when we feel that we have made a mistake or offended a client. If this occurs, we should immediately apologize, gain further clarification if necessary, ensure that we don’t repeat our mistake, and model good communication and problem-solving skills.

Our best defense to handling ruptures to rapport is a good offense. Our most effective offense is to be respectful and culturally competent. If we can convey that we have spent time and energy learning about the lives of African-Americans, many of our clients will give us some leeway to learn about their unique needs, interests and sensitivities.

Janis Sanchez-Hucles is author of The First Session With African-Americans: A Step-By-Step Guide and a professor of psychology at Old Dominion

Quest June 2001 • Volume 4 Issue 2