Therapists display discriminatory behavior towards racially- and sexually- marginalized clients at an alarming rate. A new study investigated therapist attitudes and psychological characteristics related to over-pathologizing and invalidating microaggressions against clients, finding that therapists with colorblind attitudes were least likely to believe and properly treat racially and sexually minoritized clients.
The study authors, Jermaine Dictado and Susan Torres-Harding at Roosevelt University in Chicago, explain:
“Therapists who respond to their clients with extreme discomfort or anxiety, guilt, apprehension, or dislike might be motivated to avoid uncomfortable cultural topics to manage their own emotional reactions, and thus, they may fail to appropriately integrate uncomfortable topics into their discussions and treatment planning.”
“Similarly, a therapist’s unexamined cultural stereotypes might lead them to be more likely to blame the client for treatment failures, stereotype the client, and use negative labels, such as viewing the client as resistant.”
Dictado and Torres-Harding wanted to know whether therapists in training enacted microaggressive and invalidating behavior towards racial and/or sexual minority clients. Secondly, they investigated how therapists’ psychological qualities related to their likelihood of discrimination towards racial and sexual minority clients.
Therapist qualities included countertransference (“therapists’ cognitive, affective, and behavioral responses to clients”), reports of client symptoms and severity, minimizing of clients’ reported microaggressive experiences, heterosexist attitudes towards lesbian women, multicultural competence, and empathy towards clients.
Microaggressions, in general, are “everyday interpersonal or environmental exchanges that convey hostile, derogatory, offensive, insulting, or denigrating messages to people because of their social group membership.” For example, racial microaggressions include treating racially marginalized people like perpetual foreigners, criminals, unintelligent, or sex objects based on their race. Microaggressions against sexual minorities include endorsing heteronormative beliefs by suggesting same-sex relationships are unacceptable, using transphobic language, or exoticizing gender and sexual minorities (GSMs) and their bodies.
Microaggressions in therapy most commonly include avoidance of issues related to identity, minimizing the impact of oppression on clients, and making stereotypical or insensitive assumptions about the client and treatment recommendations. More than half of REM clients experience microaggressions in therapy, while little is known about how often therapists microaggress GSMs. This is especially disturbing because microaggressions in therapy are particularly harmful and lead to adverse mental health outcomes.
“Therapy microaggressions may be especially difficult for clients because these experiences, unfortunately, reinforce existing social hierarchies of oppression, may serve as painful reminders of enduring discrimination, and may contribute to the perception that the therapy situation is not a safe or supportive environment.”
Therapy trainees from master’s and doctoral clinical and counseling psychology programs were randomly assigned to read and respond to one of four hypothetical vignettes involving a client.
There was one vignette for each possible combination of “White” or “African American” and “lesbian” or “heterosexual,” all of which involved a female student encountering common microaggressions while attending a demanding Ph.D. program and beliefs that difficulties and microaggressions were due to the client’s racial and sexual identities. After reading the vignettes, trainees responded to questions about their perceptions, diagnoses, and initial treatment approaches for the client.
Participating therapy trainees were predominantly female (84.45%), white (62.72%), heterosexual (87.27%), and from master’s level programs (60.91%). Although it was not representative of the general population, the sample included transgender, Black, Latinx, Asian, Middle Eastern, gay, lesbian, and bisexual trainees.
Trainees’ perceptions of clients’ symptom severity were not associated with clients’ racial and sexual identities; however, invalidation of microaggressive experiences was related. For example, therapists in training were most likely to believe that African-American lesbians’ experiences of microaggressions were due to their identities and least likely to believe the same for white heterosexual clients.
Trainees with more colorblind attitudes and overwhelmed and disorganized reactions (experiencing dread, resentment, and wanting to avoid the client) to clients were more likely to pathologize clients, report higher severity of symptoms, and disbelieve clients’ experiences of microaggressions. The authors explain that colorblindness involves avoiding discussing and acknowledging race in order to seem unbiased.
“Because colorblindness involves avoiding recognizing racial disparities, participants may have been predisposed to understand the client’s problems as a result of individualized deficits in clients’ problem-solving abilities and thus more indicative of a greater pathology.”
Conversely, those with more helpless/inadequate (feeling inadequate, incompetent, hopeless, or anxious) or positive (expecting a good working relationship and alliance) countertransference were most likely to believe clients’ experiences of microaggressions.
Multicultural competence, empathy, and heterosexism were not associated with ratings of microaggressive experiences. However, trainees tended to respond to each of these variables in socially desirable ways (high multicultural competence, high empathy, and low heterosexism), making it unlikely to find associations with other variables.
While this study provides evidence that therapists’ biases and psychological reactions to clients influence their interpretations and treatment planning, there are several limitations that would make it dubious to apply these exact results to real interactions in therapy.
Intersectionality matters. Dictado and Torres-Harding write that trainees may believe experiences of microaggressions from African-American lesbians the most of the studied populations due to “triple jeopardy”; awareness of the compounding effect of their three stated marginalized identities. They suggest participants were least likely to validate microaggressions experienced by hypothetical heterosexual white women because trainees overlooked the impact of sexism in our society.
Ironically, the authors present the least evidence of microaggressions against heterosexual white women in comparison with evidence of microaggressions against lesbians, African-American women, and African-American lesbians. Their finding may reflect an accurate understanding that heterosexual white women would be least likely to experience microaggressions out of the four client groups rather than an oversight. The study should be conducted with vignettes about male clients for comparison before concluding that trainees do not acknowledge the relevance nor level of impact of microaggressions against white women.
The study design limits its application to the real world. Vignettes about PhD-level clients potentially limit the study’s relevance to clients with less educational privilege. The authors acknowledge that their study addresses trainees’ appraisals of clients but not actual therapist behaviors. Similarly, trainees’ provided ratings and reactions while aware that another psychologist would see their responses. The study does not demonstrate how much trainees behave like they believe clients when the client is the only one watching.
This study is an important first step in understanding therapists’ attitudes and how those attitudes inform treatment processes for racially and sexually marginalized clients. Dictado and Torres-Harding recommend that programs provide students with an environment that supports introspection and reflection, helps students identify and cope with negative countertransference that could lead to over-pathologizing and invalidating clients, and provides emotional support for insecure trainees.
Colorblindness may lead therapists to feel they are unbiased but contributes to culturally insensitive and unfair conceptualization, diagnosis, and treatment of marginalized clients. The results emphasize the need for multicultural training to include attention to therapy trainees’ emotional, cognitive, and behavioral responses to their clients so that trainees may more intentionally manage their own countertransference reactions and attitudes. This level of introspection and awareness is necessary to provide validation, accurate assessment, and fair treatment when working with culturally diverse clients.
Dictado, J., & Torres-Harding, S. R. (2022). Predictors of therapy trainees’ pathologizing and invalidating microaggressions with sexual and racial minority therapy clients. Training and Education in Professional Psychology. Advanced online publication. https://doi.org/10.1037/tep0000424 (Link)