By Rachel Anyika
Is Ethnicity A Barrier to Therapy?
This article is adapted from an academic paper, considering how therapy is tailored to the dominant groups in society, and largely ignores the disadvantages of those in minority groups.
A dominant group in society is largely defined as, the group with the most members or the group that holds the most power and privileges in a society. Groups can form around shared race, gender, religion, work, politics etc. There are many theories as to why certain groups seek to dominate in society. Competition for resources, competition for economic surplus and a drive to improve self-esteem are some of the explanations put forward by various theories. In many societies, heterosexual white males are the dominant group, even though they might not have a majority in numbers. In this example, it is the power and privileges afforded to this group, which makes them dominant. Power and privileges usually equate to benefits like better jobs, higher income, better housing, protection of group beliefs and improved health care.To keep those powers and privileges, non-dominant groups with low status, like ethnic minorities, are often viewed negatively, and directly or indirectly discriminated against. For example, a recent survey in the UK by Opinium, found that 71% of ethnic minorities reported incidents of racial discrimination.
It has been noted by several different writers, that largely the dominant groups in society, choose to ignore or fail to understand, what it means to be in the dominant group. This makes it unlikely that they will be able to comprehend the disadvantages of being outside of the dominant group. In some instances, those in the dominant group do not feel comfortable acknowledging the privileges of being dominant, perhaps, because this could lead to the loss of those privileges. According to researcher of white culture, Dr Myriam Francois (2019) "it remains unclear whether we wish to confront this myth of colour blindness as a mask for our white privilege – or whether we harbour a more or less conscious longing for the days when white people’s privileges simply couldn’t be questioned". Littlewood & Lipsedge (1982) - believe that failing to seek to understand those outside the dominant culture leads to alienation of 'outsiders', which results in the dominant group being more likely to describe behaviour they do not understand as deviant or ill. Understanding the wider social context is important to enable us to consider the effect on the counselling and psychotherapy field.
Effects of Institutional Racism
"Many governments have passed a variety of Acts and laws that have provided a legal framework for the institutionalisation of racism". Allen (1973:101)"
The basic needs and rights of members of society should be protected in some form by the different laws and policies of the country those members reside in. However, many countries have a lengthy history of oppression of ethnic minority groups. Oppression, that was at times enshrined in the laws of that country. For countries like the UK, the oppression of ethnic minority groups resulted in large economic gains, during a history of colonialism. According to Colin Lago, institutional racism was driven by slave traders trying to justify their business practices and protect profits,
"the various government policies embodied in Britain's relationship with countries in its empire were dominated by racist perspectives" (Lago, 1996: 165).
This is describing a societal environment where alongside laws protecting slavery, pseudoscience and literature insisting on the superiority of the white race were encouraged. This caused an environment in society where the 'other' and difference was feared and even considered dangerous. This was a very effective way of dehumanising minority groups, to justify a regime of oppression. It also diverted attention away from the richer, upper class members of society, so that less questions were raised as to why they were so rich. In present-day, societies have largely moved on from such overse racism, and slavery laws have been abolished. However, it is difficult to remove the more covert policies that disadvantage ethnic minorities. There have been moves towards providing statutory protection from discrimination, with the introduction of laws like The Equality Act in the UK. But critics argue that these changes do not do enough to address the imbalances in privileges that the dominant culture still has the benefit of. D’Ardenne & Mahtani (1989) believe that "the statutory services, by their very nature, embody the cultural values, beliefs and prejudices of the majority culture. They have the furthest to travel, culturally speaking, to meet the service needs of any client from another culture." For example, statutory bodies like the judiciary, are often largely made up of the dominant group, with ethnic minorities finding it much harder to progress to senior government roles. When the people making the decisions have vested interests in protecting their own interests, it is likely this will take precedence.
It is useful to consider some statistics from different ethnic minority groups, to highlight the experience of ethnic minorities in mental healthcare in the UK. Evidence suggests that ethnic minorities are less likely to access mental health services (McKenzie 2008). Black Caribbean males have a four times higher incidence of schizophrenia than their white counterparts (NHS Digital 2008). Suicide rates among South Asian women are particularly high (Williams 2018). Compulsory detention under the Mental Health Act was sometimes four times higher in ethnic minority black groups (Fearon 2006). Irish people living in the UK have higher hospital admission rates for mental health problems than other ethnic groups. They have higher rates of depression and alcohol problems and are at greater risk of suicide (Baker 2018). Asian or Asian British are one-third less likely to be in contact with mental health services (Dowrick 2009). Currently, there is a lack of research to understand the reasons behind these differences. Which could be seen as further evidence that institutional and legislative structures are less interested to understand the needs of minority groups. A 2016 study researching BME experiences in mental healthcare in the UK, found that key barriers to accessing mental health services include the ability of providers to effectively deliver services that meet the cultural, linguistic and social needs of patients. Patients reported fear of discrimination, communication difficulties, stigma and fears of being prescribed medicine with no complimentary talking therapies offered.
"participants felt that healthcare providers did not adequately recognise or respond to their needs. They felt that the system lacked flexibility, leaving it unable to support individual or cultural preferences, particularly in relation to available therapies." (Memon, Taylor, Mohebati 2016)
Further evidence of the statutory framework ignoring the needs of minority groups appears to be the lack of funding for specialised services to those groups. Specialist services for minority groups seem manly to come from the voluntary sector. In the UK to name a few, specialist services like NAFSIYAT (1985) a London based intercultural therapy centre and The Black, African and Asian Therapy Network (BAATN) are all charitable organisations. A specialised service is much more likely to be aware of specific needs and could feel more accessible to clients from those groups. Though an interesting article from Sashi Sashidharan argues that a move towards specialised services, does nothing to combat institutionalised racism. Further, specialised services could emphasise that culture and difference should be removed from the mainstream, therefore not truly embracing a multicultural society. (Bhui & Sashidharan 2003) It could also be that not all those within ethnic minority groups wish to use a specialised service. They could have an unrelated issue, or for some smaller communities, worry that someone in the service will know of them.
With minority groups having less job opportunities and earning lower incomes, it is more likely that they need access to free counselling services in the NHS. Average waiting lists for NHS therapy can be over 6 months, with the result that those who are unable to afford private therapy could suffer a serious deterioration before they are seen. NHS therapy is likely to be on a short-term basis which will not suit the needs of every client. There are also inadequate resources for support whilst waiting for therapy and lack of alternative options like group therapy.
"A number of participants believed that community support groups and organisations are important in providing an informal structure for activities, discussion and support; but that a lack of funding for the associated costs of running these groups was an issue." (Memon, Taylor, Mohebati 2016)
Problems with Therapist Training
"Many of the current theories of therapy are rooted, historically, in central European and more latterly North American culture. As such, these theories are culturally and historically bound and as a consequence also have limitations as to their applicability to all situations and persons in a multicultural/multiracial society." Lago (1996:68)
Psychotherapy & counselling techniques and theories were developed largely by white European or American males. Some argue this has helped contribute to a Eurocentric approach to therapy. Eurocentrism is a term for judging the experiences of all people through a European American standard. Counselling theory has mainly developed through observation of work with clients. If we consider the clients of some of the most well-known theorists like Carl Jung and Sigmund Freud, they worked predominantly with European upper class, white members of society, who could afford therapy. In modern psychology, which has helped shape some of the more recent theories, studies often use a narrow population size in terms of diversity. An article in the Journal of Behavioural and Brain Sciences reported that a large majority of psychological subjects had been “western, educated, industrialised, rich and democratic”. With almost 70% of subjects being American, undergraduate students (Henrich, Heine, Norenzayan 2010).
D’Ardenne & Mahtani (1989) argue that western counselling values individualism, self-exploration, self-centredness, self-disclosure and self-determination. These values developed from a culture that is increasingly industrial with many people moving from small rural life to large anonymised cities. Western counselling values, create an exclusive, intense relationship with the therapist which may feel alien for a client from a different culture "The counsellor may not take sufficient account in the relationship of the client's perception of self in relation too family, community and culture". Here the writers are highlighting the importance placed on the individual being in ultimate control of therapy, and working with the individual to help them find solutions for their issues. Clients from ethnic minorities may struggle to understand this way of thinking. Turning to eastern societies, they are generally more Collectivist, which means interconnected through family and social groups (Robson 2017). This is something I have personally experienced being from a multi-ethnic background. My Nigerian side of the family has much larger family networks, with not only personal relationships but also business relationships often being conducted between family members. Discussion is almost always focused on family matters or different members of the family, and when meeting new people importance is placed on finding out where they are from and who their family is. Fernando (1986:130) believes that alongside eastern cultures being more based on collectivism, the effect of being in a non-dominant culture will naturally give more importance to the external world, as the client is an outsider to the dominant culture which can create a chronic sense of loss. Which perhaps illustrates that there needs to be a greater focus from the therapist on on acknowledging any discrimination the client's faces, helping them develop coping strategies and repairing self-esteem.
However, viewing mainstream counselling theory exclusively as developed from western culture, would perhaps be too dismissive of the influence of eastern philosophies on western counselling theory. Some prominent theorists have taken influence from eastern philosophies, like Buddhism. Particularly when we look at the influences of Carl Jung, who was influenced by Indian philosophy. This helped to shape his concepts of a supreme consciousness (Brahman) and ego and self, amongst others. Though it is also interesting to note that Jung believed that the insights of one regional group were not directly applicable to another and required some modification (Coward 1985). Simon Dein argues that certain theories of Freud’s where influenced by Jewish mysticism. One example being how there is a strong emphasis to look beyond manifest text or presentation to reach the hidden
meaning (Dein 2006). If we turn to more cognitive approaches to therapy, Kwee & Ellis (1998) discuss how Buddhism has been acknowledged as helping to influence the development of cognitive-behavioral therapy by its creator. Indeed, one of the fundamental principles of Buddhism is that it is a person’s reactions to events but not the events themselves that are the root to suffering, which is line with CBT goals to change the client’s thoughts and introduce more rationality. In my own experience, my interest in counselling originated from meditation and reading eastern philosophical books. This was the first time I became aware of the ability to change perspective and focus on inner life. This kind of focus on the inner life is quite different to the individual focus of the western world.
Another key problem with training appears to be the lack of diversity in counselors and psychotherapists in general. The cost of training, particularly for models like psychoanalytic therapy, is very high, which means minority groups are less likely to be able to afford the cost of training. Average costs for training course fees in the UK are around £15,000 - £25,000 with personal therapy costs of around £8,000-£12,000 in addition, and other expenditures like course reading materials, supervision fees etc. Though in the UK, the government has introduced post graduate student loans, in my experience many training organisations that are eligible to register for these loans, have failed to do so, which could be further evidence that improving accessibility to minority groups is not a priority. If those training organisations go on to hire people who trained with them, the entire structure of the organisation does not promote diversity.
"despite awareness of the shortage of trained black counsellors, few agencies had invested any effort in encouraging black applicants for training courses." (Memon, Taylor, Mohebati 2016)
Problems with Therapist Approach
"White culture is such a dominant norm that it acts as an invisible veil that prevents people from seeing counselling as a potentially biased system" (Katz 1985: 615-24)
Katz illustrates in the above quote, how preferences towards the needs of the dominant group are so ingrained, that it becomes difficult to pinpoint where they lie. A therapist in this environment, with inadequate training in diversity, is likely to be unknowingly influenced by their biases and prejudices. Evidence shows this will adversely affect the therapy outcome. A therapist needs to be aware of their own beliefs towards different groups. Many training programs do not dedicate enough time to exploring these issues. Studies show that clients from certain minority groups may be expected to be problem clients, causing the therapist to have a lower expectation of success. Lorion & Parron (1985) advise that evidence shows clients from minority groups terminate counselling sooner than clients from the dominant group. Therapists can be misinformed about ethnic minorities and less confident on their ability to successfully work with them. This is supported by Rack (1982), who maintains that therapists dealing with an alien culture will encounter difficulties in distinguishing between normal and abnormal behaviour. He argues that cultural differences in behaviour are those that are determined by the beliefs and values of the individual's culture. Dysfunction, therefore, must be seen in relation to that culture. An example of this could be a therapist with a Pakistani client, who has had an arranged marriage. The therapist assumes that the client was forced into the marriage, and that the arranged marriage is the source of the client’s issues. This is without trying to understand the client’s individual circumstances and without considering any traditional values the client has. Negative beliefs and stereotypes can be difficult to acknowledge, particularly when as therapists we are always working towards a position of non-judgmentalness. According to Ardenne & Mahtani (1989:37) if unacknowledged the therapist could treat the client as if there is no difference, which minimises the client's issues related to their difference. This is likely to leave the client feeling hesitant to share themselves fully. Research shows that ethnic minority clients feel that healthcare providers did not understand their experiences of being in a minority group. Clients reported that they wanted to see a therapist that understood their culture or was from a similar culture to them. One study participant described “I have also found that when you, for instance, talk about racism that actually a lot of them cannot deal with it”. (Memon, Taylor, Mohebati 2016)
Another key lack of consideration which often appears in counselling practice, is how language differences can impact therapy. This could be due to English being a client’s second language, or the content of language, especially in cultures where verbal self-disclosure is not usual practice. This means the client has an increasingly difficult task of making themselves understood and trying to use the therapist’s language. If the client has very limited English language, counselling would likely not be available in their native language. The availability of an interpreter is likely to be limited, and the use of an interpreter can cause misinterpretation. Lago (1996) highlighted that many therapists are unaware of how their style of vocabulary may further add to the client’s awareness of the therapist being in a position of power. Which could cause the client to feel further alienated. If therapist’s use abstract words and terminology, this is very difficult for a client from outside the culture to understand. Another area to consider is the meaning and context of the language used. For example, certain cultures have more of an intuitive or superstitious way of understanding events, compared to the western, more rational approach to understanding events. In my own experience of therapy, when discussing particular events with a therapist, I will sometimes view these through a spiritual Buddhist viewpoint, I have at times had these feelings dismissed as ‘magical thinking’, which left me feeling quite misunderstood.
As touched on above the issue is complicated, with many factors to take into consideration. The degree of complication could explain some of the ignorance of ethnic minority group’s needs. The issue is far easier to avoid. What is clear, is that there is a serious lack of research in the area, and not enough attempts to relate the research to changes to service delivery, training and practice.
It seems that not just extra resources to specialised services is the answer to solving this issue. There needs to be a general shift in therapist training to ensure there are extensive models on working with ethnic minority and other non-dominant groups. Not just with standalone models catered to those groups, but in considering how working with difference might affect every aspect of theory, including the development of modified approaches to existing theories. The other key area to address, is a more rigorous, active approach to recruiting minority groups to train as therapists, with adequate resources to ensure that the cost of training is affordable. With more ethnic minorities trained as therapists, it is hopeful that as those therapists’ progress in their careers, they will take senior roles in mental health organisations, to help ensure that the needs of minority groups are taken into consideration at all levels.