American Psychotherapy Association

Learning Objectives:
After studying this article, the reader should be able to:

1. Apply the concept of cultural countertransference in their work with African American women clients.

2. Identify three national initiatives that seek to address health care disparities for minorities.

3. Describe the role of skin color differences in the African American community and specify how it might affect the presenting problem of an African American woman.

4. Explain the benefits to the therapeutic alliance for discussing the issue of racial discrimination with African American female clients.

Running Head: Culturally-Sensitive Psychotherapy with African American Women

Keywords: African American women, racial disparities in mental health treatment, clinical interventions, role of skin color in psychotherapy

Abstract
This paper addresses the psychosocial context that gives rise to emotional problems for African American women and discusses contemporary thinking about what constitutes effective psychotherapy treatment with them. The stressors these women face can no longer be thought of as personal issues. Instead they constitute public health problems that must be responded to so that all citizens will have the benefit of mental health medical practices that are known to alleviate diseases and disabilities that are behaviorally-based. African American women are a population at high risk for early development of chronic debilitating illnesses that are due, not only to genetic and intrapsychic factors, but to stresses in their environment that continue to implicate racial discrimination. Mental health clinicians that work with this population should incorporate into their treatment content-based knowledge about African American women, exhibit a willingness to discuss racial issues with the client, and assess their own cultural countertransference as this may impinge upon the therapeutic relationship.

According to Satcher (2001), women of color encounter the same health problems as do white women but since many wrestle with social, economic and cultural barriers to achieving optimal health, “they are in poorer health, use fewer health services, and continue to suffer disproportionately from premature death, disease, and disabilities” (p. 199). For example, The Women of Color Health Data Book (Leigh & Lindquist, 1998) reports that blacks have “more undetected diseases, higher disease and illness rates (from infectious conditions such as tuberculosis and sexually transmitted diseases), more chronic conditions (such as hypertension and diabetes), and shorter life expectancies than whites. Morbidity and mortality rates for blacks from many conditions (cancer, HIV/AIDS, pneumonia, and homicide) exceed those for whites” (p.1). Genetics, poverty and racism are the factors most often cited to account for these discrepancies.

The nation’s preventive agenda for improving public health entitled Healthy People 2010, aims to eliminate health disparities for racial and ethnic minorities by the year 2010 in the areas of infant mortality, cancer screening and management, cardiovascular disease and diabetes, HIV infections/AIDS and immunizations. To illustrate the problem of racial disparities in health outcomes, consider the observation of Satcher (2001) who has noted that many are surprised to discover that AIDS is the leading cause of death among African American women between the ages of 25 and 44. The consequence is that numerous children are being left motherless and entire communities of African Americans are impacted. Leigh and Lindquist (1998) report that a sizable number of black women recently surveyed in South Florida and Los Angeles about their condom use report that they would not use a condom with their main partner even if that partner were HIV positive. Their speculation is that these responses “reflect the cultural realities the women face; they know that they are unable to override economic and gender role norms to engage in ‘safer’ sexual intercourse” (p.7).

This finding is underscored by The American Psychological Association’s (2000) position that six of the 10 leading causes of death are behaviorally- based. These behaviors include: “diet, substance abuse, HIV/AIDS, smoking, violence, and accidents. In addition, many behavioral factors are now known to increase an individual’s risk for disease, physical disability and early death. Some of these traits include physical inactivity, obesity, anxiety, traits of anger or hostility, depression; and diverse social or environmental variables (e.g., low socioeconomic status, inadequate social support, and life stress). These variables constitute risk factors for cancer and heart disease, diabetes, stroke and other major illnesses as they contribute to “their development, progression and clinical manifestations” (p. 2). These catastrophic illnesses, with their stunning emotional tolls, hit minority women at rates that exceed the averages for whites.

The section entitled, “Overview of Cultural Diversity and Mental Health Services,” in the massive tome, Mental Health: A Report of the Surgeon General, finds that the incidence of mental illness is thought to be higher among African Americans than among whites and the differences are not biological, but seem to be linked to the lower socio-economic status of blacks that place them at higher risk for mental illness. In addition, African Americans tend to be underrepresented in outpatient treatment populations, especially privately-funded care, and overrepresented in inpatient psychiatric facilities in relationship to whites. Under-representation in fee-for-services or managed care arrangements is especially true for middle-class African Americans.

One reason that African Americans delay accessing mental health services until a problem reaches crisis proportions is a pervasive mistrust of the system. The report suggests that they fear hospitalization, the treatments that are likely to be suggested and the racist slights endured in their contacts with mental health systems, an experience called “microinsults.” These insults have been substantiated especially in the areas of the underdiagnosis of depression and the overdiagnosis of schizophrenia among African Americans.

A broad conclusion of the report is that racial and ethnic minorities face barriers to seeking mental health treatment and when they do receive treatment, the therapies used may not be suitable to their needs. Minorities often feel uncomfortable with the mental health system because they see these entities as institutions of white culture created on the basis of research on white populations. With mental health graduate programs continuing to under-enroll minority students, according to the Supplement the health care providers minorities are likely to face may “represent a white-middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures” (1999).

The “Health Care Fairness Act” is a legislative initiative that seeks to redress health care related problems minorities face (including mental health and substance abuse). It uses a number of measures to achieve this goal such as funding of research on minority health, reducing health care biases by reforming the curriculum of health providers in training and increasing public awareness about minority health discrepancies. The objective is to understand the genetic and behavioral differences affecting health outcomes and to correct biases that exist in the health care system. The act notes that, while the nation has made significant advances in medicine, all citizens have not shared in this achievement (Kennedy, 1999).

With the 1999 publication of the Supplement, racial and ethnic minority disparities in mental health status and access to services have been catapulted to national prominence and are now a health care priority. Healthy People 2010, “The Health Care Fairness Act,” and Mental Health: A Report of the Surgeon General all cite the delivery of culturally competent or culturally sensitive and relevant mental health services as playing a pivotal role in reducing racial and ethnic minority mental health disparities. The remainder of this manuscript addresses an aspect of the psychosocial context that gives rise to emotional problems for one at-risk population – black women – and discusses contemporary thinking by experts in minority women’s mental health about what constitutes effective psychotherapy treatment with women.

Schulz, Parker, Israel, and Fisher (2001) write, “as a group, African American women have a shorter life expectancy and experience an earlier onset of such chronic conditions as diabetes and hypertension compared to white women. Differentials in socioeconomic status account for much, although not all of this health disparity.” Geronimus (2001) suggests that African American women must face long periods of competing obligations, scarcity of resources, energy depleting high-coping efforts and social stress that puts them at risk for accelerated aging. This is a process she calls weathering and defines as “early health deterioration as a consequence of repeated social economic, or political exclusion” (p. 133). Klonoff, Landrine, and Ullman (1999) have demonstrated that racial discrimination contributes significantly to the psychiatric symptoms among African Americans irrespective of class, background, age or income. They discovered that being a woman, encountering greater stress and greater racial discrimination predicted increased psychiatric symptomology, e.g., somatization and anxiety.

Greene (1992) advises therapists to be mindful that African American women may bring deep wounds connected to the legacy of racism to their therapeutic relationships. For example, Thompson (1996), reflecting on her own struggle and those of her patients with the issue of skin color, writes that for many black families, inquiring about the skin color of the newborn child is more important than determining the child’s sex. Shades of lightness continue to confer status and greater success both within the home and in the workplace. Since skin color in individual families can vary significantly from dark to light, the affect on parental-child attachment can be significant. For families in which skin color matters, in time, black self-definition can become intertwined with the shade of one’s skin. Consequently, skin color can either promote or detract from the caretaker’s mirroring function.

Greene (1999) has found that color differences can intensify sibling and intrafamilial rivalries. She encourages therapists to ask about skin color of family members with whom a client may be in conflict. “This may help expose some of the dynamics in clients who have been idealized or scapegoated within their families and to reveal how they may reenact those dynamics with other persons in their lives, including the therapist” (p.19). But it is not just emotional health that is affected by the contentious political meanings of skin color; current research has unveiled a link between skin color and hypertension. Darker skinned individuals who identify with an upper social class status tend to have elevated blood pressures than either high social status light-skinned blacks or dark-skinned individuals with low social status (Leigh & Lindquist, 1998).

Thompson (1996) suggests that psychotherapeutic work must include attempts to disrupt the function of skin color as a marker of self-worth. To be effective in this work, therapists must have certain knowledge and insights. Shorter-Gooden and Jackson (2000) urge therapists to seek training in content and awareness about diverse clients in order to better attend to their cultural countertransference, i.e., their own emotional reactions to the physical characteristics of their clients. The cultural countertransference is influenced by clinician biases and stereotypes about African American women and contributes to the responses of the clinician to the black woman client. Adams (2000) remarks that mental health professionals include a description of the physical appearance of the client in their mental status exam reports. In her view, clinicians must also move beyond this assessment to determine their own view of the client’s color and attractiveness. “Any therapist working with African American women might ask him- or herself how he or she regards the following: African American women who wear dreadlocks, closely cropped hair, braids, straightened hair, naturally curly or kinky hair; African American women with light, brown, or very dark skin; African American women with more African, more European, or more mixed-race features . . .” (p. 43).

Schulz et al (2001) emphasizes that the stressors black women face are not “personal problems,” rather, they are public health issues. Geronimus (2001) more emphatically states that race related stressors are significant contributors to chronic illnesses. “Racial ideologies affect clinical judgments, fuel distrust of health care professionals and public health initiatives, weaken public support for initiatives to improve the health of disadvantaged populations and open the for industries to target marginal communities for environmental hazards or unhealthy consumer products” (p.136).

For clinicians to be effective in their treatment of African American women in psychotherapy, they must be willing to acknowledge racism as a valid issue having an influence on their mental health. Whaley (2001) recommends that clinicians discuss racism with African American clients because of its cultural relevance and salience in black life. The focus should be on the client’s needs and not on the clinician’s need to demonstrate her or his own view on racism. Not only has Whaley found these discussions add a positive dimension to the therapy, but also they enhance the therapeutic alliance. Clients may include in the presentation of their problem the idea that racism is the cause of someone treating them unfairly. They may be alienated by clinicians that try to convince them that they are mistaken or that the client simply misunderstands the other person’s motives. He has found that this casts doubts “on the credibility of the clinician who would defend an unknown person” (p. 559).

African American women comprise one half of the black population and are 14 percent of the adult female population. It is likely that clinicians will encounter these women in their practices and they will need culturally sensitive care. Racial disparities in mental health status and service delivery are now public health issues. Care of these women is enhanced when clinicians know content-specific information about this population, are at least willing to acknowledge the validity of racial discrimination as a problem for African Americans that may be implicated in the underlying issues of presenting problem, and are able to examine the role of their racial attitudes in understanding cultural countertransference matters that may arise in the course of therapy. African American women are not white women with black faces. The constellation of social stressors these women encounter can be debilitating to their emotional and physical health. The legacy of historical racism requires that clinicians become comfortable with the language and symptoms of emotional distress that may be unique to this population.

References
1. Adams, J. A. (2000). Individual and group psychotherapy with African American women: Understanding the identity and context of the therapist and patient. In L. Jackson & B. Greene (Eds). Psychotherapy with African American Women: Innovations in Psychodynamic Perspective and Practice (pp. 33-61). New York: The Guilford Press.

2. American Psychological Association (2000). Fact Sheet on Racial and Ethnic Health Disparities. Retrieved on 10/7/02 from http://apa.org/ppo/issues/phealthdis.html

3. Geronimus, A. T. (2001). Understanding and eliminating racial inequalities in women's health in the United States: The role of the weathering conceptual framework. Journal of the American Medical Women’s Association, 56, 133-136.

4. Greene, B. (1992). Still here: A perspective on psychotherapy with African-American women. J. C. Chrisler & D. Howard (Eds.). New Directions in Feminist Psychology: Practice, Theory, and Research (pp. 13-25). Springer series: Focus on women, Vol. 13. New York, NY: Springer Publishing Company, Inc.

5. Kennedy, E. (1999). Background on The Health Care Fairness Act of 1999. Retrieved on 10/7/02 from http://www.senate.gov/~kennedy/statements/99/11/1999B08730.html

6. Klonoff, E. A., Landrien, H., & Ullman, J. B. (1999). Racial discrimination and psychiatric symptoms among Blacks. Cultural Diversity & Ethnic Minority Psychology, 5(4), 329-339.

7. Leigh, W. A. & Lindquist, M.A. (1998?). Women of Color Health Data Book: Adolescents to Seniors. Bethesda: Office of Research on Women's Health, Office of the Director, National Institutes of Health.

8. Satcher, D. (2001). American Women and Health Disparities. Journal of the American Medical Women’s Association, 56, 199-205.

9. Schulz, A., Parker, E., Israel, B., & Tomiko F. T. (2001). Social Context, Stressors, and Disparities in Women's Health. Journal of the American Medical Women’s Association, 56, 143-149.

10. Shorter-Gooden, K. & Jackson, L. (2000). The interweaving of cultural and intrapsychic issues in the therapeutic relationship. In L. Jackson & B. Greene (Eds). Psychotherapy with African American Women: Innovations in Psychodynamic Perspective and Practice (pp. 15-32). New York, NY: The Guilford Press.

11. Thompson, C. L. (1996). The African-American patient in psychodynamic treatment. R. Perez Foster; M. Moskowitz; & A. Javier (Eds.). Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy (pp. 115-142). Northvale, NJ: Jason Aronson, Inc.

12. U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Retrieved on 10/07/02 from http://www.mentalhealth.org/features/surgeongeneralreport/chapter2/sec8.asp

13. U.S. Department of Health and Human Services. (November, 2000). Healthy People 2010: Understanding and Improving Health. Retrieved on 10/7/02 from http://www.health.gov/healthypeople/

14. Whaley, A. (2001). Cultural mistrust and mental health services for African Americans: A review and meta-analysis. Counseling Psychologist, 29(4), 513-531.

About the Author
Kim Vaz, Ph.D. is an associate professor of Women’s Studies at the University of South Florida and maintains a private psychotherapy practice in Tampa. Address correspondence to: Department of Women’s Studies, FAO 153, University of South Florida, Tampa, FL 33620. Contact Dr. Vaz by calling her at 813-974-0985; by faxing 813-974-0336; or via e-mail at [email protected].