Psychiatric Apartheid

The Wall Street Journal, May 5, 1996

By Sally Satel

“As a member of the White group, what responsibility do you hold for the racist, oppressive, and discriminating manner by which you personally and professionally deal with minorities?” asks a popular textbook for psychotherapists, “Counseling the Culturally Different.”

Welcome to the world of multicultural therapy.

The idea behind multicultural therapy, or “cultural competence,” as it is sometimes called, is that human identity is primarily culture-dependent. The theory presumes that if therapist and patient are members of different groups, especially racial groups, they will experience miscommunication and mistrust. The therapist must therefore learn a different set of rules for treating patients of each different race.

The notion of treating patients according to their racial or ethnic groups has gained increasing acceptance in recent years. Multicultural therapy pops up regularly on the conference-and-workshop circuit and is the subject of a growing list of scholarly books. It is also an increasing part of mental health training: Only a handful of counseling programs required multicultural counseling courses in the 1970s and early 1980s, but recent surveys have found that 42% to 59% of counseling programs currently require such a course. The American Psychological Association, the American Psychiatric Association (which is meeting this week in New York), and the federal government’s Public Health Service have all gotten on the multicultural bandwagon, publishing treatment guidelines for racial and ethnic groups.

These mainstream manifestations of cultural competence rarely add up to much more than ethnic cheerleading, however, because good therapists have always evaluated the role that culture plays in their patients’ lives. Most cultural competence texts call for understanding of the patient’s traditions, sensitivity to cultural heritage, working with extended family and communities, and other common-sense considerations.

But the most ardent multiculturalists go much further in their books and classrooms, saying that membership in an oppressed group is a patient’s most clinically important attribute. They repeatedly assert that, aware of it or not, white therapists are racist. This new movement replaces clinical treatment with identity politics.

“Counseling the Culturally Different” (Wiley Interscience, 1990) asserts that counselors-in-training should be routinely subjected to racial inquisitions. “While cognitive understanding and counseling-skill training are important, what is missing for the trainee is self-exploration of one’s own racism,” it says. “Without a strong antiracism training component, trainees (especially Whites) will continue to deny responsibility for the racist system that oppresses their minority clients.”

One of the authors of “Counseling the Culturally Different,” Dr. D.W. Sue, helped the American Counseling Association produce its Multicultural Counseling Standards. The standards direct “counselors, especially whites, to understand how they have benefited from individual and institutional racism.”

“Culture-free service delivery is non-existent,” declares Elaine Pinderhughes in her book “Understanding Race, Ethnicity, and Power” (Free Press, 1989). “The differences between client and practitioner in values, norms, beliefs, lifestyles, and life opportunities extend to every aspect of the health, mental health, and social services delivery system, which is itself a cultural phenomenon.” Ms. Pinderhughes condemns psychotherapists who pursue what she calls a “White, middle-class model” of therapy, one that favors “individual responsibility . . . self-understanding and insight . . . [and] resolution of dependency needs.”

San Francisco General Hospital, a teaching subsidiary of the medical school at the University of California at San Francisco, established one of the first cultural competence programs in the U.S. Its Cultural Competence and Diversity Program demonstrates the pitfalls of operating a multicultural therapy program.

Bob Okin, chief of psychiatry at San Francisco General, describes the hospital’s procedure for assigning patients: Each patient is assigned to a treatment unit, or “team,” specializing in a specific group — blacks, Asians, Latinos, gays/lesbians/bisexuals, women and the HIV-positive. There are no general-service teams, only identity-specific teams. Each team is guided by a “curriculum” that specifies the proper procedures for treating members of the relevant group. The staff and patients are not rigidly segregated by group, he insists. But the hospital makes an effort to put staff and patients of the appropriate group into each ward; with the three ethnic specialties, about half of the patients and half of the doctors are matched to the “appropriate” group.

Straight, white, uninfected males, the only patients without a specialty team of their own, get assigned to other groups’ specialty teams on the basis of bed availability. Dr. Okin says that this does not cause any undue problems in treating these patients, because many of the doctors are also straight, white, uninfected males.

The curriculum for the Black Focus Unit says that it will “address the issue of racism as it affects mental health professionals emotionally. . . . The resulting enhanced personal awareness of racism will improve the therapeutic alliance with the African-American mental health client.” One of the unit’s “educational objectives” for the staff is to “break down denial of one’s own participation in racism.” There is no need to inquire whether any given staff member actually does participate in racism — if he or she claims not to, this is only “denial” that must be broken down, and the staff member must then be re-educated.

A certain percentage of the social workers, nurses, orderlies and other non-doctoral staff on the Black Focus Unit must be certified by the San Francisco Civil Service Commission as African-American Health Services Specialists. The certification process, from which black staff members are not exempt, entails taking a 32-hour course on African-American Health Services and logging “1,000 work hours of direct health related service hours to African-American clients,” according to the San Francisco Office of Public Health.

Predictably, this obsession with race and suspicion of white clinicians has led to problems in the Black Focus Unit. The overpowering racial theme is perceived by some as interfering with what should be the first priority: patient care. According to former psychiatric residents, relations between the staff, mostly black, and the residents, mostly white and Asian, grew so unbearably tense that the hospital stopped assigning first-year residents to the unit at all. Several of the residents described an “anti-white atmosphere,” and one former resident reported feeling “blamed, somehow, for the patients’ problems.” San Francisco General has no plans to study whether the Cultural Competence and Diversity Program is delivering improved patient care.

Morris Jackson of Bowie State University, one of Maryland’s historically black colleges, complains: “My students want to know how to do black therapy, Hispanic therapy and so on. I certainly don’t know what black therapy is. What I can teach them are principles and basic techniques that apply to human beings.” Dr. Jackson is right. The patient is a human being, not a cultural puppet. As any truly competent therapist knows, psychotherapy can never be about celebrating racial diversity. Therapy is not about groups. But it is about individuals and their infinite complexity. Clinical multiculturalism replaces individual analysis with group-based generalizations and spends more energy separating patients into groups than treating them.