Addressing Mental Health Disparities Among Minorities

24-year-old Violet Blue is a suicidal, transgender Mexican-American client at her initial appointment with Dr. Green to address her suicidal behavior. Dr. Green, a 54-year-old European-American, has been a practicing clinician for over 25 years and is considered an expert in his field. However, his clientele is predominately white males, and Violet is his first encounter working with anyone from the transgender and/or Mexican-American communities. To be honest, Dr. Green is feeling a little apprehensive and nervous about working with Violet. He doesn’t want to say anything that could be interpreted as offensive. Dr. Green tells himself to ignore these feelings and proceed as he would regularly do with his other clients – after all, we should be “colorblind” and treat everyone equally, right?

Let’s listen in on how this first visit goes:

Dr. Green: Violet, I am aware of your history of suicidal behavior and depression. I want to dive into the root causes of this. When did the suicide attempts and depression start?

Violet: I don’t know. I’m uncomfortable.

Dr. Green: Therapy can be uncomfortable, for everyone. It’s important that you immerse yourself in this experience so we can address your problems. When did the suicidal behavior and depression start?

Violet: Ok. I guess when I was seven and realized I was born in the wrong body. I told my family and they said something was wrong with me.

Dr. Green: You are referring to feeling transgender?

Violet: Yes, to being trans.

40 minutes later…

Dr. Green: OK, let’s move on to your treatment plan. I want to create a treatment plan to address your suicidal behavior. I have a homework assignment and next week we can discuss your progress.

In this brief fictional scenario, we encounter a clinician who is clearly uncomfortable working with his client, which causes him to unintentionally harm the therapeutic relationship. First, when Violet shares that she is uncomfortable, Dr. Green dismisses her discomfort by generalizing her experience and not addressing how she, specifically, feels. As Violet explains her history with suicidal behavior and depression, Dr. Green diminishes her identity (“feeling transgender”) and then quickly moves on from the topic. We start to see how Dr. Green’s discomfort is projected onto the session. He allows his nervousness and inexperience to drive the situation – which in his case means avoiding the subject of her identity. Lastly, Dr. Green informs Violet of a treatment plan, but throughout the process, Violet is delegated to backseat passenger rather than co-pilot. Her experiences are invalidated, and she is not allowed to play an active role in her recovery.

When treating suicidal clients, we often sculpt out our treatment plan within a larger framework of suicide research and practice, providing a universal treatment plan without considering the nuances of an individual’s identity that may influence their suicidal behavior. This creates an atmosphere in which the client becomes uncomfortable with the therapeutic process, lessening the bond between the client and therapist and rendering services less effective.

Working with clients belonging to marginalized and minority communities (e.g., LGBTQ, women, racial & religious minorities, etc.) presents a challenge to the modern psychologist. While the psychology workforce is becoming increasingly diverse, racial/ethnic and LGBTQ psychologists are still a minority within research and practice.1

With the majority of both caregivers and patients in the white male category, anyone who does not fit into the majority becomes the ‘other’. The ‘other’ becomes the invisible, the marginalized, and the untreated (or ineffectively treated). When we ‘other’ clients, we invalidate their experience.

5 Effective Approaches when Treating Minority Mental Health

It is important to address the needs of all suicidal clients, including examining the different societal and cultural conditions that influence the identity of an individual. The following are five effective approaches to consider when treating minority clients:

1. Acknowledge Differences.

When a client discusses experiences as a minority, it is detrimental for the therapist to avoid acknowledging the client’s positionality—the lens through which the world views an individual. Dismissing their individuality contributes to ‘othering’—and to practice a colorblind approach might create an environment where you have invalidated their experiences.

Another important note is that the minority client’s identity could be a contributing factor to their suicidal behavior. For example, a client who is Asian-American might feel isolated navigating their American and Asian identity or they could experience workplace/academic pressures that stem from cultural stressors. Addressing these caveats may improve and increase the effectiveness of treatment.

Equally important is the ability of the therapist to acknowledge their own positionality and examine how that impacts the therapeutic relationship. Minority clients may express difficulties when being treated by white therapists.2 They may feel isolated or disempowered by the heightened, unbalanced power dynamics created by systematic marginalization. To acknowledge and discuss these fears builds trust in the therapeutic relationship.

2. Validate Experiences.

As discussed in the first approach, minority clients might feel that their daily experiences are often overlooked, marginalized, and invalidated. As important as it is to acknowledge their experiences, it is equally important to validate them. For example, a suicidal gay client might confide to their therapist feelings of social alienation and rejection due to continued prejudices against gay people. These stressors may influence that client’s suicidality.

Affirming the validity of the client’s feelings and experiences is a crucial part of effective treatment. Validation does not simply mean that you understand or agree, it is the act of letting your client know that you acknowledge, recognize, and support their experiences.

3. Accept Your Limitations.

Transparency as a therapist is an important skill to develop. Let’s be honest, working with minority clients can be intimidating without a background in or experience working with these communities. What if you say the wrong words and appear insensitive – or worse, prejudice?

Your trepidation is valid, and during the right circumstances, discussing these limitations with the client may ease anxiety on both sides. For example, during an initial session treating a black client, a white therapist might observe discomfort and hesitation from the client or experience their own hesitation. Openly addressing your own limitations and the client’s anxiety builds trust and honesty between the client and therapist.

4. Use a Collaborative Approach.

The collaborative approach uses a model in which the client and therapist work together to create and implement a treatment plan. This plan is tailored to the client’s unique challenges and strengths. This process helps to create a more egalitarian relationship in which the client is respected as the expert on their experiences and the therapist as the expert on the treatment.

This approach is crucial to treating suicidal behavior because many suicidal clients express feelings of hopelessness and powerlessness. A collaborative approach provides them with the tools to begin to change the predicament and re-establish power to oneself.

Working through this therapeutic process, the client and therapist begin to build rapport and trust, and control is placed in the client’s hands. This is important, because suicidal minority clients especially may feel powerless and hopeless. Creating an environment for a safe space where the individual feels a part of something may help reduce some of the symptoms.

5. Inquire about their Community Support System.

To many minority clients, the family and community unit is an essential part of their healing and stabilization processes. Having a support system can play a big role in the responsiveness of a client and the effectiveness of treatment. For instance, an African American client might be hesitant to disclose suicidal behavior due to community and cultural ideologies about suicide. A transgender client might be more open towards the therapeutic process if they have supportive family and friends that validate their expression of self. Community support systems are complex aspects of a client’s life, and learning about these structural systems (or lack thereof) will help the therapist better address the client’s needs.

Clinician and Suicidal Minority Client Scenario

Now that we have become familiar with more healthy approaches to working with minority clients, let’s recreate the fictional scenario between Dr. Green and Violet Blue:

Dr. Green: Violet, I am aware of your history of suicidal behavior and depression. I want to dive into the root causes of this. When did the suicide attempts and depression first start?

Violet: I don’t know. I’m uncomfortable.

Dr. Green: Yes, I understand. Sometimes the therapeutic process can be uncomfortable, and that is valid. I want us to address this discomfort, so we can improve our working relationship and your treatment. Violet, would you mind sharing why you feel uncomfortable?

Violet: I guess. Sometimes it’s hard seeing therapists who don’t understand what it’s like to be a trans Chicana. My last therapist just didn’t get me. It was a waste of time.

Dr. Green: Violet, thank you for sharing with me. I am an old, white guy and to be honest, I have limited experience working with trans… Chicana? I’m not familiar with the term. Can you explain it to me?

Violet: It’s what us Mexican-American women call ourselves.

Dr. Green: Thanks for the clarification. I was not familiar with Chicana, but now it will become a part of my vocabulary. Thank you. I have limited experience working with trans Chicana women. However, I do understand suicide and I want to help you with your recovery. I hope to work with you to get a better understanding of your identity, culture and suicidal behavior. There are sometimes references that I might not understand, but it’s important for both of us to acknowledge these differences and work together. What do you think?

Violet: Yeah, we can do that. Thanks.

Dr. Green: Great. Thank you, Violet. Addressing your suicidal behavior and history with depression, can we go back to when you first started feeling this way?

Violet: I guess it was when I was 7 and realized I was born in the wrong body. I told my family and they said something was wrong with me.

Dr. Green: I can imagine that experience was hard for you. I can assure you there is nothing wrong with your identity. Does your family still think the same way about you?

Violet: Thanks. Some of them don’t, but my mom is very supportive, and I have really great friends in the trans community.

Dr. Green: I’m glad that you have a good support system through your mom and friends. I think incorporating their support into the treatment plan will be very beneficial.

Violet: Yeah, I agree.

Dr. Green: Wonderful. I would like us to sit together and discuss a treatment plan that would be right for you. I am thinking about a range of approaches that might be best. We can discuss more about what is the options are and what treatment will look like. Would you like us to do that?

Violet: Yes. That sounds good.

In this re-created scenario, Dr. Green provides a welcoming space that is conducive to building trust and improving the therapeutic process. First, when Violet shares her discomfort, he addresses her concerns and shares his limitations. Sharing his own discomfort shows Violet that Dr. Green is honest and truly cares about helping her. This time, he validates her experience when he individualizes her discomfort and re-assures her identity as a transgender Chicana woman. Even when he was confused about terminology related to her identity, he addressed those limitations.

As Violet discusses her background and support system, Dr. Green follows up with questions to assess how to include her support system within the treatment plan. Throughout the session, Dr. Green uses a collaborative approach by allowing Violet to be the expert in her experience. He provides her with an understanding of therapy, yet consults her opinion throughout their interaction.

This session is more productive, collaborative, and efficient than the previous one and is a good model of the therapeutic approach that is often used within CAMS – or Collaborative Assessment and Management of Suicidality.

Research suggests that CAMS is effective in treating minority communities.2 A major reason for this effectiveness is the use of the collaborative approach, which centers the client as an expert on navigating their suicidal behavior. The CAMS direct approach to handling suicide-related treatment also provides space for the therapist to practice a more multicultural and humanistic care, allowing for a therapeutic process that:

• acknowledges the social/cultural differences of the client-therapist dynamic,
• validates the experiences of the client,
• allows space for the therapist to acknowledge their limitations,
• provides a collaborative treatment plan, and
• seeks to learn about and include the client’s community support system in treatment.

These tips can be used within a wide scope of clinical framework, not just CAMS. Throughout my continuous training as a psychology student, I have observed my mentors, supervisors, colleagues, and myself implement these techniques while working with minority clients. As a minority, receiving therapy from a therapist who incorporated these techniques has often alleviated my own apprehension towards the process. When treating mental health — especially suicidal behavior — it is essential to consider the impact of a client’s identity.

Footnotes:

1American Psychological Association. (2015). Demographics of U.S. Psychological Workforce: Findings from the American Community Workforce. [Online pdf]. Retrieved from https://www.apa.org/workforce/publications/13-demographics/report.pdf

2 Jeffrey A. Hayes, Andrew A. McAleavey, Louis G. Castonguay, and Benjamin D. Locke. Psychotherapists’ Outcomes With White and Racial/Ethnic Minority Clients:  First, the Good News.  Journal of Counseling Psychology 2016, Vol 63, No 3, pp 261-268.  https://www.apa.org/pubs/journals/features/cou-cou0000098.pdf

3 Jayong L. Choi, James R. Rogers, James L. Werth, Jr.  Suicide Risk Assessment With Asian American College Students: A Culturally Informed Perspective. Sage Journals, Vol 37, Issue 2, pp 186-218.
https://journals.sagepub.com/doi/10.1177/0011000006292256