Guess Who’s Coming to Therapy? Getting Comfortable With
Conversations About Race and Ethnicity in Psychotherapy

Esteban V. Cardemil
Clark University

Cynthia L. Battle
Brown University and Butler Hospital

Despite the fact that clinical psychology training programs now typically offer course work in multi-
cultural issues, many professional psychologists may continue to feel unsure about how and when to
incorporate multicultural awareness into their everyday clinical work. Having open discussions with
clients regarding issues of race and ethnicity is one way to actively include a multicultural element into
psychotherapy, as well as to strengthen the therapeutic alliance and promote better treatment outcome.
The authors make several recommendations designed to provoke thought and stimulate conversation
about race and ethnicity in the context of psychotherapy.

The ability to conduct psychotherapy effectively with racially
and ethnically diverse populations is becoming increasingly im-
portant given the changing demographics of this country. Recent
estimates of population trends suggest that by the year 2050,
non-Hispanic Caucasian Americans will constitute approximately
50% of the United States population, as compared with the current
72% of the population (U.S. Census Bureau, 2001). The American
Psychological Association (APA) has recognized the critical na-
ture of integrating issues of race and ethnicity into the field of
psychology by encouraging attention to these issues in clinical
training programs (APA, Committee on Accreditation, 2002), cre-
ating therapist competency guidelines for working with racial and
ethnic minority populations (APA, 1993), and sponsoring profes-
sional meetings to identify strategies to promote sensitivity to
diversity in psychology (McGuire, 1999).

It is likely that most clinical psychologists have acquired an
intellectual appreciation of the salience of race and ethnicity in the

therapeutic context and are motivated to be sensitive to these
issues in their own practice. However, for many psychologists, a
general appreciation regarding the importance of race and ethnicity
does not equate to a clear understanding of whether, when, and
how to bring up these issues in the actual practice of clinical work.
For example, many therapists may agree that it is important to
examine one’s personal assumptions and recognize the value of
cultural beliefs and traditions other than those embraced by the
dominant European American culture (APA, 1993; Comas-Dı́az,
1992; Pinderhughes, 1989). Still, many therapists may not know
how to incorporate their appreciation of racial and ethnic diversity
into therapy in a tangible way.

We believe that having open conversations about race and
ethnicity is one way for therapists to more fully incorporate diver-
sity issues into their work. Demonstrating a willingness to engage
clients in these dialogues can promote an environment of trust and
understanding that will ultimately help the treatment process. A
stronger therapeutic alliance could, in turn, reduce problems such
as premature termination (S. Sue, 1988) and underutilization of
mental health services (Cheung & Snowden, 1990) that are often
observed among racial/ethnic minority clients.

There is a variety of reasons why psychologists may be missing
opportunities to have these conversations. Some therapists may
feel uncomfortable discussing racial and ethnic issues with their
clients of color due to the emotionally charged nature of race
relations or concerns about saying something that could be viewed
as offensive. Others may simply not know when these conversa-
tions are relevant or how to initiate the discussion. Still others may
choose to wait until their clients raise the topic before engaging in
such a conversation. Unfortunately, this approach neglects the
possibility that many clients will themselves not broach issues
related to race and ethnicity for various reasons (e.g., their own
discomfort with the topic, being unsure of therapist perspective or
bias). We believe that therapists would benefit from taking a more
active stance by initiating discussions about race and ethnicity with
their clients, particularly early in psychotherapy. This active stance
would thus allow for opportunities to explore the possible rele-
vance of these issues to the psychotherapy process.

ESTEBAN V. CARDEMIL received his PhD in clinical psychology from the
University of Pennsylvania in 2000. He is an assistant professor at the
Frances L. Hiatt School of Psychology at Clark University. His research
focuses on racial/ethnic minority mental health issues and depression
prevention.
CYNTHIA L. BATTLE received her PhD in clinical psychology from the
University of Massachusetts, Amherst in 2000. She is an assistant professor
(research) in the Department of Psychiatry and Human Behavior at Brown
University Medical School. Her research interests include women’s mental
health, family functioning, and diversity issues in psychology.
PREPARATION OF THIS ARTICLE was supported by a National Institute of
Mental Health (NIMH) Career Development Award K01 MH67571 and a
NARSAD Young Investigator Award to Esteban Cardemil and an NIMH
Career Development Award K23 MH66402 to Cynthia Battle. We wish to
express our appreciation to Ivan Miller, Lisa Uebelacker, and Benjamin
Johnson for their helpful comments on an earlier version of this article. We
also thank Emily Dings and Leslie Graham for their editorial assistance.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Es-
teban V. Cardemil, Frances L. Hiatt School of Psychology, Clark Univer-
sity, 950 Main Street, Worcester, Massachusetts 01610. E-mail:
Ecardemil@clarku.edu

Professional Psychology: Research and Practice Copyright 2003 by the American Psychological Association, Inc.
2003, Vol. 34, No. 3, 278 –286 0735-7028/03/$12.00 DOI: 10.1037/0735-7028.34.3.278

278



Therefore the purpose of this article is to encourage increased
therapist– client dialogue about race and ethnicity in the real-world
practice of psychotherapy. Initiating this type of dialogue can be
anxiety provoking, and our intention is not to minimize the con-
cerns of psychologists who find it challenging to have conversa-
tions about race and ethnicity with their clients. However, because
as psychologists we are trained to be skillful in listening,
perspective-taking, and developing empathy, we have a unique
opportunity to embrace potentially difficult conversations about
race and ethnicity and to use these experiences to grow profes-
sionally and personally. In this article, we provide several recom-
mendations designed to provoke thinking and stimulate conversa-
tions about race and ethnicity that can be incorporated throughout
the treatment process. We have deliberately chosen to direct our
comments to Caucasian therapists who work with racial/ethnic
minority clients; however, many of the issues we raise are appli-
cable regardless of the racial/ethnic identity of therapist or client.

Definitions

There are many different cultural and demographic characteris-
tics (e.g., social class, gender, race, ethnicity, sexual orientation,
disability status) that may significantly influence the life experi-
ences of clients and therapists as well as their approaches to
psychotherapy. To narrow our focus, we emphasize issues related
specifically to the race and ethnicity of clients and therapists.
Definitions of the terms race and ethnicity are varied; distinctions
between these two concepts can also be ambiguous, as indicated by
the fact that the terms are at times used interchangeably (Atkinson,
Morten, & Sue, 1998; Helms & Cook, 1999). Historical definitions
of race have tended to focus on physical or biological character-
istics (Atkinson et al., 1998; Betancourt & Lopez, 1993). Although
the term ethnicity has included references to physical characteris-
tics, for the most part it refers to the historical cultural patterns and
collective identities shared by groups from specific geographic
regions of the world (Betancourt & Lopez, 1993; Helms & Cook,
1999). Ethnicity and race have significant overlap but are clearly
not the same constructs (Alvidrez, Azocar, & Miranda, 1996;
Betancourt & Lopez, 1993).

Because of the lack of language that allows for discussions that
are simultaneously inclusive and sensitive to the varied ways in
which individuals conceptualize their identity, we describe issues
of race/ethnicity collectively, understanding that at times our def-
inition may apply more aptly to conceptions of race and at other
times to ethnicity. We have chosen to take this more encompassing
approach because the scope of this article prevents us from fully
examining and elaborating on the varied definitions of these two
terms. Moreover, we also liberally use the term minority, although
we recognize that those who are categorized under the term mi-
norities in fact constitute the majority of the overall world popu-
lation (see Tatum, 1997). However, because we are writing from
our experiences as clinicians in the United States, we have chosen
to use the term minority, given the demographic breakdown of this
country.

Recommendations for Discussing Race and Ethnicity in
Psychotherapy

We believe that there are many helpful ways in which therapists
may engage in conversations about race/ethnicity with their cli-

ents. With some clients, therapists will broach the topic once and
have a brief discussion, simply putting the topic “on the table”
should it be relevant in the future. With other clients, therapists
will find themselves engaged in a series of important conversations
about possible influences of race/ethnicity on the client, the client–
therapist relationship, and the therapy process. With still others,
the frequency and intensity of conversations on these topics may
develop gradually and change over time, with ebbs and flows. The
variability in how these conversations develop will be due to a
range of factors, including a client’s level of trust in the therapist,
a client’s understanding of his or her own racial/ethnic identity,
and the overall salience that racial/ethnic issues have for a given
client. Thus, sensitivity to the appropriateness, timing, and pace of
the conversations over the course of a therapeutic relationship is
important. There are clearly no universal rules for how and when
to have these conversations. Still, we hope that the following
general recommendations will provide some guidance to therapists
who are interested in more fully integrating multicultural issues
into their everyday clinical practice.

1. Suspend Preconceptions About Clients’ Race/Ethnicity
and That of Their Family Members

Our first recommendation is to remember that the racial/ethnic
background of clients may not be obvious. Assuming that a client
is from a particular racial or ethnic group, or that a client has had
certain past experiences, may lead to misunderstandings that could
derail the therapy process. Most psychotherapy training empha-
sizes the suspension of assumptions and preconceptions about
clients, and therefore this recommendation is hardly new. How-
ever, there are several situations in which well-intentioned thera-
pists may make incorrect assumptions with regard to race/ethnicity
that would hinder the development of the therapeutic relationship.
For example, therapists may be particularly prone to incorrect
assumptions and labels regarding biracial or multiracial clients or
clients whose racial/ethnic identity is not obvious from physical
characteristics (e.g., African American or Latino clients with light
skin tone). Similarly, clients who have a partner or other family
member (e.g., adopted children) from another racial or ethnic
group may appreciate efforts on the part of the therapist to not
make assumptions about the backgrounds of their family members.

Given that these personal characteristics may not be readily
apparent, we recommend that clinicians directly ask their clients
how they identify their race/ethnicity. Asking clients early in the
therapy process can help therapists avoid making false assump-
tions or using terminology that may be inaccurate and/or offensive
to clients. This is particularly important because not all individuals
from the same racial/ethnic background prefer the same terminol-
ogy to describe their identity (e.g., some individuals may prefer the
term African American, whereas others might prefer Black). Ask-
ing clients about their race/ethnicity could easily be woven into the
larger intake or assessment process and could be a natural supple-
ment to questions that a therapist might ask about a client’s social
and family history. So, for example, a therapist might broach the
topic in the following manner:

Often, I ask my clients about their racial and ethnic background
because it helps me have a better understanding of who they are. Is
that something you’d feel comfortable talking about?

279RACE AND ETHNICITY IN PSYCHOTHERAPY



In addition to learning about the client’s racial/ethnic back-
ground, therapists may find it useful to directly ask clients what
terms they prefer to use when describing themselves. Questions
like “How do you identify your racial or ethnic background?” can
be a relatively neutral way to continue the conversation. In our
experience, these opening queries can lead to a narrative that
includes information about familial origin, language, and religion.

2. Recognize That Clients May Be Quite Different From
Other Members of Their Racial/Ethnic Group

One significant benefit of engaging in conversations about race
and ethnicity with clients is that it reduces the likelihood of
stereotyping and the assumption that clients possess certain group
characteristics. Obviously, wide variability exists within a racial or
ethnic group and can include differences based on an individual’s
personality, country of origin, sense of racial/ethnic identity, ac-
culturation status, gender, and socioeconomic status. For example,
a low-income African American woman whose family has lived in
the United States for several hundred years may experience some
life stressors that are more similar to those of a low-income
Caucasian woman than to those of a wealthy Black business-
woman who recently immigrated to the United States from Kenya.
It would also be naive to assume that Japanese Americans share a
common cultural background with Chinese Americans or Filipino
Americans (Kim, Yang, Atkinson, Wolfe, & Hong, 2001).

Some within-group differences are less readily apparent than
others, and therefore therapists may need to be creative in their
ways of accessing this information. For instance, it is likely that
most psychologists would take gender into consideration when
working with racial/ethnic minorities and not assume that men and
women from the same group would necessarily respond similarly.
Many psychologists, however, may be less familiar with some
other characteristics that also vary within racial/ethnic group. We
briefly describe two important characteristics with which clini-
cians may not be familiar and which likely warrant some consid-
eration: racial identity development and acculturation.

Racial identity development. A large literature within the field
of counseling psychology persuasively argues that all humans,
including Caucasians, go through a process of developing a sense
of racial or ethnic identity (Cross, 1971; Helms, 1995; D. W. Sue
& Sue, 1990). Although these models differ in their specific
explanations of the identity development process and conceptual-
ization of critical stages, a theme common to these models is that
individuals at different stages of identity development assign dif-
ferent degrees of importance to the concept of race/ethnicity. For
example, D. W. Sue and Sue’s (1990) racial/cultural identity
development model posits that racial/ethnic minority individuals
move from an initial, more self-deprecating conformity stage
(preference for dominant cultural values), through a dissonance
stage (questioning and challenging beliefs of the conformity
stage), a resistance and immersion stage (endorsement of minority
views and rejection of dominant society), an introspection stage
(less rigid in resisting dominant society views), and finally to an
integrative awareness stage (appreciation of unique aspects of both
the minority and the dominant culture).

Other racial identity development models (e.g., Cross, 1971;
Helms, 1995) describe a similar process by which stages of de-
velopment influence attitudes, outlooks on life, and behavior.

Theorists are also devoting increased attention to identity devel-
opment of individuals from more than one racial/ethnic back-
ground (e.g., Herring, 1995; Poston, 1990). Racial identity is
relevant to the therapeutic process in that minority clients at
various developmental stages may have different attitudes about
working with a psychotherapist from another racial/ethnic back-
ground. Moreover, a therapist’s own process of identity develop-
ment may affect how he or she approaches these issues with clients
(Helms & Cook, 1999; D. W. Sue & Sue, 1990).

Acculturation. Acculturation refers to the gradual physical,
biological, cultural, and psychological changes that take place in
individuals and groups when contact between two cultural groups
takes place (see Chun, Organista, & Marı́n, 2003). When one
group (or individual) moves to an area dominated by an existing
cultural group, there is pressure on the newcomers to conform and
accommodate to the dominant culture’s way of life and to abandon
or devalue their own cultural roots (Berry & Kim, 1988; Chun et
al., 2003). Although typically conceptualized for individuals from
immigrant groups (e.g., Asian, Latino immigrant populations) ad-
justing to novel environmental situations (e.g., Rogler, Cortes, &
Malgady, 1991), concepts of acculturation have also been applied
to racial/ethnic minority groups (including African American)
interacting with the larger American Caucasian culture (e.g.,
Anderson, 1991). Such pressures are navigated differently by
different individuals, and research has demonstrated that “accul-
turation stress” can create vulnerabilities to certain health prob-
lems, as well as susceptibility to increases in psychological symp-
toms (Cuellar, 2000).

Various theorists have developed models and instruments of
acculturation that attempt to capture and quantify individuals’
level of acculturation. For example, Berry and Kim (1988) argued
that the extent to which individuals retain valued aspects of their
original culture, and the extent to which they seek positive rela-
tions with the larger (dominant) society, determine their mode of
acculturation. They define four modes of acculturation: integration
(both the individual’s own culture and the dominant culture are
valued), assimilation (the dominant culture is valued, but the
individual’s original culture is devalued), separation (the individ-
ual’s original culture is valued, and dominant culture is devalued),
and marginalization (both the individual’s original culture and the
dominant culture are devalued).

It is not difficult to imagine how racial identity development and
acculturation might influence psychotherapy. D. W. Sue and Sue
(1990) have suggested, for instance, that racial/ethnic minority
clients in the conformity stage of identity development may prefer
Caucasian therapists, viewing them as more competent than racial/
ethnic minority therapists. Conversely, clients in the resistance and
immersion stage may prefer a non-Caucasian therapist and may
conceptualize psychological problems as stemming solely from
oppression and racism. Similarly, with respect to acculturation, a
client who has fully integrated elements of different cultures might
feel comfortable working with a therapist of any racial/ethnic
background, whereas a client who has devalued the dominant
culture may prefer a therapist from his/her own background.

Racial identity development and acculturation are two promi-
nent ways in which individuals from the same racial/ethnic group
may differ from one another, but they are certainly not the only
ways. Moreover, researchers are beginning to consider how these
variables may interact with each other and other within-group

280 CARDEMIL AND BATTLE



differences (e.g., Chun et al., 2003; Ponterotto, Casas, Suzuki, &
Alexander, 2001). Being able to discuss a client’s individual
experience of his or her race/ethnicity may prevent the client from
feeling stereotyped and may open the door to more intimate
conversations. The following is one way a therapist might encour-
age a client to talk about these issues:

You’ve told me a bit about your racial/ethnic identity. It would be
helpful for me to get your sense of how you see your racial/ethnic
background contributing to your development over the years—your
sense of self, as well as relationships with family members, friends,
and other members of your community. Has your sense of racial/
ethnic identity always been this way, or has it changed or developed
over the years?

Although encouraging clients to discuss their racial/ethnic iden-
tity can lead to interesting insight for clients and therapists alike,
we also caution therapists to be sensitive to the fact that there will
likely be wide variation in the depth of conversations that emerge.
Some clients may feel quite comfortable discussing their perspec-
tives and feelings regarding their racial/ethnic identity, whereas
others may want to engage in a briefer or more superficial con-
versation or may prefer not to discuss the issue at all. Allowing
clients the opportunity to have this conversation and then respect-
ing their decisions regarding self-disclosure can be a positive way
for clinicians to demonstrate their willingness to delve into these
issues while conveying a sense of respect for clients’ wishes and
personal boundaries.

3. Consider How Racial/Ethnic Differences Between
Therapist and Client Might Affect Psychotherapy

Engaging clients in conversations about their racial/ethnic back-
ground is critical, but it is equally important to openly recognize
the therapist’s racial/ethnic identity and any racial/ethnic differ-
ences that might exist between the client and the therapist. Clients
may never raise these issues explicitly; however, racial/ethnic
differences may still play an important role in the therapy process.
Numerous investigators have examined how such differences be-
tween clients and therapists affect the psychotherapy process (e.g.,
Atkinson, 1983; S. Sue, 1988). Some of these differences arise
with regard to attitudes and expectations toward mental health
services (e.g., S. Sue, 1988), conceptions of the self in relation to
family and community (e.g., Marsella, 1985), and communication
and interaction styles (e.g., D.W. Sue, 1990).

Differences in conceptualization of mental health and mental
illness. Racial/ethnic differences in conceptualizations of mental
health can play a significant role in the psychotherapy process. For
example, Lee (1996) has noted that many traditional Asians may
understand mental illness through concepts like balance of yin and
yang, disturbances of chi energy, or supernatural intervention.
Therapists who are unaware of these perspectives on mental health
are likely to have trouble effectively engaging these clients. Dif-
ferences can also be found in expectations of the role that mental
health services will play in their lives. For example, some re-
searchers have suggested that members of certain racial/ethnic
minority groups may be more likely to engage in therapy when in
a current life-crisis and then withdraw when the crisis passes
(Garcı́a-Preto, 1996; Treviño & Rendón, 1994). Others have noted
that some members of racial/ethnic minority groups may view the

therapist as an expert and, accordingly, expect concrete advice and
help, an expectation that runs contrary to many traditional Western
approaches to psychotherapy (Tsui & Schultz, 1985).

Differences in conceptions of self in relation to family and
community. A second way in which differences between clients
and therapists could interfere with therapy concerns cultural dif-
ferences in conceptions of the self in relation to family and
community (D. W. Sue & Sue, 1990). Although Western psycho-
therapy tends to be very individualistic, many cultures have more
collectivistic perspectives (Helms & Cook, 1999). Caucasian ther-
apists who fail to consider how a collectivistic perspective may
affect approaches to therapy may run the risk of alienating certain
clients (Dwairy & Van Sickle, 1996; Helms & Cook, 1999). For
example, a Caucasian therapist who conceptualizes a Mexican
American woman’s depression as being related to her dissatisfac-
tion at work might encourage her to look for another job or career.
Although this intervention might ultimately prove useful, the ther-
apist might consider the ways in which the client’s strong sense of
obligation to her family is met by continuing in this seemingly
unsatisfying position.

Differences in communication styles. D. W. Sue (1990) de-
tailed a variety of ways in which cultural differences in commu-
nication can come into play during therapeutic interactions. He
noted that different styles of nonverbal communication, including
proxemics (perception of personal and interpersonal space), kine-
sics (facial expressions, posture, movement, gestures, eye contact),
and paralanguage (vocal cues such as loudness of voice, use of
silence and pauses) can lead to miscommunication and gradually
infringe on the therapeutic relationship. For example, although
some Japanese or Mexican Americans may actively avoid direct
eye contact as a sign of respect, a Caucasian therapist may interpret
this behavior as a sign of shyness or guardedness, lack of asser-
tiveness, or depressed mood. Preferences for amount of interper-
sonal space, which tend to vary across racial/ethnic groups, can
also lead to misunderstandings. A Caucasian therapist may be
accustomed to more physical space between himself and others
than may an African American client, who may be more accus-
tomed to closer interpersonal spaces. Thus, a therapist who backs
away from an African American client may send the unintentional
message that the therapist is cold, aloof, and uninterested in
communicating or connecting. Dwairy and Van Sickle (1996)
described similar miscommunications that can take place between
Caucasian therapists and Arabic clients that arise from different
styles of eye contact, different conceptualizations of time and time
commitments, and different values placed on verbal communica-
tion and self-disclosure.

It is impossible for even the most experienced and well-
intentioned therapists to identify every between-group difference
that might emerge over the course of therapy. The critical element,
rather, is espousing and conveying a willingness to consider the
relevance of racial/ethnic differences with clients. One way to
open this type of conversation might be as follows:

I know that this can sometimes be a difficult topic to discuss, but I was
wondering how you feel about working with someone who is from a
different racial/ethnic background? I ask because although it is cer-
tainly my goal to be as helpful to you as I possibly can, I also know
that there may be times when I cannot fully appreciate your experi-
ences. I want you to know that I am always open to talking about these
topics whenever they are relevant.

281RACE AND ETHNICITY IN PSYCHOTHERAPY



This type of conversation may lead to more therapist self-
disclosure (e.g., direct identification of therapist racial/ethnic iden-
tity) than some therapists might prefer. Even so, we strongly
encourage therapists to consider how not engaging in these con-
versations might impede the development of trust. Not acknowl-
edging racial/ethnic differences could send an implicit message to
the client that the therapist is uncomfortable discussing certain
topics or does not view them as important—a message that is
likely to hinder the therapy process.

4. Acknowledge That Power, Privilege, and Racism Might
Affect Interactions With Clients

Beyond addressing issues particular to any specific racial/ethnic
group, therapists should also recognize that racism, power, and
privilege can affect the therapeutic process (Pinderhughes, 1989).
Many Caucasian psychologists are certainly aware of and sensitive
to these issues, but it is likely that minority clients will have
experienced them more directly, on a personal level. Moreover,
minority clients may have had negative experiences in which the
effects of racism, power, and privilege on their lives have been
minimized or denied. Failing to acknowledge these societal issues
in the context of psychotherapy could unwittingly invalidate pain-
ful personal experiences and thus alienate minority clients.

Racism. Although institutionally sanctioned racial discrimina-
tion is now illegal in the United States, it is an unfortunate reality
that racism, prejudice, and discrimination do continue to exist. In
2000, the Federal Bureau of Investigation reported on 8,055 hate
crimes; a significant percentage of these crimes (65.1%) were
determined to be motivated by racial, ethnic, or national-origin
bias (Federal Bureau of Investigation, 2001). At more individual
levels, many members of racial/ethnic minority groups will have
had some personal experience with racism and prejudice in their
own lives or in the lives of family and friends. For example, many
African Americans report having experienced racial profiling by
police conducting traffic stops (e.g., Meredith, 2001). Other racial/
ethnic minorities living along the U.S.–Mexico border report being
routinely stopped by officers of the Immigration and Nationaliza-
tion Service who are searching for illegal immigrants (Silko,
2001). People of color may also experience more subtle forms of
racism in everyday activities, such as being watched closely by
security personnel while shopping, or overhearing racial slurs or
jokes in the classroom or workplace (Rothenberg, 2001).

Although these experiences may not always be as extreme or
overt as job discrimination or hate crimes, they can still have a
lasting and cumulative negative effect. Considering how these
types of experiences affect the therapeutic process is critical.
Racial/ethnic minority clients may have the (often correct) percep-
tion that Caucasian therapists do not adequately understand these
types of experiences or the emotions they can evoke both imme-
diately and over time. Thus, we strongly encourage therapists to
try to understand how repeated experiences with racism can create
vastly different experiences and a different outlook on life for
racial/ethnic minority clients.

Power and privilege. In addition to overt experiences with
racism and discrimination, it is important for therapists to consider
how power and privilege may influence work with racial/ethnic
minority clients (Pinderhughes, 1989). One way in which power
might manifest itself in therapy is through the construct known as

white privilege, or the set of advantages that are automatically
afforded to those who share the dominant European American
culture (McIntosh, 2001; Tatum, 1997). Caucasian Americans may
fully acknowledge, and seek to rectify, what they see as disadvan-
tages experienced by those in a minority group, but it is often more
difficult to see the reverse: The advantages afforded to those who
share the dominant culture. Some examples of these “invisible”
privileges include seeing people of one’s own race/ethnicity well
represented in film, TV, magazines, and other media; never being
asked to speak “on behalf” of one’s racial/ethnic group; and
trusting that in school, one’s children will use curricular materials
that contain images of people who look like them (McIntosh,
2001).

Conversations about racism, power, and privilege can be diffi-
cult, particularly when a therapist is a member of the group
benefiting from power discrepancies. It is much easier to engage
clients in abstract discussions or even to empathize with clients’
own personal experiences than it is to explore the effects of power,
privilege, and racism on the therapeutic relationship. The benefits
to the therapeutic alliance from having such conversations, how-
ever, are invaluable. The following is an example of how a
Caucasian therapist might engage a client who recently discussed
personal experiences of prejudice:

Today we have been talking about your sense that many of your
coworkers are prejudiced. What has this conversation with me been
like for you? What has it been like for you to share experiences of
discrimination with a White therapist who hasn’t had those kinds of
experiences?

Although there may be relatively little that a Caucasian therapist
can do on a macro level to rectify the racial/ethnic inequities that
exist in today’s society, acknowledging clients’ feelings of frus-
tration and helplessness and being willing to discuss these feelings
openly on a micro level can yield great benefits to the therapy
relationship. In this way, simply demonstrating a willingness to
discuss these difficult topics may be the critical component.

5. When in Doubt About the Importance of Race and
Ethnicity in Treatment, Err on the Side of Discussion; Be
Willing to Take Risks With Clients

Although we do not suggest that extended discussions of race/
ethnicity are necessary in every therapy relationship, we believe
that these issues warrant more attention than they are currently
given. It can be difficult for both clients and therapists to determine
when it will be useful to openly discuss issues regarding race and
ethnicity in the course of psychotherapy. Some clients may directly
bring up issues relating to race (e.g., by noting an apparent differ-
ence between the race/ethnicity of client and therapist; by express-
ing anger regarding racial discrimination; by making a racist
remark deriding a member of another group). In these cases, it may
be more apparent that race and ethnicity will be important topics to
address. Other clients may never directly raise the issue of race/
ethnicity; however there may be subtle indicators that it is an
important issue. When in doubt about the salience of these issues
in treatment, we suggest that therapists initiate discussion in order
to provide an opportunity for direct discussion should it be rele-
vant. Broaching the topic directly and matter-of-factly can convey

282 CARDEMIL AND BATTLE



a sense of openness to your client, inviting future discussion on
these issues as necessary.

Conversations about race/ethnicity can be uncomfortable due to
anxiety about offending or alienating another person or being
judged for “saying the wrong thing.” The issue may carry a strong
emotional valence (e.g., anger, fear, shame, guilt) due to both
historical and current race relations and events in this country
(Helms & Cook, 1999), as well as previous personal experiences
with individuals from different racial/ethnic groups. In addition,
some clients may simply prefer not to discuss race and ethnicity
issues with their therapist. The more comfortable therapists are
with conversations about race and ethnicity, the more easily they
will be able to respond appropriately to clients who are them-
selves uncomfortable or uninterested in participating in these
conversations.

In the event that a client expresses reticence or even frustration
when a therapist raises the topic of race and ethnicity, we recom-
mend responding as openly and as nondefensively as possible, in
the same way that a therapist would engage with a client in order
to overcome any other breach in the therapeutic alliance. One
possible response to a client who reacts negatively to a therapist
who initiates a conversation on racial/ethnic issues might be as
follows:

My intention was not to offend you when I brought up the topic of
race and ethnicity. As we’ve discussed before, I want therapy to be a
place where you can talk about anything that might be relevant to your
life. In this case, I wondered whether anything related to our racial/
ethnic differences might be affecting our therapy process. If this is not
relevant, or if it’s not something you wish to talk about here, I
certainly respect that decision.

We recommend getting practice talking openly about these
issues by having conversations about race and ethnicity with
interested family members, colleagues, friends, and coworkers and
participating in relevant race-related workshops when available.
Understandably, many therapists may still feel that raising issues
of race/ethnicity with a client in therapy constitutes a risk, no
matter how much practice they get with colleagues or at work-
shops. Nevertheless, we maintain that broaching issues of race and
ethnicity, even if the therapist is not sure of exactly what to say, is
better than ignoring the topic.

6. Keep Learning

Our final recommendation to psychologists is to keep learning
about issues of race and ethnicity. Because the United States has a
long history of oppression of racial minority groups and incidents
of racism and discrimination still frequently occur (e.g., Rothen-
berg, 2001), many opportunities to learn will inevitably arise. For
example, we urge psychologists to consider how the therapy pro-
cess might be affected by relevant current events related to racism
and discrimination (e.g., instances of race-based hate crimes, na-
tional debate regarding civil rights legislation or policies).

We also suggest that therapists increase their awareness regard-
ing some recurring sociopolitical events. For example, despite the
fact that Martin Luther King, Jr., Day is a national holiday, many
hospitals, universities, and institutions around the country do not
recognize it. What message does it send to an African American
client if a Caucasian psychologist works on Martin Luther King,

Jr., Day and does not acknowledge the importance of this holiday?
In addition, certain months of the year have specific cultural
designations (e.g., African American Heritage Month, Latino Her-
itage Month), and others have religious significance to certain
groups (e.g., Ramadan, Lent). Failing to be aware of these cultural
celebrations could be negatively perceived by some racial/ethnic
minority clients.

A wealth of resources exists for those interested in learning
more about specific racial/ethnic groups, their traditions, and their
current and historical experiences in the United States. And al-
though it is clearly not the job of psychologists to learn about every
possible cultural celebration, it is likely that psychologists who
take the extra step of learning about significant cultural and so-
ciopolitical events will convey a message of sensitivity and aware-
ness that many clients will appreciate.

In addition to information on sociopolitical and historical
events, much has been written about issues that may be of partic-
ular interest to psychologists, including identity development, po-
tential for bias in assessment and diagnosis, and the psychological
impact of bias and prejudice on groups and individuals. We have
included a listing of selected articles and resource materials that
may be useful for psychologists interested in expanding their
knowledge base in these areas (see the Appendix).

As we have emphasized throughout this article, though, learning
concrete information about different racial/ethnic groups is not
enough. Equally important is the process of considering and chal-
lenging one’s own personal worldview, assumptions, and preju-
dices about other racial/ethnic groups (Helms & Cook, 1999;
Tatum, 1997). Participating in workshops and taking advantage of
literature that promotes self-exploration regarding race and race
relations may be helpful. Involvement in professional meetings
sponsored by groups such as APA’s Division 45 (Society for the
Psychological Study of Ethnic Minority Issues) or more informal
discussions with colleagues of other racial/ethnic groups who have
similar interests in exploring these issues may be another useful
strategy. This self-exploration may not only be helpful in one’s
role as a clinical psychologist but may also be deeply fulfilling on
a personal level.

Conclusion

Sensitivity to issues of race and ethnicity is becoming increas-
ingly emphasized in psychology and has been described by some
leaders in the field as an ethical imperative (Mays, 2000). How-
ever, many practicing psychologists may be uncomfortable ad-
dressing these issues openly with their clients. Often, therapists
make the error of omission in not raising these topics rather than
risking an error of commission by initiating such a conversation.
We believe that, in most cases, racial and ethnic differences
between clients and therapists are relevant and have an impact on
the therapeutic process, and therefore it is important for psychol-
ogists to be able to discuss these topics with their clients as the
need arises. In addition, engaging in these conversations could
potentially lead to improvement in treatment retention, therapy
alliance, and treatment outcome.

Being able and willing to have conversations about issues of
race and ethnicity, including difficult topics like one’s own as-
sumptions and personal prejudices, is an important skill that does
not develop overnight or without effort. In addition to actively

283RACE AND ETHNICITY IN PSYCHOTHERAPY



learning about topics relevant to specific racial/ethnic minority
groups, one must make a shift in both attitude and behavior. This
approach requires psychologists to acknowledge the limitations of
their own worldview and to tolerate the anxiety that may accom-
pany broaching these topics in psychotherapy. Nevertheless, these
skills can be relatively easy to practice, requiring only two moti-
vated individuals who are willing to invest the time and energy to
listen to each other’s viewpoints.

References

Alvidrez, J., Azocar, F., & Miranda, J. (1996). Demystifying the concept of
ethnicity for psychotherapy researchers. Journal of Consulting and Clin-
ical Psychology, 64, 903–908.

American Psychological Association. (1993). Guidelines for providers of
psychological services to ethnic, linguistic, and culturally diverse pop-
ulations. American Psychologist, 48, 45– 48.

American Psychological Association, Committee on Accreditation. (2002).
Guidelines and principles for accreditation of programs in professional
psychology. Washington, DC: Author.

Anderson, L. P. (1991). Acculturative stress: A theory of relevance to
Black Americans. Clinical Psychology Review, 11, 685–702.

Atkinson, D. R. (1983). Ethnic similarity in counseling psychology: A
review of research. The Counseling Psychologist, 11, 79 –92.

Atkinson, D. R., Morten, G., & Sue, D. W. (1998). Counseling American
minorities (5th ed.). Boston: McGraw-Hill.

Berry, J. W., & Kim, U. (1988). Acculturation and mental health. In P. R.
Dasen, J. W. Berry, & N. Sartorius (Eds.), Cross-cultural research and
methodology series: Vol. 10. Health and cross-cultural psychology:
Toward applications (pp. 207–236). Thousand Oaks, CA: Sage.

Betancourt, H., & Lopez, S. R. (1993). The study of culture, ethnicity, and
race in American psychology. American Psychologist, 48, 629 – 637.

Cheung, F. K., & Snowden, L. R. (1990). Community mental health and
ethnic minority populations. Community Mental Health Journal, 26,
277–291.

Chun, K. M., Organista, P. B., & Marı́n, G. (2003). Acculturation: Ad-
vances in theory, measurement, and applied research. Washington, DC:
American Psychological Association.

Comas-Dı́az, L. (1992). The future of psychotherapy with ethnic minori-
ties. Psychotherapy, 29, 88 –94.

Cross, W. E. (1971). The Negro-to-Black conversion experience: Towards
a psychology of Black liberation. Black World, 20, 13–27.

Cuellar, I. (2000). Acculturation and mental health: Ecological transac-
tional relations of adjustment. In I. Cuellar & F. A. Paniagua (Eds.),
Handbook of multicultural mental health: Assessment and treatment of
diverse populations (pp. 45– 62). New York: Academic Press.

Dwairy, M., & Van Sickle, T. D. (1996). Western psychotherapy in
traditional Arabic societies. Clinical Psychology Review, 16, 231–249.

Federal Bureau of Investigation. (2001). Hate crime statistics, 2000. Re-
trieved April 15, 2002, from http://www.fbi.gov/ucr/ucr.htm

Garcı́a-Preto, N. (1996). Puerto Rican families. In M. McGoldrick, J.
Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed.,
pp. 183–199). New York: Guilford Press.

Helms, J. E. (1995). An update of Helms’ White and people of color racial
identity models. In J. G. Ponterotto, M. J. Casas, L. A. Suzuki, & C. M.
Alexander (Eds.), Handbook of multicultural counseling (pp. 181–198).
Thousand Oaks, CA: Sage.

Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling
and psychotherapy: Theory and process. Needham Heights, MA: Allyn
& Bacon.

Herring, R. D. (1995). Developing biracial ethnic identity: A review of the
increasing dilemma. Journal of Multicultural Counseling and Develop-
ment, 23, 29 –39.

Kim, B. S. K., Yang, P. G., Atkinson, D. R., Wolfe, M. M., & Hong, S.
(2001). Cultural value similarities and differences among Asian Amer-
ican ethnic groups. Cultural Diversity and Ethnic Minority Psychol-
ogy, 7, 343–361.

Lee, E. (1996). Asian American families: An overview. In M. McGoldrick,
J. Giordano, & J. K. Pearce (Eds.), Ethnicity and family therapy (2nd
ed.). New York: Guilford Press.

Marsella, A. J. (1985). Culture, self, and mental disorder. In A. J. Marsella,
G. DeVos, & F. L. K. Hsu (Eds.), Culture and self: Asian and Western
perspectives (pp. 281–307). New York: Tavistock Publications.

Mays, V. M. (2000). A social justice agenda. American Psychologist, 55,
326 –327.

McGuire, P. (1999). Multicultural summit cheers packed house: The two-
day dialogue aimed to foster creative strategies of inclusion. APA Mon-
itor, 30(3). Retrieved April 3, 2002, from http://www.apa.org/monitor/
mar99/foster.html

McIntosh, P. (2001). White privilege: Unpacking the invisible knapsack. In
P. S. Rothenberg (Ed.), Race, class, and gender in the United States: An
integrated study (5th ed., pp. 163–168). New York: Worth Publishers.

Meredith, R. (2001). DWB: Driving while Black. In P. S. Rothenberg
(Ed.), Race, class, and gender in the United States: An integrated study
(5th ed., pp. 197–199). New York: Worth Publishers.

Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The
key to efficacy in clinical practice. New York: Free Press.

Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M. (2001).
Handbook of multicultural counseling (2nd ed.). Thousand Oaks, CA:
Sage.

Poston, W. S. C. (1990). The biracial identity development model: A
needed addition. Journal of Counseling & Development, 69, 152–155.

Rogler, L. H., Cortes, D. E., & Malgady, R. G. (1991). Acculturation and
mental health status among Hispanics. American Psychologist, 46, 585–
597.

Rothenberg, P. S. (Ed.). (2001). Race, class, and gender in the United
States: An integrated study (5th ed.). New York: Worth Publishers.

Silko, L. M. (2001). The border patrol state. In P. S. Rothenberg (Ed.),
Race, class, and gender in the United States: An integrated study (5th
ed., pp. 211–213). New York: Worth Publishers.

Sue, D. W. (1990). Culture-specific strategies in counseling: A conceptual
framework. Professional Psychology: Research and Practice, 21, 424 –
433.

Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory
and practice (2nd ed.). New York: Wiley.

Sue, S. (1988). Psychotherapeutic services for ethnic minorities: Two
decades of research findings. American Psychologist, 43, 301–308.

Tatum, B. D. (1997). Why are all the Black kids sitting together in the
cafeteria? New York: Basic Books.

Treviño, F. M., & Rendón, M. I. (1994). Mental illness/mental health
issues. In C. W. Molina & M. Aguirre-Molina (Eds.), Latino health in
the U.S.: A growing challenge (pp. 447– 475). Washington, DC: Amer-
ican Public Health Association.

Tsui, P., & Schultz, G. L. (1985). Failure of rapport: Why psychothera-
peutic engagement fails in the treatment of Asian clients. American
Journal of Orthopsychiatry, 55, 561–569.

U.S. Census Bureau. (2001). United States Census 2000. Retrieved De-
cember 28, 2001, from http://factfinder.census.gov/servlet/Basic-
FactsServlet

284 CARDEMIL AND BATTLE



Appendix

Race and Ethnicity Issues in Psychotherapy: Professional Resources
and Recommended Reading

General Information

Atkinson, D. R., Morten, G., & Sue, D. W. (1998). Counseling American
minorities (5th ed.). Boston: McGraw-Hill.

Chun, K. M., Organista, P. B., & Marı́n, G. (2003). Acculturation: Ad-
vances in theory, measurement, and applied research. Washington, DC:
American Psychological Association.

Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling
and psychotherapy: Theory and process. Needham Heights, MA: Allyn
& Bacon.

McGoldrick, M. (1998). Re-visioning family therapy. New York: Guilford
Press.

Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M. (2001).
Handbook of multicultural counseling (2nd ed.). Thousand Oaks, CA: Sage.

Rothenberg, P. S. (2001). Race, class, and gender in the United States: An
integrated study (5th ed.). New York: Worth Publishers.

Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory
and practice (3rd ed.). New York: Wiley.

Tatum, B. D. (1997). Why are all the Black kids sitting together in the
cafeteria? New York: Basic Books.

U.S. Department of Health and Human Services. (2001). Mental health:
Culture, race, and ethnicity—A supplement to mental health: A report of
the Surgeon General. Rockville, MD: U.S. Department of Health and
Human Services, Substance Abuse and Mental Health Services Admin-
istration, Center for Mental Health Services.

Information for Working With Specific Racial/Ethnic Groups

Choney, S. K., Berryhill-Paapke, E., & Robbins, R. R. (1995). The accul-
turation of American Indians: Developing frameworks for research and
practice. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M.
Alexander (Eds.), Handbook of multicultural counseling (pp. 73–92).
Thousand Oaks, CA: Sage.

Chung, R. C.-Y., Bemak, F., & Okazaki, S. (1997). Counseling Americans
of Southeast Asian descent. In C. C. Lee (Ed.), Multicultural issues in
counseling (2nd ed., pp. 207–231). Alexandria, VA: American Coun-
seling Association.

Erickson, C. D., & Al-Timimi, N. R. (2001). Providing mental health
services to Arab Americans: Recommendations and considerations. Cul-
tural Diversity and Ethnic Minority Psychology, 7, 308 –327.

Mezzich, J. E., Ruiz, P., & Muñoz, R. A. (1999). Mental health care for
Hispanic Americans: A current perspective. Cultural Diversity and
Ethnic Minority Psychology, 5, 91–102.

Wilson, L. L., & Stith, S. M. (1991). Culturally sensitive therapy with
Black clients. Journal of Multicultural Counseling and Develop-
ment, 29, 32– 43.

Competency Guidelines

American Psychological Association. (1993). Guidelines for providers of
psychological services to ethnic, linguistic, and culturally diverse pop-
ulations. American Psychologist, 48, 45– 48.

Organizations

Asian American Psychological Association
PMB #527
5025 North Central Avenue
Phoenix, AZ 85012
Tel.: 602–230 – 4257
www.west.asu.edu/aapa

Association of Black Psychologists
P.O. Box 55999
Washington, DC 20040-5999
Tel.: 202-722-0808
http://www.abpsi.org

National Alliance for Hispanic Health
1501 Sixteenth Street, NW
Washington, DC 20036-1401
Tel.: 202-387-5000
http://www.hispanichealth.org

National Center for American Indian and Alaska Native Mental Health
Research

University of Colorado Health Sciences Center
Department of Psychiatry
Nighthorse Campbell Native Health Building
P.O. Box 6508, Mail Stop F800
Aurora, CO 80045-0508
Tel.: 303-724-1414
Fax: 303-724-1474
http://www.uchsc.edu/ai/ncaianmhr/

Center for Multicultural and Multilingual Mental Health Services
4750 North Sheridan Road
Suite 300
Chicago, IL 60640
Tel.: 773-751-4081
Fax: 773-271-7261

(Appendix continues)

285RACE AND ETHNICITY IN PSYCHOTHERAPY



National Center for Cultural Competence
Georgetown University Center for Child and Human Development
3307 M Street, NW, Suite 401
Washington, DC 20007-3935
Tel.: 800-788-2066
Tel.: 202-687-5387
Fax: 202-687-8899
http://www.georgetown.edu/research/gucdc/nccc/

APA Division 45
Society for the Psychological Study of Ethnic Minority Issues
Division 45 Administrative Office
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242
Tel.: 202-336-6013
http://www.apa.org/divisions/div45/

Received April 24, 2002
Revision received December 20, 2002

Accepted January 14, 2003 �

286 CARDEMIL AND BATTLE