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Individual Clinician Bias in Psychotherapy

Cynthia DellaSanta-Percy New York

Abstract: Therapists, like their clients, are human. They are products of the same conditions and influences as their clients: gender, religion, ethnicity and culture. These influences make therapist and client, peers on some level. In addition, therapists are as susceptible to the same kinds of individual biases born from their background, environment, and individuality, as are their clients. This presentation offers some examples of the way bias in an individual therapist may hamper his/her efforts to offer a success outcome to his/her clients. The American Heritage Dictionary of the English Language (2002, p. 176) defines bias as a preference or an inclination, especially one that inhibits impartial judgment; an unfair act or policy stemming from prejudice. Generally in the social sciences, prejudice is defined as the idea or attitude, while discrimination is defined as the behavior connected to that attitude. (Allport and Memmi, 2000, pp. 237-238; Wrightsman, 2001, p. 315-316) A clinician must be as self-aware as possible, particularly when it relates to individual biases. A particular prejudice in a therapist may result in an incorrect diagnosis, an erroneous treatment plan, and a less than satisfactory outcome for the client. When reading the following examples1 consider whether there is therapist bias? If so, is it positive or negative bias? What are the consequences of the bias? How might the therapist recognize his/her bias and then provide good treatment? Religion and Therapy A therapist, Ms. Jones has received a call from a former client asking for an appointment. The receptionist tells the client, Amy, that Ms. Jones is not taking any new clients, but will see Amy for a consultation since she is a former client. Amy is a 30 year old, single, Caucasian female. She tells Ms. Jones that she is pregnant and needs help deciding whether or not she should have an abortion. Although Amy is involved in what she describes as a loving relationship, neither she, nor her partner had planned on having children, particularly at this stage of their lives. Amy is Roman Catholic, as is Ms. Jones.

Examples were created especially for this paper, unless otherwise notated. Copyright 2002-2004 by Cynthia DellaSanta-Percy. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

2 Ms. Jones is a very devout practioner of her faith and is firmly against abortion under any circumstances. After much soul-searching, she decides that she cannot in good conscience help Amy make a decision if that decision might include Amy having an abortion. Even though the decision would be Amys to make, Ms. Jones feels that to include herself in that kind of decision-making would compromise her personal faith and integrity. Ms. Jones does not want to abandon Amy however. After their meeting, Ms. Jones tells Amy that although she is not in immediate crisis, it is clear that needs more time and help than Ms. Jones can give at this time. Ms. Jones offers to recommend one of several therapists with whom she thinks Amy will be able work well. Because of their previous therapeutic relationship, Ms. Jones says that she will ask whichever therapist Amy chooses to make an appointment for Amy as soon as possible. Amy appears disappointed but says she understands that Ms. Jones schedule is full and agrees to see one of the other suggested therapists. Aponte (Aponte, 1996) quotes Gassert and Hall from their book Psychiatry and Religious Faith, Is psychiatry detrimental to ones religious life? In fact it should not be since psychotherapy is interested in the spiritual life of the individual in much the same way as are many religions. The clinician looks within the individual as does the cleric, to help the person find what is lost and restore it, or find what has been missed and bring attention to it. . . .today it is not a question of science versus religion. . . .but more in what ways the spirit, however we define spirit. . .affects our emotions, psychology, and connections to people.. . . the subtle question of how the values of our politics morality and religion influence our psychotherapy. It is not whether but what kind of spirituality the psychotherapist represents. (Aponte, 1996) It may be suggested that psychotherapy is devoid of values of its own, and that the clinician should be devoid as well. However, in a time and a place where people are daily battling with demons both external and internal, it may be better that the clinician find a way to work within his/her own spiritual biases. Jung suggested 70 years ago that, It is indeed high time for the clergyman and the psychotherapist to join forces to meet this great spiritual task, (Jung, 1933, p. 229) - that of helping the individual find answers to his questions and solutions to his inner problems. In the above case, Ms. Jones did not address her personal bias to the client as it would have been judgmental and highly unethical. However, since part of the reason Amy initially chose Ms. Jones as her therapist, was because of their shared religious beliefs. Understanding that part of those religious beliefs include a firm stand against abortion, the client might feel Ms. Jones was passing judgment on her, even though Ms. Jones has said nothing to specifically indicate those feelings. It is not unethical for a therapist to refer a previous client to another therapist, if the preparation is done properly. It is not unethical to have strong faith and to incorporate that faith into daily living, including therapy. Ones faith does not stop at the treatment room door, much as we might wish at times that it did; and, there may be times when a therapists faith actually helps the therapeutic enterprise. What would be unethical in this case, would be to work with a client when the therapist knows that her counsel will not be objective and unbiased.

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3 Referring Amy and preparing her to accept a new therapist, without direct discussion of the pregnancy/abortion issue, is the most ethical way for Ms. Jones to handle this situation. Cultural Diversity and Therapy Amina,2 a 19-year old Pakistani girl, arrives to see the therapist with her mother and two sisters. The family has recently emigrated to the United States. Amina and one of her sisters speak some English, her other sister and mother speak no English. Although the therapist, Ms. Jones expected to see the entire family, Aminas sister says that their father had to be at work. The family has come to therapy because Amina has refused to attend school and has withdrawn from all social activities and from her family. Through the sister, the mother tells the therapist that she thinks Amina is so sad because she is homesick for Pakistan. Ms. Jones asks the other female members of the family to wait in the outer room while she talks with Amina alone. The mother becomes agitated, but the sisters calm her and she agrees to wait. Ms. Jones thinks that the mothers assessment of Amina being homesick is probably an accurate one and begins asking questions about Pakistan and Aminas life there. Amina is quiet and answers the questions but offers no information of her own. At the end of the session, Ms. Jones requests that the father attend the next family session. The women return for the next session again without the father. When Ms. Jones asks why, she is told again that he must be at work and would be uncomfortable talking about the womens problems. Ms. Jones tells the women that it is important that the entire family be present at family therapy sessions. Since Ms. Jones does not speak Pakistani, she asks Amina and her sister to translate for their mother and other sister. Again the group discusses Aminas homesickness and ways she might get over it, including returning to school, which Amina reluctantly agrees to do. After several similar sessions, Amina finally explains that she has withdrawn from school because of her relationships with students who are not Muslim. She finds it difficult to keep the traditions of her family, culture and faith when she is with her friends; and, feels guilty when she is with her family knowing she is not keeping their traditions when she is away from them. She is afraid that her father might find out about her friendships and her Westernization and take steps to send her back to Pakistan. Although the therapist might not have been exhibiting a distinct bias, it is clear that she is looking at this family through Western eyes. Guernina (1993) suggests that ethnic minorities in the U.S. are often seen as people who need help, yet those who attempt to give help have no knowledge of the foreign culture they are addressing. She says it could be compared to someone looking at many countries to get to know them all from one single key hole (Guernina, 1993, 2). The first stumbling block is clearly the language barrier. It would be best to have a therapist who can speak Pakistani as well as English treating this family. However, if that is not possible, the therapist should have prepared herself by listening to the language and knowing that
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This example is based on a case study by Z. Guernina in her paper, Transcultural family therapy. Copyright 2002-2004

4 the sessions will necessarily be at a slower pace because of the language problems. In addition, since the younger, school-aged family members are the ones most likely to be conversant in English, it gives them an element of power over their elders. If Ms. Jones were more aware of this, she could have addressed questions directly to the mother and elder sister and politely wait for responses to be translated, allowing the older women to maintain their dignity. Ms. Jones also overlooked the female elements of the Asian family. Since the problem is with one of the daughters in the family, it is a female concern, one which falls under the purview of the mother and elder daughters to oversee. The familys structure is based on a hierarchy where the father is the head of the household. The other family members hold their status as a result of gender, birth order and marital status (Sommers-Flanagan, 1999). Asian families hold the familys problems within the family. If there is a need to go outside the family, such as for counseling, it could jeopardize the family honor. If outside help is sought is must be as a family, though in this case only the female members of the family. While Ms. Jones understood that in most cases the maternal presence in the treatment room might not be comfortable for a teenaged girl, she failed to understand the need in this case of the mother to be there for herself and her daughter. Ms. Jones initially accepted the mothers diagnosis of her daughters homesickness, probably because it was expeditious and not because it was good clinical practice (Alarcon, Bell, Kirmayer, Lin, Ustun, & Wisner, 2000). Amina indeed had several symptoms of depression, but on further examination the problems were deeper than mild depression. While todays therapist may not be unethical in his/her practice, a good family therapist working with a more cosmopolitan community should understand the individual interactions between family members of different cultures (Guernina, 1993). To do otherwise will harm the family and the practice of psychotherapy. Therapy and the Working Poor Elizabeth, is a 28-year old white, female, married two years with no children. She appears anxious while affecting an antagonist attitude. She says she is only coming to counseling because her husband and mother are forcing her to come. She asks how much therapy will cost. Ms. Jones asks about Elizabeths general health. Elizabeth appears thin and pale, and plays with a cigarette she cannot smoke in the treatment room. She is restless and distracted, and says it is because she cannot smoke and has not been sleeping very well. Ms. Jones asks if Elizabeth has had any recent weight loss or change in appetite. Elizabeth again asks how much therapy will cost. Ms. Jones asks if Elizabeth has any insurance. Elizabeth says no, and that she does not qualify for Medicare. Ms. Jones says she has a sliding payment scale for people without insurance, and assures Elizabeth that some arrangements can be made, and suggests that they meet each month at this time. Elizabeth becomes very defensive and says the session is over. She leaves. Surprisingly to Ms. Jones, Elizabeth comes to her next session. She states she was working, but quit a month ago because she was having trouble getting along with her boss. She says she just could not keep her mind on the work and was planning to quit any way because the job wasnt going anywhere. She says she will look for something else when she does not seem so tired all the time. She says that her husband wants her to go back to work and tells her it is

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5 because they need the money. She believes it is because he doesnt trust me to be at home all day. She says she would like to have a baby but her husband wont consider it because they have so little money and because they support Elizabeths mother. Elizabeth also says that her husband has threatened to leave her if she accidentally gets pregnant. Again, Elizabeth asks about the cost of therapy. Ms. reiterates her previous explanation of the payment arrangements. Ms. Jones suggests that Elizabeth is suffering from mild depression and says she would like to meet with Elizabeth three more times over the next three months. Elizabeth says she feels sometimes like she wants to go to sleep and sleep for a very long time. She also says she thinks she would like to see Ms. Jones every week. Ms. Jones says she does not think she can lower her fee enough for Elizabeth to come in each week, but offers to suggest a mental health clinic where the cost may be free for Elizabeth. Elizabeth says she tried to get in to that clinic but the waiting list was two months long. Elizabeth quietly agrees to Ms. Jones treatment plan. Therapy and the Elderly Mrs. W,3 a married woman in her 70s, was referred to Ms. Jones by her pulmonologist who believes Mrs. Ws stress level is exacerbating her asthma attacks. Mrs. W misses her first appointment, but does come for her second. During assessment she describes difficulty with her two grown daughters; one a successful lawyer lives nearby with her family, the other, single and living abroad. Mrs. W complains continuously about other peoples behavior, especially toward her. She feels she is being taken advantage of and misunderstood. She complains that she had to wait so long to get an appointment, and told Ms. Jones that her husband told her to lie about her age because psychology services for the elderly were rubbish (Gorsuch, p. 195). Ms. Jones suggested that perhaps Mrs. W thought she was getting rubbish. Mrs. W continues by telling Ms. Jones that she had not known anything about the person she would be seeing age, marital status, children, gender and that lack of knowledge unsettled her. At the end of the session Mrs. W becomes anxious and suggests that Ms. Jones would not want to see this moaning old woman again (Gorsuch, p. 195). Mrs. W comes to the next session then misses two. Although it is her policy to follow-up on missed appointments, Ms. Jones finds it increasingly difficult to work with Mrs. W and decides just to wait to see if she comes back. These two examples are offered together because they represent two groups that are often underserved and overlooked the working poor and the aged. There are those who claim that psychotherapy for the lower classes is illadvised and a waste of resources, because the emotional problems of the poor are a result of their economic deprivation. Without realizing it, such well-meaning antagonists of psychotherapy for the lower classes introduce the very type of stereotyping of the lower classes which is responsible for the injustices they are trying to prevent (Siassi and Messer, 1976, p. 30). Various studies have shown that there is no difference between the degree of mental illness and social status; however, lower socioeconomic status (SES) clients are more likely to be given drug therapy as opposed to individual counseling. They are less likely to receive indi3

This example is based on a case study by N. Gorsuch in her article, Times winged chariot. Copyright 2002-2004

6 vidual counseling even if money is not an issue; if they do get individual counseling they are often assigned to the least experienced, and social class has been shown to be a more influential factor in treatment decisions even than diagnosis (Siassi, p. 32). Attitudes and expectations of the therapists toward clients has an effect on the course of therapy. It has been found that therapists typically have a negative attitude toward the treatment of lower SES clients, and that has been reflected in the acceptance of therapy by the client, and the length of therapy he or she agrees to. For many. . .the shift from angry suspicion or a sense of despondency to trust in psychotherapeutic engagement is difficult. There is bound to be uneasy testing before a sense of trust can emerge. The therapist who begins with the prior assumption that the service he is rendering is not needed or wanted by such patients can easily fall victim to a self-fulfilling prophecy (Siassi, p. 33). Studies have shown that therapists success in treating lower SES clients was in direct correlation to their skills as clinicians. Although the elderly are the fastest growing population segment, they are often the last to seek mental health care. Compounding the poor utilization of mental health services by the elderly is the avoidance of the elderly with these problems by healthcare providers because of their own negative attitudes and prejudices. . . .the aged stimulate the therapists fears about his (her) own old age(Herrick, Pearcey, Ross, 1997, 5) In each of the previous two examples, the therapist seemed to be giving her clients short shrift. In the case of Elizabeth, three sessions over three months are not sufficient to determine if there is good cause for her to be in therapy aside from her familys wanting her to be. In addition, the fact that she seemed to want more therapy may suggest that given a little time she may reveal secrets, concerns and worries to the therapist, who could then establish a more solid treatment plan. One more problem with the time frame the therapist chose, is that there is a long time between appointments, more than enough time for a reluctant client to decide not to come again. In the case of Mrs. W, it is most likely that her bravado, complaints and whining, mask much deeper issues. By being impatient with her, and by not following up as she normally would, the therapist is showing clear bias against this patient. It is clear that a therapist must continue to learn and educate him or herself, as much about his or her own attitudes and feelings toward people and their situations as much as anything else. A competent, ethical clinician must be able to push individual biases to the side and deny them in order to objectively serve his or her clients. They must be able to recognize their

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7 own biases and see those biases for what they are, then once identified set aside those that he/she can to work objectively with his/her client.

References Alarcon, R.D., Bell, C.C., Kirmaryer, L.J., Lin, K., Ustun, B., and Wisner, K.L. (2000) Beyond the funhouse mirrors: Research agenda on culture and psychiatric diagnosis. In D.J. Kupfer, M.B. First, and D.A. Regier (Eds.), A Research Agenda For DSM-V. Washington, D.C.: American Psychiatric Association. Allport, G.W. and A. Memmi (2000). Prejudice and discrimination. In A.G. Johnson (Ed.), The Blackwell Dictionary of Sociology A users guide to sociological language. (2nd ed., pp. 237-238). Oxford, UK: Blackwell Publishers Ltd. The American Heritage Dictionary of the English Language,4th edition. (2000). New York: Houghton Mifflin Company. Aponte, H.J. (1996) Training of psychotherapists. Psychotherapy Source, Bulletin of the Menninger Clinic, Fall 96, 60(4), 488. Corsini, R. (Ed). (2002) The Dictionary of Psychology. New York: Brunner-Routledge. Denmark, F.L. (1996). Prejudice and discrimination. In R.J. Corsini & A.J. Auerback (Eds.), Concise Encyclopedia of Psychology (2nd ed. ab., p. 676). New York: John Wiley & Sons, Inc. Gorsuch, N. (1998) Times winged chariot: Short-term psychotherapy in later life. Psychodynamic Counselling, May 1998, 4(2), 191-202. Guernina, Z. (1993). Transcultural family therapy. Counseling Psychology Quarterly, 6(4), 365. Herrick, C.A., Pearcey, L.G., and Ross, C. (1997) Stigma and ageism: Compounding influences in making an accurate mental health assessment. Nursing Forum, July-Sept 1997, 32(3) pp. 21-27. Jung, C.G. (1933) Modern Man In Search of a Soul. New York: Harcourt, Inc. Siassi, I. and Messer, S.B. (1976) Psychotherapy with patients from lower socioeconmic groups. American Journal of Psychotherapy, Jan 76, 30(1), 29. Sommers-Flanagan, R and Sommers-Flanagan, J. (1999) Clinical Interviewing (2nd ed.). New York: John Wiley & Sons, Inc. Wrightsman, L.S. (2001) Forensic Psychology. Belmont, CA: Wadsworth/Thomson Learning.

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