Professional Documents
Culture Documents
Introduction
The changing social demographics of the UK demand that culture and ethnicity
as well as other social factors are better addressed in the provision and training
of psychotherapists and counsellors. While individuals from ethnic minority
groups in the UK numbered just over 3 million (5.5 %) in 1991, the number rose
to 4.6 million over the next decade, an increase of 53% (Office for National
Statistics, 2001). It has been predicted that ethnic minorities will make up
one-fifth of the UK population by 2051, as compared to 8% in 2001 (Wohland
et al., 2010). Researchers in the USA and the UK have argued for some years
that high-quality professional clinical training is needed to take into account the
increasingly multicultural population (e.g. Constantine & Sue, 2005; Patel et al.,
2000). The majority of research and development in clinical training provision
has been carried out in the US, although there have been a number of initiatives
in the UK (e.g. Shashidharan, 2003).
There are numerous obstacles for access to mental health services by ethnic
minorities, and researchers have indicated various ways in which these can be
alleviated by the development of culturally relevant treatments and training
programmes. Specific difficulties include language barriers (e.g. Saha et al., 2007),
relating to culture and ‘race1’ often pose a challenge to such a learning space
(Tummala-Narra, 2004). Furthermore, the majority of psychotherapy super-
visors are white (D’Andrea & Daniels, 1997), and tend to address cultural issues
in supervision significantly less than minority ethnic supervisors (Hird et al.,
2004). Morgan (2007) has discussed the problem of ‘colour blindness’ in psy-
choanalytic therapy, whereby skin colour in the triad of supervisor, supervisee
and patient is often ignored on the grounds that culture, ethnicity and social
norms are viewed as external and treated as irrelevant to the therapeutic
process.
Bartoli and Pyati (2009) advocate further training to help supervisors
develop the clinical sophistication to deal with complex aspects of interracial
dialogue. Constantine and Sue (2007) conducted a study about black super-
visees’ perceptions of racial microaggressions in cross-racial supervision dyads.
Themes which emerged included white supervisors making stereotypical
assumptions about black clients and supervisees, focusing on black super-
visees’ clinical weaknesses, implicitly blaming black clients for problems
stemming from oppression, and offering culturally insensitive treatment
recommendations.
Microaggressions may not be consciously intended, but from the perspective
of the recipient they represent a negative experience. This ‘new’ manifestation
of racism has been likened to carbon monoxide: invisible but potentially lethal
(Sue & Sue, 2003). Some researchers prefer to use the term ‘racial microagres-
sion’ to describe this form of racism which occurs in the daily lives of people of
colour. They are so common and innocuous that they are often overlooked and
unacknowledged (Solorzano et al., 2000). Sue (2003) argues that: ‘This contem-
porary form of racism is many times over more problematic, damaging, and
injurious to persons of colour than overt racist acts’ (p. 48).
1
In this article we use the word ‘race’ with inverted commas to indicate that the authors
view ‘race’ as socially constructed, and that, as Rustin (2000, p. 183) states, it is both an
empty category and can be one of the most destructive and powerful forms of social
categorization.
356 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)
viewed as the preserve of the white middle class and had little to offer black
individuals, either as patients or as would-be practitioners. Furthermore, a
stipulation that training candidates have a first degree, for example, may dis-
qualify more ethnic minority individuals. What may be necessary is not a degree
as such, but the ability to deal with intellectual work at the level of higher
education (Gordon, 1993). For instance, someone who says to a prospective
applicant of colour that ‘the most qualified person should get the job’ may be
perceived as implying that people of colour are not qualified (Sue et al., 2007,
p. 73).
A recent survey of psychoanalytic trainees and practitioners in the UK found
that certain social conditions of psychoanalytic training institutes ensure that
anxiety plays a central part in most trainee experiences, with trainee conformity
as the general rule and ‘dissent’ the exception (Davies, 2008). Those running
psychoanalytic clinical training institutions are accused of creating colour blind-
ness and avoiding the issue of ‘race’ in order to maintain power and control
(Lowe, 2006). Furthermore, some academics and clinicians seriously question
the applicability of psychoanalysis to be used cross-culturally for different
ethnic groups, given its lack of appropriate attention to a range of cultural
traditions and beliefs (e.g. Littlewood & Lipsedge, 1997; Pérez-Foster et al.,
1996). Others such as Dalal (2002, 2008) Davids (2003, 2006, 2011), Fanon (1967,
1986), Kovel (1988), Morgan (2002) and Rustin (1992) have made suggestions
as to how psychoanalytic theory and practice can be drawn on to take ‘race’ and
cultural issues seriously.
Training analysis has traditionally been the central feature of the tripartite
model of psychoanalytic education, along with psychoanalytic theory, technique
and the supervised analyses of patients (Wilson, 2010). According to Kernberg
(2006), this model has created an atmosphere of submission to an established
authority, which has acted as a disincentive to innovative endeavours in
psychoanalytic institutes. He recommends that supervision should be the
centrepiece of psychoanalytic training as opposed to training analysis. Many
psychoanalytic therapy trainings in the UK follow this tripartite model. One of
the main problems of training analysis was believed to be the ‘reporting’ train-
ing analyst, a radical deviation from the clinical requirements of technical
neutrality (Kernberg, 2000). Some think of training analysis as being a strictly
therapeutic tool, while others assign it a more education role (Bosworth et al.,
2009). Although there is no longer a requirement for training analysts to carry
out detailed reporting about analysands to a training committee, some institu-
tions continue to expect analysts to inform the training committee if they think
a trainee is not fit to practise as a clinician, providing the analyst with a great
deal of power and authority in determining fitness for practice. Furthermore,
the system of psychoanalytic trainings appointing training analysts as supervi-
sors, seminar leaders and as administrative leaders has further accentuated the
power and hierarchical status of training analysts.
In view of the paucity of literature addressing psychodynamic perspectives
on multicultural education, it is important to consider that one of the goals
of psychoanalysis is emotional insight through making unconscious material
KAREN CICLITIRA AND NENA FOSTER 357
Research Aims
This research aimed to consider how issues of diversity were dealt with in a
psychoanalytic psychotherapy training institution where minority ethnic and
homosexual trainees are in a significant minority, with a view to informing
institutional practices and guidelines. This article focuses on culture, ethnicity
and racism, although the research also considered other issues of difference,
including gender, religion, sexual orientation and social class.
Method
The study consisted of an open-ended postal questionnaire and semi-structured
interviews with past trainees/current members from the British Association
of Psychotherapists2 (BAP). Participants were recruited from the three main
sections of the BAP, i.e. the Child and Adolescent, the Jungian and the Psycho-
analytic Sections.3 Ethical approval was obtained from Middlesex University’s
Psychology Department. Only the interview data will be discussed due to the
large amount of rich data collected in order to be able to give due justice to this.
Interview Schedule
Following discussions with members of a committee set up to review the issue
of ethnicity and diversity within the institution, the researchers carried out a
literature review and designed an in-depth semi-structured interview schedule.
The interview questions focused on issues of difference, including ethnicity,
social class, religion, gender and sexual orientation while exploring participants’
experiences of their clinical training and their current views about the organiza-
tion. Participants were also asked how they felt their ethnicity had impacted on
their training, and to give suggestions as to how the organization could become
more ethnically diversified.
2
The identity of the institution was anonymized for peer review.
3
In this article ‘psychoanalytic’ will be used generically, i.e. to include some of the main
theorists such as Freud, Jung and Klein.
358 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)
Interview Participants
In total 105 individuals who were members of the BAP volunteered to be
interviewed via the postal questionnaire. Due to time and resource constraints,
not all the volunteers could be interviewed, and priority was given to interview-
ing all minority ethnic members, as well as other key members and trainees
within the organization. These participants were either recruited from the
postal questionnaire or from purposive sampling. In total 24 members (21
women and 3 men) were interviewed by 11 committee members from the
institution. One participant dropped out of the study after she had received her
transcribed interview. For the sake of confidentiality any identifying factors
such as participants’ names have been changed. Participants were asked to
self-report their ethnicity as suggested by researchers (e.g. Modood et al., 1997),
but for the sake of anonymity ethnicities have been grouped into broad categor-
ies. There were 17 participants who identified as from an ethnic minority, and 5
participants who reported to be ‘white’. One participant chose not to identify
with any particular ethnicity.
Interviews
All interviewees were provided with an information sheet explaining the
purpose of the research and gave signed consent. Interviews lasted between 35
minutes and 85 minutes, were digitally recorded and transcribed verbatim by
professional transcribers utilizing transcription conventions which noted hesi-
tations, pauses and overlapping speech (Kvale, 1996). Identifying details were
removed from the transcripts and participants were given pseudonyms. For the
purpose of clarity in reporting,‘ums’,‘ers’, pauses,‘you know’,‘I mean’,‘kind of’,
‘sort of’ and word repetitions were removed. Words emphasized by participants
were put in capitals. Data from the interviews were managed utilizing
maxqda 2, qualitative data management software.
To inform the data analysis, the researchers drew on discursive psychology
(Edwards & Potter, 1992) rather than psychoanalysis. The former avoids
on-going questions about the ethics and validity of using psychoanalytic inter-
pretations when analysing interview data collected outside a clinical setting
(Hook, 2008; Parker, 2005). Data was coded and analysed thematically
(Barbour, 2008). Thirty-five main codes emerged from the data, which were
further coded into subcodes. The codes and interpretations of data were dis-
cussed and verified by the two authors. All participants were provided with
excerpts from their interviews which were to be published, and the participants
edited many of these.
Findings
Recruitment Interviews
Participants discussed various aspects of their clinical training from the initial
recruitment interviews to the point of qualification as a psychotherapist. Par-
ticipants noted how issues of diversity relevant to culture, ethnicity, racism,
gender and sexual orientation were often ignored or not fully explored within
KAREN CICLITIRA AND NENA FOSTER 359
their training. The difficulty in addressing these issues and their notable absence
manifested in various often unspoken ways. One participant noted his inter-
viewer’s initial discomfort at finding ‘a large black man’ at his door, as this
would be outside the institution’s perceived norm:
Henry: X [name of interviewer] was very easy and relaxed and welcoming. X,
I think he was a bit thrown. He wasn’t expecting me to be me, and I think he
was a little bit thrown but after that he was all right.
Interviewer: What do you mean?
Henry: I think he was a bit flustered at the door . . . because I was a large young
black man.
While Regina discussed her initial interview experience partly in a positive
way, she described a ‘blind spot’ in the organization and its members’ recogni-
tion of culture. This absence, as in this instance, was often interpreted as indi-
cating, that from this initial contact with a member of the BAP this should not
be spoken about:
The interviews I thought were very thorough. Culturally I think that there was an
element of a blind spot there. And my taking from that was something that you
didn’t really raise within an interview setting.
Training Analysis/Therapy
While there seemed to be a lack of recognition about individuals’ culture and
ethnicity in many encounters, such as the recruitment interviews, training analy-
sis was identified as a potential site where these issues could be discussed –
although this was not guaranteed, as it would depend on the individual analyst.
This private space could give the opportunity for exploration and allow minor-
ity ethnic trainees to explore their own identity, and help prepare them for
working with diverse or different patient groups. However, one participant who
insisted that these matters should be addressed in trainees’ analysis had recently
accepted that this could not be the only place where these issues are addressed,
as not all analysts would have the competence or capacity to do so:
Jackie: There’s no hope of ever addressing serious social issues like prejudice and
racism if you can’t think about them in yourself. I’m always astonished by the fact
that there are many people who don’t think about such issues analytically, or in
terms of their own capacity for racism. Having seminars on ethnicity or racism
without, at the same time, having a psychoanalyst or psychotherapist who’s willing
to think about such things is a waste of time. In fact, it would be like trying to teach
clinical seminars without having a patient. The point is that unless one is also able
to reflect on one’s own relationship to a particular problem, and realize that it
cannot be addressed in the abstract, one cannot really engage in its broader social
context . . . I’ve never actually thought this through in this way. I’ve ALWAYS
thought, I don’t agree with this whole idea about ‘we’ve got to have seminars on
racism’, and that it has to come from your analysis. But it can only come from your
analysis if you yourself are willing to think about it, and you have an analyst who’s
capable of doing so.
Additionally, it was speculated that a trainee needed to be open or to have
specific experience, perhaps a negative experience, of culture and/or ethnicity, in
360 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)
Regina asked for a black analyst and was allocated a white Irish analyst, who
was able to address culture in a way that she found meaningful:
I also had a very good analyst, because initially I’d asked for a black analyst and I
was told there aren’t any, they were in New York or something, but I had a very
good Irish analyst who seemed quite comfortable with also me bringing in cultural
issues in a very deep and meaningful way . . . That was the best part of the training
for me.
Infant Observation
An integral part of all trainee experiences was their infant observation and the
seminars linked to these observations. All trainees were required to observe a
baby or a toddler weekly for a period of one and two years, depending on their
course requirements. This was noted as a possible site of cultural recognition, as
well as cultural insensitivity. For Ava this was an enriching experience, and
presented an opportunity to recognize the importance of cultural differences:
The area where I saw and felt the differences was in my infant observation course.
Because the baby I was observing was Eastern European . . . because either way
it will be an interesting cultural experience for me, whether it’s the same culture
or different culture, baby and mother, observing such an intimate, important
362 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)
Other participants found that the way infants and their families were observed
could be reductive and misinterpreted, which Vivian described as Eurocentric:
We have a fairly Eurocentric view of how things should be. I think that in terms of
infant observation . . . and in terms of ideas about how families operate.
Participants were aware that there were missed opportunities for raising aware-
ness about cultural diversity in the infant observation seminars. Trainees’ views
suggested that they would like to be actively encouraged to read and discuss
relevant literature, and to observe minority ethnic infants.
Ruth implied that she thought that only because she trained with two black
students were there opportunities to talk about cultural issues in theoretical
seminars, but even so there were not those openings in the infant observation
seminars:
We had two people in my group who were black, and I think there were opportu-
nities in the theoretical seminars to think about race and racism and ethnicity and
so on. Where it didn’t get talked about, and I think it could’ve been talked about,
was in the infant observation seminars, and I think it’s quite significant really.
In training settings minority individuals often feel that if they speak up they
will be seen as a spokesperson for their culture, or they may fear that expressing
negative feelings will reinforce stereotypes about their cultural group (Parker
et al., 2004). Bipasha linked her difficulties in seminars to her being different,
and to being in a minority from other trainees:
It was in the clinical seminars that I felt quite got at. And I don’t know whether it
was because of that difference. And I think these sorts of training groups are quite
rivalrous anyway. And maybe that was one form that it took. That they kind of
dumped on the person who was a bit different. Or maybe there were reasons for
them to find fault with what I was doing . . . The seminar leaders didn’t seem to
think anything of it. So I thought: ‘Well, this is part of the course’.
Some noted that the clinical seminars lacked exploration of diversity and that
there was resistance to exploring these issues:
Ina: I think of them as clinical seminars where people present work with people
from other races. It is important. I know people have strong feelings about it, but I
think it is important that it has become an issue.
that there was a clear white middle-class ‘majority’ group within the training
organization. Yasmin described how she felt constrained in seminars:
I was one of a few amongst a predominantly white, middle-class member group . . .
So I feel it’s just brought that to my notice more that I was different. Whereas I
suppose generally I don’t go around feeling I’m different. But it was kind of quite
stark really . . . I don’t really think I felt fully part of the BAP. I think my experience
of being the ‘other’ here, so to speak, has also a part to play . . . I haven’t had any
experience in the BAP of being discriminated against because of my race, only a
kind of discomfort that I don’t belong. I have this feeling that I can’t engage with it,
I can’t quite find my place in it. But that might have, not necessarily to do with my
race, but to do with my sense that it is very constrained and controlled. Not
individually to do with individual members, but in the group there is something very
controlled about it.
Participants in this study mainly reported what could be considered as
‘microagressions’, rather than overt racism, which were probably unconscious,
and often downplayed, yet they were undoubtedly problematic and damaging
for the recipient (Constantine & Sue, 2007; Sue, 2003). As Ina explained:
I have a British passport, but you don’t forget that you are a foreigner. People used
to ask me: ‘When are you going back?’ A kind of reminder that you come from
somewhere else. It’s inevitable. There are constant reminders that you’re not really
from here. It does not necessarily mean that you shouldn’t be here, but a question
of what are you doing here? And when I applied for the training I was asked if I
would understand the patients, and as a mother how would I manage if the children
got ill.
Lisa highlighted the tensions of acknowledging the importance of the uncon-
scious in clinical work, while recognizing the importance of exploring both the
concept and individual experiences of culture in training:
Therapy is seen as ‘Oh my God, you go to a shrink for ten years, they change your
brain’, there’s that kind of cultural shift that needs to happen somewhere that
therapy isn’t this oddball creature, to me, it’s something about the valuing of the
unconscious which is denied in our society . . . There is a cultural thing that we have
to address in some ways.
Reshma noted that her family’s relinquishment of their ‘Indian culture’ made
it easier for her to fit into the (white) majority, and she linked this personal
experience to her experience of her training:
If had I come from Hackney through an Access course with a bit of attitude . . . I
wouldn’t have fitted in that group I don’t think. Very middle class, very, white in
terms of one’s ideas, our shared, even things like going to the pub, the shared
interests . . . That’s what my parents aimed for that we should, because there were
not any other Asians around where I was brought up. So my parents didn’t speak X
[Indian language] at home, the idea was that we should fit in at all costs, so I think
I’ve become very good at fitting in. So I think that’s why I think that’s made it easier
for me. Whereas I think someone else who’s hung on or had a stronger cultural
identity, I wonder if it would be so easy for them.
Regina described how a minority ethnic trainee could be made to feel out of
place and anxious:
KAREN CICLITIRA AND NENA FOSTER 365
I had been told by a lot of colleagues and friends this is a whole new area to go into,
very few black people train in this area and that there were risks . . . You were
taking on new ways of thinking, but were having to make readjustments externally,
and also this anxiety about losing respect. Because, in the group there was a lot of
material dug up about psychoanalytical ways of thinking and how black people, in
the past, had been somehow stereotyped and seen in particularly negative and
pernicious ways because of the psychoanalytical brain. So going into that training,
for me, was seen as well ‘X [own name] why are you doing that? Do you know what
could happen? Do you know how the whole thing about race and culture is seen
within that particular psychoanalytic?’ . . . You were a bit like being in limbo, so just
welcome but perhaps a source of anxiety, and then you were pulling a bit away from
what you’d come from. So there were huge risks. And I think some people were put
off training because of the fear of what you would be left with and how you would
be seen and perceived. I feel I’ve survived that well and with a lot of support, but
there were difficult times and times where you felt you had no place in any place.
with patients. Psychoanalytic theory allows for the fact that clinicians are
unlikely to overcome their racist feelings and attitudes: no one’s unconscious,
not even the best analyst’s, will ever disappear, but clinicians need to become
familiar with their own racism (Altman, 2006).
As Kernberg (2004) suggested, supervisors should be chosen for their capac-
ity for supervision, and seminar leaders should be selected on the basis of
demonstrated teaching ability, specialized knowledge, clarity of thinking and
talent to teach and to learn rather than because they happen to be senior
training analysts. Although many of the training analysts who also carry out
these functions in this institution are from a separate organization, their sen-
iority within the world of psychoanalysis may make it hard for training institu-
tions to require that they demonstrate their willingness to learn about and to
facilitate discussion of issues such as culture and ethnicity. Holmes (1992)
argues that racial meanings should be addressed in all training analyses as well
as by didactic learning and supervision, irrespective of trainees’ ethnicity. A
trainee’s ability to work competently in a therapeutic relationship requires that
supervisors initiate discussions about heritage, and can guide trainees’ discovery
of their values, assumptions, and biases related to racism and culture (see
Tummala-Narra, 2004).
Participants’ accounts pointed to a paradox in psychoanalytic training: insight
is integral to understanding and treating patients, but it appears very difficult for
trainees to discuss their insights about their own diversity and that of others
during their training. The acknowledgement of the impact of diversity, such as
homosexuality, gender, religion, culture and ethnicity, seemed to be particularly
difficult to reconcile within the trainings at this institution.
In the light of the feedback and recommendations from participants regarding
the training components, further attention should be paid to infant and parent
interaction to consider cultural difference in trainees’ infant observation. Train-
ees could be encouraged to observe infants from minority ethnicities and to work
with training patients from diverse backgrounds. This would provide important
opportunities in terms of exploring, appreciating and sensitizing trainees to
culture and diversity. Participants’ interviews suggest that a more active manage-
ment of the seminar sessions is needed to provide opportunities for exploring
diversity, as well as to consider these with respect to psychoanalytic theory and
the resulting tensions. Following participants’ suggestions, it would be advisable
for further training for clinical supervisors, seminar leaders and training analysts
to be provided, and for members of the institution to actively recruit individuals
with knowledge and experience of diversity issues. The integration, not just the
acknowledgement, of diversity in clinical training is essential to facilitate a much
needed modification in psychotherapy and supervision practice and the cultural
competence of a training institution (Sue & Sue, 2003).
Cooper (2010) warns that acute anxieties are often mobilized when institu-
tional racism is named and identified. However, Cooper and others (e.g. Davies,
2008) insist that change will have to be carried out at an institutional level. The
need to address diversity is evidently important both for the sake of good
practice with patients, and to encourage prospective applicants to undertake a
368 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)
Acknowledgements
We would like to thank all our research participants and in particular the
interviewees. We would also like to express our gratitude to Elise Ormerod, the
BAP administrative staff and the members of the research group who carried out
interviews or supported this project in other ways: Nick Benefield, Maggie
Cochrane,Andrew Cooper, Steven Flower, Maureen Fox,Aparna Jack, Margaret
Humphrey, Helen Morgan, Juliet Newbigin and Janine Sternberg.We would also
like to thank Ann Scott and the reviewers for their constructive comments.
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