Racism is pervasive in our society and antithetical to the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (2017), hereafter referred to as the APA Ethics Code. While our field emphasizes the importance of addressing our own racial biases to ensure ethical professional work, little discussion exists in the literature regarding how to respond to client racial bias. In this article, we discuss ethical considerations for navigating client racial prejudice that arises in the context of psychological care as well as review the scant literature on this topic.

The General Principles of the APA Ethics Code (2017), which “guide and inspire psychologists toward the very highest ethical ideals of the profession,” state that psychologists have a duty to be “aware of and respect” individual differences, including ethnicity/race, and “do not knowingly participate in or condone activities of others based upon such prejudices” (Principle E: Respect for People’s Rights and Dignity, p. 3). However, determining the most ethical course of action when a client makes a prejudiced statement—racial or otherwise—is not addressed in the APA Ethics Code. In these instances, our duty to uphold a client’s right to “self-determination” (Principle E: Respect for People’s Rights and Dignity, p. 4) and respect their worldview may be in conflict with our “professional and scientific responsibilities to society” (Principle B: Fidelity and Responsibility, p. 3) and the Principle of Justice (Principle D). As Principle A, Beneficence and Nonmaleficence, states, “psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons” (p. 3). Meta-analytic research has established that experiencing racial prejudice is associated with a myriad of negative psychological outcomes, including increased distress, depression, anxiety, substance use, and suicide risk, as well as decreased life satisfaction (Lui & Quezada, 2019), among other negative sequalae; thus, racial prejudice is not innocuous. As psychologists, how do we weigh our obligations to an individual client against society, and “resolve these conflicts in a responsible fashion that avoids or minimizes harm” (Principle A, p. 3)?

In general, there is a dearth of published literature on whether and how psychologists should address client prejudice—racial or otherwise. Commonly discussed clinical considerations in the literature include:

• Quality of and threat to the therapeutic relationship (Bartoli & Pyati, 2009; King, 2014; Mbroh, Najjab, Knapp, & Gottlieb, 2020)
• Relevance to a client’s presenting concerns (Bartoli & Pyati, 2009; King, 2014)
• Clinical context (e.g., short-term stabilization of a suicidal or psychotic client in an inpatient facility versus a long-term outpatient therapy client; Mbroh et al., 2020)
• Likeliness of intervention success/client’s readiness to change (Bartoli & Pyati, 2009; King, 2014; Mbroh et al., 2020)
• Psychologists’ motivations for intervening or not intervening (e.g., potential therapeutic benefits, desire for retaliation; Bartoli & Pyati, 2009; King, 2014)

A psychologist’s own racial identity may be another important consideration. To date, published literature on the experiences of client racism among BIPOC (Black, Indigenous, and People of Color) mental health providers is lacking. To the authors’ knowledge, only two such publications exist, a book chapter titled, “When Racism Is Reversed: Therapists of Color Speak about their Experiences with Racism from Clients, Supervisees, and Supervisors,” and a qualitative study of eight BIPOC counselors (seven Black, one Southeast Asian). In the former, one author described their experience of being “thrown off” their “professional balance” and feeling vulnerable when clients made racist comments, as well as being unsure how to respond (Ali et al., 2005). In the latter publication, Branco and Bane (2020) identified qualitative themes related to BIPOC counselor experiences of “bracing and buffering” in response to or anticipation of racist client statements as well as “intrusions” of microaggressions on treatment and the therapeutic relationship, with covert bias being more common that overt racist statements.

In the face of client racial prejudice, depending on the nature of the comments and the psychologist’s own racial identity and life experiences, it may be difficult for them to remain unbiased towards the client, which could impair competence (Code 2, “Competence”). In many cases, consultation, while maintaining client confidentiality (Codes 4.01, 4.05, 4.06), may be warranted for weighing conflicting ethical obligations, exploring personal reactions to the client’s specific statements, and determining a course of action that avoids and minimizes harm to the client (Code 3.04, “Avoiding Harm”) and others. While having a reaction to racist statements is hardly a “personal problem,” but, rather, an understandable and normal response to prejudice, Code 2.06 “Personal Problems and Conflicts” may still be relevant. This Code states, “When psychologists become aware of personal problems that may interfere with their performing duties adequately, they take appropriate measures, such as obtaining professional consultation.”

In rare cases, if continued services could be expected to cause the client or others harm (Code 3.04, “Avoiding Harm”), the psychologist might determine the most ethical course of action is to terminate services (Code 10.10a) and “suggest alternative service providers” (10.10c). The psychologist might also decide to terminate services if, based on the nature of the comments and their own identity, they feel “threatened or otherwise endangered by the client” (Code 10.10b). However, while termination of services might be in the best interest of a client at times, or warranted if a psychologist feels threatened, it might also be considered discrimination related to the client’s beliefs (Code 3.01 “Unfair Discrimination”), and cessation of services could result in harm to the client (Code 3.04).

Moreover, addressing a client’s racial prejudice in the context of psychological care— rather than ignoring biased comments or choosing to not work with the client—may not only have benefits for society, but benefits for the individual client. In psychological treatment, we often explore and challenge a client’s false beliefs that may be harming the client or contributing to their personal and interpersonal challenges. Racial prejudice, being generalized preconceived notions of an entire racial/ethnic group that is not based upon reason, represent faulty beliefs. Thus, intervening when a client makes racially prejudiced statements may be therapeutically indicated in many cases.

Whether and how mental health professionals respond to client racial bias is understudied. To the authors’ knowledge, only two studies have been conducted on this topic. Most recently, in Branco and Bane’s (2020) secondary qualitative analysis of interviews with eight BIPOC counselors, three main responses were identified: reframing or redirecting the client, trying to understand the client within the context of their worldview, or directly responding to the racist statement. Counselors considered likelihood of success and relevance to presenting problems, given client’s racial identity and awareness, when determining whether to address racism comments. Relatedly, in a small, mixed-methods study among 17 primarily White clinical and counseling psychologists, King (2014) found that reactions to racist comments by White clients in the context of therapy ranged widely and were motivated by various client, relational, and psychologist factors. When a client made a racist comment in therapy, some psychologists reported challenging or disagreeing with the statement, while others described exploring the comment further; still others described ignoring the comment completely or changing the subject. With regards to motivations for addressing or not addressing prejudiced statements, psychologists described several client factors, including client vulnerability or readiness to change and relationship contextual factors, such as level of rapport and power and identity differences within the relationship, as well as psychologist factors, including personal values related to client autonomy or anti-racism, theoretical orientation, and self-doubt regarding one’s abilities to effectively address the issue.

While there remains a lack of research on best practices when faced with client racism, a recent theoretical article on this topic presents five useful general guidelines to assist in navigating ethical dilemmas, which they apply to determining whether and how to address all types of client prejudice that arise in psychological treatment (Mbroh et al., 2020). First, they recommended that psychologists generally remain up-to-date on psychological literature as a means of being “proactive in their ethical decision making and approaches to navigating ethical dilemmas” (p. 288; “Education”). They also advised weighing the costs and benefits of various decisions by “considering all the potential consequences” of an intervention (“Application of Knowledge”). In the case of client prejudice, one might consider, “Could addressing these beliefs bring about any positive changes in the patient’s life or for society?” (p. 289). Mbroh and colleagues also encouraged “Self-Reflection,” or examining one’s motives. They asserted that psychologists should consider whether the goals of an intervention “are both realistic and directly related to the benefit of the patient and society and not merely for the psychologist’s own benefit,” such as an “unconscious goal of retaliation” (p. 289). “Consultation” is another recommendation, which they highlighted as particularly important if a psychologist’s emotional response to a client’s prejudiced comment could impair their work with the client. Finally, the authors described a three-pronged “Intervention,” emphasizing the importance of a collaborative, non-confrontational approach. First, they recommended that psychologists empathize with the emotions behind the client’s comment. This serves to promote the client’s ability to remain open when the psychologist next challenges the belief by creating dissonance between a client’s beliefs and their goals, or highlights how a client’s beliefs may negatively impact their relationships. In the final step, psychologists invite the client to explore the origins, accuracy, or emotions related to their beliefs. Through this process, psychologists can challenge a client’s problematic beliefs and validate their emotions without supporting the prejudice, and “provide an open environment to explore these beliefs if the patient is willing” (p. 289).

Ultimately, as psychologists, we are tasked with minimizing harm when “conflicts occur among psychologists’ obligations” (Principle A: Beneficence and Nonmaleficence; p. 3), as may be the case when a client makes a racially prejudiced comment in the course of assessment or treatment. There are many considerations regarding whether and how to address client racial prejudice based on client, psychologist, and therapeutic relationship factors. However, with thoughtful consideration of relevant ethical and clinical issues, and use of the clinical tools at our disposal for helping clients examine unhelpful thoughts and behaviors, encountering client racial prejudice in treatment is also an opportunity to foster positive change for individual clients as well as society.

References 

Ali, S. R., Flojo, J. R., Chronister, K. M., Hayashino, D., Smiling, Q. R., Torrest, D. & McWhirter, E. H. (2005). When racism is reversed. In M. Rastogi & E. Wieling (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 117-134). Thousand Oaks, CA: Sage Publications.

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2001, amended effective June 1, 2010 and January 1, 2017). www.apa.org/ethics/code/

Bartoli, E., & Pyati, A. (2009). Addressing clients’ racism and racial prejudice in individual psychotherapy: Therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training, 46(2), 145-157.  https://psycnet.apa.org/doi/10.1037/a0016023

Branco, S. F., & Bayne, H. B. (2020). Carrying the burden: Counselors of color’s experiences of microaggressions in counseling. Journal of Counseling & Development, 98(3), 272-282. https://doi.org/10.1002/jcad.12322

King, M. (2014). What do clinicians do? Addressing white clients' racist comments in the therapy room (Unpublished doctoral dissertation).Southern Illinois University at Carbondale.

Lui, P. P., & Quezada, L. (2019). Associations between microaggression and adjustment outcomes: A meta-analytic and narrative review. Psychological Bulletin, 145(1), 45-78. https://psycnet.apa.org/doi/10.1037/bul0000172

Mbroh, H., Najjab, A., Knapp, S., & Gottlieb, M. C. (2019). Prejudiced patients: Ethical considerations for addressing patients’ prejudicial comments in psychotherapy. Professional Psychology: Research and Practice, 51(3), 284–290. https://psycnet.apa.org/doi/10.1037/pro0000280