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How some therapists are helping patients heal by tackling structural racism

Culturally responsive therapy is a growing trend, as therapists of color try to make counseling more inclusive.
Kristen Uroda for NPR

Cambodian American Eden Teng was was born in a refugee camp on the border of Thailand and Cambodia just a few years after the Cambodian genocide. She moved to the U.S. with her mom and aunt when she was 6.

Teng attributes much of her own resilience in transitioning to the U.S. to her exuberant mom, who wore whatever she wanted and wasn't afraid to defy social norms — even when it was embarrassing for a teenage Teng.

But when she was growing up, Teng also witnessed the negative impacts of historical, racial and intergenerational trauma on her mom's wellbeing. Teng often felt confused by the way her mom's emotions could spiral out of control for seemingly no reason, or why why she had so many health problems.

When Teng first encountered psychology in college, she realized that her mother's past was directly connected to her emotional and physical health. (Scientists are learning that stress and trauma are sometimes linked to chronic illnesses, like hypertension, diabetes and kidney disease.)

It was this realization that compelled Teng to become a therapist; in 2018 she began her graduate studies in Seattle.

But when COVID-19 hit and the Black Lives Matter movement came into full force, with communities of color having a more public conversation about their struggles in the U.S., Teng says she started feeling differently about her training and the profession she'd be entering. She began to notice how dealing with certain issues, including race and immigration, were not given priority in her clinical training — even though she knew how important they are in shaping a life.

"I didn't feel represented, and I felt that so much of my family's history just didn't feel like it was considered," she says, adding that she was studying under teachers who were predominantly white. "I just felt silenced in my own history [and] my own experience in the work that I was doing."

Teng's graduate program isn't the only one like this. Therapy is a predominantly white field in the U.S. — 80% of psychologists, 63% of counselors and 59% of social workers are white, according to Data USA, a website that constructs visualizations of public federal data.

Many of the founding ideas, techniques and schools of practice of therapy were developed by white scholars or practitioners. As a result, the field has marginalized the experiences of people of color, therapists and patients say. Microaggressions are also pervasive in psychological practice, researchers note, and many immigrants report not attending therapy because of language barriers, a lack of insurance and high costs.

That's why Teng wanted to take a new approach. For her, that meant joining a growing movement of other counselors hoping to transform the practice of therapy, to make it more accessible and relevant to people of color and — ultimately — to help them find healing.

Embracing a practice of 'decolonizing therapy'

Teng was initially inspired by people like Dr. Jennifer Mullan, who refer to this work as "decolonizing therapy," a process of addressing the structural racism and other forms of oppression that keep therapy from serving many marginalized communities.

"I think the best way to describe decolonized therapy is that it is really making space to examine the external pressures, stressors, and layers of oppression that my clients have endured and survived," Teng says.

She gives the example of microaggressions in the workplace, or job interviews. "There are opportunities that are not given to you because of your identities," she says, "But if we look at it through the lens of self-esteem, it's like 'Something is wrong with you. You just need to think better about yourself,' right? Like you need to be more positive."

But for people of color, that framework of just being "more positive" doesn't always work. It doesn't account for racism, xenophobia and other forms of discrimination directed toward them. "The challenge," Teng explains, "is to recognize that how you're feeling about yourself can also be internalized oppression."

Teng's practice in decolonizing therapy digs into family history, helping her clients of color better understand how the historical oppression of their ancestors affects them. She says this is true for people from her own community, who experienced the genocide when the Khmer Rouge regime killed about 2.2 million people. "When we're talking about Cambodian refugees and immigrants, there's a history here that is so horrific, rich, and devastating."

Teng finds children of Cambodian refugees who have been through the genocide can struggle with guilt. "In first-generation or second-generation Cambodian Americans, there's this experience that your parents have sacrificed or have gone through so much," she says. "They've experienced tremendous loss. And having that sense of their sacrifices, we feel we need to hold that harm and that grief and that pain."

Holding onto a parent's pain leads into tricky territory, says Teng. "We also feel that we have to transcend it by being perfect or striving to be so successful that we are becoming millionaires ... versus really being with the gentleness of the grief, and the emotions that are being held and passed down."

Using culturally responsive techniques

To respond to these issues, Teng has developed a few approaches that are different from the way she was trained. First, Teng often brings in the family to her practice.

"This may mean that we involve parents in sessions so that we can hear from their point of view," she says. "When we're in that space, there are a lot of opportunities to shed light on the impacts of being a child of immigrants. And through that lens — of being someone like a first generation immigrant — we can discuss the harm that is very much connected to the harm that parents have navigated."

Teng supports the children and parents in openly discussing experiences like racism and genocide in a secure and validating environment. She says many who survived the genocide, had to suppress their feelings. "And so, when you have the experience of suppressing those [painful] emotions, you're also suppressing joy and connection, belonging."

Allowing her clients and their parents to experience the full spectrum of emotions can be healing, she says. "[They] can allow for positive attachments and relationships that feel meaningful."

Teng also works against the stereotype of the detached therapist-as-expert. She makes clear to her clients that she may not have all of the answers, and prefers to be transparent with her clients about her own intergenerational trauma. "When we can really be with what's hurting, we know we're together in this," she says. "I'm a part of this collective healing journey with my clients."

Growing acceptance of the role of historical trauma

Like Teng, Ramona Beltran became interested in decolonizing therapy because of the issues she was seeing in her community of origin. She identifies as Xicana of Yaqui and Mexica descent and is a professor of social work at the University of Denver.

When she was at the start of her career, several of her family members passed away before they reached 60 years old and she found herself asking what the links are between her community's history of trauma and their health.

When Beltran entered a doctorate program to study historical trauma 20 years ago, she wasn't taken seriously at first, she says — such as when she gave some presentations on the theoretical framework of historical trauma and healing. "I remember this one [presentation] where they forwarded me the feedback, and several people were like, 'This is political. It's ideological. It doesn't count as research. There's nothing empirical about this. This isn't like real academic work.'"

Now, Beltran says things have changed, "I teach a whole class on historical trauma and healing, and it's always one of the classes that gets filled up right away," she says. "And that, to me, is progress."

When she was working on her master's degree in social work, she says, she noticed that all of the evidence-based styles of practice she had learned in grad school weren't enough.

"They were just like these kind of mainstream approaches to therapy that were generated from, primarily white, primarily middle class families," Beltran remembers. "And so maybe they would be translated into Spanish, but to me, what I was seeing was that those practices weren't really generating a lot of healing."

Now when she teaches, Beltran emphasizes that decolonizing can take different forms, depending on the experience of the therapist and the shared experiences of the community the therapist is trying to reach.

She highlights three key aspects of culturally responsive therapy: building authentic relationships, ensuring community representation, and re-connecting with one's cultural background. Like Teng, Beltran is especially interested in working with clients to help them see their culture as a form of intergenerational strength, rather than suffering.

A growing need for culturally responsive therapy

While therapists like Beltran and Teng are committed to making therapy more inclusive, communities of color continue to struggle with getting access to therapists. Teng gets a lot of people contacting her who she simply cannot help. "I'm only licensed to see folks in my area, and there are so many that are interested. And it breaks my heart every time, where I'm not able to provide support."

She notes that this is especially common for clients living in areas with few clinicians available. "I had one from Kansas most recently, who was like, 'We don't have any Khmer therapists anywhere in the state.' But, unfortunately, I'm not able to provide that service."

Teng knows what it's like to lack access to therapy. "I myself haven't had a therapist of my own who practiced the way that I do until most recently," she says.

But there have been some recent moves in the right direction, Teng says. Organizations like Inclusive Therapists created the BIPOC Therapy Fund to provide financial help for at least four initial sessions for people of color seeking therapy. The Asian Mental Health Collective also created the Lotus Therapy Fund to provide financial support to Asian therapy seekers for eight sessions.

And the largest professional organization of psychologists in the U.S. is also promising to make changes. Last year, the American Psychological Association issued a formal apology for its role in what it called "promoting, perpetuating and failing to challenge racism, racial discrimination and human hierarchy in the U.S."

The APA promised to support more research centered on non-Western perspectives, provide more access to culturally competent training, and create more opportunities for people of color to enter the field of psychology. This August, the organization committed $1.1 million to a new Racial Equity Fund to carry out these three goals.

Teng says she hopes to see more funds dedicated to helping people of color get access to therapy that recognizes their history and experiences.

"There's no way that we can just say that we're going to look at this from a cultural lens without actually looking through the historical, intergenerational lens," she says. "And so, it has to be comprehensive and interconnected for it to truly honor the human being that is in front of you."

Copyright 2022 NPR. To see more, visit https://www.npr.org.

Lauren Beard