Amer. J. Orthops-ychiat. 61(3), July 1991

CLINICAL

ETHNOCULTURAL TRANSFERENCE AND COUNTERTRANSFERENCE IN THE THERAPEUTIC DYAD

Lillian Comas-Diaz, Ph.D., and Frederick M. Jacobsen, M.D., M.P,H.

The relevance and validity of ethnocultural factors in transference and countertransference reactions are proposed. Some of those prevalent in dyadic psychotherapy are described, focusing on intra-ethnic and inter-ethnic dyads. Case vignettes are presented to illustrate the ways in which et/rnocultura.lfactors serve as catalystsfor such major therapeutic issues as trust, ambivalence, anger, and acceptance of disparate parts of the self

he influences of culture and etlmicity tients since social images of blacks make T on the psychotherapeutic process have them easier targets for therapists’ projec- been previously acknowledged (Devereu.x, tions. Similarly, Spiegel (1965) asserted that 1953; Gr~7th,1977; Tic/to, 1971), and have working with patients from different cul- recently been recognized as key factors in tural backgrounds engenders a very com- therapy(Comas-D(az & Gr(ffith, 1988; Dud- plicated strain within the therapist. Psycho- ley & Rawlins, 1985; Goleman, 1989; therapy with the ethnoculturally different McGoldrick, Pearce, & Giordano, 1982). patient frequently provides more opportu- While some of these influences are imme- nities for empathic and dynamic stumbling diately available to the senses (sights, blocks, in what might be termed “ethno- sounds, smells, etc.), it has been postulated cultural disorientation.” that every culture also has its own unique In traditional therapeutic orientations,pa- form of unconscious (Hall, 1981), which tients’ racial and ethnic remarks in therapy may have powerful effects on the process have been attributed to a defensive shift of psychotherapy. Ethnicity and culture can away from underlying conflict, and the ther- touch deep unconscious feelings in most apist’s role has been to interpret them as individuals and may become targets for pro- defense and resistance (Evans, 1985). How- jection by both patient and therapist, thus ever, inour own clinical experience we have becoming more available in therapy. For found that this approach hinders the explo- example, Jones (1985) stated that black pa- ration of conflicts related to ethnicity and tients often evoke more complicated coun- culture. By encouraging the elaboration of tertransferential reactions than white pa- ethnoculturally-focused devaluing concepts

Based on a paper presented at the 1989 Confrrence on Psychotherapy of Diversity: cross-cultural Treatment Issues, Harvard Medical School, C~bridge,Mass. Authors are at the Transcultural Mental Health Institute, Washington, D.C.

392 © 1991 American Ortho~sychiatricAssociation, Inc. COMAS-DIAZ AND JACOBSEN 393 and feelings, the therapist can offer patients ference are influenced by a feeling of es- a richer opportunity to know and resolve trangement that afflicts both therapist and their own ethnocultural and racial conflicts patient as each of them is inclined to mis- (Evans, 1985). For instance, Comas-Diaz interpret the other’s nonverbal communica- and Jacobsen (1987) reported that in cross- tion in terms of his or her own cultural cultural psychotherapy, projective identifi- reality. However, it is important to remem- cation may be shaped by ethnocultural val- ber that factors such as gender, sexual ori- ues. These identifications frequently occur entation, physical appearance, and per- spontaneously, as when the patient at- sonal experience also influence the process tributes to the therapist certain qualities or of cross-cultural psychotherapy (Jones, features characteristic of the patient’s own 1985). Given the complexity and multiplic- ethnocultural identity. This process of eth- ity of ethnocultural factors, therapists need nocultural identification may be facilitated an understanding of their own ethnicity and by the fact that identification is one of the culture as well as of their patients’ so that chiefmanifestations of culture(Hall, 1981), they can achieve effectivecross-cultural psy- as well as a major dynamic force in therapy chotherapy (Jacobsen, 1988; Jones, 1984). (Erikson, 1959). In order to examine the ethnocultural trans- As they do in the traditional psychother- ference and countertransference in greater apeutic dyad, transference and countertrans- detail, it is helpful to explore these pro- ference have critical significance for the cesses within the framework of the patient- cross-cultural clinical encounter. The ac- therapist dyad from both interethnic and in- knowledgment of ethnic and racial factors traethnic perspectives. in the psychotherapeutic relationship often To illustrate the relevance and validity of appears to catalyze the transference, lead- ethnocultural factors in transference and ing to a more rapid unfolding of core prob- countertransference, several of those that lems (Schachter & Butts, 1968). However, are prevalent in dyadic psychotherapy are cultural and ethnic aspects of behavior of- described in this article, along with the com- ten make the evaluation of transference and mon underlying dynamic themes that char- countertransference difficult (Bash-Kahre, acterize them. Case vignettes are used for 1984; Zaphiropoulos, 1982) and may be a illustration, with identifying data altered to stumbling block to therapeutic progress(Jen- protect confidentiality. kins, 1985), particularly when the therapist fails to acknowledge such differences ETHNOCULTUIRAL TRANSFERENCE (Varghese, 1983). Therapists also tend to lnterethnic Transference bring their imprinting of ethnic and racial There are many possible transference it- stereotypes into psychotherapy (Riess, actions within the interethnic dyad, rang- 1971), and these stereotypes frequently play ing from overcompliance and friendliness a significant role in the manifestation of to suspiciousness and hostility (Jackson, transference and countertransference. Coun- 1973). Transference reactions can occur at tertransference reactions are often compli- any stage of treatment, although they ap- cated by ethnocultural issues such as prej- pear more likely to occur at some than at udice, discrimination, and feelings of guilt others. (Coznas-DIaz & Minrath, 1985). Overcompliance and friendliness. This Ethnic and cultural parameters of trans- type of reaction is frequently observed when ference and countertransference may rein- there is a societal power differential in the force each other, sometimesdeveloping into patient-therapist dyad. Perhaps the most a vicious cycle. For instance, Bash-Kahre common example of such a power differ- (1984) asserted that in cross-cultural psy- ential in the United States is that of a white chotherapy, transference and countertrans- therapist with a patient from an ethnic mi- 394 ETHNOCULTURAL TRANSFERENCE nority. This kind of situation can be seen me?”) is a common transference reaction in in the example of a Latino professional the interethnic dyad. Unacknowledged eth- woman, accustomed to being assertive in nocultural differences promote mistrust and her own professional context, who does not suspicion in the patient. One form this can negotiate the scheduling of her appoint- take is concern on the part of the patient ment with her therapist, even though the about therapist’s “real” motivations in the offered time is inconvenient for her. Asked therapy. For example, a black patient said why she did not attempt negotiation, she to her Hispanic male therapist during the stated: “As a Hispanic professional women, initial interview: “I wonder how good you I did not want to reinforce ethnic stereo- are if you are working with me in this inner types. I did not want to make waves and city clinic.” A more extreme example of was avoiding being labeled as difficult.” mistrust and suspicion is provided by the Thus, the patient overcomplieswiththe ther- following case of a German therapist- apist, compromising the therapeutic alli- Israeli patient dyad: ance. After two years ofintensive psychotherapy, the patient Notwithstanding such power differen- was still struggling with issues of trust. He was ac- tials in our society, the overcompliance and tively fantasizing about his therapist’s possible partic- friendliness type of transference reactions ipation in Nazi military activities. He confronted the can also occur when the therapeutic dyad is therapist, who answered from a classical analytic stance: of an ethnic minority therapist and a non- “You are wondering about my participation in Na- zism,” and left it there. Finally, the patient developed minority patient. In such instances, the a plan to catch the therapist. During a session, he transference reaction can take the form of presented his own experiences as an officer in the concern about being a good patient. For Sinai war. The therapist’s response implied that he example, a white female said to her Chi- understood the activities of an officer, thereby height- ening the patient’s anxiety about the therapist’s pos- nese male therapist: “I wish I could speak sible role in the Holocaust. Shortly thereafter, the pa- Cantonese, so I can be like your Chinese tient dropped out of treatment. When discussing this patients.” therapy with close friends several years later, the pa- Denial ofethnicity and culture. This type tient stated that his therapyhad been disrupted because of reaction involves avoidance by the pa- of his therapist’s refusal to address this issue. tient of any issue pertinent to ethnicity or Mistrust and suspicion can eventually lead culture. In discussingcolor blindness among to hostility, as in the following example: people of color, Greene (1985) suggested that this denial may stem from a fear of A Portuguese family was meeting with their daugh- confronting racism within the self. She fur- ter’s clinician. The therapist, although culturally iden- ti~’inghimself as being from india, was originally ther suggested that some members of op- from Goa, an island off the coast of India that was pressed groups may be so afraid of divi- colonized by Portugal. When the patient’s parents asked siveness that they tend to obscure the the therapist where he had learned Portuguese, he told differences between themselves and others, them that he had learned it in Goa. The father then therebyavoiding confrontation of their own said, in a pejorative way, “Ah, you are from one of our colonies.” ethnicity or culture. The following example illustrates this type of reaction: Ambivalence. Patients in an interethnic psychotherapy dyad may struggle with neg- A Pakistani graduate school student sought treatment for problems in her relationship with her parents. Her ative feelings toward their therapists, while therapist in the college counseling clinic was a black simultaneously developing an attachment to male. In response to the therapist’s inquiry about her them. Issues of identification and intemal- family ethnic background, she replied: “My parents ization within the interethnic dyad can cre- are Pakistani but that has no relation to my problems.” ate ambivalence in the patient. For in- Mistrust, suspicion and hostility. Mis- stance, questions such as “How can an trust (or “How can this person understand ethnic minority patient living in an inner COMAS-DIAZ AND JACOBSEN 395

city take a white middle-class therapist as a at the need for such a meeting, stating: “1 come here model for identification and subsequent in- and I hardly have to discuss my problems because, by ternalizating?” emerge in discussion of being black, Dr. S knows everything about me. Dr. S is the only good black doctor who can help me.” This transference within this dyad (Comas-Diaz revelation of the patient’s omniscient transference & Minrath, 1985). Another aspect of this helped the therapist to resolve the impasse. transference reaction involves patients’ awareness of their own ambivalence. As an The omniscient-omnipotent transference illustration, as assertive black patient told reaction can take several forms. One is that of the savior, inwhich patient and therapist his Latino therapist: “I have mixed feelings about you. By you not being white, I can be are from a similar ethaocultural minority; because the therapist has been able to sur- less suspicious of you. Since you are not vive in the mainstream society, the patient black, I can tell you about some negative feelings about being black. However, by expects the therapist to come back to rescue him or her. This transference reaction fre- you not being black, I am not sure if you can totally understand me.” quently reinforces a dependent and passive The question of intemalization of the ther- position. For example, a female Chinese- American patient said to her Chinese male apistis no less provocative when the patient is white and the therapist is from an ethnic therapist: “We are both Chinese and that helps a lot. You are such a great doctor and minority. A black female psychiatry resi- dent, writing about issues of race and trans- a great person, I know that you can make me well, take away the pain, and make ference, presented a clinical vignette illus- trative of such ambivalence (Harris, 1990). things OK for me.” In the vignette a white female patient de- Another version of omniscient-omnipo- scribed to the therapist feelings of persecu- tent transference is that of the folk hero or tion by Latino tellers in a bank, who were heroine, This reaction is more predominant among ethnic groups, particularly minori- rude to her, When the therapist raised the ties, that have experienced hardship and op- question of whether the patient might have feelings about having a black therapist, she pression within the larger society. In this replied that even if she had feelings about reaction, the therapist’s accomplishments the therapist’s race, she would not bring (such as going to graduate school, leaving the ghetto, migrating, and being socially them up because she “did not want to hurt the therapist.” Such a response suggests the successful) all contribute to the mythology existence of transferential ambivalence, in of the ethnic minority person who “made that the patient was experiencing racial feel- it.” Consider the following example: ings, but at the same time, due to her at- A Hispanic woman said to her Hispanic female ther- tachment to her therapist, she did not want apist, “I place myself in your hands—you have done to hurt her by discussing them. so well. I have told everybody in the barrio about you and all the good things that you have done. Pretty soon I will bring my daughters to see you and I know that Intraethnjc Transference you will help them.” Exploration revealed that the The omniscient-omnipotent therapist. patient had been telling people in the barrio that her This type of transference involves a com- therapist was the director ofthe clinic, when in reality she was in a training position. plete idealization of the therapist and the fantasy of reunion with the perfect, all- The traitor. The converse reaction to ide- good parent, facilitated by the ethnic sim- alization of the therapist is the process of ilarity: devaluation. In this transference reaction, the patient exhibits resentment and envy at A black therapist felt that his work with a black woman was at an impasse. He consulted his supervisor who the therapist’s success, and equates it with suggested a conjoint session with the patient. During betrayal and “selling out” of the therapist’s the conjoint session, the patient expressed her surprise culture, as the following vignette illustrates: 396 ETHNOCULTURAL TRANSFERENCE

A black male said to his black male therapist: “You cultural and gender issues.” She further identified the have to be an Oreo to be working for the Man. You therapeutic match as providing a positive and correc- don’t even live in a black neighborhood anymore and tive experience for her identity. However, as therapy you pretendthat you are helping your people by work’ progressed, the patient expressed fears of being too ing in this white institution.” close and of being engulfed by the therapist. Although the patient acknowledged progress in her therapy, she The autoracist. This type of transference decided to terminate treatment on the grounds of her is more prevalent among groups that expe- inability to deal with her strong ambivalence. rience racial prejudice accompanied by so- ETIINOCULTURAL cioeconomic oppression - Patients with this COUNTERTRANSFERENCE reaction do not want to work with a then- lnterethnic Countertransference pist of their own ethnocultural group be- cause they experience strong negative feel- Denial of ethnocultural differences. The ings toward themselves and project these denial of ethnic or cultural differences, or feelings onto an ethnically similar thera- the belief that “all patients are (or should be pist. Usually these patients experience con- treated as if they are) the same,” contrib- flicts intheir ethnoculturalidentities and do utes to a negation of countertransferential not want to be forced to address these con- influences in the therapeutic process. This flicts by being in therapy with a memberof type of denial by the therapist may also take an ethnoculturally similar group. Working the form of feeling that one is (orshould with a therapist from their own ethnic group be) above the cultural and political influ- may signify to them that they are receiving ences of the society (Gorkin, 1986). The inferior treatment; they prefer a member of following case vignette illustrates the ef- the dominant group as a therapist. Consider fects that such a countertransferential reac- the following example: tion may have:

A Latina who has been assigned to a Latina therapist A Panamanian woman in treatment with a Puerto Ri- can female therapist had been talking for several ses- during the initial evaluation tells the therapist: “I don’t want b work with you. I am Latina and I know that sions about feeling alienated from her mother and fam- Latinos are lazy and like to gossip. I want a white ily. In response to the patient’s repeated reviews of the doctor.” reasons for her immigration to the United States, the therapist asked the patient about her feelings regarding Ambivalence. Questions of identification the political situation in Panama. The patient then ex- with and internalization of the therapist can pressedconcern about her family’s security in Panama and guilt about being safe herself in the United States. be provocative when raised within an intra- She said that she had not realized that she could talk ethnic dyad. Patients in this dyad may feel about politics in therapy, because a previous therapist at once comfortable with the shared ethno- of hers had apparently taken a position negating the cultural background and at the same time political context of the patient’s clinical presentation. fearful of too much psychological close- If her current therapist had not addressed the p-oli~ical situation in Panama, the patient’s clinical work would ness, When such closeness occurs in ther- have been seriously compromised. apy, it may bring to the fore the patients’ unresolved issues about their ethnocultural The clinical anthropologist syndrome. In background. This mix of feelings may lead this reaction, the therapist is overly cu- to a subtle but rather profound ambivalence rious about the patient’s ethnocultural that can easily be missed or may be con- background, and may spend an inordinate fusing to the unsuspecting therapist. For ex- amount of time exploring aspects of the pa- ample: tient’s culture at the expense of the pa- tient’s needs (Devereuic, 1953). Roughly A Latina mental health worker in psychotherapy with speaking, this reaction is nearly the oppo- a Latina therapist, initially expressed concerns about site of denial of ethnocultural differences confidentiality, given their common professional net- work. Simultaneously, she expressed delight at work- just discussed. Such apparent interest by ing with a Latina therapist who could “understand my the therapist may superficiallybe quite grat- COMAS-DIAZ AND JACOBSEN 397 ifying to the patient, who may thus encour- pity for the previously well-to-do patients, who began age it with a seemingly inexhaustible series to discuss in therapy all the friends and relatives that they were losing in Iran. Consultation helped the ther- of fascinating cultural anecdotes. Such coun- apist identify his own paralyzing pity and bveridenti- tertransferential reactions most frequently fication with the experiences of his own family during serve to derail the therapeutic process, and World War II. can even be potentially dangerous, as when the therapist attributes cultural explanations Aggression. According to Gorkin (1986), to actual pathology: guilt and aggression can be intertwined in the countertransference reactions of inter- A Brazilian male patient regaled his Anglo therapist ethnic dyads. He asserted that therapists can- with colorful tales ofpartying through the night during not avoid negative feelings towards pa- camival and during almost weekly music-making ses- sions with friends. Substantial time was spent in ther- tients who repeatedly arouse guilt in them. apy discussing the cultural meanings of the patient’s However, aggressive countertransferential intense and somewhat erratic interactions with his reactions are not always associated with friends and of various aspects of Brazilian culture and guilt, as the following example illustrates: music. However, certain biological aspects of the pa- tient’s experiences, namely hypomanias of a mild bi- In working with a Hispanic woman, a Jewish female polar disorder induced by sleep deprivation, were therapist found herself overly confrontational and ac- missed. tive, although her usual therapeutic style was psycho- dynamic and exploratory. During consultation she iden- Guilt. This type of reaction can emerge tified her patient’s passive aggressiveness as the cause when societal and political realities dictate of the change in her treatment style. However, further a lower status for people of certain ethnic exploration revealed that the patient reminded the ther- apist of a Spanish singer (Charo) who although com- and cultural background. For example, in petent, portrayed herself as stupid. Consequently, the describing the countertransference ina Jew- therapist was very angry with her patient for present- ish therapist and Arab patient dyad, Gorkin ing herself as stupid when, as the therapist knew, the (1986) asserted that guilt is a recurrent coun- patient was smart; thus, the therapist felt that her pa- tertransferential reaction. Although the per- tient “was trying to fool her.” vasive political antagonism between the two Ambivalence. In working with ethnic mi- ethnic groups may render this particular dyad norities or culturally different patients, ther- an extreme one, guilt is also prevalent in apists carry value and attitudinal conflicts relatively less dramatic interethnic dyads, that have an impact on treatment and need as well. Let us examine the case of a white to be addressed so that psychotherapy can therapist and Native American patient: be effective (Evans, 1985). A therapist’s A Native American man was referred to therapy by his ambivalence toward a patient’s culture may employer due to a drinking problem. The therapist, a originate inan ambivalence towardthe ther- socially responsible white man, felt guilty, which trans- apist’ s own ethnicity and culture. For in- lated into discussions of relationship problems rather stance, Giordano and Giordano (1977) stated than of the patient’s drinking problem. In discussing the case with a colleague, the therapist said, ‘~Ifeel that upwardly mobile, middle-class profes- that all he has left is drinking and we taught them how sionals have a personal ambivalence to- to anesthetize themselves after ripping them off.” ward ethnicity because they have embraced universalist life-styles and value systems, Pity. Within the interethnic clinical en- counter, pity is• a derivate of guilt or an leaving their own ethnicity behind. The fol- expression of political impotence within the lowing case example highlights this type of reaction: therapeutic hour. The example of a Jewish therapist and Iranian patient dyad illustrates An Italian-American therapist working with a black this issue: woman began to experience profound ambivalence whenever the patient discussed crime-related incidents A Jewish therapist was workirig with an Iranian couple in her neighborhood. Her feelings heightened when when the Ayatollah Khomeini overthrew the Iranian the patient presented material about a cousin who had government. The therapist began to feel considerable been unjustly incarcerated on drug trafficking charges. 398 ETHNOCULTURAL TRANSFERENCE

During consultation, the therapist was able to identify prevented him from addressing the patient’s dysfunc- feelings of ambivalence about her own Italian back- tional and destructive behavior. ground. More specifically, she was able to examine her unresolved ethnic shame due to what she called Distancing. In order toprevent overiden- “the societal connection between organized crime (the tification problems and because of the fear Mafia) and Italians.” of getting too close, the therapist may af- Intraethnic Countertransference fectively distance him or herself from the patient. Consider the following example: Overidentification. In the intraethnic dyad, overidentification on the part of the A Hispanic woman was in therapy with a Hispanic female clinician. They were ethnoculturally similar therapist can be detrimental to the contin- and initially this similarity facilitatedthe development uation and success of psychotherapy (Mays, of a therapeutic alliance. Because she had been reared 1985). For example, some therapists from by her maternal grandparents, the patient was strug- ethnic minorities may choose activist and gling with the issue of feeling rejected by her parents. supportive therapy approaches for their pa- In addressing this issue, the therapist discussed the rearing by maternalgrandparents as a cultural practice tients from ethnic minorities because of un- among some Hispanic families. The therapist herself conscious fears or of overidentification with had been raised by her grandparents and had struggled the intrapsychic aspects of their patients’ between feelings of abandonment and acceptance of problems (Evans, 1985). this culturally sanctioned practice. By offering the cul- Us and them. An extreme version of over- tural explanation and neglecting to explore the pa- tient’s feelings of abandonment and mistrust engen- identification is that of the “us and them” dered by her upbringing, the therapist found herself mentality. This reaction tends to be more affectively distanced from the clinical situation. Clin- prevalent among groups who have a history ical consultation helped her to address the situation of oppression and discrimination, and thus a properly. lowersocietal status, as is the case with many Cultural myopia. This involves an inabil- ethnic minorities. The therapist may overi- ity to see clearly because ethnocultural fac- dentify with patients in terms of their shared tors obscure therapy. It canoccur when ther- victimization because of racial discrimina- apist and patient share similar ethnic and tion and may attribute the patients’ problems cultural backgrounds and is usually accom- to their ethnic identity. Therapy may then panied by unconscious collusion. In ex- become a shared fortress against perceived treme cases, cultural myopia can reach the

common threats (us against the world), as proportions of cultural blindness - illustrated in the following vignette: An example of cultural myopia was pro- A Hispanic female patient told her therapist how she vided by Gottesfeld (1978) ssho, in discuss- was “beating the system” by working full time while ing countertransference and ethnic similar- receiving disability insurance benefits. The therapist, ity, described an Italian therapist/patient a Hispanic male, did not confront her with the illegal- dyad in which the therapist’s psychological ity of her behavior,nor did he discuss its implications. familiarity with the patient developed what Later on, the patient was fired from work because she was suspected of embezzlement. The therapist sought she labeled as too much “psychic together- consultation after the patient admitted that she had ness.” She stated that the characteristically indeed embezzled the money. In presenting this case, Italian need to hold on to family to the ex- the therapist was surprised at the consultant’s opinion clusion of outsiders caused this dyad to re- that the therapist had been colluding with the patient and had given her permission to engage in illegal acts. inforce each other’s positions, and hin- However, upon exploration, the therapist acknowl- dered therapeutic progress. The patient edged the possibility, saying, “Perhaps I colluded with withheld family information and the thera- the patient in beating the system because, as a His- pist allowed her to retain her family secrets, panic, I am also angry at the system.” He went on to and thus control the therapy. say that he had not been promoted in the past two years and cited discrimination against his ethnic back- Ambivalence. In the intraethnic dyad, this ground as the key factor in his lack of advancement. can be manifested in the therapist’s own Colluding with the patient in the us and them attitude ethnic and cultural ambivalence, a situation COMAS-DIAZ AND JACOBSEN 399 which is often more prevalent among eth- mother and that the therapist had blamed his mother nic minority individuals. Being an individ- for the situation. ual of ethnic minority in the United States Survivor~sguilt. This type of reaction means facing some inherent cultural con- tends to be more prominent among ethnic flicts, since ethnic minorities are often bi- minority and immigrant therapists from cultural or multicultural (Smith, Burlew, working-class or low socioeconomic status Mosley, & Whitney, 1978). Moreover, many backgrounds. By education, income, or minorities experience oppression and must other means, these therapists may have es- cope with experiences of racial prejudice caped those origins, common to ethnic mi- and discrimination (Comer, 1980). Work- norities. In doing so, they may have left ing in an intraethnic dyad may intensify family and friends behind, thus generating these feelings and thereby generate ambiv- conflict and guilt. The survivor’s guilt can alence toward working with patients from impede their professional growth and lead similar ethnic backgrounds. This can lead to denial of their patients’ real psycholog- therapists to overlook their own ethnicity ical problems (Munoz, 1981), as in the fol- while pursuing a quest for universalist val- lowing case: ues (Giordano & Giordano, 1977). The fol- lowing vignette illustrates this reaction: A black dentistry student presented to therapy with sleeping problems that had no organic basis. Upon A black female therapist complained that she was be- exploration, be complained that he was the victim of ing assigned too many black cases. When she was racial discrimination in his school and cogently pre- asked to expand upon her concerns, she stated that she sented data to sustain his allegation. The therapist, a was “tired of hearing black women complain about black female, had experienced a similar situation when their men’s inability to find regular jobs,” thus voic- she was in graduate school. Therapy concentrated on ing herprofound ambivalence about working with black helping the patient exert his options and, with the females. She stated that although she was able to help therapist’s support, he filed a formal grievance. How- some of her racial sisters, their problems reminded her ever, after this, his symptoms worsened. In discussing ofher own personal situation and of the fact that “there the case with a consultant, the therapist realized that were no jobs out there for black men.” By acknowl- she had overlooked the fact that the patient’s mother edging her ambivalence she was able to ask for a had remarried and that the patient was extremely an- limitation to be put on the number of black female gry about her decision. Instead, the therapist’s focus cases assigned to her. had been on the patient’s racial victimization. She became aware that she was plagued by guilt at having Anger. The ambivalence in an intraeth- been able to survive the racial discrimination in her nic dyad can be taken to extremes and con- own graduate training. She had translated her survival verted to anger. Being too close to a patient guilt into a politicization of her patient’s clinical sit- ethnoculturally may uncover painful intra- uation, failing to explore the intrapsychic and inter- psychic issues that are unresolved. The fol- personal elements of his presentation. After the ther- apist addressed these dynamics, she effectively lowing example illustrates this reaction: combined intrapsychic components with the manage- A black male therapist forgot to inform his black fe- ment of reality issues, and the patient progressed. male patient about his pending vacation until their last S session before it was due to stats, although he had Hope and despair. Alternatively, the eth- remembered to tell all his other patients. This partic- nic minority therapist may experience de- ular patient had a history ofbeing abandoned by black spair because of having been able toescape men and this was a recurring theme in therapy. In the fate of family and friends without guilt. discussing the case with a colleague, the therapist re- Such despair may alternate with hope of alized that he did not want to deal with the reactions he anticipated from his patient to the news of his vaca- improving the situation of the patients or of tion; furthennore, he was angry about them. By for- the ethnic community at large (Muhoz, getting to tell her until their last session, he could 1981). For example: minimize the amount of time he would have to spend dealing with her feelings about being abandoned once A black female social work student was working in more by a black man. Further exploration revealed therapywith a black female therapist. Patientand ther- that the therapist’s own father had abandoned his apist shared similar socioeconomic backgrounds. The 400 ETHNOCULTURAL TRANSFERENCE

therapist was initially hopeful about outcome because catalysts for the acceptance of disparate parts of the patient’s achievement in getting into graduate of the self. Monitoring and properly ad- school. However, the patient brought to therapy feel- ings of having abandoned her community by attaining dressing such reactions canadvance the ther- a professional status. This situation evoked feelings of apeutic process and promote growth. Con- despair in the therapist because of her own lack of sider the following vignette: guilt about having escaped her own depressed socio- An Anglo-Mexican female, in therapy with an Anglo economic background. After consultation, the thera- pist was able to address her countertransferential re- female, presented depressive symptoms around prob- lems within romantic relationships. She professed to actions effectively. be a “woman who loves too much.” When the ther- apist raised the issue of their differing ethnic back- IMPLICATIONS grounds, she replied: “It doesn’t matter, lam also half The ethnocultural parameters of transfer- Anglo,” which the therapist interpreted as a denial transference reaction. When the patient’s depressive ence and countertransference tend to facil- symptoms subsided, she began to manifest an over- itate the uncovering of unconscious feel- compliant transference reaction; such behavior was ings and thereby advance the therapeutic inconsistent with the patient’s professional assertive process. The clinician’s acknowledgement style as a medical student. Upon exploration it was of these reactions may lead to a more rapid revealed that she perceived the therapist as an author- ity figure—a member of the dominant society who emergence of conflicts underlying major could not be openly questioned. When this issue was therapeutic issues such as trust, ambiva- addressed, the patient was able to connect this reaction lence, and anger. Let us consider the fol- to her own behavioral style with her Mexican and lowing example: Hispanic friends. She realized that she often behaved in a rigidly authoritarian style toward them, Such a A lewish man working with a Latino therapist iden- style appeared to be congruent with her perception of tified their shared experience of being outsiders as her “Anglo side.” Conversely, she reported being rel- facilitative in developing a therapeutic alliance. He atively unassertive with her Anglo friends, this being remarked to his therapist: “You can relate to my ex- congruent with her “Mexican side.” This realization perience of being Jewish because, as a Latino, you promoted a discussion by the patient of her ethnic also are different from the mainstream society.” The ambivalence. For example, although she was an at- patient’s presentation ofbeing the only Jew in a mostly tractive and petite young woman, she felt that the WASP environment was permeated by concerns about shading ofher skin was not light enough, that she was his self-image. Initially, he complained that his co- “too Mexican looking.” She stated that as a child she workers and superiors did not trust him, and saw his had been blond, and that in Mexico she was called La ethnic identity as the cause for this mistrust. After the Gringa. therapeutic relationship was cemented, the patient be- After this revelation came the unfolding of her feel- gan to make humorous statements about the therapist’s ings about her sense of attractiveness as a female. She lack of a Spanish accent. When this issue was con- had dated both Hispanic and Anglo men and perceived fronted, the patient was able to admit to his ambiva- them as always abandoning her for “tall, blond, Anglo lence about working with a Latino therapist. From this women.” She was examining these issues with a tall, emerged his ambivalence about being Jewish. He said, blond and Anglo female therapist, however, and her for example, that he had tried to change his local transference reaction turned into mistrust augmented (Long Island) accent to avoid being singled out as by several derogatory references to the Gringos. The Jewish. The mistrust (both as an object and as a sub- therapist developed a countertransference reaction of ject) he had perceived as engendered by his ethnicity pity, and after a consultation, she decided to address was re-labeled as mistrust ot himself for having be- ‘the patient’s mistrust transference directly. Examining come what he called an impostor. Themes of self- the patient’s ethnocultural transference facilitated an image and self-esteem emerged and rapidly unfolded approach to her ambivalence about her Mexican and in therapy. This process helped the patient to see that Anglo backgrounds. She expressed frustration and said ambivalence was central to his personality structure, that she sometimes felt like two different people who regardless of his ethnicity. The patient had used the did not communicate with each other. ethnocultural paradigm as a metaphor for his mistrust In accordance with Chin (in press), who and his generalized ambivalence. has asserted that splitting is an adaptive de- Ethnocultural transference and counter- fense mechanism among people of color, transference reactions may emerge at vat-i- her apparent splitting was interpreted as part ous times during therapy. They can act as of her adaptive coping style. Although ra- COMAS-DIAZ AND JACOBSEN 401

cial ambivalence is common among indi- trust, anger, acknowledgement of ambiva- viduals of mixed race (Root, in press), the lence, and acceptance of disparate parts of expression of the patient’s ambivalence the self. through ethnocultural transference mobi- lized the unfolding of her anger. She had REFERENCES externalized and dichotomized her expres- Bash’Kahre, B. (1984). On difficulties arising in trans- sion of anger toward Angloswhen she faced ference and countertransference when the analyst her affiliative needs, and toward Mexicans and analysand have different socio-cultural back- grounds. International Review of Psycho-Analysis, when she dealt withher self-affirmation and 11, 61—67. assertive needs. The different ethnocultural Chin, IL. (in press). Psychodynamic approaches. In transference reactions that were emerging L. Comas-Diaz& B. Greene (Eds.), Women ofcolor and mental health. New York: Guilford Press. were acknowledged by the therapist and con- Comas-Diaz, L., & Griffith, E.H.E. (Eds.). (1988). nected to the patient’s ethnocultural disori- Clinical guidelines in cross cultural mental health. entation. By encouraging elaboration of her New York: John Wiley. Comas-Diaz, L., & Jacobsen, F.M. (1987). Ethno- ethnoculturally-focused devaluing concepts cultural identification in psychotherapy. Psychiatry, and feelings, the patient was given an op- 50, 232—241. portunity to understand and resolve her own Comas-DIaz, L., & Minrath, M. (1985). Psychother- apy with ethnic minority borderline clients. Psycho- ethnocultural and racial conflicts. Further- therapy, 22 (Suppl.), 418—426. more, these conflicts became tools for the Comer, J.P. (1980). White racism: Its root form, and identification of the disparate parts of the function. In R.L. Jones (Ed.). Black Psychology, (2nd ed). New York: Harper & Row. patient’s self,namely her racial,ethnic, gen- Devereux, 0. (1953). Cultural factors in psychoana- der, and personal identities, and examina- lytic therapy. Journal of the American Psychoana. tion of the ethnocultural issues led to her lytic Association, 1, 629—655. Dudley, OR., & Rawlins, MR. (Eds.). (1985). Psy- acceptanceof these disparate parts. The eth- chotherapy with ethnic minorities [Special issue]. nocultural context thus acted as a catalytic Psychotherapy, 22 (Suppl.). agent in providing a barometer for the pa- Erikson, E.H. (1959). Identity and the life cyèle. Psy- chological Issues, 1, 1—171. tient’s problems with ambivalence, anger, Evans, D. (1985). Psychotherapy and black patients: and self esteem. Problems of training, trainees, and trainers. Psy- chotherapy, 22 (Suppl.), 457—460. Giordano, J., & Giordano, OP. (1977). The ethno- CONCLUSIONS culturalfactor in mental health: A literature review Ethnicity, culture, and race can touch and bibliography. New York: Institute on Pluralism deep unconscious feelings in most individ- and Gmup Identity. Goleman, D. (1989, March 7). The self: From Tokyo uals and may become matters for projection to Topeka, it changes. The New York Times, pp. by both patient and therapist, usually in the Cl, C6. form of transference and countertransfer- Gorkin, M. (1986). Countertransference in cross- cultural psychotherapy: The example ofJewish ther- ence. Ethnocultural issues constitute key el- apist and Arab patient. Psychiatry, 49, 69—79. ements in psychotherapy. Acknowledging Greene, B. (1985). Considerations in the treatment of them does not negate individual uniqueness black patients by white therapists. Psychotherapy, 22 (Suppl.), 389—393. stemming from developmental, biological, Griffith, MW. (1977). The influences of race on the structural, and contextual factors compris- psychotherapeutic relationship. Psychiatry, 40, 27— ing the psychological makeup of each per- 40. Gottesfeld, ML. (1978). Countertransference and eth- son. As with other relevant variables in nic similarity. Bulletin ofthe Menninger Clinic, 42, psychotherapy, ethnocultural factors in 63—67. transference and countertransference not Hall, E.T. (1982). Beyond culture. Garden City, NY: Anchor Books. only influence individuals’ presentations in Harris, L.S. (1990, November). Race and transfer- the clinical discourse, but also significantly ence issues in the therapeutic relationship. Psy- affect the process and outcome of psycho- chiatric Times: Medicine & Behavior, 7(11), 54—55, therapy. Moreover, they can serve as cata- Jacobsen, F.M. (1988). Ethnoculttiral assessment. In lysts for such major therapeutic issues as L. Comas-DIaz & E.H.E. Griffith (Eds.), Clinical 402 ETHNOCULTURAL TRANSFERENCE

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