I have been participating in talk therapy at varying frequencies for the past five years. It has had a great impact. It’s given me diagnoses that allowed people in my life to take my experiences more seriously. It has alleviated many severe symptoms that had haunted me through my childhood and adolescence. It has given me the necessary coping skills to take care of myself in the face of trauma and setbacks. It has made me a radically different person, someone that prioritizes communication and connection, someone that welcomes vulnerability instead of running from it, someone that is healthy. And this is true for so many people. There is a reason why the practice is so popular; it’s because there are many benefits. But there are also many ways in which therapy has failed its patients. This is because those aforementioned benefits exist within a system designed with only a certain group of people in mind. Therapy becomes an institution rather than a method of treatment. It makes you pause and ask: who was this institution designed to benefit? What happens when you aren’t a part of this group? What can therapy do for you then?

Psychotherapy as we know it today began to be formulated at the end of the 19th and beginning of the 20th century, when Sigmund Freud and subsequently several other European men introduced “psychoanalysis.” Freud believed that mental illness was caused by a storing of memories and thoughts in the unconscious. He aimed to bring these memories to the conscious mind by listening to the patient and providing interpretations in order to cure the illness, or at least to alleviate symptoms. Mid 20th century saw a rise in other, more active therapies such as behavioral psychology and cognitive behavioral therapy. Eventually we ended up with a few widely practiced therapeutic approaches and a number of smaller ones as well. And in many ways, therapy today is extremely different from what it once was at the turn of the 20th century. But what remains the same is the patient demographics the methodology of psychotherapy was designed to treat. Freud’s psychoanalysis sessions were done with European, middle and upper class, cisgender, heterosexual, able-bodied, white men. His diagnostic system and his treatment methods were derived from his analysis of the minds of these white men. And these diagnostic systems and methods of treatment have informed our modern understanding of psychotherapy and the human mind.

To more specifically outline what I mean by this and how this concept negatively affects marginalized communities seeking therapy, one example lies in the “flawed patient” idea. Therapy nearly always operates on the assumption that a patient’s symptoms or illnesses stem from an individual, personal cause: genetics and/or some kind of childhood trauma manifesting in symptoms. This individuality stems from the same Eurocentrism that I mentioned above. Eurocentric views of humanity seek to individualize a person’s lived experience and detach it from the communities and identities that make said experience distinctly human. For example, the eurocentric and therefore individualistic model for therapy favors objectivity (“Assuming we can identify and understand reality in a detached way, unbiased by human senses and knowledge”) and rationality (“Presumes a linear, cause-effect, logical, material understanding of phenomena”), which in turn contribute to the flawed patient idea. In a discussion on misogyny in psychotherapy, Sarah Hosseini aptly describes the flawed patient idea:

Many people who’ve done talk therapy will tell you it is a transformational experience. Therapy can help process thoughts and feelings, provide powerful insights, and is bolstered by the indulgent 1:1 model. It’s also built on the premise that the individual is somehow flawed, disordered, and defective, rather than the systems, cultures, and societies into which they were born, and so they need to be drug-dependent and keep coming back and “doing the work” in order to get better. For women, who already feel inherently flawed and defective in every single way society tells them, this presents the possibility of real harm.”
(MIC)

This “flawed patient” idea means that the job of psychotherapy becomes to cure the patient of their individual symptoms, rather than to acknowledge the systemic methods of harm that a marginalized patient experiences, or to develop coping skills that can persevere through an existence fraught with experiences of systemic oppression. This is where marginalized people looking for a therapist find psychotherapy severely lacking. Anyone looking for a therapist that supports and/or holds marginalized identities is intimately aware of this– the fact that it is near impossible to find someone adequate.

As a person who holds several marginalized identities, my experience with therapy has been complicated. It has provided me with a lot, as I’ve described above. But there are also countless moments in which I’ve gotten stuck, specifically in my lack of affinity with my cisgender, heterosexual, white, female therapist. It’s complicated, because this woman knows me better than some of my close friends. She has access to some parts of me that no one else does. She sees things about me that I cannot see in myself. But I’ve learned to hold back after seeing the disconnect between us manifest in her confusion about my lived experiences. There are whole parts of me that don’t make it into the conversation. Parts of me that I have to leave at the door and sacrifice, parts that I have to pretend don’t make me who I am. My therapist and I have never talked about race. We’ve never talked about queerness or transness, never about my cultural experiences. I worry what she’ll say to me if I bring up my anxieties about how my family and I exist in the world. Is me being anxious when my mom goes for late night walks a symptom of anxiety? Or is it the knowledge that she is a Black woman walking alone at night in rural Pennsylvania? Is my fierce protectiveness over who knows about my queerness and transness a paranoia stemming from my childhood trauma? Or is it the result of me witnessing my communities being brutalized and rejected at the first sign of difference?

The questions continue: Why was I given diagnoses years after I started seeing my therapist? Would I have received the same diagnoses if I didn’t hold certain privileges, such as having light skin, being able-bodied, and holding U.S. citizenship? And how much longer can I hold out before our differences become too much? 

This is one manifestation of how modern psychotherapy can disproportionately harm marginalized patients. When looking more in depth at diagnosis, the effects become sharper and more present. A system of diagnoses designed with white men in mind leads to an extreme rate of misdiagnosing for marginalized people. You only need to take a look at the true origins of Stockholm Syndrome to understand this phenomenon. But this issue extends to modern day and how marginalized patients of color are viewed in relation to patients with more privilege. In an article on misdiagnosis in Black patients, Aisha Beau Johnson discusses how this trend of misdiagnosis directly affects Black people: “A Black child who is disruptive in school may be identified by the teacher as having operational defiant disorder and be treated punitively. On the other hand, a white child being equally disruptive may be identified as having ADHD and be handled with more compassion and less punishment.” (Psycom)

It’s not hard to see how these trends of misdiagnosis lead to over-policing and increased institutionalization for marginalized patients. When a patient’s lived experience is seen as defiant against the existing structure of society, when that lived experience threatens the system around us, that patient is much more likely to experience misdiagnosis, overdiagnosis, and policing of experiences. If you are a woman distrustful of police due to a history of being ignored and brutalized by police officers such as Kristin Enmark in the 1973 Stockholm bank robbery, there must be something wrong with you. You must be sick. If you are a young Black boy who is disruptive in the classroom, if you are both Black and loud, you must be a threat. You must be punished. 

Few marginalized people tend to find hope even when they do find a therapist who understands their experiences. Oftentimes, these therapists were trained and qualified under the same system that reproduces these white supremacist and heterosexist structures. It’s incredibly hard to find hope in a system that was designed to exclude you.

But hope does exist in the current rise of therapeutic practices geared toward aiding marginalized people. For example, there are organizations with the goal of connecting marginalized patients with therapists who will support their experiences, such as the Black Mental Health Alliance and Asians do Therapy. There are collectives of therapy options for people of color such as Therapy for Black Girls. The resources continue to grow. As they do, it is vital for therapists to understand the profound impact of identity on people’s experiences and to welcome these conversations into the room in order to actually help patients.

For Further Reading