One of the earliest stains on the legacy of psychiatry, my medical specialty, dates to the American 1840 census, when the US government first began systematically collecting information on “idiocy” and “insanity.” According to the results, the purported rates of mental illness among free blacks in northern cities were deemed to exceed those among enslaved blacks in the south by an 11-to-one ratio. South Carolina Senator John C. Calhoun, a notoriously strident defender of slavery, seized upon the results as “proof” that “the African is incapable of self-care and sinks into lunacy under the burden of freedom. It is a mercy to him to give this guardianship and protection from mental death.”
Five years later, the American Statistical Association published a new analysis of the census data, in which it illuminated what distinguished American psychiatrist Edward Jarvis called the “inconsistencies, contradictions, and falsehoods” of the original. Jarvis’s own review revealed recording errors and deliberate misuse of data. Yet many citizens in pro-slavery states continued to believe that enslaved blacks were less inclined toward insanity because they were spared the social pressures associated with owning property, engaging in commerce, and participating in civic affairs. So comfortable was the state of bondage, this perverse thinking went, that slaves who fled must have been impelled by madness.
In 1851, Samuel Cartwright, a Louisiana physician (though not a psychiatrist) gave that invented form of madness a name: Drapetomania (in Greek, drapétis means fugitive). Some called it “runaway-slave syndrome,” and suggested it could be prevented through whippings and the amputation of toes. Cartwright also claimed to “discover” something called dysaesthesia aethiopica (an “abnormal sensation” characterized by reduced intellectual ability, laziness, and partial insensitivity of the skin). The American Psychiatric Association (APA), formed in 1844 as the Association of Medical Superintendents of American Institutions for the Insane, isn’t known to have formally commented on these invented diagnoses, nor their application.
Cartwright’s taxonomy expired with the formal abolition of chattel slavery. But the relationship between the psychiatric profession and black Americans remained a deeply troubled one. During the Civil Rights movement, for example, many psychiatrists considered the anger of black patients to be a form of “neurotic hostility.” A 1970 issue of the American Journal of Psychiatry devoted a special section to racism, in which an article detailed the custom of regarding black patients as “not motivated for treatment, having primitive character structure, not psychologically minded, and impulse-ridden.” It was also common that behaviors deemed criminal in blacks were regarded as the product of sickness when they manifested in white patients.
Even today, there remains a tendency among psychiatrists to misdiagnose blacks with the more severe diagnosis of schizophrenia while categorizing whites with similar presentations as having mood disorders. The genuinely shameful nature of this legacy moved the association to issue an apology this past January, and announce that “the APA is beginning the process of making amends for both the direct and indirect acts of racism in psychiatry.”
In my opinion, one of the best ways to compensate for past transgressions is to educate the public in regard to what skilled psychotherapy should look like, so that patients can recognize (and avoid) practitioners—psychiatrists or otherwise—whose methods are compromised by ideological agendas.
* * *
A concerned London-based psychotherapist, Val Thomas, has warned of a new trend that she terms Critical Social Justice Therapy, or CSJT: “a practice that views people not as individual actors but rather as representatives of particular groups which are nested within systems of power and trains therapist-activists to diagnose patients through a collective lens.” Last year, Thomas founded an online community, Critical Therapy Antidote, as a hub for practitioners and clients dedicated to “protecting the integrity of talking therapies.”
(Before proceeding further, it is worth setting out the somewhat confusing professional typology at play here. The word “therapist” describes anyone who talks to patients or clients with a view toward providing psychological aid. The term “psychotherapy” sounds more specific to a layperson—but, in practice, that term, too, is also applied widely. A “counselor” usually has a Master’s degree in counseling, and a counseling psychologist usually has a PhD—though practitioners in these areas will use different terms, including “psychodynamic psychotherapy” or “behavioral therapy,” to describe their work. Many psychiatrists, who are physicians by training, also provide psychotherapy. Finally, there are “analysts,” who can come from a variety of educational backgrounds, but generally must attend a lengthy program of formal psychoanalytic training at a recognized institute. For a time, only medical doctors could train as analysts, but that has changed.)
To picture CSJT in its purest form, imagine a black patient whose white therapist systematically conceives of the patient’s problems in love, work, and family life as products of racism. Odd as that may sound to anyone familiar with conventional psychotherapy, this overtly ideological approach is becoming increasingly prominent among a cadre of counseling professionals. At the Graduate Counseling Program at the University of Vermont, for instance, the coordinator has issued a proposal to “structurally align” the program with the Black Lives Matter movement and begin “the work of undoing systemic white supremacy.”
According to a detailed blueprint recently sent out to Counseling Program staff, the revised program would “take up the work of Dr. Ibram X. Kendi [and] adopt his definition of both racist and anti-racist, and integrate these definitions into our program philosophy”—though the coordinator also concedes that “my internalized whiteness limits even my best intentions in brainstorming how to operationalize anti-racism within our program.”
Aaron Kindsvatter, a professor in the University of Vermont’s department of Education and Social Services, recently spoke out against these pending changes in an interview with YouTuber Benjamin Boyce. “Eventually counselors are going to feel that it is their job to help clients who are experiencing mental distress understand themselves in these terms of racist or antiracist,” Kindsvatter said. “Children and people who are in mental distress need nuanced conversations about morality and ethics and this is an ideology that says no there is no nuance to those conversations. Two years ago, I would have said this could never happen.” (Needless to say, critics at the university are now calling for his resignation.)
The American Counseling Association, the organization representing licensed American counseling professionals, features a division called “Counselors for Social Justice,” which “works to promote social justice in our society through confronting oppressive systems of power and privilege.” Some counseling programs now teach students how to organize protests. And journal articles are appearing with titles such as Black Lives Matter: A Call to Action for Counseling Psychology Leaders. Gauging applicants’ commitment to social-justice advocacy has become part of some admissions processes.
Alexander Adams, a pseudonymous recent graduate of an American Master’s program in counseling, recently wrote an essay for Critical Therapy Antidote entitled, My Master’s Degree in Counseling Psychology Taught me a lot about ‘Social Justice’ But Very Little about Counseling or Psychology. He describes two and a half years of “incompetence and mediocrity”—at a cost of $70,000 in (borrowed) money—during which teachers felt free to lecture students about their political beliefs, and trainees were instructed on “the dynamics and dilemmas of microaggressions,” and “developing a nonracist and antiracist white identity.”
On the same site, a Master’s degree candidate in counseling (identified pseudonymously as “Student J”) asked what this pedagogy would mean for white patients: “When you seek counseling, how [would] you feel knowing that the person supposedly providing you with empathy and care sees you as an oppressor? … How is this healthy and productive for anyone?”
A white woman who recently obtained her doctoral degree in counseling psychology, whom I’ll call “N,” was struck by the overt bias among instructors. They routinely derided conservatives as “ignorant and uneducated,” she told me. Like Adams and “Student J,” “N” noted that antagonism was directed at trainees who questioned the relevance of social justice dogma to their clinical cases. “If we were not combating oppression, we were contributing to it,” “N” said.
A therapist is free to personally believe that Black Lives Matter and Ibram X. Kendi should (or should not) serve as guiding lights in the creation of a new kind of social contract. But in regard to clinical practice, Critical Social Justice Therapy violates core tenets of sound psychotherapy. Instead of addressing the individual person in need, it applies a pre-programmed ideological agenda that classifies individuals as oppressor or oppressed based on identity group.
The task of the therapist, said Anthony Storr, the late British psychiatrist and psychoanalyst, is “to get the patient to talk as freely as possible whilst he himself stays in the background.” But talking freely is possible only if a therapist assumes a posture of caring neutrality, openness, and curiosity. And learning to maintain compassionate detachment lies at the heart of practitioner training. The mature therapist keeps her private passions from distorting the work. She is attuned to the development of what Freud called “countertransference,” wherein her own emotional reaction to a patient clouds her clinical judgment. Even seasoned therapists engage trusted supervisors to help them understand and manage such complexities as they emerge in therapeutic relationships.
The “therapeutic alliance” between therapist and patient depends on their agreement in regards to the methods employed and the goals pursued. And research has shown that the quality of this alliance can help predict whether the therapy will be successful. In his classic 1961 book, Persuasion and Healing: A Comparative Study of Psychotherapy, psychiatrist Jerome D. Frank described the alliance as “the therapist’s acceptance of the sufferer, if not for what he or she is, then for what he or she can become.”
When a therapist comes to the first session armed with an ideological program that dictates what the patient should become, such an alliance is doomed. Even insofar as a patient may agree to this program before treatment begins, what they will be receiving isn’t psychotherapy so much as anti-racism cant delivered under the pretext of therapeutic treatment. Where the patient should be inculcated in the habit of self-observation, he will instead be taught to search outside himself for sources of all duress; instead of traveling a path to greater autonomy, he will be instead rewarded for adopting the victim role.
How could a therapist wedded to anti-racist sentiments relate empathically to, say, a white, straight young man who voted for Donald Trump? How could a patient regard a therapist as benign and caring if she tells him, or even strongly implies, that she thinks he is a bigot—and, furthermore, that many of his personal problems are rooted in this presumed bigotry?
Velma Olden (a pseudonym) writes of being alienated by group therapy with a counselor who pronounced himself an avowed Black Lives Matter supporter (which is fine, of course, so long as the instructor does not use his professional role as a means to proselytize). He also encouraged the group to discuss race issues in the service of what Olden described as “extreme left activism.” In one case, there was a discussion about how to talk to one’s family “about social justice” over an upcoming weekend.
Olden, like most people who pursue psychotherapy, wanted to find clarity, relief from suffering, and freedom from the habits that had imprisoned her for years. Instead, she was told that we were “victims of vague societal forces outside of our control.”
This is not to say that psychotherapists shouldn’t be sensitive to matters of race, and racism more generally—much as they should be familiar with the other important dynamics that shape one’s mental life. Before the dawn of the civil rights era, psychotherapy was overwhelmingly the province of white practitioners and the white patients who could afford their care. After World War II, the number of public mental-hygiene clinics expanded markedly. Some of the new clients were black workers who sought assistance in adjusting to newly integrated workplaces. The American Psychological Association recognized the importance of doctoral students becoming “familiar with the broad problems of social structure and organization, with cultural conditions, and with the heterogeneity of subgroup patterns within our culture.” And rightly so.
In 1950, psychologist Ralph W. Heine addressed the issue in a Journal of Clinical Psychology article entitled, The Negro Patient in Psychotherapy. Heine considered whether “the notion of communicating real feelings or interpersonal problems [to a white therapist] would be difficult for [a black patient] to accept.” In turn, he wondered whether the therapist could respond to a black patient as an individual rather than a member of a minority group. Perhaps, Heine speculated (prophetically, I might add), the white therapist might feel “too guilty to be of help.”
He also offered this cautionary remark, which seems apt in light of the modern identitarian thrust in counseling education: “No attempt will be made here to generalize on the character structure of Negroes as a group. [This] writer, at least, has never found characterological studies of entire groups of specific help in working with one member of that group.” Later in the article, Heine affirms that “the therapist must clearly communicate to his patient that he is interested in him only as an individual … and not as symbols or as representatives of the racial minority.”
Even by the 1970s and 1980s, Heine’s benign vision was giving way to a dubious movement called “multicultural counseling,” effectively a precursor to today’s CSJT. In a 1981 textbook entitled Counseling the Culturally Different, authors Derald Wing and David Sue directed (white) counselors in training to ask themselves, “as a member of the white group, what responsibility do you hold for the racist depressive and discriminating manner by which you personally and professionally deal with minorities?” As for the “worldview of the culturally different client,” write the authors, it “boils down to one important question: ‘What makes you any different from all the others out there who have oppressed and discriminated against me.” Their textbook, now in its eighth edition (the words “culturally different” having been changed to “culturally diverse”) is still in wide use.
In the four decades that have passed since the original publication of that book, some academics have tried to demonstrate the effectiveness of this multicultural approach. But as a set of critiques published in 2018 demonstrated, researchers purporting to show the value of “multicultural counseling” typically have failed to even define this therapeutic subcategory with any precision. As well, many of their studies neglected to randomize subjects to control groups; instead, the researchers simply relied on self-reporting by selected clients and therapists. In all, one is hard-pressed to find any systematic evidence that the latest wave of CSJT techniques offer any real benefit.
* * *
According to the plain wording contained in the most recent iteration of the American Counseling Association Code of Ethics, the ACA should condemn CJST:
Counselors are [to be] aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.
The imposition of a particular set of “values, attitudes, and beliefs,” remember, is what the CJST project is all about. It threatens to collapse a time-honored sanctuary for introspection under the weight of stereotyping, conditional compassion, rehearsed oppression narratives, and, perhaps most pernicious of all, the gratification of the therapist’s own quest, sincere as it may be, for high moral ground.
Certainly, it speaks volumes about the current ideological environment that officials at the University of Vermont’s Counseling Program would feel at liberty to endorse the adoption of Kendi-esque imperatives without any apparent fear of censure from the ACA. Yet it is difficult to gauge how deeply the CJST ethos has penetrated the real world of practicing counselors.
I’ve heard reports of patients being scolded by therapists for voting the “wrong” way. And I’ve exchanged emails with a former academic who has an informal side gig referring conservative (and ideologically non-compliant liberals) to “non-woke,” neutral therapists. But these examples may be outliers: Many, perhaps most, practitioners may well be reasonable and humane clinicians. Even in a university setting, where the pursuit of ideological fads is always more pronounced, the majority of professionals may simply be mouthing CJST platitudes for public consumption by their own colleagues and bosses, but then, behind closed doors, getting on with the real work of helping people in an ethical, clear-eyed way. Even so, politicizing the counseling curricula siphons precious time away from preparing trainees to treat their future patients.
The American Psychiatric Association has just wrapped up its 2021 annual meeting. To the extent that the association’s incoming leaders are sincere about making amends for the APA’s sordid past, when patients were judged by the color of their skin instead of the content of their thoughts and feelings, I would encourage them to state as much, and in resolute fashion. No one disputes that social justice is (in theory, at least) a worthy political goal. But neither political activism—nor crude race-based stereotypes—have any place in the relationship between a psychotherapist and her client.
Sally Satel MD is a visiting professor of Psychiatry at the Columbia University’s Vagelos College of Physicians and Surgeons and a resident scholar at the American Enterprise Institute.