Black Family Therapy Research

Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2009.00166.x
April 2011, Vol. 37, No. 2, 153–168

UNDERSTANDING THE EXPERIENCE OF BLACK
CLIENTS IN MARRIAGE AND FAMILY THERAPY
Christiana I. Awosan
Drexel University

Jonathan G. Sandberg
Brigham Young University

Cadmona A. Hall
Past research on Black clients’ utilization of therapy focused on the barriers that prevent
Black clients from attending therapy and the reasons for these barriers. However, few studies have been conducted that focus on how Black clients attending therapy actually experience these barriers. This study utilized both Likert and open-ended questions to examine the obstacles 16 Black clients face in their attempts to attend family therapy.
The most frequently identified obstacles were related to concerns over family member response and cultural barriers to therapy. Participants also reported concerns about racial and ⁄ or cultural differences and a lack of understanding by non-Black therapists. The implications of this study addressed how to effectively meet the therapeutic needs of Black clients. Researchers have indicated that Black clients underutilize therapeutic services and are inconsistent in their usage of the services once sought (Brown, 2003; Neighbors, 1988; Sussman,
Robins, & Earls, 1987). Research on Black clients’ attitudes toward and experience with therapeutic services has highlighted several key issues: premature termination (Sue, Fujino, Hu,
Takeuchi, & Zane, 1991; Terrell & Terrell, 1984; Tidwell, 2004), racial and ethnic match between client and therapist (Laszloffy & Hardy, 2000; Snowden, 1999), psychological misdiagnosis (Garretson, 1993), and cultural mistrust (Hardy & Laszloffy, 1995; Terrell & Terrell,
1984; Whaley, 2001). Although several studies (Nickerson, Helms, & Terrell, 1994; Terrell &
Terrell, 1984; Thompson, Bazile, & Akbar, 2004; Watkins & Terrell, 1988) have examined the obstacles that Black clients face in their attempts to utilize therapy, few studies examine how
Black clients make meaning of their experience in therapy (Brown, 2003; Ward, 2005). No studies can be found that explore how Black clients attending therapy sought to overcome these obstacles. The purpose of this study is to better understand the obstacles that Black clients face in their effort to utilize family therapy, their attempts to overcome these obstacles, and how therapy can be beneficial to them.

LITERATURE REVIEW
Given the diversity in demographic factors among individuals of African descent (Hardy,
1989), it is important to recognize the variations among Blacks as these differences relate to the underutilization of therapy. People of African descent are not all the same (Hardy, 1989); the rich differences among Black families relate to many factors, such as unique cultural orientations, varying circumstances related to geographic location, and distinct differences in cultural values and beliefs. Although it is problematic to make a generalization of sameness for Blacks across the world, Ahia (2006) did note some similarities: ‘‘Afrocentric scholars are in general

Christiana I. Awosan, MA, Drexel University; Jonathan G. Sandberg, PhD, Brigham Young University;
Cadmona A. Hall, PhD.
Address correspondence to Christiana I. Awosan, Drexel University, Couple and Family Therapy, 1505 Race
Street, Philadelphia, Pennsylvania 19102; E-mail: [e-mail]

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agreement that there exists a composite of African-oriented existential tendencies, philosophies, behaviors, ideas, and artifacts among people worldwide who trace their roots to Black Africa’’
(p. 57). According to Boyd-Franklin (1987) and Wilson and Stith (1991), Blacks are fairly united in their negative perceptions of therapy. Their ‘‘negative’’ attitudes toward therapy can be linked to shared experiences of racism and oppression in a White society (Hardy & Laszloffy,
1995). However, based on education level, racial identity stage, and socioeconomic status, research suggests there are some differences in Blacks’ attitude toward therapy (Boyd-Franklin,
1987; Wilson & Stith, 1991).
African Americans and Mental Health Services
There is substantial research that points toward the reasons why many Black clients are wary of mental health services. In order to grasp this skepticism toward therapy, clinicians need to understand a concept termed Eurocentrism in the literature. Eurocentrism is characterized as a perception in which European (White) values, customs, traditions, and behaviors are used as the exclusive normative standards of merit against which other races and events in the world are viewed (Helms, 1989; Jones, 1997; Katz, 1985). Brown (2003) has linked Eurocentrism and scientific racism. According to Brown (2003), scientific racism is embedded in the history of psychology, which compares the experiences of Blacks in psychotherapy and research to that of
Whites (Sue & Sue, 1999) and thus considers their experiences to lack normalcy and be inferior to those of Whites.
The history of Blacks around the world, particularly in the United States, cannot be compared to that of Whites. In a world where Blacks have experienced and are still experiencing subjugation, racism, and oppression it is unfair to compare these experiences to those of Whites who most often have power and privilege afforded them based on skin color (Ruff & Fletcher,
2003). In order to understand the reluctance of many Blacks to engage in therapy, it is crucial to understand the perceptions and experiences in therapy of this population (Brown, 2003;
Ward, 2005).
In her study on African Americans clients’ subjective experiences in counseling, Ward
(2005) used a constructivist paradigm and dimensional analysis to examine the counseling experiences of African Americans at a community mental health center. In the study, 13 African
Americans, ranging from 26 to 53 years of age, were involved in a comprehensive interview.
Participants reported client-therapist match, safety in therapy, and counselor’s effectiveness as three factors that influenced the therapy experience. In addition, the results of this study emphasized that the obstacles that Black clients face in their effort to attend therapy can only be understood through their historical and present experiences as Black people in a world that is dominated by Eurocentric notions and power (Ward, 2005). The difficulty for many Blacks in attending an institution that considers Black culture, values, and practices to be inferior or not normal has been indicated as one of the reasons why Black clients underutilize therapy and discontinue therapy after a few sessions (Vereen, 2007).
Mercer (1984) asserted that misdiagnosis of Blacks in the mental health services has a profound connection to the pathologization of Black culture. Pathologization or overpathologization of Black patients has been linked to the fact that most non-Black clinicians lack empathy or understanding of Black culture and system values (Garretson, 1993). Lack of empathy or understanding of Black culture has allowed many non-Black clinicians to stereotype or overpathologize Black people. Steinberg, Perdes, Bjork, and Sport (1977) noted that psychological racist assumptions influence clinicians’ diagnostic processes. Similarly, Garretson (1993) stated,
‘‘Historically, the symptoms that led to the most frequent misdiagnoses of psychiatric disorders in Black patients were hallucinations, delusions, suspiciousness and flat or inappropriate affect.
These symptoms are the most misunderstood in terms of cultural context, and the ones most likely to lead to misdiagnosis’’ (pp. 123–124). These authors have noted that the racist assumptions and multicultural ignorance of some clinicians have led to the misdiagnosis of Black clients.
Consequently, the fear of being misdiagnosed, stereotyped, or pathologized keeps many Black people from seeking mental health services, which often misinterpret their culture and behavior.
In addition, historical acts of betrayal and oppression such as the Tuskegee syphilis study
(Thomas & Quinn, 1991), among others, has laid the foundation of great and valid distrust
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among Blacks for such institutions in the United States that are dominated by White people and culture. According to their article on how the impact of the Tuskegee syphilis study influences the progression of HIV and AIDS risk education programs in the Black community,
Thomas and Quinn (1991) stated that ‘‘the continuing legacy of the Tuskegee Syphilis Study has contributed to Blacks’ belief that genocide is possible and that Public Health authorities cannot be trusted’’ (p. 2).
Mistrust
In their effort to cope with the impact of historical and present mistreatment, oppression, racism, and discrimination, Terrell and Terrell (1981) asserted that most Blacks employ what is known as cultural mistrust in their interactions with Whites. Nickerson et al. (1994) stated that cultural mistrust could be an indicator of how Blacks orientate themselves toward Whites and that cultural mistrust influences most Blacks’ lack of initiation or maintenance of therapeutic services provided by Whites.
Numerous studies have indicated that this concept of cultural mistrust undeniably influences Black clients’ self-disclosure to White therapists and attitudes about therapy in general
(Boyd-Franklin, 1989; Davey & Watson, 2008; Ridley, 1984; Tidwell, 2004; Whaley, 2001).
Self-disclosure among Black clients in therapy is strongly intertwined with the levels of comfort and safety clients experience with their non-Black therapist. Black clients assess for levels of comfort and safety in the initial stage of therapy by observing the salience of cultural and ⁄ or race identity with the therapist and cultural understanding or sensitivity of the therapist (Ward,
2005). Boyd-Franklin (1989) asserted that due to subtle ways that racism manifests itself socially, Blacks are attuned to pay closer attention to the ways non-Blacks perceive their skin color and ⁄ or culture. The trust is therefore an essential element in obtaining and maintaining therapeutic services.
Thus, mistrust of Black clients toward White or other non-Black therapists serves as a great barrier to therapeutic success. Laszloffy and Hardy (2000) described how cultural mistrust can hinder Black clients from disclosing ways that racism is connected with many problems they bring to therapy. They stated that most Blacks fear how a White therapist, or therapist of color whom they perceive as being aligned with Whites by virtue of being members of the same social class, would react or respond to these problems in therapy.
Risk of Self-Disclosure in Therapy
Drawing upon the Multicultural Perspective (MCP) model, Hardy and Laszloffy (2002) emphasized that in any dyadic relationship where inequality of power is present, one individual exemplifies ‘‘the privileged,’’ while the other ‘‘the subjugated’’ individual. They assert, ‘‘The subjugated [partner] has less power and is more vulnerable to exploitation, violation and degradation in the relationship’’ (p. 575). Hence, it can be dangerous for Black clients to self-disclose to White therapists whom they perceive as representing the oppressor. Self-disclosure in an environment that Black clients perceive as unsafe, and to White therapists whom they have some level of cultural paranoia for (Boyd-Franklin, 1989) can impede the therapeutic process by making it less beneficial and effective for Black clients.
Consistent with the tenets of Emotionally Focused Therapy (EFT; Johnson, 2004), the individual in the vulnerable position is inherently more likely to be reinjured in the therapeutic process, the client-therapist relationship, and ultimately relationship of the client to self. Thus, it would be unwise for Black clients to abandon their coping style in an environment and interaction with individuals they perceive as unsafe. As mentioned previously, ‘‘mental health services’’ often represent an institution that possesses great power and privilege to most Black clients.
Therefore, lessening the burden of cultural mistrust among Black clients in their attempt to seek and maintain therapeutic services becomes a paramount responsibility for mental health service providers, particularly White therapists. It is crucial for White therapists to consciously and consistently address issues of power, privilege, racism, and oppression. As Hardy and Laszloffy
(2002) pointed out, in a relationship such as one between Black clients and White therapists, where inequality of power encompasses interactions within the relationship, the person with the most power also carries the greatest responsibility in that relationship. Cultural mistrust will
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likely continue to impede the therapeutic process and be a factor in Black clients’ underutilization of therapy if therapists do not embrace their responsibility and work to reconcile their own lack of historical cultural understanding and cultural sensitivity toward Black clients.
The Field of Marriage and Family Therapy and Black Clients
In general, the field of marriage and family therapy (MFT) has struggled to recognize and focus on the topic of race and culture. According to Hardy (1989), ‘‘In the family therapy field, little has changed in the case of minorities. Race, culture, and ethnicity still have not been fully incorporated into mainstream family therapy literature’’ (p. 17). Although marriage and family therapy is a field that is founded upon systems theory and an understanding of families in their context, it has failed to understand Black clients in their racial and cultural context. In recent years, authors of theoretical and training articles in MFT have made efforts to shed light on how the field delivers therapy to Black clients (Bean, Perry, & Bedell, 2002; Davey & Watson,
2008; Turner & Wieling, 2004). Additional articles have been written in regard to training competent multicultural therapists, avoiding Theoretical Myth of Sameness (TMOS), addressing the issue of racism, incorporating religion and spirituality, involving fathers or ⁄ and males in therapy, acknowledging the strength of Black families, doing home visits, and using problem-solving focus (Aponte, 1978, 1994; Bean et al., 2002; Boyd-Franklin, 2003; Davey & Watson, 2008;
Hardy, 1989; Hardy & Laszloffy, 1992, 1995; Hines & Boyd-Franklin, 1982; Wilson & Stith,
1991). These articles provide profound and in-depth insights as to how to effectively and ethically provide therapy for Black clients in the field. However, little empirical research has been conducted in the field of MFT that focuses on Black clients’ experience in therapy and how family therapy can be beneficial to them (Allgood & Crane, 1991; Bean et al., 2002). In her article, Malone-Colon (2007) called for research with representative samples of African Americans in this field. There is a great need for empirical research with Black clients in MFT in order to improve the service family therapists provide for Black families.

METHODS
Procedure
In order to better understand the barriers that Black clients face when seeking marital or family therapy, we mailed a questionnaire to 104 individuals who identified themselves as of African descent or Black. These individuals had initiated, and attended, at least one session of family therapy at an on-campus couple and family therapy clinic at a major university in the northeastern region of the United States. As part of the mailing, potential respondents were asked to sign a consent form, complete the questionnaire, and return it in a business reply envelope. They were also informed they would receive a $5 gift certificate for completing the forms. Individuals who completed and returned the questionnaire were sent a $5 gift certificate. After approximately 3 weeks, a reminder note was mailed to potential participants who had not responded and appeared to have an accurate address. A second reminder was mailed approximately 1 month after the first one. In order to facilitate additional responses, a phone call was made to individuals who had provided a phone number that was still valid.
In total, 104 questionnaires were mailed out. Fifty-eight (56%) were returned as undeliverable. Sixteen participants responded to either the mailing or the phone call and returned a completed questionnaire. After removing the inaccurate addresses, the response rate was 35%; in other words, 35% of respondents with a valid address returned a questionnaire. The overall response rate, including bad addresses, was 15%. As would be expected in a clinical study attempting to recruit individuals who had participated in therapy as many as 10 years prior to the mailing, the response rate was low. Possible explanations for a low response rate and implications for future research are discussed in the limitations section.
Sample
The sample from this study was solicited from a university-based couple and family therapy clinic and comprised those individuals who identified themselves racially as Black or
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African American on an intake form. The average age of the 16 respondents was 36 years old; most were women (75%). Of the nine participants who responded to a question regarding ethnicity, only three used additional descriptors (beyond African American) to describe their ethnicity (Jamaican, African, Bermudian). The majority of participants described themselves as religiously affiliated (75%). At the time of therapy, on average, the individuals in the sample had received 3 years of college education, were employed, and had an annual income of
$24,000.
At the time of therapy, half of the sample had never been married; 31% was married or living with a partner. Of those with children, the average number of children in the home was one at the onset of therapy. The majority of the sample (57%) expressed some satisfaction with their overall health.
Measures
The questionnaire was developed specifically for this study (see the appendix). After a review of the literature, our research team met to discuss key factors relating to family therapy with Black clients, particularly barriers preventing African American clients from engaging in marital or family therapy. Drawing upon personal and clinical experience, as well as extant literature, we divided the questionnaire into three main sections. The first section assessed participant demographics. The second section asked participants to rate factors that may have presented an obstacle in their efforts to engage in therapy. The third section asked participants to describe, in an open-ended format, additional issues that may have been obstacles in their journey to therapy. This section provided clients with a space and format to speak to their experience without prompts.
RESULTS
The results from this study are reported by section, as outlined in the questionnaire (see the appendix). Due to the small sample size, the quantitative results are reported largely in terms of mean scores, correlations, and basic associations (comparison of means tests).
Responses to questions in section three are presented in a qualitative format.
Section One
Of the key demographic variables (age, gender, ethnicity, religion, education, yearly income, relationship status, and health), only three were significantly correlated with any of the obstacles identified in section two of the study. One, participants who were unemployed at the time of therapy described the obstacle ‘‘concerns about working with White therapists’’ (p < .003) as significantly more difficult than those who were employed. Two, the men in the study rated ‘‘lack of privacy in therapy’’ as a significantly more difficult
(p < .014) obstacle than the women. And three, higher levels of income were correlated with higher difficulty ratings for the obstacles ‘‘lack of privacy in therapy’’ (p < .041) and ‘‘lack of trust in therapist’’ (p < .041). Among the key demographic variables themselves, as would be expected, higher levels of education were significantly correlated with higher levels of income (p < .008).
Section Two
In this section, participants were asked to rate on a four-point Likert scale (ranging from not difficult to very difficult) how difficult it was to overcome 14 potential obstacles in the pursuit of family therapy services (see the appendix). According to participants, the most difficult barriers to overcome relate to the potential resistance to therapy by family and community due to cultural beliefs. The obstacle ‘‘concerns about how my family ⁄ friends would react’’ and ‘‘cultural beliefs encourage me to work out own problems’’ (both mean of 1.75) were the highest rated obstacles. Literally one half the sample indicated concerns over family and friends’ reactions were in some form a roadblock to therapy, with 19% rating it as a serious issue (‘‘difficult’’ or ‘‘very difficult’’ to overcome). Forty-four percent of the sample described cultural beliefs as an obstacle on some level, with 25% of the responses falling into either the ‘‘difficult’’ or ‘‘very difficult’’ categories.
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‘‘Concerns about working with White therapists’’ was the next highest rated obstacle
(m = 1.57). It was identified by 44% of the sample as an issue, with six of the seven responses in the ‘‘somewhat difficult’’ grouping. Similarly, ‘‘lack of cultural understanding of therapist’’
(m = 1.53) was described as at least ‘‘somewhat difficult’’ by 40% of the sample. Thirty-eight percent of the sample described ‘‘therapy is a sign of weakness’’ (m = 1.50) and ‘‘difficulties in paying for therapy’’ (m = 1.50) as at least ‘‘somewhat difficult’’ obstacles. And finally, 44% of the sample described ‘‘lack of trust in therapist’’ (m = 1.44) as a ‘‘somewhat difficult’’ obstacle to overcome.
When a correlation analysis was run with all the ‘‘obstacles,’’ only two sets of items were correlated with each other at greater than a .800 level (Pearson correlation coefficient). ‘‘Negative views about therapy’’ was significantly correlated with both ‘‘risk of being blamed by my therapist for my problems’’ (p = .831) and ‘‘fear of my therapist being racist’’ (p=.800).
Section Three
In this section, participants were given the opportunity to respond to six open-ended questions about their experience in therapy (see the appendix). Unfortunately, due to the small sample size, only the answers to three of the six questions (#1, #3, and #6), yielded sufficient responses, both in terms of number and depth, to allow for common themes to emerge. The answers to these three questions—‘‘Which obstacles was the most difficult to overcome?’’ ‘‘In what ways was therapy better than you imagined?’’ and ‘‘What advice would you give us about removing obstacles for Black families to come to therapy?’’—did provide valuable insight to the experience of Black clients in family therapy.
The researchers used one of the basic components of qualitative methodology, the constant comparison method, to analyze the data (Corbin & Strauss, 1990). Statements made by the participants were compared for similarities and differences in properties, dimensions, and processes; the research team then attempt to conceptualize and group similar concepts (Rafuls
& Moon, 1996). Because of the limited responses, both in actual number as well as length, similar concepts were grouped and labeled (coded, see Charmaz, 1983), but no higher-level analyses could be performed. Listed below are the actual number of comments for each grouping of concepts (code), as well as sample quotes from each grouping.
The participants provided 18 different responses to the question about the ‘‘most difficult obstacles.’’ The most common response (four total) related to concerns about racial and ⁄ or cultural differences. Examples of these concerns are as follows:
‘‘Finding a person I could identify with. I wanted an African American person, my insurance circle was very limited in that area.’’
‘‘I’m pretty certain that I feel distrustful of my white-female therapist.’’
‘‘The ethnicity of the therapist (white) being different from our own (African American).
We desired someone with cultural understanding and sensitivity.’’
The second most common response (three total comments) related to the cost of therapy.
The responses in this area were short and specific, describing the need for therapy and the struggle to pay for it.
Participants provided 16 responses to question #3, ‘‘In what ways was therapy better than you imagined?’’ The most common responses highlighted the opportunity to discuss feelings and problems (eight total). Examples of these are as follows:
‘‘Helped to clarify thoughts, regain a positive perspective and to prioritize life’s concerns.’’ ‘‘It was great to be able to express my feelings in an environment that was safe.’’
‘‘Just to release my problems verbally to another human.’’
Eleven out of 16 participants responded ‘‘Yes’’ to question 5, which asked, ‘‘Was therapy helpful?’’ Examples of why therapy was helpful are as follows:
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‘‘Yes, I grew through some personal issues with a past relationship and it allowed me to see potential patterns in my own life.’’
‘‘Yes, I realized therapy is to help me ⁄ us arrive at our own healing not inspire by judgment.’’
‘‘Yes, I was allowed to release stress, tension, and problems. Leave them there and move on.’’
When responding to question #6, which requested advice on how to best remove obstacles for Black families desiring to initiate therapy, participants provided 21 different comments.
Responses to this question can be organized in two major groups: shift in culture toward therapy and advice for therapists.
Shift in culture toward therapy. Seven different comments were made about the need to help create a shift in Black culture toward therapy so it can be seen as a potentially good and helpful option for dealing with problems.
‘‘Many Black families have been indoctrinated to believe therapy is wrong and will only exacerbate your problems.’’
‘‘Campaign must be done within the cultural context and with the emphasis on the power of communication not ‘telling folks your problem.’
‘‘Letting them know there should not be a stigma about talking to a professional who is trying to help.’’
This theme emerged across participants and a range of different topics.
These open-ended responses coincide with the quantitative identification of concerns regarding family and cultural views of therapy as the most significant obstacle to therapy.
Advice for therapists. Responses in this category (12 total) range from a need for increased advertising to a request for more overt discussions of videotaping. However, the most common theme in the advice given relates to the therapists’ ability to demonstrate understanding of and respect for the experiences of Black families. One quote powerfully represents a major theme in this category.
‘‘I would encourage those who can to try to place themselves where they can experience the disparity . . . take up residence in a Black neighborhood. And if you can alter your appearance to resemble a person of color that would be better. To remove obstacles is to educate yourselves as much as you can about race and cultural issues in
America. Education is key because until all Americans are educated, the obstacles will still be
there.’’
Four different participants made specific requests for therapists of color and ⁄ or made suggestions for recruiting therapists of color.
‘‘Create a program ⁄ campaign to attract people of all cultures to become therapists.’’
‘‘Encourage more African Americans to become therapists.’’
Participants also made suggestions regarding how non-Black therapists could become more aware of and sensitive to the Black experience.
‘‘Connect with others [in the] black community. [Be] open to Afro-centric approaches in therapy and need to understand black culture.’’
‘‘[Need for] therapists introducing topic of race in session . . . open door for conversation.’’
Finally, participants again made a clear and repeated call to make therapy more affordable
(four comments) and accessible (two comments) in the Black community.
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DISCUSSION
This study is one of the first in the field of MFT to seek the perspective of Black clients who did attend family therapy, particularly regarding obstacles they face in their effort to utilize therapy. The unique findings from this study will help MFTs better understand the obstacles that confront Black clients in their effort to utilize family therapy, their attempts to overcome these obstacles, and how family therapy can be made a more viable option for Black families. This study does provide additional research support regarding the well-established clinical dilemma that Black families are in need of services and support, yet often feel they cannot trust the system. However, the findings go beyond this basic, but important fact. This research also sheds new light on unique obstacles relating to the lack of family and cultural support for therapy and the challenges of working with non-Black clinicians, findings based on the words and experiences of Black clients who actually sought and attended family therapy.
Obstacles Relating to Lack of Family and Cultural Support for Therapy
Concerns relating to a lack of family and cultural support for therapy were the barriers participants identified as the most difficult to overcome. The participants’ identification of these obstacles may be embedded in Blacks’ historical and ⁄ or present experiences in a Eurocentricdominated world and the resultant cultural mistrust of Whites and White institutions (Brown,
2003; Wilson & Stith, 1991). The results of this study indicate that some participants see therapy as a sign of weakness or associated with being ‘‘crazy,’’ which is supported in extant literature that there is a stigma of therapy in Black culture (Franklin, 1992). Participants in this study stated that an obstacle to therapy was the reactions of friends and family, suggesting there is real fear of stigmatization or rejection by family members or the larger community
(Thompson et al., 2004). Therefore, some participants indicated that a barrier to therapy in the
Black community may be a reluctance to seek therapeutic help outside of the traditional patterns of seeking help among family members, friends, community, and ⁄ or religious leaders
(Franklin, 1987).
An additional explanation for why concerns about family and cultural views of therapy are serious obstacles may be related to specific negative experiences (misconstrue family values and culture identity, misdiagnose) of close family and friends in therapy. This idea was supported by at least one participant in the study, who stated,
‘‘Many Black families have been indoctrinated to believe therapy is wrong and will only exacerbate your problems.’’
This statement also lends supports to research from Nickerson et al. (1994) that found cultural mistrust to be a significant issue for Black students seeking services at a university clinic that was predominately staffed by White counselors.
Another possible reason for the identification of the family and cultural support obstacle indicated by participants is the cultural belief that a strong family should be able to resolve issues without professional help. Thompson et al. (2004) noted that participants in their study expressed ‘‘the historical expectation that life would be difficult and that African Americans as a cultural group could and would cope with all adversity’’ (p. 22). Similarly, Boyd-Franklin
(1989) also noted that many Black families have the belief that family problems should be kept within the family and not be exposed to the public. According to our finding, these two beliefs, that families should solve their own problems and these problems should be kept private, may have created some concerns for some clients seeking therapy, especially if the potential client feels he or she will disrespect family members or their community if therapy is initiated.
Obstacles Relating to Working With Non-Black Therapists
The second major obstacle identified by participants related to concerns about working with White therapists. Our finding confirms numerous studies that suggest most Black clients prefer Black therapists to White therapists (Atkinson, 1983; Brown, 2003; Heffernon & Bruehl,
1971, June, 1986; Nickerson et al., 1994; Okonji, Ososkie, & Pulos, 1996; Sue et al., 1974).

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Specifically, Nickerson et al. (1994) reported that African Americans in their study would likely come to therapy if they know that the therapist they would see is African American. This finding may be related to Black clients’ cultural mistrust of White therapists and ⁄ or the concern that a White therapist would not be able to relate to or understand the life experience of Black clients. Existing research supports this concept; specifically, Watkins and Terrell (1988) found that ‘‘highly mistrustful’’ Blacks expected White therapists to be less accepting, trustworthy, successful, and experienced than Black therapists.
The results of the current study found that ‘‘lack of cultural understanding of therapist’’ was indicated by participants as a somewhat difficult obstacle to overcome in their attempt to seek family therapy. Likewise, Thompson et al. (2004) highlighted the need for Black clients to feel that their therapists have an ‘‘adequate knowledge of African American life’’ and do not need to ‘‘struggle to accept or understand them’’ (p. 23). The fear of being stereotyped by
White therapists who have limited knowledge, training, and understanding of Black culture and family life can be a real and prevalent barrier to therapy. As noted by Hardy and Laszloffy
(1992), a therapist’s lack of cultural competency, awareness, and sensitivity toward Black culture and families can impede trust in therapy between Black clients and White therapists.
One of the unique findings of this study is that ‘‘negative views about therapy’’ was significantly correlated with both ‘‘risk of being blamed by my therapist for my problems’’ and ‘‘fear of my therapist being racist.’’ This finding lends support to Brown’s (2003) assertion that
‘‘when African Americans do seek therapy they face negative stereotypes, biases, and assumptions that are based solely on the color of their skin that are held by dominant culture and portrayed in the media’’ (p. 12). Cultural stereotypes that Blacks are lazy, ignorant, morally and intellectually inferior, and poor may create fears of being blamed for one’s problems by a
White therapist who holds these stereotypic views and is unfamiliar with the diversity among
Black families. Boyd-Franklin (1989) and Grier and Cobbs (1968) describe this ‘‘healthy cultural paranoia’’ among Blacks in dominant White society. The results of this study confirmed previous research which states that mistrust of non-Black therapists continues to be a major, and well-justified, obstacle for Black clients.
Implications for Clinicians
The findings of this study provide several important implications for family therapists working with Black clients. First, Black clients are often wary of working with White therapists. Second, family therapists can address this concern of Black clients by taking active steps, both in and out of session, to adopt a multicultural perspective and approach in therapy.
Because issues of trust and cultural sensitivity are critical, it is imperative that family therapists develop a true understanding of Black culture and how it impacts the therapeutic relationship.
Hardy and Laszloffy (2000) state that family therapists need to move beyond racial awareness to racial sensitivity. These authors define racial awareness as ‘‘the ability to recognize that race exists and that it shapes reality in inequitable and unjust ways’’ (p. 36); however, individuals who are racially sensitive ‘‘actively challenge attitudes, behaviors, and conditions that create or reinforce racial injustice’’ (Hardy & Laszloffy, 1998, p. 119).
One pathway through racial awareness and onto racial sensitivity can be termed self-of-thetherapist work. This work can be done ethically and effectively when therapists explore their own race and ethnicity and address their own racist notions or levels of internalized racism
(Hardy and Laszloffy, 2000). There are many ways that this self-of-the-therapist work can be done. Hardy & Laszloffy (2000) recommend reading publications and books, and watching movies produced by and about Blacks, followed by attending cross-racial and culturally sponsored events, all in an effort to engage in a racial self-exploration process regarding race. The importance of this process, where therapists gain an in-depth understanding of their own racial scripts followed by an immersion in Black history and culture, is an important first clinical implication of this study for family therapists seeking to provide racially sensitive therapy for Black families.
Second, family therapists must learn how to discuss race in session. The need for therapists to address the impact of race and culture on a client’s life experience and problems was a major finding of this study. The need to discuss race is particularly important for White therapists working with Black clients. As Hargrave and Pfitzer (2003) noted, a history of White people
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exploiting People of Color has damaged the trustworthiness that could exist between races. Providing the opportunity to discuss exploitation and oppression can be an important first step toward establishing trust in the therapeutic relationship. As mentioned previously, and as supported in the findings of this study, it is the therapist’s responsibility as the person in a position of power in the therapeutic relationship to open the door to a discussion of race.
In their text, Hargrave and Pfitzer (2003) provide a helpful vignette, a practical and clinical starting point for a discussion of how to address race in session. In the vignette, a White female therapist acknowledges and addresses race in therapy with her client, who is a Black man:
Therapist: Now that I know a bit about what brings you to therapy, I would like to spend a short time talking about our relationship.
Man: What do you mean?
Therapist: We come from a very different perspective. I am female and you are male. I am white and you are black [lowercase is utilized in original text and is not a representation of the authors’ values]. We come from different family backgrounds, and I’m the counselor, whereas you are the client.
Man: I don’t suppose you can understand what it’s like to be a black man in this society, any more than I can understand what it’s like to be a woman.
Therapist: You are right. We can never really fully understand one another. But I do want to be aware of anytime I’m asking you to do something that feels demanding or insensitive. Man: (Laughs) That may be most of the time.
Therapist: Did I already say something that made you feel angry or hopeless?
Man: (long pause) Many white people say they want to understand and be more sensitive. But when it gets down to it, they just give lip service to it.
Therapist: How can you help me to avoid that position?
Man: (Looks at the therapist a long time in silence) I will tell you when I feel that
‘‘white’’ coming out of you at me. (p. 23)
This vignette provides a good example of a racially aware therapist who is willing to acknowledge the intersection between race and gender while in session. She actively creates space for a conversation about race and leaves the door open for future dialogue.
The vignette would be even more instructive if the therapist included a dialogue about the role of power in the therapeutic relationship. Hargrave and Pfitzer (2003) suggest that by using a one-down position in therapy, through enlisting the client’s help, the therapist was able to create space for the client to be honest. We would propose that as a White therapist she will always maintain a privileged position and will never truly be ‘‘one-down.’’ Although the client states he will speak up, the fact that he is a Black man may influence his willingness to fully share feelings that he is often denied or punished for in society, like anger. In order to move from cultural awareness to sensitivity, the therapist would need to discuss with the client how it may be hard for him to feel safe enough to be honest. Even if he wants to share deeply held feelings, it will likely be hard and unwise for him to ignore the power differential with the accompanying potential of labeling ⁄ diagnosing based on stereotypes. And perhaps more importantly, a culturally sensitive therapist would not place the responsibility on the client to speak up when the ‘‘white’’ comes out of her toward the client, but would instead use her inherent power as a therapist (and the accompanying responsibility that flows from it) to monitor herself through self exploration and supervision (Constantine, 2007; Sue, 2007). As mentioned previously, it is not the responsibility of the oppressed to teach the oppressor.
Respondents in this study also indicated that privacy is a concern. Discussing confidentiality is a mandatory aspect of family therapy as stated in the American Association for Marriage and Family Therapy (AAMFT) code of ethics (AAMFT, 2001). However, clinicians should be
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aware that a discussion of confidentiality may be of particular importance to Black clients
(Bean et al., 2002). Taking extra time to process issues of confidentiality and privacy can show
Black clients that a therapist is aware of past exploitation of Blacks both in and out of therapy.
Such cultural sensitivity can work to address the chronic barrier of mistrust.
Two additional implications relate to utilizing a strengths-based approach and including spirituality ⁄ religion in therapy. Because participants described cultural and family resistance to therapy as a major barrier, clinicians need to understand the origin of these barriers and how to address them in therapy. Participants described a cultural ⁄ family belief that Blacks need to solve problems themselves, rather than seeking help. In 1987, Sherman James coined a phrase known as John Henryism1 that describes this belief in action (James, 1994). It is characterized by individuals overcoming challenges through utilizing persistent, unrelenting energy at the cost of their own healthy functioning (Breland-Noble, Bell, & Nicolas, 2006). Clinicians need to be aware of these cultural beliefs, and their inherent risks to clients, so that they can be assessed and addressed early in therapy. One of the ways clinicians can work with Black clients to do this is to utilize a strengths perspective by highlighting the ways clients may already be successfully connected to people and organizations that serve as a helpful resource. If clients can be helped to see positive connection with others (even some reliance on them) as a sign of strength, then perhaps resistance to therapy can be lessened.
In addition, the results indicated that 75% of the participants in this study were religiously affiliated. A therapist can effectively utilize a strength-based perspective by asking clients how spirituality and religion can serve or has served as a positive resource in their efforts to deal with life’s problems. Specifically, a conversation in session about how clients might seek additional support from a religious leader further highlights the strength and wisdom necessary to seek help in times of trouble. Improving collaboration between MFTs and clergy is suggested as a helpful intervention for therapists working with Black clients (Weaver, Koenig, & Larson, 1997). In both cases, the idea is to help the client reframe ‘‘seeking assistance’’ as a sign of strength.
Implications for Future Research
Not surprisingly, the greatest challenge confronting any project seeking feedback from a marginalized and oppressed group, one that is traditionally and justifiably mistrustful of the mental health services field, is participant recruitment. As noted previously, over one half of the questionnaires mailed out in this study were returned because of ‘‘bad addresses.’’ However, once successfully contacted, 35% of potential participants did respond to a request for research participation. This finding is encouraging, lending hope that conscientious and repeated efforts to engage Black clients with therapy experience in research projects can be successful. Perhaps the greatest implication for future research is that if sought, many Blacks may be willing to respond to questions about their experiences in family therapy. In addition, future researchers may wish to address potential sample size problems by collaborating with multiple clinics to increase research participation.
Because the questionnaire utilized in this study did not illicit numerous responses regarding how barriers to family therapy were actually overcome by Black clients, future researchers may wish to adjust both the timing and format of research questions to best address this important area of concern. For example, it is likely that clients would best be able to address specific questions about overcoming barriers to therapy at the beginning of the therapy process or while it is occurring. This type of ‘‘progress research’’ can provide therapists with in-the-moment data regarding current and difficult obstacles, rather than a retrospective lament, which could potentially help MFTs address issues occurring in session and make it more likely for Blacks to see therapy as a viable option for healing (Pinsof and Wynne, 2000, p. 7).
Also, because there is still little known about specific barriers to family therapy for Blacks, some form of qualitative inquiry could help researchers gain a deeper understanding of how clients make decisions to attend therapy and persevere through and overcome common obstacles.
For example, results from this study suggest that a lack of family and cultural acceptance of

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therapy is a major obstacle confronting Blacks considering therapy; future research that utilizes in-depth qualitative interviews could help identify how clients address these obstacles, and perhaps more importantly, how they understand and make meaning of family ⁄ cultural resistance to therapy.

LIMITATIONS
Due to sample size restrictions in this exploratory study, the results were limited in a number of key ways. First, the type and complexity of statistical analysis were restricted. Therefore, it was very difficult to gain a clear understanding of the nature and strength of the relationships between key variables. Second, because of the low response rate, the sample is biased. Determining the nature of that bias, however, is much more challenging. In an effort to understand potential biases, the sample of those who did not participate in the research was compared to those who did. The analysis revealed no major differences on key demographic variables.
Therefore, the results from this study do not seem to be merely related to income level, gender, or age of participants. It is difficult to hypothesize how else the sample may differ from those who were contacted and did not respond, except that it is likely that only the most hardy and resilient may find the time and energy to respond to a study that in no way is related to the harsh realities of survival faced by many who experience oppression on a day-to-day basis.
And third, sample size and statistical limitations do not allow the results from this study to be generalized to a wide variety of clinical settings. Nevertheless, the results do prompt a series of interesting questions regarding Blacks’ experience in family therapy and the larger intersection between the culture of therapy and Black culture. What steps can be taken to both encourage more Blacks to consider mental health services as a career and help non-Black therapists learn to provide an ‘‘open door’’ (as one participant eloquently described) to conversations about race in therapy? In what way can MFTs of all colors best provide assistance to Black clients as they struggle with family and cultural resistance to therapy? What can MFTs and even the AAMFT do to help heal wounds and build trust in the Black community?
In conclusion, we sincerely hope that more MFTs and MFT researchers will struggle with and seek answers to the questions raised in this study, thereby highlighting honoring the voices, experiences, and therapeutic needs of the Black community. Perhaps, it is the best way for family therapists to begin to overcome mistrust and build credibility in the eyes of Black clients.

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NOTE
1

Refers to the story of John Henry, a freed slave in the nineteenth century who worked for the Chesapeake and Ohio Railroad as a steel driver. He competed against a steam-powered drill and defeated the machine, but died from the effort. See Hall (2008) for more in-depth analysis of the story and the link to African American culture.

APPENDIX
Questionnaire: Understanding the Experiences of Black Clients in Therapy.
Section 1: Please answer each of the following questions about you and ⁄ or your family at the present time.
1. Age: ____________ Gender: _______________
2. Race: ______________
3. Ethnic origin: _______________
4. Are you religiously affiliated? If so, what affiliation? _________________
5. Number of children in the home: _______________
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6.
7.
8.
9.

Years of education: _________________________
Are you employed? YES ____________________ NO ______________________
Yearly income: ________________
Relationship status (please circle one that best applies):
A. Never married B. Living with someone C. Married D. Separated
E. Divorced F. Widowed
10. How satisfied are you with your overall health (please circle one):
A. Very dissatisfied B. Somewhat dissatisfied C. Mixed
D. Somewhat satisfied E. Very satisfied
Please answer each of the following questions about you and ⁄ or your family at the time you and ⁄ or your family was in therapy. Date: ____________________
1. Number of children in the home at that time: __________
2. Years of education at that time: _________________________________
3. Were you employed? YES ____________________ NO ________________________
4. Yearly income at that time: _____________
5. Relationship status (please circle one that best applies):
A. Never married B. Living with someone C. Married D. Separated
E. Divorced F. Widowed
6. How satisfied were you with your overall health (please circle one):
A. Very dissatisfied B. Somewhat dissatisfied C. Mixed
D. Somewhat satisfied E. Very satisfied
Please answer the following questions for the time period you began therapy.
Date: _______________
Section 2: Please answer the following questions regarding obstacles you faced in your efforts to attend therapy.
On the scale of 1 to 4, please pick the answer that best describes how difficult each obstacle was to overcome.
a. Lack of trust in therapist
1
2
3
4
Not Difficult Somewhat Difficult Difficult Very Difficult
b. Lack of trust in therapy in general
1
2
3
4
Not Difficult Somewhat Difficult Difficult Very Difficult
c. Lack of cultural understanding by therapist
1
2
3
4
Not Difficult Somewhat Difficult Difficult Very Difficult
d. Risk of being blamed by therapist
1
2
3
4
Not Difficult Somewhat Difficult Difficult Very Difficult
e. Fear of my therapist being racist
1
2
3
4
Not Difficult Somewhat Difficult Difficult Very Difficult
f. Lack of privacy in therapy
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
g. Negative views about therapy (Therapy is for crazy people)
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
h. Lack of knowledge in community about therapy
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
i. Difficulties in paying for therapy
1
2
3
4

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Not Difficult/NA Somewhat Difficult Difficult Very Difficult
Concerns about working with white therapists
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
k. Religion or spirituality discourages therapy
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
l. Therapy is a sign of weakness
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
m. Cultural beliefs encourage me to work out my own problems
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
n. Concerns about how my family ⁄ friends would react
1
2
3
4
Not Difficult/NA Somewhat Difficult Difficult Very Difficult
j.

Section
1.
2.
3.
4.
5.
6.

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3: Please describe your experiences facing obstacles in your efforts to attend therapy.
Which obstacle was the most difficult to overcome?
How did you overcome this obstacle?
In what ways was therapy better than you imagined?
In what ways was therapy worse than you imagined?
Was therapy helpful? If YES, why? If NO, why not?
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