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Diversity and Clinical Training

ATTENTION TO CULTURE AND DIVERSITY IN


PSYCHOANALYTIC TRAININGS

Karen Ciclitira and Nena Foster


ABSTRACT Ethnically and culturally diverse groups increasingly undertake psycho-
therapy, but insufficient attention is often paid to aspects of diversity. This article
explores qualitative data from a mixed-method study, conducted at a UK psychoanalytic
psychotherapy training institution, in which 24 participants from diverse backgrounds
were interviewed individually about their experiences of clinical training. Participants
were asked how their ethnicity had impacted on their training, and also how social class,
sexual orientation, religion and gender might affect the training experience. The data
were analysed thematically, and a principal theme that emerged was the way that
psychoanalytical clinical trainings tend, for theoretical reasons, to explore ‘internal’
psychological issues at the expense of ‘external’ material issues such as ethnicity. Similar
concerns arose in connection with social class, gender and sexual orientation, with a
specific theme being that of trainees feeling silenced and finding it difficult to openly
discuss various aspects of diversity.
Key words: psychoanalytic training, culture, diversity, ethnicity, homosexuality,
minority

Introduction
The changing social demographics of the UK demand that culture and ethnicity
as well as other social factors are better addressed in the provision and training
of psychotherapists and counsellors. While individuals from ethnic minority
groups in the UK numbered just over 3 million (5.5 %) in 1991, the number rose
to 4.6 million over the next decade, an increase of 53% (Office for National
Statistics, 2001). It has been predicted that ethnic minorities will make up
one-fifth of the UK population by 2051, as compared to 8% in 2001 (Wohland
et al., 2010). Researchers in the USA and the UK have argued for some years
that high-quality professional clinical training is needed to take into account the
increasingly multicultural population (e.g. Constantine & Sue, 2005; Patel et al.,
2000). The majority of research and development in clinical training provision
has been carried out in the US, although there have been a number of initiatives
in the UK (e.g. Shashidharan, 2003).
There are numerous obstacles for access to mental health services by ethnic
minorities, and researchers have indicated various ways in which these can be
alleviated by the development of culturally relevant treatments and training
programmes. Specific difficulties include language barriers (e.g. Saha et al., 2007),

KAREN CICLITIRA PhD CPsychol is a psychoanalytic psychotherapist and a Princi-


pal Lecturer in Psychology at Middlesex University. Her research interests include
racism, gender, psychoanalysis, sexuality, health, feminist research and discourse analy-
sis.Address for correspondence: [k.ciclitira@mdx.ac.uk]
NENA FOSTER PhD is a Senior Lecturer in Public Health at the University of East
London. Her research interests include diversity and culture.Address for correspond-
ence: [nena@uel.ac.uk]
© The authors
British Journal of Psychotherapy © 2012 BAP and Blackwell Publishing Ltd, 9600
Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 353
DOI: 10.1111/j.1752-0118.2012.01298.x
354 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

lack of cultural awareness among professionals, recognizing culturally diverse


expressions of mental health problems, modes of treatment (Fernando, 2005),
and the unavailability of ethnically similar clients and clinicians (Sass et al.,2009).
Religion has also been found to play a significant role in influencing service users’
perspectives on accessing psychological therapies (e.g. Whittaker et al., 2005).

Clinical Trainings, Cultural and Ethnic Diversity


It is generally accepted by researchers and clinicians that mental health profes-
sionals need specialist training to deliver effective services to ethnically and
culturally diverse service users (Patel et al., 2000; Ridley et al., 2000), and that
there is a need for more clinicians from ethnic minority groups to be service
providers (e.g. O’Sullivan et al., 1989). Additionally, training programmes are
legally obliged to meet diversity requirements. The Race Relations (Amend-
ment) Act (2000) prohibits institutions from discriminating, directly or indir-
ectly, on the grounds of colour, ‘race’, nationality, ethnic or national origin. The
Act specifically addresses education and training, and calls on public institutions
to develop and implement a ‘race equality scheme’.
Research has shown that clinical training programmes often fail to address
ethnicity and culture adequately. Institutional and psychological barriers
prevent changes being implemented in clinical trainings: Tummala-Narra
(2009) suggests that racial and cultural diversity are not just overlooked
in clinical trainings, but actively avoided, because of the types and intensity
of emotion that the subject evokes. Multicultural education for mental
health professionals can, however, encourage the development of attitudes,
knowledge, and skills associated with multicultural clinical competence (see
Smith et al., 2006), which can facilitate effective client–clinician relationships
(Lambert & Bergin, 1994).
Clinical trainings need to adapt to the level of multicultural competence of the
students, to help avoid negative outcomes that occur when students’ receptivity
to new information, openness to change and/or experience is over-estimated
(Sue, 1995). Enquiring directly about a client’s ethnicity, and discussing therapy–
dyad heritage differences has been found to help to establish a good therapeutic
alliance, as well as using empathy to support a client’s expressed ambivalence
about differences and self-assessing multicultural competence (Fuertes et al.,
2002). Minority ethnic therapists tend to be more aware of the impact of being a
minority in therapy compared with white therapists (Yi, 1998).
Clinical supervision is a central part of most clinical trainings and allows for
trainees to address emotionally difficult areas with a trained clinician. It has
been argued that: ‘Clinical supervision is the most practical vehicle through
which conscious and unconscious pathologizing and exoticization of clients and
therapists of colour can be examined’ (Tummala-Narra, 2004, p. 301). However,
supervisors seldom receive any formal training about these issues (Constantine,
1997, 2001).
Clinical supervisors are expected to encourage and foster environments
conducive to interpersonal learning with supervisees. However, charged issues
KAREN CICLITIRA AND NENA FOSTER 355

relating to culture and ‘race1’ often pose a challenge to such a learning space
(Tummala-Narra, 2004). Furthermore, the majority of psychotherapy super-
visors are white (D’Andrea & Daniels, 1997), and tend to address cultural issues
in supervision significantly less than minority ethnic supervisors (Hird et al.,
2004). Morgan (2007) has discussed the problem of ‘colour blindness’ in psy-
choanalytic therapy, whereby skin colour in the triad of supervisor, supervisee
and patient is often ignored on the grounds that culture, ethnicity and social
norms are viewed as external and treated as irrelevant to the therapeutic
process.
Bartoli and Pyati (2009) advocate further training to help supervisors
develop the clinical sophistication to deal with complex aspects of interracial
dialogue. Constantine and Sue (2007) conducted a study about black super-
visees’ perceptions of racial microaggressions in cross-racial supervision dyads.
Themes which emerged included white supervisors making stereotypical
assumptions about black clients and supervisees, focusing on black super-
visees’ clinical weaknesses, implicitly blaming black clients for problems
stemming from oppression, and offering culturally insensitive treatment
recommendations.
Microaggressions may not be consciously intended, but from the perspective
of the recipient they represent a negative experience. This ‘new’ manifestation
of racism has been likened to carbon monoxide: invisible but potentially lethal
(Sue & Sue, 2003). Some researchers prefer to use the term ‘racial microagres-
sion’ to describe this form of racism which occurs in the daily lives of people of
colour. They are so common and innocuous that they are often overlooked and
unacknowledged (Solorzano et al., 2000). Sue (2003) argues that: ‘This contem-
porary form of racism is many times over more problematic, damaging, and
injurious to persons of colour than overt racist acts’ (p. 48).

Psychoanalysis and Diversity: Culture, Ethnicity,


Class and Homosexuality
Multicultural education has increasingly become integrated in counselling and
psychology trainings in the USA and the UK (Patel et al., 2000; Smith et al.,
2006), but psychoanalytic trainings have lagged behind (Cooper, 2010). There
has been reluctance among minority ethnic students to seek psychoanalytically
oriented training programmes which have historically failed to adequately
engage with issues of ‘race’ and culture (Tummala-Narra, 2004).
Leading psychoanalysts have called for radical changes in the organizational
structure of psychoanalytic institutes and psychoanalytic education for some
time (e.g. Garza-Guerrero, 2002a, 2002b; Kernberg, 2006; Levine, 2003; Mayer,
2003). In a survey of trainings and policies in psychoanalytic psychotherapy
trainings in the UK, it was found that psychoanalytic training in particular is

1
In this article we use the word ‘race’ with inverted commas to indicate that the authors
view ‘race’ as socially constructed, and that, as Rustin (2000, p. 183) states, it is both an
empty category and can be one of the most destructive and powerful forms of social
categorization.
356 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

viewed as the preserve of the white middle class and had little to offer black
individuals, either as patients or as would-be practitioners. Furthermore, a
stipulation that training candidates have a first degree, for example, may dis-
qualify more ethnic minority individuals. What may be necessary is not a degree
as such, but the ability to deal with intellectual work at the level of higher
education (Gordon, 1993). For instance, someone who says to a prospective
applicant of colour that ‘the most qualified person should get the job’ may be
perceived as implying that people of colour are not qualified (Sue et al., 2007,
p. 73).
A recent survey of psychoanalytic trainees and practitioners in the UK found
that certain social conditions of psychoanalytic training institutes ensure that
anxiety plays a central part in most trainee experiences, with trainee conformity
as the general rule and ‘dissent’ the exception (Davies, 2008). Those running
psychoanalytic clinical training institutions are accused of creating colour blind-
ness and avoiding the issue of ‘race’ in order to maintain power and control
(Lowe, 2006). Furthermore, some academics and clinicians seriously question
the applicability of psychoanalysis to be used cross-culturally for different
ethnic groups, given its lack of appropriate attention to a range of cultural
traditions and beliefs (e.g. Littlewood & Lipsedge, 1997; Pérez-Foster et al.,
1996). Others such as Dalal (2002, 2008) Davids (2003, 2006, 2011), Fanon (1967,
1986), Kovel (1988), Morgan (2002) and Rustin (1992) have made suggestions
as to how psychoanalytic theory and practice can be drawn on to take ‘race’ and
cultural issues seriously.
Training analysis has traditionally been the central feature of the tripartite
model of psychoanalytic education, along with psychoanalytic theory, technique
and the supervised analyses of patients (Wilson, 2010). According to Kernberg
(2006), this model has created an atmosphere of submission to an established
authority, which has acted as a disincentive to innovative endeavours in
psychoanalytic institutes. He recommends that supervision should be the
centrepiece of psychoanalytic training as opposed to training analysis. Many
psychoanalytic therapy trainings in the UK follow this tripartite model. One of
the main problems of training analysis was believed to be the ‘reporting’ train-
ing analyst, a radical deviation from the clinical requirements of technical
neutrality (Kernberg, 2000). Some think of training analysis as being a strictly
therapeutic tool, while others assign it a more education role (Bosworth et al.,
2009). Although there is no longer a requirement for training analysts to carry
out detailed reporting about analysands to a training committee, some institu-
tions continue to expect analysts to inform the training committee if they think
a trainee is not fit to practise as a clinician, providing the analyst with a great
deal of power and authority in determining fitness for practice. Furthermore,
the system of psychoanalytic trainings appointing training analysts as supervi-
sors, seminar leaders and as administrative leaders has further accentuated the
power and hierarchical status of training analysts.
In view of the paucity of literature addressing psychodynamic perspectives
on multicultural education, it is important to consider that one of the goals
of psychoanalysis is emotional insight through making unconscious material
KAREN CICLITIRA AND NENA FOSTER 357

conscious. This has obvious relevance to identity struggles involved in multicul-


tural learning. Contributions of psychodynamic perspectives to multicultural
education could be relevant not only to psychoanalytic trainees but to other
mental health trainees, because they involve a study of individual and group
dynamics (Tummala-Narra, 2009). However, the minimization of external socio-
cultural and cultural experiences within psychoanalytic theory and practice can
be seen to preclude these issues being fully considered and addressed in a useful
way in treatment (e.g. Littlewood & Lipsedge, 1997). Furthermore, aspects of
diversity remain more contentious within this field than others. For example,
some clinicians still view homosexuality as psychopathological (e.g. Bergeret,
2002), which inevitably has a profound impact on the outcome of research,
training and clinical work (Phillips, 2003). In 2011, the British Psychoanalytic
Council finally issued a statement on homosexuality, which rejects discrimination
on the basis of sexual orientation for future trainees – indicating a shift in views.

Research Aims
This research aimed to consider how issues of diversity were dealt with in a
psychoanalytic psychotherapy training institution where minority ethnic and
homosexual trainees are in a significant minority, with a view to informing
institutional practices and guidelines. This article focuses on culture, ethnicity
and racism, although the research also considered other issues of difference,
including gender, religion, sexual orientation and social class.

Method
The study consisted of an open-ended postal questionnaire and semi-structured
interviews with past trainees/current members from the British Association
of Psychotherapists2 (BAP). Participants were recruited from the three main
sections of the BAP, i.e. the Child and Adolescent, the Jungian and the Psycho-
analytic Sections.3 Ethical approval was obtained from Middlesex University’s
Psychology Department. Only the interview data will be discussed due to the
large amount of rich data collected in order to be able to give due justice to this.

Interview Schedule
Following discussions with members of a committee set up to review the issue
of ethnicity and diversity within the institution, the researchers carried out a
literature review and designed an in-depth semi-structured interview schedule.
The interview questions focused on issues of difference, including ethnicity,
social class, religion, gender and sexual orientation while exploring participants’
experiences of their clinical training and their current views about the organiza-
tion. Participants were also asked how they felt their ethnicity had impacted on
their training, and to give suggestions as to how the organization could become
more ethnically diversified.

2
The identity of the institution was anonymized for peer review.
3
In this article ‘psychoanalytic’ will be used generically, i.e. to include some of the main
theorists such as Freud, Jung and Klein.
358 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

Interview Participants
In total 105 individuals who were members of the BAP volunteered to be
interviewed via the postal questionnaire. Due to time and resource constraints,
not all the volunteers could be interviewed, and priority was given to interview-
ing all minority ethnic members, as well as other key members and trainees
within the organization. These participants were either recruited from the
postal questionnaire or from purposive sampling. In total 24 members (21
women and 3 men) were interviewed by 11 committee members from the
institution. One participant dropped out of the study after she had received her
transcribed interview. For the sake of confidentiality any identifying factors
such as participants’ names have been changed. Participants were asked to
self-report their ethnicity as suggested by researchers (e.g. Modood et al., 1997),
but for the sake of anonymity ethnicities have been grouped into broad categor-
ies. There were 17 participants who identified as from an ethnic minority, and 5
participants who reported to be ‘white’. One participant chose not to identify
with any particular ethnicity.

Interviews
All interviewees were provided with an information sheet explaining the
purpose of the research and gave signed consent. Interviews lasted between 35
minutes and 85 minutes, were digitally recorded and transcribed verbatim by
professional transcribers utilizing transcription conventions which noted hesi-
tations, pauses and overlapping speech (Kvale, 1996). Identifying details were
removed from the transcripts and participants were given pseudonyms. For the
purpose of clarity in reporting,‘ums’,‘ers’, pauses,‘you know’,‘I mean’,‘kind of’,
‘sort of’ and word repetitions were removed. Words emphasized by participants
were put in capitals. Data from the interviews were managed utilizing
maxqda 2, qualitative data management software.
To inform the data analysis, the researchers drew on discursive psychology
(Edwards & Potter, 1992) rather than psychoanalysis. The former avoids
on-going questions about the ethics and validity of using psychoanalytic inter-
pretations when analysing interview data collected outside a clinical setting
(Hook, 2008; Parker, 2005). Data was coded and analysed thematically
(Barbour, 2008). Thirty-five main codes emerged from the data, which were
further coded into subcodes. The codes and interpretations of data were dis-
cussed and verified by the two authors. All participants were provided with
excerpts from their interviews which were to be published, and the participants
edited many of these.

Findings

Recruitment Interviews
Participants discussed various aspects of their clinical training from the initial
recruitment interviews to the point of qualification as a psychotherapist. Par-
ticipants noted how issues of diversity relevant to culture, ethnicity, racism,
gender and sexual orientation were often ignored or not fully explored within
KAREN CICLITIRA AND NENA FOSTER 359

their training. The difficulty in addressing these issues and their notable absence
manifested in various often unspoken ways. One participant noted his inter-
viewer’s initial discomfort at finding ‘a large black man’ at his door, as this
would be outside the institution’s perceived norm:
Henry: X [name of interviewer] was very easy and relaxed and welcoming. X,
I think he was a bit thrown. He wasn’t expecting me to be me, and I think he
was a little bit thrown but after that he was all right.
Interviewer: What do you mean?
Henry: I think he was a bit flustered at the door . . . because I was a large young
black man.
While Regina discussed her initial interview experience partly in a positive
way, she described a ‘blind spot’ in the organization and its members’ recogni-
tion of culture. This absence, as in this instance, was often interpreted as indi-
cating, that from this initial contact with a member of the BAP this should not
be spoken about:
The interviews I thought were very thorough. Culturally I think that there was an
element of a blind spot there. And my taking from that was something that you
didn’t really raise within an interview setting.
Training Analysis/Therapy
While there seemed to be a lack of recognition about individuals’ culture and
ethnicity in many encounters, such as the recruitment interviews, training analy-
sis was identified as a potential site where these issues could be discussed –
although this was not guaranteed, as it would depend on the individual analyst.
This private space could give the opportunity for exploration and allow minor-
ity ethnic trainees to explore their own identity, and help prepare them for
working with diverse or different patient groups. However, one participant who
insisted that these matters should be addressed in trainees’ analysis had recently
accepted that this could not be the only place where these issues are addressed,
as not all analysts would have the competence or capacity to do so:
Jackie: There’s no hope of ever addressing serious social issues like prejudice and
racism if you can’t think about them in yourself. I’m always astonished by the fact
that there are many people who don’t think about such issues analytically, or in
terms of their own capacity for racism. Having seminars on ethnicity or racism
without, at the same time, having a psychoanalyst or psychotherapist who’s willing
to think about such things is a waste of time. In fact, it would be like trying to teach
clinical seminars without having a patient. The point is that unless one is also able
to reflect on one’s own relationship to a particular problem, and realize that it
cannot be addressed in the abstract, one cannot really engage in its broader social
context . . . I’ve never actually thought this through in this way. I’ve ALWAYS
thought, I don’t agree with this whole idea about ‘we’ve got to have seminars on
racism’, and that it has to come from your analysis. But it can only come from your
analysis if you yourself are willing to think about it, and you have an analyst who’s
capable of doing so.
Additionally, it was speculated that a trainee needed to be open or to have
specific experience, perhaps a negative experience, of culture and/or ethnicity, in
360 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

order for them to be addressed in their analysis. Individuals coming from a


minority are more likely to engage with these issues and want to explore them
from a personal point of view. As in Kevin’s case, identity and ethnicity were
central to his analysis. Although his ‘white analyst’ was able to explore these
issues with him, the topics which were outside his analysis had to be ‘managed’
by himself:
Identity and ethnicity was a significant feature of my analysis . . . I had a terrific
analyst who was a white elderly man . . . There were fantasies about what would be
the impact, how would I be perceived, what pathologies might be assigned to me . . .
I had to manage the journey. It wasn’t something that was going to be managed for
me.

An insensitive therapeutic encounter may be experienced as a repetition of


racial oppression and its accompanying power issues (Bhugra & Bhui, 2006).
Barbara, who identified as a ‘black trainee’, discussed the difficulties of relating
to a ‘white analyst’ with a different set of cultural and ethnic identifications. She
described how relieved she was to discover that her analyst could deal sensi-
tively and meaningfully with issues such as racism. However, she highlighted the
fact that other analysts and supervisors may exclude these issues to the detri-
ment of minority ethnic patients:
What makes it difficult sometimes for the black trainee is how much do you think
you can be yourself. At the end of the day do you have a good enough experience
of the analysis if you feel that sometimes you have to hide behind something? . . .
But with the analyst I had I did pluck up the courage to say: ‘I didn’t want to come
in today’. She said: ‘Why?’ And I told her why, and the idea that I wouldn’t think
that she could understand what it’s like to be in that position, and how it would feel
coming in was really helpful. But it’s whether every training, whether every analyst,
and every supervisor, and every whatever could be sensitive enough to do that
when they’ve got other things to be thinking of . . . You equally will lose a patient
if, just like my analyst could’ve lost me, because that was a real experience and if she
somehow couldn’t grapple with that, I think, then, I just would not have continued
with any confidence, because she would’ve been excluding a big part of me that was
in tatters.

Regina asked for a black analyst and was allocated a white Irish analyst, who
was able to address culture in a way that she found meaningful:
I also had a very good analyst, because initially I’d asked for a black analyst and I
was told there aren’t any, they were in New York or something, but I had a very
good Irish analyst who seemed quite comfortable with also me bringing in cultural
issues in a very deep and meaningful way . . . That was the best part of the training
for me.

In summary, the relationship between analyst and trainee was seen as


extremely important for bringing particular issues to the fore, including
notions of ethnicity and difference. It was noted that an astute and sensitive
analyst was needed in order to explore these issues adequately. If left un-
addressed, it seemed that these issues could damage the trainee/analyst
KAREN CICLITIRA AND NENA FOSTER 361

relationship as well as impact on the trainee’s future professional capacity


with their own patients.

Individual Clinical Supervision


When asked about their experiences of clinical supervision, some participants
felt that their supervisor was a source of support throughout the training. For
example, Maryam said:
I spoke with my supervisor, at the time I was with X [supervisor] and obviously I
spoke about it to my analyst, and neither of them agreed with what Mrs X [seminar
leader] had said about me . . . It was very helpful at the time . . . she [supervisor]
actually said to me that she thinks that X is very English, and that she could’ve
misunderstood some of my ways.

Conflicts in supervision were sometimes considered to be due to differing


levels of cultural awareness between minority ethnic trainees and their often
white supervisors:
Kevin: I had a challenging experience with one particular supervisor but it was a
question of ‘what do I know?’ I didn’t have lots of supervisors at that stage, and it
was a different level of training, a different level of supervision, a different level of
intensity and the interactional style is unique between two individuals. But I didn’t
find it a difficult or aversive experience. If I hadn’t have been a qualified mental
health professional already, or had other sorts of esteem, or had parents who kind
of made me feel good, or whatever, I might have had an issue with it.

Various tensions regarding individual clinical supervision and clinical semi-


nars, and the recognition of ethnic or cultural diversity issues were raised:
Interviewer: Did your training at the BAP adequately address issues concerning
ethnicity, racism and anti-discriminatory practice?
Henry: Not at all. Not at all. The training didn’t but supervision did . . . clinical
seminars wasn’t there, but it was in my supervision.As it inevitably would be because
I was a black person working with two white patients intensively, long-term.

Participants’ reports varied, with some participants finding their supervisors


were facilitative when it came to the discussion of difference, but in some cases
this was not the case and supervision was a source of challenge or conflict.

Infant Observation
An integral part of all trainee experiences was their infant observation and the
seminars linked to these observations. All trainees were required to observe a
baby or a toddler weekly for a period of one and two years, depending on their
course requirements. This was noted as a possible site of cultural recognition, as
well as cultural insensitivity. For Ava this was an enriching experience, and
presented an opportunity to recognize the importance of cultural differences:
The area where I saw and felt the differences was in my infant observation course.
Because the baby I was observing was Eastern European . . . because either way
it will be an interesting cultural experience for me, whether it’s the same culture
or different culture, baby and mother, observing such an intimate, important
362 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

relationship . . . In presenting my observations of this baby and the baby’s cultural


environment it was not just me, but also my colleagues who commented often on
how different the flavour of the family, of the responses between the baby and the
various members of the family, and the people dropping in, and how they
responded to the baby and the baby to them.

Barbara reported that her experience of the infant observation proved to be


a site for appreciation of the cultural differences between the observer and the
observed:
I found it a very good experience. The idea about watching a baby and its relation-
ship with its mother and how that develops. And all the cultural things about
circumcision, and different ways of perceiving the child, and linking it with the
forefathers, and all that kind of thing are fascinating and don’t really happen in
West Indian cultures in the same way.

Other participants found that the way infants and their families were observed
could be reductive and misinterpreted, which Vivian described as Eurocentric:
We have a fairly Eurocentric view of how things should be. I think that in terms of
infant observation . . . and in terms of ideas about how families operate.

Others felt that exploring an infant’s development through a cultural or cultur-


ally sensitive lens was important, as well as considering material issues such as
social class:
Regina: The assumption that it’s one homogenous group, rather than there are
differences within the Afro-Caribbean community, and there are class differences
as well, so it’s a much more complex picture I think. The danger is it becomes so
simplistic.

Some participants felt that if students were encouraged to observe families


from different cultures this would enrich their learning experiences:
Sarah: Thinking about culture is through the whole infant observation experience
of trying to have a variety of cultures, there’s a tremendous possibility there of
different experiences, of different family structures and races and cultures. And I
think we could do much more about trying to really influence that and make sure
that it is much more varied.

Participants were aware that there were missed opportunities for raising aware-
ness about cultural diversity in the infant observation seminars. Trainees’ views
suggested that they would like to be actively encouraged to read and discuss
relevant literature, and to observe minority ethnic infants.

Theoretical and Clinical Seminars


Participants noted that these seminars, like the clinical seminars, did not foster
discussions on diversity or difference in trainee or patient experiences:
Regina: I certainly feel in terms of theoretical seminars having a focus on intercul-
tural differences and differences give a sense that it’s a training that’s thinking
about it. But certainly when I was training you didn’t have the theoretical seminars
on cultural difference or working with refugees.
KAREN CICLITIRA AND NENA FOSTER 363

Ruth implied that she thought that only because she trained with two black
students were there opportunities to talk about cultural issues in theoretical
seminars, but even so there were not those openings in the infant observation
seminars:
We had two people in my group who were black, and I think there were opportu-
nities in the theoretical seminars to think about race and racism and ethnicity and
so on. Where it didn’t get talked about, and I think it could’ve been talked about,
was in the infant observation seminars, and I think it’s quite significant really.

In training settings minority individuals often feel that if they speak up they
will be seen as a spokesperson for their culture, or they may fear that expressing
negative feelings will reinforce stereotypes about their cultural group (Parker
et al., 2004). Bipasha linked her difficulties in seminars to her being different,
and to being in a minority from other trainees:
It was in the clinical seminars that I felt quite got at. And I don’t know whether it
was because of that difference. And I think these sorts of training groups are quite
rivalrous anyway. And maybe that was one form that it took. That they kind of
dumped on the person who was a bit different. Or maybe there were reasons for
them to find fault with what I was doing . . . The seminar leaders didn’t seem to
think anything of it. So I thought: ‘Well, this is part of the course’.

Being from a cultural minority reportedly could put pressure on minority


trainees as they were expected to ‘have all of the answers’ about racism and
culture:
There’s something very strange about being the only one of something in a group.
Some of the things that you were very aware of was like when it came to questions
about race and culture, you either had to make a conscious decision that you were
not going to be the one that always brought this issue up or answered this question;
that you didn’t want your other group members just to pay lip service, look to you
for the answers.

Some noted that the clinical seminars lacked exploration of diversity and that
there was resistance to exploring these issues:
Ina: I think of them as clinical seminars where people present work with people
from other races. It is important. I know people have strong feelings about it, but I
think it is important that it has become an issue.

In summary, clinical and theoretical seminars were enjoyed by many of the


participants for their content, structure and interactive nature, but some
reported feeling that conflicts and unpleasant group dynamics were not well
managed by the seminar leaders. Seminars were seen as a potential forum for
addressing diversity, but these opportunities were often not taken up.

Challenging Psychoanalytic Theory


Participants noted that the negative historical representations of ethnicity and
‘race’ in psychoanalytic theory were a potential deterrent for minority ethnic
individuals to undertake a psychoanalytic training. Additionally, it was reported
364 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

that there was a clear white middle-class ‘majority’ group within the training
organization. Yasmin described how she felt constrained in seminars:
I was one of a few amongst a predominantly white, middle-class member group . . .
So I feel it’s just brought that to my notice more that I was different. Whereas I
suppose generally I don’t go around feeling I’m different. But it was kind of quite
stark really . . . I don’t really think I felt fully part of the BAP. I think my experience
of being the ‘other’ here, so to speak, has also a part to play . . . I haven’t had any
experience in the BAP of being discriminated against because of my race, only a
kind of discomfort that I don’t belong. I have this feeling that I can’t engage with it,
I can’t quite find my place in it. But that might have, not necessarily to do with my
race, but to do with my sense that it is very constrained and controlled. Not
individually to do with individual members, but in the group there is something very
controlled about it.
Participants in this study mainly reported what could be considered as
‘microagressions’, rather than overt racism, which were probably unconscious,
and often downplayed, yet they were undoubtedly problematic and damaging
for the recipient (Constantine & Sue, 2007; Sue, 2003). As Ina explained:
I have a British passport, but you don’t forget that you are a foreigner. People used
to ask me: ‘When are you going back?’ A kind of reminder that you come from
somewhere else. It’s inevitable. There are constant reminders that you’re not really
from here. It does not necessarily mean that you shouldn’t be here, but a question
of what are you doing here? And when I applied for the training I was asked if I
would understand the patients, and as a mother how would I manage if the children
got ill.
Lisa highlighted the tensions of acknowledging the importance of the uncon-
scious in clinical work, while recognizing the importance of exploring both the
concept and individual experiences of culture in training:
Therapy is seen as ‘Oh my God, you go to a shrink for ten years, they change your
brain’, there’s that kind of cultural shift that needs to happen somewhere that
therapy isn’t this oddball creature, to me, it’s something about the valuing of the
unconscious which is denied in our society . . . There is a cultural thing that we have
to address in some ways.
Reshma noted that her family’s relinquishment of their ‘Indian culture’ made
it easier for her to fit into the (white) majority, and she linked this personal
experience to her experience of her training:
If had I come from Hackney through an Access course with a bit of attitude . . . I
wouldn’t have fitted in that group I don’t think. Very middle class, very, white in
terms of one’s ideas, our shared, even things like going to the pub, the shared
interests . . . That’s what my parents aimed for that we should, because there were
not any other Asians around where I was brought up. So my parents didn’t speak X
[Indian language] at home, the idea was that we should fit in at all costs, so I think
I’ve become very good at fitting in. So I think that’s why I think that’s made it easier
for me. Whereas I think someone else who’s hung on or had a stronger cultural
identity, I wonder if it would be so easy for them.
Regina described how a minority ethnic trainee could be made to feel out of
place and anxious:
KAREN CICLITIRA AND NENA FOSTER 365

I had been told by a lot of colleagues and friends this is a whole new area to go into,
very few black people train in this area and that there were risks . . . You were
taking on new ways of thinking, but were having to make readjustments externally,
and also this anxiety about losing respect. Because, in the group there was a lot of
material dug up about psychoanalytical ways of thinking and how black people, in
the past, had been somehow stereotyped and seen in particularly negative and
pernicious ways because of the psychoanalytical brain. So going into that training,
for me, was seen as well ‘X [own name] why are you doing that? Do you know what
could happen? Do you know how the whole thing about race and culture is seen
within that particular psychoanalytic?’ . . . You were a bit like being in limbo, so just
welcome but perhaps a source of anxiety, and then you were pulling a bit away from
what you’d come from. So there were huge risks. And I think some people were put
off training because of the fear of what you would be left with and how you would
be seen and perceived. I feel I’ve survived that well and with a lot of support, but
there were difficult times and times where you felt you had no place in any place.

The difficulties of psychoanalysis being considered as an ‘orthodoxy’


(Bornstein, 2001; Kernberg, 2004) and participants feeling silenced were
also discussed. For example, Bipasha commented:
There was this quite immovable orthodoxy about the training. And there seemed to
be little scope for bringing up differences which were outside the orthodoxy. And it
wasn’t possible to debate some of these things, and I felt that if it was outside this
field, it couldn’t be brought up.

Participants also reported difficulties with discussing and addressing issues


related to social class, religion, gender and sexual orientation. For example,
Ruth described how she found that it was unacceptable to discuss gender in any
political way and that there were repercussions for daring to do so:
I encountered a very difficult time with one male seminar leader where I wanted to
address some issues about gender in a more political way. I think it was somebody
whose approach was a more classical, archetypal Jungian classical approach and
wanting to challenge some of that, and bring in a more political element. And that
was very difficult. I felt he became very defensive and wouldn’t talk about it, and
actually the feedback that I got from that seminar was very personalized and rather
trivializing, I think of what I was raising, as though it didn’t belong in a seminar. So
I did actually feel very angry about that.

Psychoanalysis and Homosexuality


Participants reported that those who did not identify as heterosexual would
experience difficulties due to homosexuality being viewed as a psychopathology
in classical psychoanalytic theory:
Reshma: As far as I know everyone in that group was heterosexual, and I think it
would have been difficult for somebody who was not. I really do think that would’ve
been difficult. Partly, because as I said before, the prevailing theoretical culture was
that there would not have been, I think, a discussion about the inclusion, for
example, of homosexuality within the disorders-framework, as opposed to it being
on the normal spectrum, a normal continuum . . . The prevailing wisdom within the
BAP, whatever individuals thought separately, would’ve been, I think, negative.
366 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

Ryan explained how difficult it could be for a homosexual trainee:


To try and decide how open to be, and when they’re applying, and how open they
can be with seminar leaders, and how openly they could raise that in various forms.
I think it’s essentially the fear of being regarded as deviant. The old traditional
Freudian view of being gay and therefore problematic – Oedipal.
One participant reported that discussions about sexual orientation were
implicitly discouraged by a ‘don’t ask, don’t tell’ type of policy and echoed by
the lack of space devoted in the curriculum to discussing sexual orientation:
Henry: I think sexuality is something the BAP never ever makes reference to for
anybody about anything. No, nobody asks, they don’t talk about it. So there might
have been people who were lesbian or gay who were training in the group, but
nobody would ever know because it was never ever mentioned, it was not of
importance.And I had a feeling that they didn’t want to know. Because if they knew
they’d have to do something about it. Or they might have to have a view about it,
so I think they adopted a kind of a neutral position which is ‘don’t tell us and then
we don’t have to know’.
In summary, while those who identified as heterosexual reported that their
sexuality did not have an impact on their training experience, there was ample
recognition that identifying as homosexual would present difficulties, largely
due to the theoretical basis of psychoanalytic theory. Some participants
believed that homosexuality was even more difficult to discuss openly than
other issues of difference, such as culture, gender or ethnicity. A lack of open-
ness within the organization was felt to silence those identifying as homosexual,
as well as those from different social backgrounds and cultural heritages. The
lack of formal discussions about the various aspects of diversity was seen to
impact on the preparedness of all of the trainees to address their own differ-
ences, as well as that of their patients.

Discussion: The Implications for Psychoanalytic


Psychotherapeutic Training
Students on all the clinical trainings in this institution are required to have a
lengthy training analysis or therapy. Historically, many of the trainees from this
institution have been encouraged to see a psychoanalyst from another institu-
tion for their personal therapy, and many of the seminar leaders and clinical
supervisors come from a relatively small group of respected training analysts.
Participants’ views about their training analysis suggested that on the whole
they experienced it positively, but minority ethnic participants described
various ways in which they felt excluded or othered.
It was generally accepted by participants that training analysis should not be
the sole site for exploring diversity. As Bhugra and Bhui warn (2006, p. 50),
racism and culture may often not be properly scrutinized in trainees’ personal
analysis, nor are they in training programmes. They accept that psychoanalytic
trainees’ are encouraged to explore their own self-awareness to prevent per-
sonal reactions from interfering in therapy, but that trainees need both this
self-understanding as well as an understanding of different cultures to work well
KAREN CICLITIRA AND NENA FOSTER 367

with patients. Psychoanalytic theory allows for the fact that clinicians are
unlikely to overcome their racist feelings and attitudes: no one’s unconscious,
not even the best analyst’s, will ever disappear, but clinicians need to become
familiar with their own racism (Altman, 2006).
As Kernberg (2004) suggested, supervisors should be chosen for their capac-
ity for supervision, and seminar leaders should be selected on the basis of
demonstrated teaching ability, specialized knowledge, clarity of thinking and
talent to teach and to learn rather than because they happen to be senior
training analysts. Although many of the training analysts who also carry out
these functions in this institution are from a separate organization, their sen-
iority within the world of psychoanalysis may make it hard for training institu-
tions to require that they demonstrate their willingness to learn about and to
facilitate discussion of issues such as culture and ethnicity. Holmes (1992)
argues that racial meanings should be addressed in all training analyses as well
as by didactic learning and supervision, irrespective of trainees’ ethnicity. A
trainee’s ability to work competently in a therapeutic relationship requires that
supervisors initiate discussions about heritage, and can guide trainees’ discovery
of their values, assumptions, and biases related to racism and culture (see
Tummala-Narra, 2004).
Participants’ accounts pointed to a paradox in psychoanalytic training: insight
is integral to understanding and treating patients, but it appears very difficult for
trainees to discuss their insights about their own diversity and that of others
during their training. The acknowledgement of the impact of diversity, such as
homosexuality, gender, religion, culture and ethnicity, seemed to be particularly
difficult to reconcile within the trainings at this institution.
In the light of the feedback and recommendations from participants regarding
the training components, further attention should be paid to infant and parent
interaction to consider cultural difference in trainees’ infant observation. Train-
ees could be encouraged to observe infants from minority ethnicities and to work
with training patients from diverse backgrounds. This would provide important
opportunities in terms of exploring, appreciating and sensitizing trainees to
culture and diversity. Participants’ interviews suggest that a more active manage-
ment of the seminar sessions is needed to provide opportunities for exploring
diversity, as well as to consider these with respect to psychoanalytic theory and
the resulting tensions. Following participants’ suggestions, it would be advisable
for further training for clinical supervisors, seminar leaders and training analysts
to be provided, and for members of the institution to actively recruit individuals
with knowledge and experience of diversity issues. The integration, not just the
acknowledgement, of diversity in clinical training is essential to facilitate a much
needed modification in psychotherapy and supervision practice and the cultural
competence of a training institution (Sue & Sue, 2003).
Cooper (2010) warns that acute anxieties are often mobilized when institu-
tional racism is named and identified. However, Cooper and others (e.g. Davies,
2008) insist that change will have to be carried out at an institutional level. The
need to address diversity is evidently important both for the sake of good
practice with patients, and to encourage prospective applicants to undertake a
368 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

psychoanalytic training programme. Instead of overt expressions of white racial


superiority, research supports the contention that racism has evolved into more
subtle, ambiguous and unintentional manifestations in social, political and
economic life. Without documentation and analysis, the threats that racist
microaggressions pose and the assaults they justify can easily be ignored or
downplayed (Solorzano et al., 2000). Lack of multicultural training may lead to
racism of this kind in clinical practice. Any clinician, regardless of ethnicity,
background, or motives can engage in unintentional racism (see Ridley et al.,
2000); and insidious forms of racism can arise if clinicians with good intentions
engage in harmful interventions.
Assumptions about diversity are not only a product of personal history, but
also of social history and rooted in shared experiences. It was noted by partici-
pants that the focus on the ‘internal world’ and the difficulties of incorporating
the ‘external world’ into theory and discussion often created a barrier to train-
ees’ discussing certain experiences. Lowe (2008) highlights the necessity for
students to study the psychological legacy of slavery, colonization and empire.
Research has indicated that completion of diversity-related courses appeared to
increase trainees’ multicultural therapy competencies, especially awareness of
their own cultural and personal biases and knowledge and skills of working with
diverse populations (Neville et al., 1996). Teaching about culture, diversity and
ethnicity within mental health trainings can lay the groundwork for critical
learning, impasses and enactments. Trainees need to understand their own, as
well as their patients’ cultural backgrounds, as far as they can (Helms, 1990).
Experiential exercises have been suggested as an effective way to increase
trainees’ personal awareness of possible biases and assumptions in a context
where participants feel safe enough to discuss difficult ideas and process uncom-
fortable emotions (Rogers-Sirin, 2008).
In conclusion, the topic of diversity in clinical trainings and work is multi-
faceted. This study focused mainly on ethnicity and culture, and gave less
consideration to issues such as sexual orientation, religion, class and gender
(and did not consider others such as disability). However, these factors inter-
sect, and, for example, privileging ethnicity over gender can have serious impli-
cations for minority ethnic women living in the UK. The dynamics of racism,
class and gender need to be recognized and worked with. This is not to deny the
importance of cultural understandings, but to emphasize the importance of
being alert to issues of power and oppression (Chantler et al., 2001).
Greene (2006) warns that psychoanalytic paradigms continue to be ‘blatantly
ethnocentric, sexist and heterosexist’; particularly in the way child development
and human behaviour are viewed. They can therefore be seen as unsuitable for
the treatment of ‘diverse ethnoracial individuals and sexual minorities’ (pp.
164–5). Many trainees who reported that they would have liked further discus-
sion about these issues felt reluctant to do so, and ill-equipped to consider these
issues with their patients. However, psychodynamic theory, particularly theories
of intersubjectivity, can provide a good basis for students and trainers to learn
about these issues (Tummala-Narra, 2009). Multicultural education should
involve a close examination of affective processes and the mutual influence of
KAREN CICLITIRA AND NENA FOSTER 369

students and instructors. Psychodynamic perspectives on multicultural educa-


tion can encourage the introspective inquiry related to diversity that is critical
to appropriately addressing concerns of clients in psychotherapy (Tummala-
Narra, 2009, p. 332).
Guidelines for all training organizations need to go beyond an idea of multi-
culturalism that focuses solely on services provided to clients, and must
embrace the culture of the organization itself (Constantine & Sue, 2005). Issues
of racism, culture and ethnicity in the theory, practice and training in psychody-
namic counselling and other forms of clinical trainings are increasingly visible
(e.g. Palmer, 2002), but they continue to be marginalized in psychoanalytic
psychotherapy and psychoanalysis (Moodley & Palmer, 2006). Furthermore, the
lack of consideration to all external matters, and not only diversity, within
psychoanalytic practice, can leave patients feeling unfairly blamed for external
factors which they may have no control over (e.g. redundancy and difficulties at
work). The recognition for change with regard to addressing diversity is long
overdue. Diversity needs to be addressed in all aspects of psychoanalytic train-
ings and not just tacked on by adding a few seminars. Trainees should be given
contemporary literature to study which addresses diversity and not focus solely
on classical psychoanalytic theory.
There should be more active recruiting and training of minority ethnic clini-
cians while simultaneously increasing and developing the cultural competence of
all clinicians (Smith et al., 2006). Bornstein (2001) recommends the acceptance of
more theoretical pluralism within psychoanalytic institutes.The aim would be to
create a less monolithic and hierarchical atmosphere within seminars by foster-
ing supervisors’ openness toward alternative orientations within their own insti-
tute, particularly those preferred by individual candidates. There is a growing
recognition by psychoanalytic organizations such as the British Psychoanalytic
Council (BPC) to recognize the importance of research and scientific investiga-
tion (e.g. BPC, 2011, p. 7). However, more empirical research is urgently needed
to address questions regarding the effectiveness of psychoanalysis compared
with alternative approaches, so as to transform psychoanalytic education into a
more open, dynamic, creative educational system geared to generating new
interest in the practice (e.g. Auchincloss & Michels, 2003; Fonagy, 2004).
More than a decade ago Kernberg (2000) warned that the neglect of research
training and the lack of developing a research attitude were a major problem for
contemporary psychoanalytic education, and reflected a dangerous lack of
concern for the scientific standing of psychoanalysis. Classical psychoanalytic
theory is under attack from those who emphasize evidence-based practice and
cost-effectiveness in the UK National Health Service, and is threatened by the
rise in popularity of cognitive–behavioural treatments and psychotropic medi-
cine (Kernberg, 2000). This isolation has also manifested itself in a lack of
consistent concern for the educational experience of students and a denial of the
effects of external, social reality on psychoanalytic education. Some of the
difficulties highlighted regarding the selection of students, the criteria for gradu-
ation and the ways supervision and seminars are conducted (see Kernberg, 2006)
are likely to have a particularly strong impact on minority ethnic individuals.
370 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

A conservative organizational hierarchy reinforces structures and systems,


irrespective of intention, making trainees apprehensive about being openly
different. The expectation of silent conformity about material issues such as
diversity would seem to stifle trainee development and alienate minority train-
ees and members. Given that one of the aims of psychoanalysis is to facilitate
openness and insight, a fear of openness and reluctance to engage in critical
debate on such issues are regrettable. The limitations of this study were the
small sample size, the lack of generalizability, and the fact that the participants
were those who had been accepted on to the training and had been able to
remain at the institution. Although some attention has been given to diversity
in psychology and counselling research over the past 20 years, it has been
neglected within psychoanalytic trainings, and this research makes a start at
addressing that neglect.
This research was generally viewed as a positive first step towards diversify-
ing the training programmes and the organization. The current administrative
leaders of the BAP have demonstrated their commitment to this research, and
moves are being made towards improving the culture of the organization and
including diversity issues into different aspects of the trainings. The BPC issued
a statement in 2011 to stipulate that its member institutions should not discrimi-
nate against individuals due to their sexual orientation; however, this is an area
which will need active involvement from the psychoanalytic community in
order to change long-standing prejudices. It is important for psychoanalytic
institutions to address how difference fits within a psychoanalytic paradigm;
there are excellent theoretical and clinical papers that address diversity such as
ethnicity and homosexuality, but these are rarely given due consideration. The
emphasis on the ‘internal world’ and the unconscious in the trainings can make
it problematic to consider the ‘external world’; but issues that are externally as
well as internally mediated such as gender, homosexuality and ethnicity can be
introduced into the training in fruitful ways.

Acknowledgements
We would like to thank all our research participants and in particular the
interviewees. We would also like to express our gratitude to Elise Ormerod, the
BAP administrative staff and the members of the research group who carried out
interviews or supported this project in other ways: Nick Benefield, Maggie
Cochrane,Andrew Cooper, Steven Flower, Maureen Fox,Aparna Jack, Margaret
Humphrey, Helen Morgan, Juliet Newbigin and Janine Sternberg.We would also
like to thank Ann Scott and the reviewers for their constructive comments.

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