Attention to Culture and Diversity in Psychoanalytic Trainings

Diversity and Clinical Training

ATTENTION TO CULTURE AND DIVERSITY INPSYCHOANALYTIC TRAININGS

Karen Ciclitira and Nena FosterABSTRACT Ethnically and culturally diverse groups increasingly undertake psycho-therapy, but insufficient attention is often paid to aspects of diversity. This articleexplores qualitative data from a mixed-method study, conducted at a UK psychoanalyticpsychotherapy training institution, in which 24 participants from diverse backgroundswere interviewed individually about their experiences of clinical training. Participantswere 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 datawere analysed thematically, and a principal theme that emerged was the way thatpsychoanalytical clinical trainings tend, for theoretical reasons, to explore ‘internal’psychological issues at the expense of ‘external’ material issues such as ethnicity. Similarconcerns arose in connection with social class, gender and sexual orientation, with aspecific theme being that of trainees feeling silenced and finding it difficult to openlydiscuss various aspects of diversity.

Key words: psychoanalytic training, culture, diversity, ethnicity, homosexuality,minority

IntroductionThe changing social demographics of the UK demand that culture and ethnicityas well as other social factors are better addressed in the provision and trainingof psychotherapists and counsellors. While individuals from ethnic minoritygroups in the UK numbered just over 3 million (5.5 %) in 1991, the number roseto 4.6 million over the next decade, an increase of 53% (Office for NationalStatistics, 2001). It has been predicted that ethnic minorities will make upone-fifth of the UK population by 2051, as compared to 8% in 2001 (Wohlandet al., 2010). Researchers in the USA and the UK have argued for some yearsthat high-quality professional clinical training is needed to take into account theincreasingly multicultural population (e.g. Constantine & Sue, 2005; Patel et al.,2000). The majority of research and development in clinical training provisionhas been carried out in the US, although there have been a number of initiativesin the UK (e.g. Shashidharan, 2003).

There are numerous obstacles for access to mental health services by ethnicminorities, and researchers have indicated various ways in which these can bealleviated by the development of culturally relevant treatments and trainingprogrammes.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 includeracism, gender, psychoanalysis, sexuality, health, feminist research and discourse analy-sis.Address for correspondence: [[email protected]]

NENA FOSTER PhD is a Senior Lecturer in Public Health at the University of EastLondon. Her research interests include diversity and culture.Address for correspond-ence: [[email protected]]

© The authorsBritish Journal of Psychotherapy © 2012 BAP and Blackwell Publishing Ltd, 9600Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 353DOI: 10.1111/j.1752-0118.2012.01298.x

lack of cultural awareness among professionals, recognizing culturally diverseexpressions 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 DiversityIt is generally accepted by researchers and clinicians that mental health profes-sionals need specialist training to deliver effective services to ethnically andculturally diverse service users (Patel et al., 2000; Ridley et al., 2000), and thatthere is a need for more clinicians from ethnic minority groups to be serviceproviders (e.g. O’Sullivan et al., 1989). Additionally, training programmes arelegally 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. TheAct specifically addresses education and training, and calls on public institutionsto develop and implement a ‘race equality scheme’.

Research has shown that clinical training programmes often fail to addressethnicity and culture adequately. Institutional and psychological barriersprevent changes being implemented in clinical trainings: Tummala-Narra(2009) suggests that racial and cultural diversity are not just overlookedin clinical trainings, but actively avoided, because of the types and intensityof emotion that the subject evokes. Multicultural education for mentalhealth professionals can, however, encourage the development of attitudes,knowledge, and skills associated with multicultural clinical competence (seeSmith 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 thestudents, to help avoid negative outcomes that occur when students’ receptivityto 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 therapeuticalliance, as well as using empathy to support a client’s expressed ambivalenceabout differences and self-assessing multicultural competence (Fuertes et al.,2002). Minority ethnic therapists tend to be more aware of the impact of being aminority in therapy compared with white therapists (Yi, 1998).

Clinical supervision is a central part of most clinical trainings and allows fortrainees to address emotionally difficult areas with a trained clinician. It hasbeen argued that: ‘Clinical supervision is the most practical vehicle throughwhich conscious and unconscious pathologizing and exoticization of clients andtherapists 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 environmentsconducive to interpersonal learning with supervisees. However, charged issues

354 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(3)

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 issuesin 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, superviseeand patient is often ignored on the grounds that culture, ethnicity and socialnorms are viewed as external and treated as irrelevant to the therapeuticprocess.

Bartoli and Pyati (2009) advocate further training to help supervisorsdevelop the clinical sophistication to deal with complex aspects of interracialdialogue. 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 stereotypicalassumptions about black clients and supervisees, focusing on black super-visees’ clinical weaknesses, implicitly blaming black clients for problemsstemming from oppression, and offering culturally insensitive treatmentrecommendations.

Microaggressions may not be consciously intended, but from the perspectiveof the recipient they represent a negative experience. This ‘new’ manifestationof 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 ofcolour. They are so common and innocuous that they are often overlooked andunacknowledged (Solorzano et al., 2000). Sue (2003) argues that: ‘This contem-porary form of racism is many times over more problematic, damaging, andinjurious 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 andpsychology trainings in the USA and the UK (Patel et al., 2000; Smith et al.,2006), but psychoanalytic trainings have lagged behind (Cooper, 2010). Therehas been reluctance among minority ethnic students to seek psychoanalyticallyoriented training programmes which have historically failed to adequatelyengage with issues of ‘race’ and culture (Tummala-Narra, 2004).

Leading psychoanalysts have called for radical changes in the organizationalstructure of psychoanalytic institutes and psychoanalytic education for sometime (e.g. Garza-Guerrero, 2002a, 2002b; Kernberg, 2006; Levine, 2003; Mayer,2003). In a survey of trainings and policies in psychoanalytic psychotherapytrainings 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 authorsview ‘race’ as socially constructed, and that, as Rustin (2000, p. 183) states, it is both anempty category and can be one of the most destructive and powerful forms of socialcategorization.

KAREN CICLITIRA AND NENA FOSTER 355

viewed as the preserve of the white middle class and had little to offer blackindividuals, either as patients or as would-be practitioners. Furthermore, astipulation that training candidates have a first degree, for example, may dis-qualify more ethnic minority individuals.What may be necessary is not a degreeas such, but the ability to deal with intellectual work at the level of highereducation (Gordon, 1993). For instance, someone who says to a prospectiveapplicant of colour that ‘the most qualified person should get the job’ may beperceived 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 foundthat certain social conditions of psychoanalytic training institutes ensure thatanxiety plays a central part in most trainee experiences, with trainee conformityas the general rule and ‘dissent’ the exception (Davies, 2008). Those runningpsychoanalytic 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 questionthe applicability of psychoanalysis to be used cross-culturally for differentethnic groups, given its lack of appropriate attention to a range of culturaltraditions 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 suggestionsas to how psychoanalytic theory and practice can be drawn on to take ‘race’ andcultural issues seriously.

Training analysis has traditionally been the central feature of the tripartitemodel of psychoanalytic education, along with psychoanalytic theory, techniqueand the supervised analyses of patients (Wilson, 2010). According to Kernberg(2006), this model has created an atmosphere of submission to an establishedauthority, which has acted as a disincentive to innovative endeavours inpsychoanalytic institutes. He recommends that supervision should be thecentrepiece of psychoanalytic training as opposed to training analysis. Manypsychoanalytic therapy trainings in the UK follow this tripartite model. One ofthe main problems of training analysis was believed to be the ‘reporting’ train-ing analyst, a radical deviation from the clinical requirements of technicalneutrality (Kernberg, 2000). Some think of training analysis as being a strictlytherapeutic tool, while others assign it a more education role (Bosworth et al.,2009). Although there is no longer a requirement for training analysts to carryout detailed reporting about analysands to a training committee, some institu-tions continue to expect analysts to inform the training committee if they thinka trainee is not fit to practise as a clinician, providing the analyst with a greatdeal 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 thepower and hierarchical status of training analysts.

In view of the paucity of literature addressing psychodynamic perspectiveson multicultural education, it is important to consider that one of the goalsof psychoanalysis is emotional insight through making unconscious material


conscious. This has obvious relevance to identity struggles involved in multicul-tural learning. Contributions of psychodynamic perspectives to multiculturaleducation could be relevant not only to psychoanalytic trainees but to othermental health trainees, because they involve a study of individual and groupdynamics (Tummala-Narra, 2009). However, the minimization of external socio-cultural and cultural experiences within psychoanalytic theory and practice canbe seen to preclude these issues being fully considered and addressed in a usefulway in treatment (e.g. Littlewood & Lipsedge, 1997). Furthermore, aspects ofdiversity 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 PsychoanalyticCouncil finally issued a statement on homosexuality,which rejects discriminationon the basis of sexual orientation for future trainees – indicating a shift in views.

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

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

Interview ScheduleFollowing discussions with members of a committee set up to review the issueof ethnicity and diversity within the institution, the researchers carried out aliterature 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 ontheir training, and to give suggestions as to how the organization could becomemore 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 maintheorists such as Freud, Jung and Klein.


Interview ParticipantsIn total 105 individuals who were members of the BAP volunteered to beinterviewed 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 traineeswithin the organization. These participants were either recruited from thepostal questionnaire or from purposive sampling. In total 24 members (21women and 3 men) were interviewed by 11 committee members from theinstitution. One participant dropped out of the study after she had received hertranscribed interview. For the sake of confidentiality any identifying factorssuch as participants’ names have been changed. Participants were asked toself-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 5participants who reported to be ‘white’. One participant chose not to identifywith any particular ethnicity.

InterviewsAll interviewees were provided with an information sheet explaining thepurpose of the research and gave signed consent. Interviews lasted between 35minutes and 85 minutes, were digitally recorded and transcribed verbatim byprofessional transcribers utilizing transcription conventions which noted hesi-tations, pauses and overlapping speech (Kvale, 1996). Identifying details wereremoved from the transcripts and participants were given pseudonyms. For thepurpose of clarity in reporting, ‘ums’, ‘ers’, pauses, ‘you know’, ‘I mean’, ‘kind of’,‘sort of’ and word repetitions were removed.Words emphasized by participantswere put in capitals. Data from the interviews were managed utilizingmaxqda 2, qualitative data management software.

To inform the data analysis, the researchers drew on discursive psychology(Edwards & Potter, 1992) rather than psychoanalysis. The former avoidson-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 werefurther coded into subcodes. The codes and interpretations of data were dis-cussed and verified by the two authors. All participants were provided withexcerpts from their interviews which were to be published, and the participantsedited many of these.

Findings

Recruitment InterviewsParticipants discussed various aspects of their clinical training from the initialrecruitment 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


their training.The difficulty in addressing these issues and their notable absencemanifested in various often unspoken ways. One participant noted his inter-viewer’s initial discomfort at finding ‘a large black man’ at his door, as thiswould 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 hewas 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 youngblack man.

While Regina discussed her initial interview experience partly in a positiveway, 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 notbe spoken about:

The interviews I thought were very thorough. Culturally I think that there was anelement of a blind spot there. And my taking from that was something that youdidn’t really raise within an interview setting.

Training Analysis/TherapyWhile there seemed to be a lack of recognition about individuals’ culture andethnicity 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 forworking with diverse or different patient groups. However, one participant whoinsisted that these matters should be addressed in trainees’ analysis had recentlyaccepted 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 andracism if you can’t think about them in yourself. I’m always astonished by the factthat there are many people who don’t think about such issues analytically, or interms of their own capacity for racism. Having seminars on ethnicity or racismwithout, at the same time, having a psychoanalyst or psychotherapist who’s willingto think about such things is a waste of time. In fact, it would be like trying to teachclinical seminars without having a patient. The point is that unless one is also ableto reflect on one’s own relationship to a particular problem, and realize that itcannot be addressed in the abstract, one cannot really engage in its broader socialcontext . . . I’ve never actually thought this through in this way. I’ve ALWAYSthought, I don’t agree with this whole idea about ‘we’ve got to have seminars onracism’, and that it has to come from your analysis. But it can only come from youranalysis if you yourself are willing to think about it, and you have an analyst who’scapable of doing so.

Additionally, it was speculated that a trainee needed to be open or to havespecific experience, perhaps a negative experience, of culture and/or ethnicity, in


order for them to be addressed in their analysis. Individuals coming from aminority are more likely to engage with these issues and want to explore themfrom a personal point of view. As in Kevin’s case, identity and ethnicity werecentral to his analysis. Although his ‘white analyst’ was able to explore theseissues 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 terrificanalyst who was a white elderly man . . . There were fantasies about what would bethe 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 forme.

An insensitive therapeutic encounter may be experienced as a repetition ofracial oppression and its accompanying power issues (Bhugra & Bhui, 2006).Barbara, who identified as a ‘black trainee’, discussed the difficulties of relatingto a ‘white analyst’ with a different set of cultural and ethnic identifications. Shedescribed how relieved she was to discover that her analyst could deal sensi-tively and meaningfully with issues such as racism. However, she highlighted thefact 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 thinkyou can be yourself. At the end of the day do you have a good enough experienceof 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 comein today’. She said: ‘Why?’ And I told her why, and the idea that I wouldn’t thinkthat she could understand what it’s like to be in that position, and how it would feelcoming 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 thatwhen they’ve got other things to be thinking of . . . You equally will lose a patientif, just like my analyst could’ve lost me, because that was a real experience and if shesomehow couldn’t grapple with that, I think, then, I just would not have continuedwith any confidence, because she would’ve been excluding a big part of me that wasin tatters.

Regina asked for a black analyst and was allocated a white Irish analyst, whowas 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 Iwas told there aren’t any, they were in New York or something, but I had a verygood Irish analyst who seemed quite comfortable with also me bringing in culturalissues in a very deep and meaningful way . . . That was the best part of the trainingfor me.

In summary, the relationship between analyst and trainee was seen asextremely important for bringing particular issues to the fore, includingnotions of ethnicity and difference. It was noted that an astute and sensitiveanalyst was needed in order to explore these issues adequately. If left un-addressed, it seemed that these issues could damage the trainee/analyst


relationship as well as impact on the trainee’s future professional capacitywith their own patients.

Individual Clinical SupervisionWhen asked about their experiences of clinical supervision, some participantsfelt that their supervisor was a source of support throughout the training. Forexample, Maryam said:

I spoke with my supervisor, at the time I was with X [supervisor] and obviously Ispoke about it to my analyst, and neither of them agreed with what Mrs X [seminarleader] 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’vemisunderstood some of my ways.

Conflicts in supervision were sometimes considered to be due to differinglevels of cultural awareness between minority ethnic trainees and their oftenwhite supervisors:

Kevin: I had a challenging experience with one particular supervisor but it was aquestion of ‘what do I know?’ I didn’t have lots of supervisors at that stage, and itwas a different level of training, a different level of supervision, a different level ofintensity and the interactional style is unique between two individuals. But I didn’tfind it a difficult or aversive experience. If I hadn’t have been a qualified mentalhealth professional already, or had other sorts of esteem, or had parents who kindof 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 concerningethnicity, racism and anti-discriminatory practice?

Henry: Not at all. Not at all. The training didn’t but supervision did . . . clinicalseminars wasn’t there,but it was in my supervision.As it inevitably would be becauseI was a black person working with two white patients intensively, long-term.

Participants’ reports varied, with some participants finding their supervisorswere facilitative when it came to the discussion of difference, but in some casesthis was not the case and supervision was a source of challenge or conflict.

Infant ObservationAn integral part of all trainee experiences was their infant observation and theseminars linked to these observations. All trainees were required to observe ababy or a toddler weekly for a period of one and two years, depending on theircourse requirements.This was noted as a possible site of cultural recognition, aswell as cultural insensitivity. For Ava this was an enriching experience, andpresented 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 wayit will be an interesting cultural experience for me, whether it’s the same cultureor different culture, baby and mother, observing such an intimate, important


relationship . . . In presenting my observations of this baby and the baby’s culturalenvironment it was not just me, but also my colleagues who commented often onhow different the flavour of the family, of the responses between the baby and thevarious members of the family, and the people dropping in, and how theyresponded to the baby and the baby to them.

Barbara reported that her experience of the infant observation proved to bea site for appreciation of the cultural differences between the observer and theobserved:

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 aboutcircumcision, and different ways of perceiving the child, and linking it with theforefathers, and all that kind of thing are fascinating and don’t really happen inWest Indian cultures in the same way.

Other participants found that the way infants and their families were observedcould 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 ofinfant 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 associal class:

Regina: The assumption that it’s one homogenous group, rather than there aredifferences within the Afro-Caribbean community, and there are class differencesas well, so it’s a much more complex picture I think. The danger is it becomes sosimplistic.

Some participants felt that if students were encouraged to observe familiesfrom different cultures this would enrich their learning experiences:

Sarah: Thinking about culture is through the whole infant observation experienceof trying to have a variety of cultures, there’s a tremendous possibility there ofdifferent experiences, of different family structures and races and cultures. And Ithink we could do much more about trying to really influence that and make surethat 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’ viewssuggested that they would like to be actively encouraged to read and discussrelevant literature, and to observe minority ethnic infants.

Theoretical and Clinical SeminarsParticipants noted that these seminars, like the clinical seminars, did not fosterdiscussions 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 thinkingabout it. But certainly when I was training you didn’t have the theoretical seminarson cultural difference or working with refugees.


Ruth implied that she thought that only because she trained with two blackstudents were there opportunities to talk about cultural issues in theoreticalseminars, but even so there were not those openings in the infant observationseminars:

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 andso 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 theywill be seen as a spokesperson for their culture, or they may fear that expressingnegative feelings will reinforce stereotypes about their cultural group (Parkeret 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 itwas because of that difference. And I think these sorts of training groups are quiterivalrous anyway. And maybe that was one form that it took. That they kind ofdumped on the person who was a bit different. Or maybe there were reasons forthem to find fault with what I was doing . . . The seminar leaders didn’t seem tothink anything of it. So I thought: ‘Well, this is part of the course’.

Being from a cultural minority reportedly could put pressure on minoritytrainees as they were expected to ‘have all of the answers’ about racism andculture:

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 questionsabout race and culture, you either had to make a conscious decision that you werenot 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 youfor the answers.

Some noted that the clinical seminars lacked exploration of diversity and thatthere was resistance to exploring these issues:

Ina: I think of them as clinical seminars where people present work with peoplefrom other races. It is important. I know people have strong feelings about it, but Ithink it is important that it has become an issue.

In summary, clinical and theoretical seminars were enjoyed by many of theparticipants for their content, structure and interactive nature, but somereported feeling that conflicts and unpleasant group dynamics were not wellmanaged by the seminar leaders. Seminars were seen as a potential forum foraddressing diversity, but these opportunities were often not taken up.

Challenging Psychoanalytic TheoryParticipants noted that the negative historical representations of ethnicity and‘race’ in psychoanalytic theory were a potential deterrent for minority ethnicindividuals to undertake a psychoanalytic training.Additionally, it was reported


that there was a clear white middle-class ‘majority’ group within the trainingorganization. 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 Isuppose generally I don’t go around feeling I’m different. But it was kind of quitestark really . . . I don’t really think I felt fully part of the BAP. I think my experienceof being the ‘other’ here, so to speak, has also a part to play . . . I haven’t had anyexperience in the BAP of being discriminated against because of my race, only akind 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 myrace, but to do with my sense that it is very constrained and controlled. Notindividually to do with individual members, but in the group there is something verycontrolled 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 damagingfor 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 usedto ask me: ‘When are you going back?’ A kind of reminder that you come fromsomewhere else. It’s inevitable. There are constant reminders that you’re not reallyfrom here. It does not necessarily mean that you shouldn’t be here, but a questionof what are you doing here? And when I applied for the training I was asked if Iwould understand the patients, and as a mother how would I manage if the childrengot ill.

Lisa highlighted the tensions of acknowledging the importance of the uncon-scious in clinical work, while recognizing the importance of exploring both theconcept and individual experiences of culture in training:

Therapy is seen as ‘Oh my God, you go to a shrink for ten years, they change yourbrain’, there’s that kind of cultural shift that needs to happen somewhere thattherapy isn’t this oddball creature, to me, it’s something about the valuing of theunconscious which is denied in our society . . .There is a cultural thing that we haveto address in some ways.

Reshma noted that her family’s relinquishment of their ‘Indian culture’ madeit easier for her to fit into the (white) majority, and she linked this personalexperience to her experience of her training:

If had I come from Hackney through an Access course with a bit of attitude . . . Iwouldn’t have fitted in that group I don’t think. Very middle class, very, white interms of one’s ideas, our shared, even things like going to the pub, the sharedinterests . . . That’s what my parents aimed for that we should, because there werenot 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 thinkI’ve become very good at fitting in. So I think that’s why I think that’s made it easierfor me. Whereas I think someone else who’s hung on or had a stronger culturalidentity, I wonder if it would be so easy for them.

Regina described how a minority ethnic trainee could be made to feel out ofplace and anxious:


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 weretaking 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 ofmaterial dug up about psychoanalytical ways of thinking and how black people, inthe past, had been somehow stereotyped and seen in particularly negative andpernicious 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 whatcould happen? Do you know how the whole thing about race and culture is seenwithin that particular psychoanalytic?’ . . .You were a bit like being in limbo, so justwelcome but perhaps a source of anxiety, and then you were pulling a bit away fromwhat you’d come from. So there were huge risks.And I think some people were putoff training because of the fear of what you would be left with and how you wouldbe seen and perceived. I feel I’ve survived that well and with a lot of support, butthere 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 werealso discussed. For example, Bipasha commented:

There was this quite immovable orthodoxy about the training.And there seemed tobe little scope for bringing up differences which were outside the orthodoxy. And itwasn’t possible to debate some of these things, and I felt that if it was outside thisfield, it couldn’t be brought up.

Participants also reported difficulties with discussing and addressing issuesrelated to social class, religion, gender and sexual orientation. For example,Ruth described how she found that it was unacceptable to discuss gender in anypolitical 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 toaddress some issues about gender in a more political way. I think it was somebodywhose approach was a more classical, archetypal Jungian classical approach andwanting to challenge some of that, and bring in a more political element. And thatwas very difficult. I felt he became very defensive and wouldn’t talk about it, andactually the feedback that I got from that seminar was very personalized and rathertrivializing, I think of what I was raising, as though it didn’t belong in a seminar. SoI did actually feel very angry about that.

Psychoanalysis and HomosexualityParticipants reported that those who did not identify as heterosexual wouldexperience difficulties due to homosexuality being viewed as a psychopathologyin classical psychoanalytic theory:

Reshma: As far as I know everyone in that group was heterosexual, and I think itwould have been difficult for somebody who was not. I really do think that would’vebeen difficult. Partly, because as I said before, the prevailing theoretical culture wasthat there would not have been, I think, a discussion about the inclusion, forexample, of homosexuality within the disorders-framework, as opposed to it beingon the normal spectrum, a normal continuum . . . The prevailing wisdom within theBAP, whatever individuals thought separately, would’ve been, I think, negative.


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 theycan 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 traditionalFreudian view of being gay and therefore problematic – Oedipal.

One participant reported that discussions about sexual orientation wereimplicitly discouraged by a ‘don’t ask, don’t tell’ type of policy and echoed bythe lack of space devoted in the curriculum to discussing sexual orientation:

Henry: I think sexuality is something the BAP never ever makes reference to foranybody about anything. No, nobody asks, they don’t talk about it. So there mighthave been people who were lesbian or gay who were training in the group, butnobody would ever know because it was never ever mentioned, it was not ofimportance.And I had a feeling that they didn’t want to know. Because if they knewthey’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 thenwe don’t have to know’.

In summary, while those who identified as heterosexual reported that theirsexuality did not have an impact on their training experience, there was amplerecognition that identifying as homosexual would present difficulties, largelydue to the theoretical basis of psychoanalytic theory. Some participantsbelieved that homosexuality was even more difficult to discuss openly thanother 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. Thelack of formal discussions about the various aspects of diversity was seen toimpact 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 PsychoanalyticPsychotherapeutic Training

Students on all the clinical trainings in this institution are required to have alengthy training analysis or therapy. Historically, many of the trainees from thisinstitution have been encouraged to see a psychoanalyst from another institu-tion for their personal therapy, and many of the seminar leaders and clinicalsupervisors come from a relatively small group of respected training analysts.Participants’ views about their training analysis suggested that on the wholethey experienced it positively, but minority ethnic participants describedvarious ways in which they felt excluded or othered.

It was generally accepted by participants that training analysis should not bethe sole site for exploring diversity. As Bhugra and Bhui warn (2006, p. 50),racism and culture may often not be properly scrutinized in trainees’ personalanalysis, nor are they in training programmes. They accept that psychoanalytictrainees’ are encouraged to explore their own self-awareness to prevent per-sonal reactions from interfering in therapy, but that trainees need both thisself-understanding as well as an understanding of different cultures to work well


with patients. Psychoanalytic theory allows for the fact that clinicians areunlikely to overcome their racist feelings and attitudes: no one’s unconscious,not even the best analyst’s, will ever disappear, but clinicians need to becomefamiliar 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 ofdemonstrated teaching ability, specialized knowledge, clarity of thinking andtalent to teach and to learn rather than because they happen to be seniortraining analysts. Although many of the training analysts who also carry outthese 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 tofacilitate discussion of issues such as culture and ethnicity. Holmes (1992)argues that racial meanings should be addressed in all training analyses as wellas by didactic learning and supervision, irrespective of trainees’ ethnicity. Atrainee’s ability to work competently in a therapeutic relationship requires thatsupervisors initiate discussions about heritage, and can guide trainees’ discoveryof their values, assumptions, and biases related to racism and culture (seeTummala-Narra, 2004).

Participants’ accounts pointed to a paradox in psychoanalytic training: insightis integral to understanding and treating patients, but it appears very difficult fortrainees to discuss their insights about their own diversity and that of othersduring their training. The acknowledgement of the impact of diversity, such ashomosexuality, gender, religion, culture and ethnicity, seemed to be particularlydifficult to reconcile within the trainings at this institution.

In the light of the feedback and recommendations from participants regardingthe training components, further attention should be paid to infant and parentinteraction to consider cultural difference in trainees’ infant observation. Train-ees could be encouraged to observe infants from minority ethnicities and to workwith training patients from diverse backgrounds. This would provide importantopportunities in terms of exploring, appreciating and sensitizing trainees toculture and diversity.Participants’ interviews suggest that a more active manage-ment of the seminar sessions is needed to provide opportunities for exploringdiversity, as well as to consider these with respect to psychoanalytic theory andthe resulting tensions. Following participants’ suggestions, it would be advisablefor further training for clinical supervisors, seminar leaders and training analyststo be provided, and for members of the institution to actively recruit individualswith knowledge and experience of diversity issues. The integration, not just theacknowledgement, of diversity in clinical training is essential to facilitate a muchneeded modification in psychotherapy and supervision practice and the culturalcompetence 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. Theneed to address diversity is evidently important both for the sake of goodpractice with patients, and to encourage prospective applicants to undertake a


psychoanalytic training programme. Instead of overt expressions of white racialsuperiority, research supports the contention that racism has evolved into moresubtle, ambiguous and unintentional manifestations in social, political andeconomic life. Without documentation and analysis, the threats that racistmicroaggressions pose and the assaults they justify can easily be ignored ordownplayed (Solorzano et al., 2000). Lack of multicultural training may lead toracism 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 intentionsengage in harmful interventions.

Assumptions about diversity are not only a product of personal history, butalso 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 incorporatingthe ‘external world’ into theory and discussion often created a barrier to train-ees’ discussing certain experiences. Lowe (2008) highlights the necessity forstudents to study the psychological legacy of slavery, colonization and empire.Research has indicated that completion of diversity-related courses appeared toincrease trainees’ multicultural therapy competencies, especially awareness oftheir own cultural and personal biases and knowledge and skills of working withdiverse populations (Neville et al., 1996). Teaching about culture, diversity andethnicity within mental health trainings can lay the groundwork for criticallearning, impasses and enactments. Trainees need to understand their own, aswell as their patients’ cultural backgrounds, as far as they can (Helms, 1990).Experiential exercises have been suggested as an effective way to increasetrainees’ personal awareness of possible biases and assumptions in a contextwhere 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 lessconsideration 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 theimportance of cultural understandings, but to emphasize the importance ofbeing alert to issues of power and oppression (Chantler et al., 2001).

Greene (2006) warns that psychoanalytic paradigms continue to be ‘blatantlyethnocentric, sexist and heterosexist’; particularly in the way child developmentand human behaviour are viewed. They can therefore be seen as unsuitable forthe 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 theseissues with their patients. However, psychodynamic theory, particularly theoriesof intersubjectivity, can provide a good basis for students and trainers to learnabout these issues (Tummala-Narra, 2009). Multicultural education shouldinvolve a close examination of affective processes and the mutual influence of


students and instructors. Psychodynamic perspectives on multicultural educa-tion can encourage the introspective inquiry related to diversity that is criticalto 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 mustembrace the culture of the organization itself (Constantine & Sue, 2005). Issuesof 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 psychoanalyticpsychotherapy and psychoanalysis (Moodley & Palmer, 2006). Furthermore, thelack of consideration to all external matters, and not only diversity, withinpsychoanalytic practice, can leave patients feeling unfairly blamed for externalfactors which they may have no control over (e.g. redundancy and difficulties atwork). The recognition for change with regard to addressing diversity is longoverdue. 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 givencontemporary literature to study which addresses diversity and not focus solelyon classical psychoanalytic theory.

There should be more active recruiting and training of minority ethnic clini-cians while simultaneously increasing and developing the cultural competence ofall clinicians (Smith et al.,2006).Bornstein (2001) recommends the acceptance ofmore theoretical pluralism within psychoanalytic institutes.The aim would be tocreate 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 growingrecognition by psychoanalytic organizations such as the British PsychoanalyticCouncil (BPC) to recognize the importance of research and scientific investiga-tion (e.g. BPC, 2011, p. 7). However, more empirical research is urgently neededto address questions regarding the effectiveness of psychoanalysis comparedwith alternative approaches, so as to transform psychoanalytic education into amore open, dynamic, creative educational system geared to generating newinterest in the practice (e.g. Auchincloss & Michels, 2003; Fonagy, 2004).

More than a decade ago Kernberg (2000) warned that the neglect of researchtraining and the lack of developing a research attitude were a major problem forcontemporary psychoanalytic education, and reflected a dangerous lack ofconcern for the scientific standing of psychoanalysis. Classical psychoanalytictheory is under attack from those who emphasize evidence-based practice andcost-effectiveness in the UK National Health Service, and is threatened by therise in popularity of cognitive–behavioural treatments and psychotropic medi-cine (Kernberg, 2000). This isolation has also manifested itself in a lack ofconsistent concern for the educational experience of students and a denial of theeffects of external, social reality on psychoanalytic education. Some of thedifficulties 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.


A conservative organizational hierarchy reinforces structures and systems,irrespective of intention, making trainees apprehensive about being openlydifferent. The expectation of silent conformity about material issues such asdiversity would seem to stifle trainee development and alienate minority train-ees and members. Given that one of the aims of psychoanalysis is to facilitateopenness and insight, a fear of openness and reluctance to engage in criticaldebate on such issues are regrettable. The limitations of this study were thesmall sample size, the lack of generalizability, and the fact that the participantswere those who had been accepted on to the training and had been able toremain at the institution. Although some attention has been given to diversityin psychology and counselling research over the past 20 years, it has beenneglected within psychoanalytic trainings, and this research makes a start ataddressing that neglect.

This research was generally viewed as a positive first step towards diversify-ing the training programmes and the organization. The current administrativeleaders of the BAP have demonstrated their commitment to this research, andmoves are being made towards improving the culture of the organization andincluding diversity issues into different aspects of the trainings. The BPC issueda statement in 2011 to stipulate that its member institutions should not discrimi-nate against individuals due to their sexual orientation; however, this is an areawhich will need active involvement from the psychoanalytic community inorder to change long-standing prejudices. It is important for psychoanalyticinstitutions to address how difference fits within a psychoanalytic paradigm;there are excellent theoretical and clinical papers that address diversity such asethnicity and homosexuality, but these are rarely given due consideration. Theemphasis on the ‘internal world’ and the unconscious in the trainings can makeit problematic to consider the ‘external world’; but issues that are externally aswell as internally mediated such as gender, homosexuality and ethnicity can beintroduced into the training in fruitful ways.

AcknowledgementsWe would like to thank all our research participants and in particular theinterviewees. We would also like to express our gratitude to Elise Ormerod, theBAP administrative staff and the members of the research group who carried outinterviews or supported this project in other ways: Nick Benefield, MaggieCochrane,Andrew Cooper,Steven Flower,Maureen Fox,Aparna Jack,MargaretHumphrey, Helen Morgan, Juliet Newbigin and Janine Sternberg.We would alsolike to thank Ann Scott and the reviewers for their constructive comments.

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