Ethnocultural Transference

Amer. J, Orthopsychial. 61(3), July 1991

CLINICAL

ETHNOCULTURAL TRANSFERENCEAND COUNTERTRANSFERENCE IN THE

THERAPEUTIC DYADLillian Comas-Diaz, Ph.D., and Frederick M. Jacobsen, M.D., M.P.H.

The relevance and validity of ethnocultural factors in transference andcounter-transference reactions are proposed. Some of those prevalent in dyadicpsychotherapy are described, focusing on intra-ethnic and inter-ethnic dyads.Case vignettes are presented to illustrate the ways in which ethnocultural factorsserve as catalysts for such major therapeutic issues as trust, ambivalence, anger,and acceptance of disparate parts of the self.

The influences of culture and ethnicityon the psychotherapeutic process have

been previously acknowledged (Deverewc,1953; Griffith, 1977; Ticho, 1971), and haverecently been recognized as key factors intherapy (Comas-Diaz & Griffith, 1988; Dud-ley & Rawlins, 1985; Goleman, 1989;McGoldrick, Pearce, & Giordano, 1982).While some of these influences are imme-diately available to the senses (sights,sounds, smells, etc.), it has been postulatedthat every culture also has its own uniqueform of unconscious (Hall, 1981), whichmay have powerful effects on the processof psychotherapy. Ethnicity and culture cantouch deep unconscious feelings in mostindividuals and may become targets for pro-jection by both patient and therapist, thusbecoming more available in therapy. Forexample, Jones (1985) stated that black pa-tients often evoke more complicated coun-tertransferential reactions than white pa-

tients since social images of blacks makethem easier targets for therapists' projec-tions. Similarly, Spiegel (1965) asserted thatworking with patients from different cul-tural backgrounds engenders a very com-plicated strain within the therapist. Psycho-therapy with the ethnoculturally differentpatient frequently provides more opportu-nities for empathic and dynamic stumblingblocks, in what might be termed "ethno-cultural disorientation."

In traditional therapeutic orientations, pa-tients' racial and ethnic remarks in therapyhave been attributed to a defensive shiftaway from underlying conflict, and the ther-apist's role has been to interpret them asdefense and resistance (Evans, 1985). How-ever, in our own clinical experience we havefound that this approach hinders the explo-ration of conflicts related to ethnicity andculture. By encouraging the elaboration ofethnoculturally-focused devaluing concepts

Based on a paper presented at the 1989 Conference on Psychotherapy of Diversity: Cross-Cultural TreatmentIssues, Harvard Medical School, Cambridge, Mass. Authors are at the Transcultural Mental Health Institute,Washington, D.C.

392 © 1991 American Orthopsychiatric Association, Inc.

COMAS-DIAZ AND JACOBSEN 393

and feelings, the therapist can offer patientsa richer opportunity to know and resolvetheir own ethnocultural and racial conflicts(Evans, 1985). For instance, Comas-Diazand Jacobsen (1987) reported that in cross-cultural psychotherapy, projective identifi-cation may be shaped by ethnocultural val-ues. These identifications frequently occurspontaneously, as when the patient at-tributes to the therapist certain qualities orfeatures characteristic of the patient's ownethnocultural identity. This process of eth-nocultural identification may be facilitatedby the fact that identification is one of thechief manifestations of culture (Hall, 1981),as well as a major dynamic force in therapy(Erikson, 1959).

As they do in the traditional psychother-apeutic dyad, transference and countertrans-ference have critical significance for thecross-cultural clinical encounter. The ac-knowledgment of ethnic and racial factorsin the psychotherapeutic relationship oftenappears to catalyze the transference, lead-ing to a more rapid unfolding of core prob-lems (Schachter & Butts, 1968). However,cultural and ethnic aspects of behavior of-ten make the evaluation of transference andcountertransference difficult (Bash-Kahre,1984; Zaphiropoulos, 1982) and may be astumbling block to therapeutic progress (Jen-kins, 1985), particularly when the therapistfails to acknowledge such differences(Varghese, 1983). Therapists also tend tobring their imprinting of ethnic and racialstereotypes into psychotherapy (Riess,1971), and these stereotypes frequently playa significant role in the manifestation oftransference and countertransference. Coun-tertransference reactions are often compli-cated by ethnocultural issues such as prej-udice, discrimination, and feelings of guilt(Comas-Diaz & Minrath, 1985).

Ethnic and cultural parameters of trans-ference and countertransference may rein-force each other, sometimes developing intoa vicious cycle. For instance, Bash-Kahre(1984) asserted that in cross-cultural psy-chotherapy, transference and countertrans-

ference are influenced by a feeling of es-trangement that afflicts both therapist andpatient as each of them is inclined to mis-interpret the other's nonverbal communica-tion in terms of his or her own culturalreality. However, it is important to remem-ber that factors such as gender, sexual ori-entation, physical appearance, and per-sonal experience also influence the processof cross-cultural psychotherapy (Jones,1985). Given the complexity and multiplic-ity of ethnocultural factors, therapists needan understanding of their own ethnicity andculture as well as of their patients' so thatthey can achieve effective cross-cultural psy-chotherapy (Jacobsen, 1988; Jones, 1984).In order to examine the ethnocultural trans-ference and countertransference in greaterdetail, it is helpful to explore these pro-cesses within the framework of the patient-therapist dyad from both interethnic and in-traethnic perspectives.

To illustrate the relevance and validity ofethnocultural factors in transference andcountertransference, several of those thatare prevalent in dyadic psychotherapy aredescribed in this article, along with the com-mon underlying dynamic themes that char-acterize them. Case vignettes are used forillustration, with identifying data altered toprotect confidentiality.

ETHNOCULTURAL TRANSFERENCE

Interethnic Transference

There are many possible transference re-actions within the interethnic dyad, rang-ing from overcompliance and friendlinessto suspiciousness and hostility (Jackson,1973). Transference reactions can occur atany stage of treatment, although they ap-pear more likely to occur at some than atothers.

Overcompliance and friendliness. Thistype of reaction is frequently observed whenthere is a societal power differential in thepatient-therapist dyad. Perhaps the mostcommon example of such a power differ-ential in the United States is that of a whitetherapist with a patient from an ethnic mi-

394 ETHNOCULTURAL TRANSFERENCE

nority. This kind of situation can be seenin the example of a Latino professionalwoman, accustomed to being assertive inher own professional context, who does notnegotiate the scheduling of her appoint-ment with her therapist, even though theoffered time is inconvenient for her. Askedwhy she did not attempt negotiation, shestated: "As a Hispanic professional women,I did not want to reinforce ethnic stereo-types. I did not want to make waves andwas avoiding being labeled as difficult."Thus, the patient overcomplies with the ther-apist, compromising the therapeutic alli-ance.

Notwithstanding such power differen-tials in our society, the overcompliance andfriendliness type of transference reactionscan also occur when the therapeutic dyad isof an ethnic minority therapist and a non-minority patient. In such instances, thetransference reaction can take the form ofconcern about being a good patient. Forexample, a white female said to her Chi-nese male therapist: "I wish I could speakCantonese, so I can be like your Chinesepatients."

Denial of ethnicity and culture. This typeof reaction involves avoidance by the pa-tient of any issue pertinent to ethnicity orculture. In discussing color blindness amongpeople of color, Greene (1985) suggestedthat this denial may stem from a fear ofconfronting racism within the self. She fur-ther suggested that some members of op-pressed groups may be so afraid of divi-siveness that they tend to obscure thedifferences between themselves and others,thereby avoiding confrontation of their ownethnicity or culture. The following exampleillustrates this type of reaction:

A Pakistani graduate school student sought treatmentfor problems in her relationship with her parents. Hertherapist in the college counseling clinic was a blackmale. In response to the therapist's inquiry about herfamily ethnic background, she replied: "My parentsare Pakistani but that has no relation to my problems."

Mistrust, suspicion and hostility. Mis-trust (or "How can this person understand

me?") is a common transference reaction inthe interethnic dyad. Unacknowledged eth-nocultural differences promote mistrust andsuspicion in the patient. One form this cantake is concern on the part of the patientabout therapist's "real" motivations in thetherapy. For example, a black patient saidto her Hispanic male therapist during theinitial interview: "I wonder how good youare if you are working with me in this innercity clinic." A more extreme example ofmistrust and suspicion is provided by thefollowing case of a German therapist-Israeli patient dyad:

After two years of intensive psychotherapy, the patientwas still struggling with issues of trust. He was ac-tively fantasizing about his therapist's possible partic-ipation in Nazi military activities. He confronted thetherapist, who answered from a classical analytic stance:"You are wondering about my participation in Na-zism," and left it there. Finally, the patient developeda plan to catch the therapist. During a session, hepresented his own experiences as an officer in theSinai war. The therapist's response implied that heunderstood the activities of an officer, thereby height-ening the patient's anxiety about the therapist's pos-sible role in the Holocaust. Shortly thereafter, the pa-tient dropped out of treatment. When discussing thistherapy with close friends several years later, the pa-tient stated that his therapy had been disrupted becauseof his therapist's refusal to address this issue.

Mistrust and suspicion can eventually leadto hostility, as in the following example:

A Portuguese family was meeting with their daugh-ter's clinician. The therapist, although culturally iden-tifying himself as being from India, was originallyfrom Goa, an island off the coast of India that wascolonized by Portugal. When the patient's parents askedthe therapist where he had learned Portuguese, he toldthem that he had learned it in Goa. The father thensaid, in a pejorative way, "Ah, you are from one ofour colonies."

Ambivalence. Patients in an interethnicpsychotherapy dyad may struggle with neg-ative feelings toward their therapists, whilesimultaneously developing an attachment tothem. Issues of identification and internal-ization within the interethnic dyad can cre-ate ambivalence in the patient. For in-stance, questions such as "How can anethnic minority patient living in an inner


city take a white middle-class therapist as amodel for identification and subsequent in-ternalizating?" emerge in discussion oftransference within this dyad (Comas-Diaz& Minrath, 1985). Another aspect of thistransference reaction involves patients'awareness of their own ambivalence. As anillustration, as assertive black patient toldhis Latino therapist: "I have mixed feelingsabout you. By you not being white, I can beless suspicious of you. Since you are notblack, I can tell you about some negativefeelings about being black. However, byyou not being black, I am not sure if youcan totally understand me."

The question of internalization of the ther-apist is no less provocative when the patientis white and the therapist is from an ethnicminority. A black female psychiatry resi-dent, writing about issues of race and trans-ference, presented a clinical vignette illus-trative of such ambivalence (Harris, 1990).In the' vignette a white female patient de-scribed to the therapist feelings of persecu-tion by Latino tellers in a bank, who wererude to her. When the therapist raised thequestion of whether the patient might havefeelings about having a black therapist, shereplied that even if she had feelings aboutthe therapist's race, she would not bringthem up because she "did not want to hurtthe therapist." Such a response suggests theexistence of transferential ambivalence, inthat the patient was experiencing racial feel-ings, but at the same time, due to her at-tachment to her therapist, she did not wantto hurt her by discussing them.

Intraethnic Transference

The omniscient-omnipotent therapist.This type of transference involves a com-plete idealization of the therapist and thefantasy of reunion with the perfect, all-good parent, facilitated by the ethnic sim-ilarity:

A black therapist felt that his work with a black womanwas at an impasse. He consulted his supervisor whosuggested a conjoint session with the patient. Duringthe conjoint session, the patient expressed her surprise

at the need for such a meeting, stating: "I come hereand I hardly have to discuss my problems because, bybeing black, Dr. S knows everything about me. Dr. Sis the only good black doctor who can help me." Thisrevelation of the patient's omniscient transferencehelped the therapist to resolve the impasse.

The omniscient-omnipotent transferencereaction can take several forms. One is thatof the savior, in which patient and therapistare from a similar ethnocultural minority;because the therapist has been able to sur-vive in the mainstream society, the patientexpects the therapist to come back to rescuehim or her. This transference reaction fre-quently reinforces a dependent and passiveposition! For example, a female Chinese-American patient said to her Chinese maletherapist: "We are both Chinese and thathelps a lot. You are such a great doctor anda great person, I know that you can makeme well, take away the pain, and makethings OK for me."

Another version of omniscient-omnipo-tent transference is that of the folk hero orheroine. This reaction is more predominantamong ethnic groups, particularly minori-ties, that have experienced hardship and op-pression within the larger society. In thisreaction, the therapist's accomplishments(such as going to graduate school, leavingthe ghetto, migrating, and being sociallysuccessful) all contribute to the mythologyof the ethnic minority person who "madeit." Consider the following example:

A Hispanic woman said to her Hispanic female ther-apist, "I place myself in your hands—you have doneso well. I have told everybody in the barrio about youand all the good things that you have done. Pretty soonI will bring my daughters to see you and I know thatyou will help them." Exploration revealed mat thepatient had been telling people in the barrio that hertherapist was the director of the clinic, when in realityshe was in a training position.

The traitor. The converse reaction to ide-alization of the therapist is the process ofdevaluation. In this transference reaction,the patient exhibits resentment and envy atthe therapist's success, and equates it withbetrayal and "selling out" of the therapist'sculture, as the following vignette illustrates:


A black male said to his black male therapist: "Youhave to be an Oreo to be working for the Man. Youdon't even live in a black neighborhood anymore andyou pretend that you are helping your people by work-ing in this white institution."

The autoracist. This type of transferenceis more prevalent among groups that expe-rience racial prejudice accompanied by so-cioeconomic oppression. Patients with thisreaction do not want to work with a thera-pist of their own ethnocultural group be-cause they experience strong negative feel-ings toward themselves and project thesefeelings onto an ethnically similar thera-pist. Usually these patients experience con-flicts in their ethnocultural identities and donot want to be forced to address these con-flicts by being in therapy with a member ofan ethnoculturally similar group. Workingwith a therapist from their own ethnic groupmay signify to them that they are receivinginferior treatment; they prefer a member ofthe dominant group as a therapist. Considerthe following example:

A Latina who has been assigned to a Latina therapistduring the initial evaluation tells the therapist: "I don'twant to work with you. I am Latina and I know thatLatinos are lazy and like to gossip. I want a whitedoctor."

Ambivalence. Questions of identificationwith and internalization of the therapist canbe provocative when raised within an intra-ethnic dyad. Patients in this dyad may feelat once comfortable with the shared ethno-cultural background and at the same timefearful of too much psychological close-ness. When such closeness occurs in ther-apy, it may bring to the fore the patients'unresolved issues about their ethnoculturalbackground. This mix of feelings may leadto a subtle but rather profound ambivalencethat can easily be missed or may be con-fusing to the unsuspecting therapist. For ex-ample:

A Latina mental health worker in psychotherapy witha Latina therapist, initially expressed concerns aboutconfidentiality, given their common professional net-work. Simultaneously, she expressed delight at work-ing with a Latina therapist who could "understand my

cultural and gender issues." She further identified thetherapeutic match as providing a positive and correc-tive experience for her identity. However, as therapyprogressed, the patient expressed fears of being tooclose and of being engulfed by the therapist. Althoughthe patient acknowledged progress in her therapy, shedecided to terminate treatment on the grounds of herinability to deal with her strong ambivalence.

ETHNOCULTURALCOUNTERTRANSFERENCE

lnterethnic Countertransference

Denial of ethnocultural differences. Thedenial of ethnic or cultural differences, orthe belief that "all patients are (or should betreated as if they are) the same," contrib-utes to a negation of countertransferentialinfluences in the therapeutic process. Thistype of denial by the therapist may also takethe form of feeling that one is (or shouldbe) above the cultural and political influ-ences of the society (Gorkin, 1986). Thefollowing case vignette illustrates the ef-fects that such a countertransferential reac-tion may have:

A Panamanian woman in treatment with a Puerto Ri-can female therapist had been talking for several ses-sions about feeling alienated from her mother and fam-ily. In response to the patient's repeated reviews of thereasons for her immigration to the United States, thetherapist asked the patient about her feelings regardingthe political situation in Panama. The patient then ex-pressed concern about her family's security in Panamaand guilt about being safe herself in the United States.She said that she had not realized that she could talkabout politics in therapy, because a previous therapistof hers had apparently taken a position negating thepolitical context of the patient's clinical presentation.If her current therapist had not addressed the politicalsituation in Panama, the patient's clinical work wouldhave been seriously compromised.

The clinical anthropologist syndrome. Inthis reaction, the therapist is overly cu-rious about the patient's ethnoculturalbackground, and may spend an inordinateamount of time exploring aspects of the pa-tient's culture at the expense of the pa-tient's needs (Devereux, 1953). Roughlyspeaking, this reaction is nearly me oppo-site of denial of ethnocultural differencesjust discussed. Such apparent interest bythe therapist may superficially be quite grat-


ifying to the patient, who may thus encour-age it with a seemingly inexhaustible seriesof fascinating cultural anecdotes. Such coun-tertransferential reactions most frequentlyserve to derail the therapeutic process, andcan even be potentially dangerous, as whenthe therapist attributes cultural explanationsto actual pathology:

A Brazilian male patient regaled his Anglo therapistwith colorful tales of partying through the night duringCarnival and during almost weekly music-making ses-sions with friends. Substantial time was spent in ther-apy discussing the cultural meanings of the patient'sintense and somewhat erratic interactions with hisfriends and of various aspects of Brazilian culture andmusic. However, certain biological aspects of the pa-tient' s experiences, namely hypomanias of a mild bi-polar disorder induced by sleep deprivation, weremissed.

Guilt. This type of reaction can emergewhen societal and political realities dictatea lower status for people of certain ethnicand cultural background. For example, indescribing the countertransference in a Jew-ish therapist and Arab patient dyad, Gorkin(1986) asserted that guilt is a recurrent coun-tertransferential reaction. Although the per-vasive political antagonism between the twoethnic groups may render this particular dyadan extreme one, guilt is also prevalent inrelatively less dramatic interethnic dyads,as well. Let us examine the case of a whitetherapist and Native American patient:

A Native American man was referred to therapy by hisemployer due to a drinking problem. The therapist, asocially responsible white man, felt guilty, which trans-lated into discussions of relationship problems ratherthan of the patient's drinking problem. In discussingthe case with a colleague, the therapist said, "I feelthat all he has left is drinking and we taught them howto anesthetize themselves after ripping them off "

Pity. Within the interethnic clinical en-counter, pity is a derivate of guilt or anexpression of political impotence within thetherapeutic hour. The example of a Jewishtherapist and Iranian patient dyad illustratesthis issue:

A Jewish therapist was working with an Iranian couplewhen the Ayatollah Khomeini overthrew the Iraniangovernment. The therapist began to feel considerable

pity for the previously well-to-do patients, who beganto discuss in therapy all the friends and relatives thatthey were losing in Iran. Consultation helped the ther-apist identify his own paralyzing pity and overidenti-fication with the experiences of his own family duringWorld War II.

Aggression. According to Gorkin (1986),guilt and aggression can be intertwined inthe countertransference reactions of inter-ethnic dyads. He asserted that therapists can-not avoid negative feelings towards pa-tients who repeatedly arouse guilt in them.However, aggressive countertransferentialreactions are not always associated withguilt, as the following example illustrates:

In working with a Hispanic woman, a Jewish femaletherapist found herself overly confrontational and ac-tive, although her usual therapeutic style was psycho-dynamic and exploratory. During consultation she iden-tified her patient's passive aggressiveness as the causeof the change in her treatment style. However, furtherexploration revealed that the patient reminded the ther-apist of a Spanish singer (Charo) who although com-petent, portrayed herself as stupid. Consequently, thetherapist was very angry with her patient for present-ing herself as stupid when, as the therapist knew, thepatient was smart; thus, the therapist felt that her pa-tient "was trying to fool her."

Ambivalence. In working with ethnic mi-norities or culturally different patients, ther-apists carry value and attitudinal conflictsthat have an impact on treatment and needto be addressed so that psychotherapy canbe effective (Evans, 1985). A therapist'sambivalence toward a patient's culture mayoriginate in an ambivalence toward the ther-apist's own ethnicity and culture. For in-stance, Giordano and Giordano (1977) statedthat upwardly mobile, middle-class profes-sionals have a personal ambivalence to-ward ethnicity because they have embraceduniversalist life-styles and value systems,leaving their own ethnicity behind. The fol-lowing case example highlights this type ofreaction:

An Italian-American therapist working with a blackwoman began to experience profound ambivalencewhenever the patient discussed crime-related incidentsin her neighborhood. Her feelings heightened whenthe patient presented material about a cousin who hadbeen unjustly incarcerated on drug trafficking charges.


During consultation, the therapist was able to identifyfeelings of ambivalence about her own Italian back-ground. More specifically, she was able to examineher unresolved ethnic shame due to what she called"the societal connection between organized crime {theMafia) and Italians."

Intraethnic Countertransference

Overidentification. In the intraethnicdyad, overidentification on the part of thetherapist can be detrimental to the contin-uation and success of psychotherapy (Mays,1985). For example, some therapists fromethnic minorities may choose activist andsupportive therapy approaches for their pa-tients from ethnic minorities because of un-conscious fears or of overidentification withthe intrapsychic aspects of their patients'problems (Evans, 1985).

Us and them. An extreme version of over-identification is that of the "us and them"mentality. This reaction tends to be moreprevalent among groups who have a historyof oppression and discrimination, and thus alower societal status, as is the case with manyethnic minorities. The therapist may overi-dentify with patients in terms of their sharedvictimization because of racial discrimina-tion and may attribute the patients' problemsto their ethnic identity. Therapy may thenbecome a shared fortress against perceivedcommon threats (us against the world), asillustrated in the following vignette:

A Hispanic female patient told her therapist how shewas "beating the system" by working full time whilereceiving disability insurance benefits. The therapist,a Hispanic male, did not confront her with the illegal-ity of her behavior, nor did he discuss its implications.Later on, the patient was fired from work because shewas suspected of embezzlement. The therapist soughtconsultation after the patient admitted that she hadindeed embezzled the money. In presenting this case,the therapist was surprised at the consultant's opinionthat the therapist had been colluding with the patientand had given her permission to engage in illegal acts.However, upon exploration, the therapist acknowl-edged the possibility, saying, "Perhaps I colluded withthe patient in beating the system because, as a His-panic, I am also angry at the system." He went on tosay that he had not been promoted in the past twoyears and cited discrimination against his ethnic back-ground as the key factor in his lack of advancement.Colluding with the patient in the us and them attitude

prevented him from addressing the patient's dysfunc-tional and destructive behavior.

Distancing. In order to prevent overiden-tification problems and because of the fearof getting too close, the therapist may af-fectively distance him or herself from thepatient. Consider the following example:

A Hispanic woman was in therapy with a Hispanicfemale clinician. They were ethnocuiturally similarand initially this similarity facilitated the developmentof a therapeutic alliance. Because she had been rearedby her maternal grandparents, the patient was strug-gling with the issue of feeling rejected by her parents.In addressing this issue, the therapist discussed therearing by maternal grandparents as a cultural practiceamong some Hispanic families. The therapist herselfhad been raised by her grandparents and had struggledbetween feelings of abandonment and acceptance ofthis culturally sanctioned practice. By offering the cuj-tural explanation and neglecting to explore the pa-tient's feelings of abandonment and mistrust engen-dered by her upbringing, the therapist found herselfaffectively distanced from the clinical situation. Clin-ical consultation helped her to address the situationproperly.

Cultural myopia. This involves an inabil-ity to see clearly because ethnocultural fac-tors obscure therapy. It can occur when ther-apist and patient share similar ethnic andcultural backgrounds and is usually accom-panied by unconscious collusion. In ex-treme cases, cultural myopia can reach theproportions of cultural blindness.

An example of cultural myopia was pro-vided by Gottesfeld (1978) who, in discuss-ing countertransference and ethnic similar-ity, described an Italian therapist/patientdyad in which the therapist's psychologicalfamiliarity with the patient developed whatshe labeled as too much "psychic together-ness." She stated that the characteristicallyItalian need to hold on to family to the ex-clusion of outsiders caused this dyad to re-inforce each other's positions, and hin-dered therapeutic progress. The patientwithheld family information and the thera-pist allowed her to retain her family secrets,and thus control the therapy.

Ambivalence. In the intraethnic dyad, thiscan be manifested in the therapist's ownethnic and cultural ambivalence, a situation


which is often more prevalent among eth-nic minority individuals. Being an individ-ual of ethnic minority in the United Statesmeans facing some inherent cultural con-flicts, since ethnic minorities are often bi-cultural or multicultural (Smith, Burlew,Mosley, & Whitney, 1978). Moreover, manyminorities experience oppression and mustcope with experiences of racial prejudiceand discrimination (Comer, 1980). Work-ing in an intraethnic dyad may intensifythese feelings and thereby generate ambiv-alence toward working with patients fromsimilar ethnic backgrounds. This can leadtherapists to overlook their own ethnicitywhile pursuing a quest for universalist val-ues (Giordano & Giordano, 1977). The fol-lowing vignette illustrates this reaction:

A black female therapist complained that she was be-ing assigned too many black cases. When she wasasked to expand upon her concerns, she stated that shewas "tired of hearing black women complain abouttheir men's inability to find regular jobs," thus voic-ing her profound ambivalence about working with blackfemales. She stated that although she was able to helpsome of her racial sisters, their problems reminded herof her own personal situation and of the fact that" therewere no jobs out there for black men." By acknowl-edging her ambivalence she was able to ask for alimitation to be put on the number of black femalecases assigned to her.

Anger. The ambivalence in an intraeth-nic dyad can be taken to extremes and con-verted to anger. Being too close to a patientethnoculturally may uncover painful intra-psychic issues that are unresolved. The fol-lowing example illustrates this reaction:

A black male therapist forgot to inform his black fe-male patient about his pending vacation until their lastsession before it was due to start, although he hadremembered to tell all his other patients. This partic-ular patient had a history of being abandoned by blackmen and this was a recurring theme in therapy. Indiscussing the case with a colleague, the therapist re-alized that he did not want to deal with the reactions heanticipated from his patient to the news of his vaca-tion; furthermore, he was angry about them. By for-getting to tell her until their last session, he couldminimize the amount of time he would have to spenddealing with her feelings about being abandoned oncemore by a black man. Further exploration revealedthat the therapist's own father had abandoned his

mother and that the therapist had blatned his motherfor the situation.

Survivor's guilt. This type of reactiontends to be more prominent among ethnicminority and immigrant therapists fromworking-class or low socioeconomic statusbackgrounds. By education, income, orother means, these therapists may have es-caped those origins, common to ethnic mi-norities. In doing so, they may have leftfamily and friends behind, thus generatingconflict and guilt. The survivor's guilt canimpede their professional growth and leadto denial of their patients' real psycholog-ical problems (Munoz, 1981), as in the fol-lowing case:

A black dentistry student presented to therapy withsleeping problems that had no organic basis. Uponexploration, he complained that he was the victim ofracial discrimination in his school and cogently pre-sented data to sustain his allegation. The therapist, ablack female, had experienced a similar situation whenshe was in graduate school. Therapy concentrated onhelping the patient exert his options and, with thetherapist's support, he filed a formal grievance. How-ever, after this, his symptoms worsened. In discussingthe case with a consultant, the therapist realized thatshe had overlooked the fact that the patient's motherhad remarried and that the patient was extremely an-gry about her decision. Instead, the therapist's focushad been on the patient's racial victimization. Shebecame aware that she was plagued by guilt at havingbeen able to survive the racial discrimination in herown graduate training. She had translated her survivalguilt into a pohticization of her patient's clinical sit-uation, failing to explore the intrapsychic and inter-personal elements of his presentation. After the ther-apist addressed these dynamics, she effectivelycombined intrapsychic components with the manage-ment of reality issues, and the patient progressed.

Hope and despair. Alternatively, the eth-nic minority therapist may experience de-spair because of having been able to escapethe fate of family and friends without guilt.Such despair may alternate with hope ofimproving the situation of the patients or ofthe ethnic community at large (Munoz,1981). For example:

A black female social work student was working intherapy with a black female therapist. Patient and ther-apist shared similar socioeconomic backgrounds. The


therapist was initially hopeful about outcome becauseof the patient's achievement in getting into graduateschool. However, the patient brought to therapy feel-ings of having abandoned her community by attaininga professional status. This situation evoked feelings ofdespair m the therapist because of her own iack ofguilt about having escaped her own depressed socio-economic background. After consultation, the thera-pist was able to address her countertransferential re-actions effectively.

IMPLICATIONS

The ethnocultural parameters of transfer-ence and countertransference tend to facil-itate the uncovering of unconscious feel-ings and thereby advance the therapeuticprocess. The clinician's acknowledgementof these reactions may lead to a more rapidemergence of conflicts underlying majortherapeutic issues such as trust, ambiva-lence, and anger. Let us consider the fol-lowing example:

A Jewish man working with a Latino therapist iden-tified their shared experience of being outsiders asfacilitative in developing a therapeutic alliance. Heremarked to his therapist: "You can relate to my ex-perience of being Jewish because, as a Latino, youalso are different from the mainstream society." Thepatient's presentation of being the only Jew in a mostlyWASP environment was permeated by concerns abouthis self-image. Initially, he complained that his co-workers and superiors did not trust him, and saw hisethnic identity as the cause for this mistrust. After thetherapeutic relationship was cemented, the patient be-gan to make humorous statements about the therapist'slack of a Spanish accent. When this issue was con-fronted, the patient was able to admit to his ambiva-lence about working with a Latino therapist. From thisemerged his ambivalence about being Jewish. He said,for example, that he had tried to change his local(Long Island) accent to avoid being singled out asJewish. The mistrust (both as an object and as a sub-ject) he had perceived as engendered by his ethnicitywas re-labeled as mistrust of himself for having be-come what he called an impostor. Themes of self-image and self-esteem emerged and rapidly unfoldedin therapy. This process helped the patient to see thatambivalence was central to his personality structure,regardless of his ethnicity. The patient had used theethnocultural paradigm as a metaphor for his mistrustand his generalized ambivalence.

Ethnocultural transference and counter-transference reactions may emerge at vari-ous times during therapy. They can act as

catalysts for the acceptance of disparate partsof the self. Monitoring and properly ad-dressing such reactions can advance the ther-apeutic process and promote growth. Con-sider the following vignette:

An Anglo-Mexican female, in therapy with an Anglofemale, presented depressive symptoms around prob-lems within romantic relationships. She professed tobe a "woman who loves too much." When the ther-apist raised the issue of their differing ethnic back-grounds, she replied: "It doesn't matter, I am also halfAnglo," which the therapist interpreted as a denialtransference reaction. When the patient's depressivesymptoms subsided, she began to manifest an over-compliant transference reaction; such behavior wasinconsistent with the patient's professional assertivestyle as a medical student. Upon exploration it wasrevealed that she perceived the therapist as an author-ity figure—a member of the dominant society whocould not be openly questioned. When this issue wasaddressed, the patient was able to connect this reactionto her own behavioral style with her Mexican andHispanic friends. She realized that she often behavedin a rigidly authoritarian style toward them. Such astyle appeared to be congruent with her perception ofher "Anglo side." Conversely, she reported being rel-atively unassertive with her Anglo friends, this beingcongruent with her "Mexican side." This realizationpromoted a discussion by the patient of her ethnicambivalence. For example, although she was an at-tractive and petite young woman, she felt that theshading of her skin was not light enough, that she was"too Mexican looking." She stated that as a child shehad been blond, and that in Mexico she was called LaGringa.

After this revelation came the unfolding of her feel-ings about her sense of attractiveness as a female. Shehad dated both Hispanic and Anglo men and perceivedthem as always abandoning her for "tall, blond, Anglowomen." She was examining these issues with a tall,blond and Anglo female therapist, however, and hertransference reaction turned into mistrust augmentedby several derogatory references to the Gringos. Thetherapist developed a countertransference reaction ofpity, and after a consultation, she decided to addressthe patient's mistrust transference directly. Examiningthe patient's ethnocultural transference facilitated anapproach to her ambivalence about her Mexican andAnglo backgrounds. She expressed frustration and saidthat she sometimes felt like two different people whodid not communicate with each other.

In accordance with Chin (in press), whohas asserted that splitting is an adaptive de-fense mechanism among people of color,her apparent splitting was interpreted as partof her adaptive coping style. Although ra-


cial ambivalence is common among indi-viduals of mixed race (Root, in press), theexpression of the patient's ambivalencethrough ethnocultural transference mobi-lized the unfolding of her anger. She hadexternalized and dichotomized her expres-sion of anger toward Anglos when she facedher affiliative needs, and toward Mexicanswhen she dealt with her self-affirmation andassertive needs. The different ethnoculturaltransference reactions that were emergingwere acknowledged by the therapist and con-nected to the patient's ethnocultural disori-entation. By encouraging elaboration of herethnoculturally-focused devaluing conceptsand feelings, the patient was given an op-portunity to understand and resolve her ownethnocultural and racial conflicts. Further-more, these conflicts became tools for theidentification of the disparate parts of thepatient's self, namely her racial, ethnic, gen-der, and personal identities, and examina-tion of the ethnocultural issues led to heracceptance of these disparate parts. The eth-nocultural context thus acted as a catalyticagent in providing a barometer for the pa-tient's problems with ambivalence, anger,and self esteem.

CONCLUSIONS

Ethnicity, culture, and race can touchdeep unconscious feelings in most individ-uals and may become matters for projectionby both patient and therapist, usually in theform of transference and countertransfer-ence. Ethnocultural issues constitute key el-ements in psychotherapy. Acknowledgingthem does not negate individual uniquenessstemming from developmental, biological,structural, and contextual factors compris-ing the psychological makeup of each per-son. As with other relevant variables inpsychotherapy, ethnocultural factors intransference and countertransference notonly influence individuals' presentations inthe clinical discourse, but also significantlyaffect the process and outcome of psycho-therapy. Moreover, they can serve as cata-lysts for such major therapeutic issues as

trust, anger, acknowledgement of ambiva-lence, and acceptance of disparate parts ofthe self.

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For reprints: Lillian Comas-Diaz. Ph.D., Transcultura! Mental Health Institute, 1301 20th Street, N.W., Suite 711,Washington, DC 20036-6043

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Ethnocultural Transference