When and How Therapists Raise Issues of Race and Racism in Session: A Qualitative Analysis of Therapist Practices and Reflections

Racism has well-documented impacts on mental health, yet people of color have long been underserved by mental health services. Researchers have increasingly examined how therapeutic practices can better address the realities of racial trauma and systemic oppression. This qualitative study explored how therapists engaged clients around issues of race and racism in the years following the COVID-19 pandemic and the surge in public and professional attention to the Black Lives Matter movement and systemic racism. Based on ten focus groups and follow-up affinity groups with 46 psychotherapists conducted between 2022 and 2024 in the United States, this analysis examines how therapists navigate conversations about race and racism in clinical practice. Thematic analysis revealed differences in how Black and White therapists described addressing race and racism in clinical practice. Black therapists more often raised race early, integrated it throughout treatment, and drew on lived experience to validate clients’ realities, whereas White therapists more often waited for clients to broach race and reported greater uncertainty. Across racial groups, therapists viewed racism as a potential source of trauma but reported limited awareness and use of racism-related assessment tools. Black therapists more often questioned the clinical utility of these measures, whereas White therapists more often viewed them as conversation starters. Racialized dynamics also shaped therapists’ experiences, with Black therapists describing disproportionate burdens related to discussing and teaching about racism. Findings suggest growing recognition of racial trauma alongside persistent gaps in the training, implementation, and organizational supports needed to address racism in clinical practice.