How To Address Unconscious Bias As A Therapist

Nearly every therapist tries to do the best for their patients. They often put in considerable effort to tend to their own mental well-being, form genuine connections with patients, and protect the therapeutic rapport. Such efforts are likely to be beneficial and help the therapist enhance their practice, but unknown factors may influence how they interact with clients. One of those factors is likely the therapist’s unconscious biases. 

As the name suggests, the therapist is not aware of these biases. They are innate and require conscious effort to understand and address. Everybody has personal biases they aren’t aware of, and making an effort to address the subtle changes in thoughts, feelings, and behavior caused by biases is likely to be beneficial. 

What does research say about biases in therapy?

The concept of a mental health practitioner unintentionally allowing subjective opinions to change how they interact with a patient is nothing new. Freud spoke of countertransference in classical psychoanalysis over 100 years ago, referring to a process where the psychoanalyst’s own psychological needs and conflicts unconsciously interfere with their interpretation of a patient’s psyche. Modern research focuses heavily on cognitive distortions and heuristics, both of which are extremely common and are typically considered part of normal thought processes. 

Where do biases come from?

Biases are thought to develop in nearly everyone, starting at a very young age. They are imparted by what a child observes in their environment and what adults and other authority figures teach them. Over time, the child internalizes this information, allowing them to take mental shortcuts as they grow older. These mental shortcuts are commonly called cognitive heuristics, and researchers believe they developed to allow humans to make quick decisions with little energy expenditure.

For example, consider the familiarity heuristic. The familiarity heuristic refers to how most people show more favorable opinions regarding things they have experienced before as opposed to new experiences. From an evolutionary perspective, the favorability heuristic likely biased early humans toward known experiences, which were likely safer because outcomes could be predicted. A person didn’t need to consider every situation equally, being able to access and rely on previously learned information quickly. 

Many researchers suggest that cognitive biases that evolved in an entirely different environment to modern humanity could explain several issues in contemporary society and culture. For example, the familiarity heuristic may have helped protect early humans from enemies by biasing them towards people they knew. Today, that same heuristic may partially contribute to racism and discrimination.

The impact on the patient

Social psychologists have investigated biases on a societal level, examining how unconscious bias can disrupt proactive social interactions between individuals, groups, and entire cultures. In recent years, increased attention has been given to biases that appear in those who provide helping services to others, namely healthcare workers and mental health practitioners. Evidence suggests that implicit bias is prevalent among service providers. Most practitioners, if not all, carry unconscious negative or stigmatizing biases that automatically appear during patient interactions. 

Which biases are most common?

Biases most likely begin to form in early childhood, and exact biases might differ from person to person. However, research has identified several cognitive distortions that contribute to common biases. A few of the more common ones are listed below: 

• Confirmation bias is the tendency to favor information confirming a previously held belief. For example, consider a therapist who strongly adheres to traditional gender roles and believes certain gender stereotypes. The therapist might believe that one gender is inherently more prone to outbursts of emotion and might dismiss a patient’s emotional experiences as typical, which confirms their previously held beliefs and introduces a distinct gender bias. 
• Availability bias refers to the tendency to judge outcomes as more likely if they come easily to mind. For example, consider a therapist whose patient has recently died by suicide. Following the loss of their patient, the therapist becomes preoccupied with the thought that other patients of theirs may want to end their life. The therapist then becomes increasingly concerned with their patients, over-investigating the threat of suicide and potentially harming therapeutic rapport. 
• Affinity bias is the tendency to favor people with similar interests, backgrounds, and experiences. In therapy, a practitioner might struggle to limit their own unconscious bias when interacting with a patient they strongly relate to. For example, a therapist might disregard important information or project their own experiences onto the patient. 
• Framing bias refers to how the initial framing of information may affect how it is eventually perceived. For example, a therapist who sees clients with substance use disorders may be more likely to believe that a well-dressed, affluent, well-spoken patient is not currently using substances compared to a less articulate and affluent patient. 
• The sunk-cost fallacy refers to a type of bias that occurs after a clinician has put considerable effort and resources into a patient but has not seen the expected results, leading to “doubling down” on ineffective strategies instead of moving on to new strategies. 

How can biases be managed?

Many therapists and others in the helping professions dedicate considerable effort to tackle unconscious biases. Unconscious bias training and education regarding how bias occurs are becoming more commonplace in educational programs that train mental health practitioners. In addition, many employers in various industries are taking steps to reduce bias in the workplace using many of the strategies that were first developed for healthcare workers. Likely, strategies used to develop an inclusive workplace will be helpful across industries. 

Working to overcome unconscious bias takes conscious time and effort, but evidence suggests that most people can make considerable progress toward understanding and working around their biases. Below are some strategies from the National Center for Cultural Competence at Georgetown University that therapists may find to be useful: 

1. Acknowledge that your biases exist and take responsibility. It can be emotionally challenging to admit that you have internal biases, but evidence suggests that there are very few people, if any, who are bias-free. Biased thinking is deeply ingrained and develops without any conscious input, but it is still your responsibility to consider and address it.
2. Engage in self-reflection.  It is important to ask yourself difficult questions and work proactively to identify your biases. Journaling may be helpful, as would taking an Implicit Association Test to understand your biases better. 
3. Use data effectively. It may be helpful to collect data like patient satisfaction scores, impressions of clinician competence, or other measures to identify demographic trends that may point to where biases impact your practice. 
4. Increase exposure. Once you identify your most prominent biases, increase the amount of time you are exposed to the group your bias affects. That may mean spending more time in the community, finding ways to make your office space more welcoming for that group, or attending specific training functions designed to help familiarize you with that group. 
5. Increase cultural and linguistic competence. Bring your understanding of a certain group to light in your practice, paying special attention to language barriers. It may be most helpful to a patient to receive services in their native language, making a referral worthwhile if a language barrier is present. 

Getting support while overcoming biases

Investigating biases requires intense self-reflection, and many people find it difficult to accept the results of that reflection. It is important to remember that these biases are unconscious, not the result of deliberate choices. Still, if you’re struggling to accept or address your biases, contacting a therapist may be helpful. You might also consider online therapy, which allows you to access most of the benefits of traditional therapy from the comfort of your home. 

An online therapist uses the same evidence-based techniques as traditional therapists to help their patients grow. They might recommend acceptance and commitment therapy to help you manage the distress of your biases or suggest you try certain journaling techniques to understand them better. Whatever the need, meeting with a therapist can likely help you advance your self-understanding and become a more culturally competent practitioner.