Do DEI Guidelines Conflict With Clinical Theory?

APA’s (2017) multicultural guidelines have much to recommend them. They also, perforce, contain certain contradictions. For example, Guideline 6 states, “Psychologists seek to promote culturally adaptive interventions….” But some efforts to adapt to one’s culture make people worse. An obvious example involves a culture’s strict gender roles and people (which turns out to be everyone) who have traits of both sexes.

This post is about a different inherent conflict. Guideline 1 states, “Psychologists seek to recognize and understand that identity and self-definition are fluid and complex and that the interaction between the two is dynamic.” But Guideline 10 advocates a strength-based approach, by which is meant, among other things, extolling the benefits of a strong ethic, racial, or intersectional identity. The conflict is between a loosening or dismantling of identity, which is often necessary in the process of psychological change, and a strengthening of identity, which is often experienced as strength-based and culturally adaptive.

In clinical training, this conflict appears at various levels.

On the clinical level, students may resist any approach that questions the patient’s lived experience. These students validate and affirm their clients, typically without questioning whether there may be a downside to a judgmental therapy relationship. The primary downside is that patients won’t tell judgmental therapists their worst secrets, even if the therapist’s judgments are all positive. They also won’t learn genuine self-acceptance if the therapist is picking and choosing which aspects of the patient to accept.

On the training level, some students say that they can’t be their whole selves in the classroom or in supervision. Rather than appreciate the bumpiness of the road of change to becoming an excellent clinician, that it involves loosening or dismantling their own identities, they seem to expect to be the same person at the end of the program that they were at the start. You can’t learn a role as distinct as “therapist” (or, for that matter, surgeon, lawyer, or CEO) without undergoing a lot of change in who you are.

I recall hearing the following from a retired colleague: “Being uninformed about identity is taken to be a form of ‘ignorance’ in DEI, whereas accepting as true what you have been informed about identity (by any source) is taken to be a form of ‘ignorance’ in Buddhism.”

I would add that the same is true of the major clinical theories. The DEI emphasis on honoring, validating, or affirming one’s self-definition conflicts not only with the principle that identity is “fluid” and “dynamic” but also with clinical theories: psychoanalytic, systemic, cognitive behavioral therapy (CBT), behavioral, and existential-humanistic (E-H). These conflicts do not imply that DEI is incorrect; they imply that good trainees, good therapists, and good therapies have to be able to embrace conflicting ideas in a reflective space.

Different psychoanalytic theories all agree on the suspect status of self-definition.

What we mean when we say “I” is self-serving. The “I” in any thought ignores much of the self that embarrasses us. One goal of any psychoanalytic therapy is to include more of who we actually are in our sense of self. Empathy for the patient has salutary effects because it welcomes emotional states and memories that the patient typically excludes from the self-definition.

The “self” in systems theory is evasive, a series of roles one plays in life. The claim that one or a handful of these roles is primary is very difficult to sustain. When a role is thrust upon us to marginalize us, we naturally fight for that role and identify more with it, so these roles are harder to acknowledge as arbitrary, fluid, and dynamic.

Many CBT case formulations can be summarized as the person knowing what to do but not believing they are the sort of person to do it. For example, a woman compelled to punish and scold mistakes knows perfectly well that it is better to incentivize getting things right, but she just doesn’t see herself as the kind of person who can shrug at errors. CBT asks the patient to investigate what sort of person she is. (It turns out that we are all pretty much the same sort of person, i.e., ordinary.)

Behaviorism even more radically than systems theory questions whether we have a psychological self at all. Skinner defined the self as the skin and everything in it—he meant to include hair and fingernails as well. The rest is fiction, a way of thinking about the body that gets socially reinforced and then reified.

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Albert Ellis described humanism as having only one tenet: there are no superhumans or sub-humans. Much self-definition is an effort to differentiate oneself from “the mass of men” to avoid what Thoreau called “lives of quiet desperation.” Identity categories in E-H theory ward off, rather than resolve, a sense of isolation and meaninglessness.

We don’t have to choose between DEI and clinical sophistication. Like Walt Whitman, we can “contain multitudes.” Like good therapists, we can embrace and coordinate rather than eliminate conflict. Niels Bohr said, “The opposite of a fact is a falsehood, but the opposite of one profound truth may very well be another profound truth.” I know who I am may be a profound truth in that sense.