|
Research has shown high prevalence rates of microaggressions in individual therapy, and conversely demonstrated the importance of addressing such microaggressions in therapy (Kivlighan & Chapman, 2018). Shockingly, most clients experience at least one microaggression within any given counselling relationship (Kivlighan et al., 2020), while a large number of therapists remain unable to accurately identify the presence of a microaggression (McSorley, 2020). Such microaggressions might involve stereotyping, misgendering, or denying experiences of oppression (McSorley, 2020).
One problem here is that the industry remains overwhelmingly White. Back in 2012 only 3% of marriage and family therapists and only 6% of all psychologists in North America were racialized practitioners. Even if we account for potential increases in these numbers over the previous decade it still means that the likelihood of a racialized individual receiving services from a White practitioner is very high – even if their presenting issue is related to racism (Henderson-Daniel et al., 2004; Hall & Sandberg, 2012). The issue here is that studies have shown that if the therapist is at all uncomfortable with the issue of race, it is highly unlikely that they will be able to help their clients work through these difficulties (Stevens & Abernethy, 2018). Studies have also shown that most White therapists do report discomfort with broaching the topic of race in therapy, whether directly or indirectly, due to their own cultural and racial socialization (Knox et al., 2003; Chang & Yoon, 2011). Some even report allowing clients to focus on universalities rather than cross-racial differences because of this discomfort (Zaharopoulos & Chen, 2018), while others can resort to strategies such as color blindness and assumed racial superiority to avoid engaging in explicit conversations about race (Kivlighan et al., 2019). Such defensive reactions have been shown to adversely impact communication and the ability to collaborate effectively across racial lines (Chang & Yoon, 2011) and may also result in racialized clients feeling burdened to take care of their therapists by monitoring their disclosures in order to protect the therapist's feelings (Henderson-Daniel et al., 2004). Experiences of racism can often be traumatic, and as clients share their personal experiences with such they may experience in session all the feelings these bring up, such as grief, and anger. These feelings and experiences may well in turn activate varied and challenging feelings within a White therapist, who in an effort to cope may react in any number of defensive ways, such as by withdrawing, asserting their lack of racial bias, or dismissing their clients' experiences as anecdotal or as ‘reading too much into things’. These defensive responses can be potentially traumatizing for the client (Nagai, 2009; Stevens & Abernethy, 2018). It is therefore critically important that racialized folks not encounter such responses when in need and actively seeking care and support. Chang, D. F. & Yoon, P. (2011). Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research, 21 (5), pp. 567-582. DOI: 10.1080/10503307.2011.592549 Hall, C. A. & Sandberg, J. G. (2012). “We Shall Overcome”: A Qualitative Exploratory Study of the Experiences of African Americans Who Overcame Barriers to Engage in Family Therapy. The American Journal of Family Therapy, 40:445–458. DOI: 10.1080/01926187.2011.637486 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. DOI: 10.1002/jclp.20014 Kivlighan, D. M. & Chapman, N. A. (2018). Extending the Multicultural Orientation (MCO) Framework to Group Psychotherapy: A Clinical Illustration. Psychotherapy, 55 (1), 39–44. http://dx.doi.org/10.1037/pst0000142 Kivlighan, D. M., Drinane, J. M., Tao, K. W., Owen, J. & Liu, W. M. (2019). Detrimental Effect of Fragile Groups: Examining the Role of Cultural Comfort for Group Therapy Members of Color. Journal of Counseling Psychology, 66 (6), 763–770. http://dx.doi.org/10.1037/cou0000352 Kivlighan, D. M., Swancy, A. G., Smith, E., & Brennaman, C. (2020). Examining Racial Microaggressions in Group Therapy and the Buffering Role of Members’ Perceptions of Their Group’s Multicultural Orientation. Journal of Counseling Psychology. Advance online publication. http://dx.doi.org/10.1037/cou0000531 Knox, S. Burkard, A. W., Johnson, A. J., Suzuki, L. A. & Ponterotto, J. G. (2003). African American and European American Therapists’ Experiences of Addressing Race in Cross-Racial Psychotherapy Dyads. Journal of Counseling Psychology, Vol. 50, No. 4, 466–481. DOI: 10.1037/0022-0167.50.4.466 McSorley, K. (2020). Sexism and cisgenderism in music therapy spaces: An exploration of gender microaggressions experienced by music therapists. The Arts in Psychotherapy, 71, pp. 1-9. https://doi.org/10.1016/j.aip.2020.101707 Nagai, C. (2009). Ethno-cultural and linguistic transference and countertransference: from Asian perspectives. American Journal of Psychotherapy, 63 (1), pp. 13 – 23. Stevens, F. L. & Abernethy, A. D. (2018). Neuroscience and Racism: The Power of Groups for Overcoming Implicit Bias. International Journal of Group Psychotherapy, 68:4, 561-584, DOI: 10.1080/00207284.2017.1315583 Zaharopoulos, M. & Chen, E. C. (2018). Racial-Cultural Events in Group Therapy as Perceived by Group Therapists. International Journal of Group Psychotherapy, 68:4, 629-653, DOI: 10.1080/00207284.2018.1470899. For many racialized folks, racial socialization occurs in stark contrast to that of White folks (Kivlighan et al., 2019). Engagement in explicit conversations about race is critical not just for the development of a positive racial identity, but also for successful navigation of the hostile world around us (Kivlighan et al., 2019). An example of this is the tragic necessity of early conversations between Black parents and their children about how to respond to law enforcement, how to exist in public spaces, and how to make sense of the messages they receive about themselves from the world around them – conversations which facilitate protective factors such as healthy skepticism and self-esteem (Kivlighan et al., 2019). A therapeutic relationship between a client and a racialized therapist can provide an extension of this dynamic - indeed, many studies have indicated engagement with culturally similar peers to be more advantageous for racialized folks (Jones & Pritchett-Johnson, 2018).
However, even in racialized therapeutic pairs it is impossible to fully match client and practitioner, since many aspects of identity - such as sexuality and disability - can remain invisible (Chen et al., 2008). It is dangerous to assume that all racial minorities share the same experience and awareness of racism. I can't remember who I am paraphrasing here, but it is often the ones who look most like you that can hurt you the most - by which is meant that when faced with an oppressor you can at least prepare for impact, but when the slap comes from an unexpected, closer to home source, you can be caught dangerously off-guard. Internalized racism is a powerful mechanism in the maintenance of that oppressive structure. It becomes even more important to be aware of when considered in the context of the therapeutic relationship - I know I cannot ever make the assumption that any individual shares my own understanding of what it means to exist on the margins. Poor cultural competency in counselling can result in inappropriate and harmful case conceptualizations and interventions, an inability to recognize when microaggressions occur, poor counselling outcomes, poor adherence to treatment, poor health outcomes, increased prevalence of adverse events, and ultimately, premature termination of counselling services (Henderson-Daniel et al., 2004; Chang & Yoon, 2011; Brooks et al., 2019). Further, discrimination and prejudice in the lives of marginalized populations impacts access to health care resources in the first place (Henderson-Daniel et al., 2004; Collado et al., 2017), with marginalized folks more likely to receive poorer quality mental health care and more likely to drop out from treatment than White populations (Yeh et al., 2004; Chang & Yoon, 2011; Collado et al., 2017; Graham-LoPresti et al., 2017; Pinedo et al., 2018; Horwitza et al., 2020). One issue here is that the mental health field continues to be understood and situated in a predominantly Eurocentric western paradigm and is often managed through programs and interventions that ignore cultural, historical, and socio-political contexts (Henderson-Daniel et al., 2004; Lavallee & Poole, 2010; Daniels & Fitzpatrick, 2013; Vukic et al., 2011) What literature there is on this issue indicates that due to the mistrust of service providers racialized folks tend make particular decisions about how they present and may tend to be reluctant to disclose in the therapeutic environment, because of the fear of being misinterpreted, misunderstood, stereotyped, overpathologized, even incarcerated, as a result (Moodley et al., 2008; Awosan et al., 2011; Chang & Yoon, 2011; Phiri et al., 2019). In this context, how exactly is healing meant to occur for racialized populations? Awosan, C. I., Sandberg, J. G. & Hall, C. A. (2011). Understanding the experience of black clients in marriage and family therapy. Journal of Marital and Family Therapy, 37 (2), pp. 153-168. doi: 10.1111/j.1752-0606.2009.00166.x Brooks, L. A., Manias, E. & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26, pp. 383–391. https://doi.org/10.1016/j.colegn.2018.09.007 Chang, D. F. & Yoon, P. (2011). Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research, 21 (5), pp. 567-582. DOI: 10.1080/10503307.2011.592549 Chen, E. C., Kakkad, D. & Balzan, J. (2008). Multicultural Competence and Evidence-Based Practice in Group Therapy. Journal of Clinical Psychology: In Session, 64 (11), 1261-1278. DOI: 10.1002/jclp.20533 Collado, A., Lim, A. C., & MacPherson, L. (2017). A systematic review of depression psychotherapies among Latinos. Clinical Psychology Review, 45, 193-209. doi: 10.1016/j.cpr.2016.04.001 Daniels, C. & Fitzpatrick, M. (2013). Integrating Spirituality into Counselling and Psychotherapy: Theoretical and Clinical Perspectives. Canadian Journal of Counselling and Psychotherapy, 47 (3), pp. 315–341. Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S. & Hayes-Skelton, S. A. (2017). Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Disorder: A Case Paper. Cognitive and Behavioral Practice, 24, pp. 459-471 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. DOI: 10.1002/jclp.20014 Horwitza, A. G., McGuire, T., Busby, D. R., Eisenberg, D., Zheng, K., Pistorello, J., Albucher, R., Coryell, W. & King, C. A. (2020). Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk. Journal of Affective Disorders, 271, pp. 123–130. https://doi.org/10.1016/j.jad.2020.03.115 Jones, M. K. & Pritchett-Johnson, B. (2018). “Invincible Black Women”: Group Therapy for Black College Women. The Journal for Specialists in Group Work, 43 (4), 348-375. DOI: https://doi.org/10.1080/01933922.2018.1484536 Kivlighan, D. M., Drinane, J. M., Tao, K. W., Owen, J. & Liu, W. M. (2019). Detrimental Effect of Fragile Groups: Examining the Role of Cultural Comfort for Group Therapy Members of Color. Journal of Counseling Psychology, 66 (6), 763–770. http://dx.doi.org/10.1037/cou0000352 Lavallee, L. F. & Poole, J. M. (2010). Beyond Recovery: Colonization, Health and Healing for Indigenous People in Canada. International Journal of Mental Health and Addiction, 8, pp. 271–281. DOI: 10.1007/s11469-009-9239-8 Moodley, R., Sutherland, P. & Oulanova, O. (2008) Traditional healing, the body and mind in psychotherapy. Counselling Psychology Quarterly, 21:2, 153-165, DOI: 10.1080/09515070802066870 Phiri, P., Rathod, S., Gobbi, M., Carr, H. & Kingdon, D. (2019). Culture and therapist self-disclosure. The Cognitive Behaviour Therapist , 12 (e25), pp. 1-20. doi:10.1017/S1754470X19000102 Pinedo, M., Zemore, S. & Rogers, S. (2018). Understanding barriers to specialty substance abuse treatment among Latinos. Journal of Substance Abuse Treatment, 94, 1–8. https://doi.org/10.1016/j.jsat.2018.08.004 Vukic, A., Gregory, D., Martin-Misener, R. & Etowa, J. (2011). Aboriginal and Western Conceptions of Mental Health and Illness. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 9 (1), pp. 65-86. Yeh, C. J., Hunter, C. D., Madan-Bahel, A., Chiang, L. & Arora, A. K. (2004). Indigenous and Interdependent Perspectives of Healing: Implications for Counseling and Research. Journal of Counseling & Development, 82, pp. 410-419 “…numbness is a quality of transgression.” (Kapil, 2001)
“Addiction is often seen as a way to find sanctuary, a way out of the feelings of powerlessness.” (hooks, 2004) Some folks respond to the stressor of racism with fatalism and resignation, passively accepting their racialized reality. This is referred to as learned helplessness (Seligman, 1974, 1992; Carver et al., 1989; Carver et al., 1993). Others exhibit depression (Isaacowitz & Seligman, 2007), while others still respond by striking out at those around them with aggressive behaviour (Hoobler & Brass, 2006; Marcus-Newhall et al., 2000). Another response is a lack of impulse control, leading to excessive patterns of eating, smoking, gambling, and alcohol and drug use (Tice et al., 2001; O’Connor & Conner, 2011; McClernon & Gilbert, 2007; Wood & Griffiths, 2007; Grunberg et al., 2011), while many people develop other, varied defense mechanisms - a term for internal methods of distorting a threatening reality so that it doesn’t seem so threatening - in response (Vaillant, 1994; Aldwin, 2007). Blaming oneself is a common response – the tendency to become highly self-critical (Ellis, 1973, 1987). The racial stressor also takes its toll on the ability to perform effectively on a task at hand (Baumeister, 1984). Being surrounded by faces that don’t look like yours and knowing that you are being seen and judged differently leads to a level of self-consciousness that disrupts attention. This and the stress response can lead to burnout (Maslach & Leiter, 1997) - a physical and emotional exhaustion, cynicism, and lowered sense of self-efficacy that can be brought on gradually by chronic stress. Racism can therefore be understood as a self-perpetuating wheel of oppression, designed to keep a racialized person forever one-down, both out in the world and - perhaps most perniciously - within our own bodies. Aldwin, C. M. (2007). Stress, coping, and development: An integrative perspective (2nd ed.). New York, NY: Guilford Press. Baumeister, R. F. (1984). Choking under pressure: Self-consciousness and paradoxical effects of incentives on skillful performance. Journal of Personality and Social Psychology, 46, 610–620. Carver, C. S., Pozo, C., Harris, S. D., Noriega, V., Scheier, M. F., Robinson, D. S., et al. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology, 65, 375–390. Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267–283. Ellis, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New York: Julian Press. Ellis, A. (1987). The evolution of rational-emotive therapy (RET) and cognitive behavior therapy (CBT). In J. K. Zeig (Ed.), The evolution of psychotherapy. New York: Brunner/Mazel Grunberg, N. E., Berger, S. S., & Hamilton, K. R. (2011). Stress and drug use. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science: Biology, psychology, and health (pp. 111–121). New York, NY: Springer Publishing. Hoobler, J. M., & Brass, D. J. (2006). Abusive supervision and family undermining as displaced aggression. Journal of Applied Psychology, 91(5), 1125–1133. hooks, b. (2004). We Real Cool: Black Men and Masculinity. Routledge, New York. Isaacowitz, D. M., & Seligman, M. E. P. (2007). Learned helplessness. In G. Fink (Ed.), Encyclopedia of stress. San Diego: Elsevier. Kapil, B. (2001). The Vertical Interrogation of Strangers. Kelsey Street Press, CA. Marcus-Newhall, A., Pedersen, W. C., Carlson, M., & Miller, N. (2000). Displaced aggression is alive and well: A meta-analytic review. Journal of Personality and Social Psychology, 78, 670–689. Maslach, C., & Leiter, M. P. (1997). The Truth about Burnout. San Francisco: Jossey-Bass. McClernon, F. J., & Gilbert, D. G. (2007). Smoking and stress. In G. Fink (Ed.), Encyclopedia of stress (2nd ed.). San Diego, CA: Academic Press. O’Connor, D. B., & Conner, M. (2011). Effects of stress on eating behavior. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science: Biology, psychology, and health (pp. 111–121). New York, NY: Springer. Seligman, M. E. P. (1974). Depression and learned helplessness. In R. J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research. New York: Wiley. Seligman, M. E. P. (1992). Helplessness: On depression, development, and death. New York: Freeman. Tice, D. M., Bratslavsky, E., & Baumeister, R. F. (2001). Emotional distress regulation takes precedence over impulse control: If you feel bad, do it! Journal of Personality and Social Psychology, 80, 53–67. Vaillant, G. E. (1994). Ego mechanisms of defense and personality psychopathology. Journal of Abnormal Psychology, 103, 44 Wood, R. A. & Griffiths, M. D. (2007). A qualitative investigation of problem gambling as an escape- based coping strategy. Psychology & Psychotherapy: Theory, Research & Practice, 80(1), 107–125. I know the consequences of the internalizations that may arise for racialized and marginalized folks. Both sets of my grandparents were born in India under British rule and as such were colonized subjects. My people entered the United Kingdom as immigrants and I was born into an England in which the politician Enoch Powell, echoing the majority feeling of the population, made his famous “Rivers of Blood” speech in the House of Commons calling for violence against those arriving from colonized lands. At the time of my birth London was host to numerous race riots, and the National Front, a far-right organization characterized by its violent skinhead youth, was extremely active. There was a deafening silence about this fact in my family, however, perhaps an internalized manifestation of the constant efforts (still) made in the dominant discourse to deny the effects of colonial practices, and that systemic racism even exists (Turner, 2020).
There is a growing literature about the profoundly negative impact of racism on mental health outcomes, the way in which oppression is internalized, and the various consequences of this. The experience of racism has been linked to higher levels of issues such as depression, psychosis, anxiety and posttraumatic stress (Henderson-Daniel et al., 2004; Karlsen et al., 2005; La Roche & Lustig, 2013; Graham-LoPresti et al., 2017). Research suggests that anxiety, including Social Anxiety Disorder, is more persistent and chronic in racialized populations than White populations. Women are already 60% more likely to have anxiety and 80 % more likely to have major depressive disorder compared to men, but racialized women often experience discrimination based on both gender and race. Psychoses are also reported to be more common in racialized groups, with a significant increased risk of schizophrenia in migrant groups from the Global South. This is just an example of what the pernicious, quotidian experience of racism can lead to in terms of mental health outcomes. “I am talking of millions […] who have been skillfully injected with fear, inferiority complexes, trepidation, servility, despair, abasement.” (Césaire, A., 1955) Césaire, A. (1955). Discours sur le Coloniali. Editions Présence Africaine. Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S. & Hayes-Skelton, S. A. (2017). Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. DOI: 10.1002/jclp.20014 Karlsen S., Nazroo J.Y., McKenzie K., Bhui K. & Weich, S. (2005). Racism, psychosis and common mental disorder among ethnic minority groups in England. Psychological Medicine. 35 (12), pp. 1795-803. doi: 10.1017/S0033291705005830 La Roche, M. & Lustig, K. (2013). Being Mindful About the Assessment of Culture: A Cultural Analysis of Culturally Adapted Acceptance-Based Behavior Therapy Approaches. Cognitive and Behavioral Practice, 20, pp. 60-63 Turner, D. (2020). Fight the power: A heuristic exploration of systemic racism through dreams. Counselling and Psychotherapy Research, 00:1–6. DOI: 10.1002/capr.12329 Chronic overactivation of the stress response (such as is a result of racism) can have damaging effects on many organ systems, undermining and disrupting the immune, hormonal and metabolic systems, for example (Kiecolt-Glaser & Glaser, 1995; Segerstrom & Miller, 2004; Mikkonen & Raphael, 2010). It is implicated in acute cardiac symptoms, increases in inflammation (contributing to cardiovascular risk), rheumatoid arthritis, back pain, diabetes, herpes, and irritable bowel syndrome to name but a few issues (Baker, Suchday, & Krantz, 2007; Blanchard & Keefer, 2003; Kop et al., 2008; Davis et al., 2008; Lampe et al., 1998; Landel-Graham, Yount, & Rudnicki, 2003; Padgett & Sheridan, 2000).
There are also effects on the brain: Van der Kolk (2015) argues that there are three major ways that the brain changes as a response to trauma, with the fear centre becoming oversensitive, our ability to filter out what is relevant from what isn’t becoming compromised, and the part of the brain responsible for how we experience the world changing, too. Stress can also interfere with neurogenesis, which is the formation of new neurons, primarily in key areas in the hypothalamus, which enhances learning and memory. In fact, suppressed neurogenesis may be a key component of depression. People with histories of trauma often have abnormalities in the hippocampus, the amygdala, the prefrontal cortex and changes to the autonomic nervous system (Dranovsky & Hen, 2006; McEwan, 2009; Pal & Elbers, 2018). Trauma can also effect epigenetics; it changes the way DNA is expressed, and these changes can be passed on to the next generations, which can affect how the children and grandchildren of trauma survivors react to stress, adapt to various environments, their vulnerability to certain illnesses and even their mortality (Avramova, 2015; Mangassarian, 2016). Apply this to the multi-generational experience of racism, and you get a heart-breaking picture of what happens to our communities. Avramova, Z. (2015). Transcriptional 'memory' of a stress: Transient chromatin and memory (epigenetic) marks at stress-response genes. Plant Journal, 83(1), 149-159. https://doi.org/10.1111/tpj.12832 Baker, G. J., Suchday, S., & Krantz, D. S. (2007). Heart disease/attack. In G. Fink (Ed.), Encyclopedia of stress. San Diego: Elsevier. Blanchard, E. B., & Keefer, L. (2003). Irritable bowel syndrome. In A. M. Nezu, C. M. Nezu, & P. A. Geller (Eds.), Handbook of psychology (Vol. 9): Health psychology. New York: Wiley. Davis, M. C., Zautra, A. J., Younger, J., Motivala, S. J., Attrep, J., & Irwin, M. R. (2008). Chronic stress and regulation of cellular markers of inflammation in rheumatoid arthritis: Implications for fatigue. Brain, Behavior, and Immunity, 22(1), 24–32. Dranovsky, A., & Hen, R. (2006). Hippocampal neurogenesis: Regulation by stress and antidepressants. Biological Psychiatry, 59, 1136–1143. Kiecolt-Glaser, J. K., & Glaser, R. (1995). Measurement of immune response. In S. Cohen, R. C. Kessler, & L. U. Gordon (Eds.), Measuring stress: A guide for health and social scientists. New York: Oxford University Press. Kop, W. J., Weissman, N. J., Zhu, J., Bonsall, R. W., Doyle, M., Stretch, M. R., et al. (2008). Effect of acute mental stress and exercise on inflammatory markers in patients with coronary artery disease and healthy controls. American Journal of Cardiology, 101, 767–773. Lampe, A., Soellner, W., Krismer, M., Rumpold, G., Kantner-Rumplmair, W., Ogon, M., & Rathner, G. (1998). The impact of stressful life events on exacerbation of chronic low-back pain. Journal of Psychosomatic Research, 44, 555–563. Landel-Graham, J., Yount, S. E., & Rudnicki, S. R. (2003). Diabetes mellitus. In A. M. Nezu, C. M. Nezu, & P. A. Geller (Eds.). Handbook of psychology (Vol. 9): Health psychology. New York: Wiley. Mangassarian, S. (2016). 100 Years of Trauma: the Armenian Genocide and Intergenerational Cultural Trauma. Journal of Aggression Maltreatment & Trauma, 25 (4), pp. 1-11. doi:10.1080/10926771.2015.1121191 McEwen, B. S. (2009). Stress and coping. In G. G. Berntson & J. T. Cacioppo (Eds.), Handbook of neuroscience for the behavioral sciences (Vol. 2, pp. 1220–1235). Hoboken, NJ: Wiley. Mikkonen, J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management. Padgett, D. A., & Sheridan, J. F. (2000). Herpes viruses. In G. Fink (Ed.), Encyclopedia of stress (pp. 357–363). San Diego: Academic Press. Pal, R., & Elbers, J. (2018). Neuroplasticity: The Other Side of the Coin. Pediatric Neurology, 84, 3–4. https://doi.org/10.1016/j.pediatrneurol.2018.03.009 Segerstrom, S. C., & Miller, G. E. (2004). Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130, 601–630. Van der Kolk, B. A. (2015). The body keeps the score: brain, mind, and body in the healing of trauma. New York, New York: Penguin Books. One helpful conceptualization of racial trauma comes from Dr Shelly Harrell (2000). She offers a six-level framework that examines the ways in which we are harmed by racism, through:
1. Racism-related life events - these are racial events such as assaults and other acts of race discrimination that target us directly and unequivocally. For example: When we are called a racist term or assaulted. I don’t wish to provide examples of this; I’ll offer some writing instead: "Certain moments send adrenaline to the heart, dry out the tongue, and clog the lungs. Like thunder they drown you in sound, no, like lightning they strike you across the larynx." (Rankine, 2014) 2. Vicarious racism - when the exposure to racism is indirect, for example when we hear stories of or witness racism occurring to those around us. This is painfully evident if you pay just a little attention to the news cycle, with the endless repetitions of deaths of racialized folks, and Black and Indigenous folks in particular, at the hands of the police. This is also the reason why you should never, ever share videos of such killings on social media. 3. Daily racist micro-stressors - these are subtle, normalised and ambiguous acts of racist denigration, the kinds of things we today call microaggressions, for example being asked: 'Where are you really from?'. The cumulative, pervasive nature of microaggressions is harmful to a person’s physical, intellectual, emotional, and social health. They can limit access to resources, contributing to employment barriers, unequal representation, and pay inequity. The resultant chronic stress can contribute to a range of physical health complications. They can also lead to feelings of isolation and an invalidation of experience. Microaggressions can sometimes result in greater overall harm than more overt forms of oppression. “…one did not have to be abnormally sensitive to be worn down to a cutting edge by the incessant and gratuitous humiliation and danger one encountered every working day, all day long.” (Baldwin, 1963) 4. Chronic contextual stressors - the mere awareness of structural race inequality and unequal distribution of resources. For example: simply being exposed to race inequality statistics via the media or popular culture. Or the chronic contextual stressor of the gaslighting involved in the reporting of police violence against racialized folks, where the passive voice tends to be used to subtly absolve the perpetrators of any responsibility. “You were born into a society which spelled out with brutal clarity, and in as many ways as possible, that you were a worthless human being.” (Baldwin, 1963) 5. Collective experiences of racism - which involves witnessing the racism inflicted on one's racial group. 6. Transgenerational transmission of group trauma - when aspects of oppression related to historical events are passed on. An example of this from my own family: India was colonized by the British in the 1800s and they remained there until 1947, meaning both sets of my grandparents were born under British rule and were colonized subjects. In 1947, in order to enable a self-serving withdrawal and leave behind two separate states, an arbitrary, last minute line was drawn from the Himalayas down to the sea by Sir Cyril Radcliffe, with the western side labelled Pakistan, and the eastern side labelled India. This led to the mass displacement of between 10 to 20 million people, as Muslims on the Indian side and Hindus and Sikhs on the Pakistani side abandoned their homes and tried to get to the other side of the border. There was mass bloodshed as those escaping were set upon as they tried to leave, with up to 2 million people believed to have been killed. This randomly assigned border split the native land of my people - the Punjab – in two, making it the scene for the worst of the violence. This theme - of division, of dislocation and of otherness - runs through my story. My experience was of splits and lines everywhere that harked back to the original Radcliffe line – the split between Indian and English culture, and the split between my maternal and paternal families, for example. Dr. Harrell’s framework highlights the chronic nature of racial trauma, which sets it apart from most other forms of trauma. Secondly, the last three levels stress the collective impact of racism, something that tends to be missed in most conversations on racial trauma. Baldwin, J. (1963). The Fire Next Time. The Dial Press, New York. Harrell, S (2000). A Multidimensional Conceptualization of Racism-Related Stress: Implications for the Well-Being of People of Color. American Journal of Orthopsychiatry, 70 (1), pp. 42-57. doi:10.1037/h0087722 Rankine, C. (2014). Citizen: An American Lyric. Graywolf Press, Minnesota. It's exhausting to be a guest
In somebody else's house Forever. Even though the host invites The guest to say Whatever it is they want to say, The guest knows that host logic Is variable. Prick me. And I will cut off the energy To your life. Kapil, B. (2020). How to Wash a Heart. Pavillion Poetry, Liverpool University Press. When thinking about the effects of racism, a key variable to consider is that of stress. Stress usually refers to things that threaten or are perceived to threaten our well-being and therefore tax our coping abilities. This creates what is called an allostatic load – an overall “wear and tear” on the body that has very real physiological consequences (McEwan & Stellar, 1993). Because racism is a unique and often daily stressor, it leads to very real consequences on the bodies and souls of racialized folks everywhere.
Theorists have suggested two kinds of stressors: acute stressors, which are threatening events that have a relatively short duration and a clear endpoint, and chronic stressors, which are threatening events that have a relatively long duration and no apparent time limit. Both acute and chronic stressors can result in internal conflict, which is when two or more incompatible motivations or impulses compete for expression. Conflicts have been described as coming in three types (Lewin, 1935): approach–approach conflict, which involves a choice between two attractive goals, and is least stressful; approach–avoidance conflict, which involves a choice about whether to pursue a single goal with both attractive and unattractive aspects , and can be quite stressful; and finally avoidance–avoidance conflict, which involves a choice between two unattractive goals, and is highly stressful. Let’s think about the internal experience of racial trauma: because of the minority status of the person on the receiving end, when you are in that position you are forced to ask yourself - do I accept this discrimination and othering, or do I push back, when pushing back means not just against an individual, but against an entire structural edifice? Neither option is much fun, and if you have to face this every day, you will soon be exhausted. Which is, by the way, the whole point: to keep you exhausted. Hans Selye (1956) proposed a theory of stress reactions described as the “General Adaptation Syndrome”. It involves three stages: alarm, whereby physiological arousal occurs and the body musters its resources to combat the challenge, then resistance, where physiological arousal remains higher than normal but may stabilize somewhat as coping efforts kick in, and finally, after some time, exhaustion, which occurs because the body’s resources for fighting stress are limited, and will become depleted. Now apply this to the life-long experience of racialized people, and you begin to understand the challenge we face. Lewin, K. (1935). A Dynamic Theory of Personality. New York: McGraw-Hill. McEwen, B. S. & Stellar, E. (1993). Stress and the individual. Mechanisms leading to disease. Archives of Internal Medicine. 153 (18): pp. 2093-101. doi:10.1001/archinte.153.18.2093 Selye H. (1956). The Stress of Life. New York: McGraw-Hill Book Company. Immigrants typically face a broad range of stressors upon arrival in a new country, such as a lack of environmental mastery, social support, language proficiency and socioeconomic status, as well as a painful loss of familial connections, all of which tend to yield a higher rate of mental disorders in the population (Khawaja, Gomez & Turner, 2009). Racialized immigrants also face the challenge of racism at the institutional, cultural, and individual levels, potentially resulting in experiences of prejudice, discrimination, and violence (Chen & Chen, 2020). The subsequent effect of all this on second generation children of immigrants may involve developmental issues around forming an identity associated with ethnicity and subsequent related adverse mental health symptoms (Lee & Neese, 2020).
It’s no easy task to leave your homeland and all that you know for a new life in another country, nor is it easy to be descended from immigrants and find yourself neither one thing or another, but a separate, third thing – one that belongs nowhere. I am gratefully able to personally attest to the fact that therapy can be a key tool to unlocking a more resilient and adaptable sense of your own self in the face of such overwhelming challenges. Chen, H. & Chen, E. C. (2020) Working with Interpreters in Therapy Groups for Forced Migrants: Challenges and Opportunities. International Journal of Group Psychotherapy, 70:2, 244-269, doi: 10.1080/00207284.2019.1685885 Khawaja, N. G., Gomez, I. & Turner, G. (2009). Development of the Multicultural Mental Health Awareness Scale. Australian Psychologist, 44(2), pp. 67–77. DOI: 10.1080/00050060802417801 Lee, H. Y. & Neese, J. A. (2020). Mental and Behavioral Health of Immigrants in the United States. Published by Elsevier Inc. https://doi.org/10.1016/B978-0-12-816117-3.00008-7. Racialized women can experience discrimination based on both gender and race, and as such be doubly at risk of psychological effects (Hall & Sandberg, 2012; Jones & Pritchett-Johnson, 2018). However, the heterogeneity of racialized women prevents a one-size-fits-all approach (Henderson-Daniel et al., 2004). For example, Black women may experience pressure to embody strength and resilience rather than seek support or express emotional needs (Jones & Pritchett-Johnson, 2018), while for Indigenous women an awareness of the legacy of colonization and current social practices which wreak devastation upon Indigenous peoples’ mental and physical health may be the minimum understanding required of a therapist (Lavallee & Poole, 2010). Asian women may require consideration of other factors, such as the greater somatization seen in this broad category (Presley & Day, 2019). For Latinx women the scapegoating of Latinx people in North America may have exposed them to higher risk for mental health issues (Elias-Juarez & Knudson-Martin, 2016).
The intersecting oppression experienced by these populations is linked to various mental and physical health issues (Rojas-Vilches et al., 2011; Nygaard, 2012; Abrams et al., 2019) as well as an underutilization of services (Yeh et al., 2004; Interian & Díaz-Martínez, 2007; Chen et al., 2008; Awosan et al., 2011). Each client’s meaning-making around race in the therapeutic relationship may impact their presentation and disclosure (Chang & Yoon, 2011), while issues of transference and countertransference may arise (Nagai, 2009), with practitioners needing to be particularly attuned to potentially traumatizing responses (Stevens & Abernethy, 2018). Conversations about race may be critical to treatment (Kivlighan et al., 2019) - but even if not related to the client’s presenting problem, an understanding of the unique stressors that result from multiple marginalized identities is key for any therapist aiming to create safety and develop and maintain a functioning therapeutic alliance (Jones & Pritchett-Johnson, 2018). Abrams, J. A., Hill, A. & Maxwell, M. (2019). Underneath the Mask of the Strong Black Woman Schema: Disentangling Influences of Strength and Self-Silencing on Depressive Symptoms among U.S. Black Women. Sex Roles, 80, pp. 517–526. https://doi.org/10.1007/s11199-018-0956-y Awosan, C. I., Sandberg, J. G. & Hall, C. A. (2011). Understanding the experience of black clients in marriage and family therapy. Journal of Marital and Family Therapy, 37 (2), pp. 153-168. doi: 10.1111/j.1752-0606.2009.00166.x Chang, D. F. & Yoon, P. (2011). Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research, 21 (5), pp. 567-582. doi:10.1080/10503307.2011.592549 Chen, E. C., Kakkad, D. & Balzan, J. (2008). Multicultural Competence and Evidence-Based Practice in Group Therapy. Journal of Clinical Psychology: In Session, 64 (11), pp. 1261-1278. doi:10.1002/jclp.20533 Elias-Juarez, M. A. & Knudson-Martin, C. (2016). Cultural attunement in therapy with Mexican-heritage couples: a grounded theory analysis of client and therapist experience. Journal of Marital and Family Therapy, 43 (1), pp. 100–114. doi: 10.1111/jmft.12183 Hall, C. A. & Sandberg, J. G. (2012). “We Shall Overcome”: A Qualitative Exploratory Study of the Experiences of African Americans Who Overcame Barriers to Engage in Family Therapy. The American Journal of Family Therapy, 40, pp. 445–458. doi: 10.1080/01926187.2011.637486 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. doi:10.1002/jclp.20014 Interian, A. & Díaz-Martínez, A. M. (2007). Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients. Cognitive and Behavioral Practice, 14, pp. 84—97. https://doi.org/10.1016/j.cbpra.2006.01.006 Jones, M. K. & Pritchett-Johnson, B. (2018). “Invincible Black Women”: Group Therapy for Black College Women. The Journal for Specialists in Group Work, 43 (4), pp. 348-375. doi:https://doi.org/10.1080/01933922.2018.1484536 Kivlighan, D. M., Drinane, J. M., Tao, K. W., Owen, J. & Liu, W. M. (2019). Detrimental Effect of Fragile Groups: Examining the Role of Cultural Comfort for Group Therapy Members of Color. Journal of Counseling Psychology, 66 (6), pp. 763–770. http://dx.doi.org/10.1037/cou0000352 Lavallee, L. F. & Poole, J. M. (2010). Beyond Recovery: Colonization, Health and Healing for Indigenous People in Canada. International Journal of Mental Health and Addiction, 8, pp. 271–281. doi:10.1007/s11469-009-9239-8 Nagai, C. (2009). Ethno-cultural and linguistic transference and countertransference: from Asian perspectives. American Journal of Psychotherapy, 63 (1), pp. 13-23. doi: 10.1176/appi.psychotherapy.2009.63.1.13 Nygaard, A. (2012). Cultural Authenticity and Recovery Maintenance in a Rural First Nation Community. International Journal of Mental Health and Addiction, 10, pp. 162–173. doi:10.1007/s11469-011-9317-6 Presley, S. & Day, S. X. (2019). Counseling Dropout, Retention, and Ethnic/Language Match for Asian Americans. Psychological Services, 16 (3), pp. 491–497. http://dx.doi.org/10.1037/ser0000223 Rojas-Vilches, A. P., Negy, C. & Reig-Ferrer, A. (2011). Attitudes toward seeking therapy among Puerto Rican and Cuban American young adults and their parents. International Journal of Clinical and Health Psychology, 2 (2), pp. 313-341. Stevens, F. L. & Abernethy, A. D. (2018). Neuroscience and Racism: The Power of Groups for Overcoming Implicit Bias. International Journal of Group Psychotherapy, 68: 4, pp. 561-584. doi:10.1080/00207284.2017.1315583 Yeh, C. J., Hunter, C. D., Madan-Bahel, A., Chiang, L. & Arora, A. K. (2004). Indigenous and Interdependent Perspectives of Healing: Implications for Counseling and Research. Journal of Counseling & Development, 82, pp. 410-419. https://doi.org/10.1002/j.1556-6678.2004.tb00328.x Not only do women have to contend with overt forms of violence and control at the hands of men, they also have to contend with gender microaggressions on a daily basis - such as sexual objectification, assumptions of inferiority, assumptions of traditional gender roles, use of sexist language, denial of individual sexism, invisibility, denial of the reality of sexism, and environmental gender microaggressions (McSorley, 2020).
Women in general - and racialized women in particular - experience more social disadvantage than men, which is a mental health risk factor and which also impacts access to care (Straiton et al., 2016). Trans women may likely have experienced quotidian microaggressions and possibly violent discrimination as a result, both linked to depression, anxiety, and suicidality (Hughto et al., 2017; McSorley, 2020), while any female-coded client’s sexual orientation, and the world’s response to it, may play a big part in their well-being; 2LGBTQ+ people face heterosexism, violence, and discrimination again associated with mental and physical health problems (American Psychological Association, 2012) - lesbians and bisexual women face this in relation to both sexuality and gender, while the cumulative effects of heterosexism, sexism, and racism puts racialized 2LGTBTQ+ people at unique risk (American Psychological Association, 2012). The literature suggests that all of these experiences have a profoundly negative impact on mental health outcomes, with women being 60% more likely to have anxiety and 80% more likely to have major depressive disorder as compared to men (McSorley, 2020), while the lifetime prevalence rate of Social Anxiety Disorder has been found to be 5.7% in women compared to 4.2% in men (Straiton et al., 2016; Graham-LoPresti et al., 2017). And yet, despite this, therapy itself continues to be contextualized within the dominant patriarchal culture that upholds narratives situating cis men as superior to cis women (McSorley, 2020). As a male practitioner, the absolute minimum I require of myself in order to be culturally competent while working with this demographic is to divest from such conceptualizations. A list of gender microaggressions that women might experience during therapy includes: objectification, stereotypes about their psychological distress, assumptions about diagnoses, insensitive treatment suggestions, and neglect of gender issues (McSorley, 2020). Furthermore, interventions in which the practitioner uses manipulation, persuasion, and assimilation into the male-dominant society also shows a lack of knowledge of a female-coded client’s worldview and are thus flawed (Henderson-Daniel et al., 2004). Holding all of this in mind is critical in my attempts to embody an anti-oppressive practice. How my identity as a male-coded individual affects others continues to be a priority for my inward gaze, and involves attentiveness to both my client’s and my own reactions, facilitated by an awareness of my own values, assumptions, and biases. American Psychological Association (2012). Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. American Psychologist, 67 (1), pp. 10–42. doi: 10.1037/a0024659 Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S. & Hayes-Skelton, S. A. (2017). Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Disorder: A Case Paper. Cognitive and Behavioral Practice, 24, pp. 459-471 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. DOI: 10.1002/jclp.20014 Hughto, J. M. W., Clark, K. A., Altice, F. L., Reisner, S. L., Kershaw, T. S. & Pachankis, J. E. (2017). Improving correctional healthcare providers' ability to care for transgender patients: Development and evaluation of a theory-driven cultural and clinical competence intervention. Social Science & Medicine, 195, pp. 159–169. http://dx.doi.org/10.1016/j.socscimed.2017.10.004 McSorley, K. (2020). Sexism and cisgenderism in music therapy spaces: An exploration of gender microaggressions experienced by music therapists. The Arts in Psychotherapy, 71, pp. 1-9. https://doi.org/10.1016/j.aip.2020.101707 Straiton, M., Powell, K., Reneflot, A. & Díaz, E. (2015). Managing Mental Health Problems Among Immigrant Women Attending Primary Health Care Services. Health Care For Women International, Vol. 36. 10.doi: 1080/07399332.2015.1077844. Families are where we first learn “what feelings are acceptable and family authorized and what feelings are prohibited” (Bradshaw, 1988b). Many young boys experience a “shaming of all emotions” (Bradshaw, 1988a), in particular that of any expression of pain, of grief, as being unmanly and a sign of weakness. It is in this way that men “are socialized to mistrust feelings, particularly difficult feelings, to experience them as threatening, overwhelming, and of little value” (Real, 2002). As bell hooks (2004a) states, “Soul murder is the psychological term that best describes this crushing of the male spirit in boyhood”.
The effect of this ‘soul murder’ is greater than only inhibiting certain emotional experiencing, however. It can also lead to a privileging of acting out in anger, something that is socially rewarded – the lesson being that anger is the “only emotion that patriarchy values when expressed by men” (hooks, 2004b), with the bottom line being that “manhood is synonymous with the domination and control over others” and the use of “coercion and/or violence to gain and maintain power” (hooks, 2004a). Indeed, it can be argued that “...violence is boyhood socialization” (Real, 2002). In psychodynamic terms, acting out in anger can thus became men’s primary defense against feeling our grief. “When we are raging, we feel unified within—no longer split. We feel powerful. Everyone cowers in our presence. We no longer feel inadequate and defective. As long as we can get away with it, our rage becomes our mood altered of choice. We become rage addicts” (Bradshaw, 1988a). Acting out our rage “is the perfect cover-up for … unreconciled grief” (hooks, 2004a) - while healing “begins with acknowledging and feeling the pain” (hooks, 2004a). This can be quite challenging, however, given that most men refuse to acknowledge their deep childhood losses, “seem incapable of grieving and mourning on an individual basis” (Dutton, 1995) and are unsupported in this attempt because “male models for grieving are few” (Dutton, 1995). Therapy can be a space in which to challenge this damaging status quo, a space for masculinity to be given the freedom - to just be. Bradshaw, J. (1988a). Healing the Shame That Binds You. Deerfield Beach, Fla: Health Communications. Bradshaw, J. (1988b). Bradshaw on: the family: A revolutionary way of self-discovery. Pompano Beach, Fla: Health Communications. Dutton, D. (1995). The Batterer: a Psychological Profile. Basic Books, New York. hooks, b. (2004a). We Real Cool: Black Men and Masculinity. Routledge, New York. hooks, b. (2004b). The Will to Change: Men, Masculinity, and Love. Atria Books, New York. Real, T. (2002). How Can I Get Through to You? Closing the Intimacy Gap Between Men and Women. Simon and Schuster, New York Every boy is inducted into the code of patriarchal masculinity, and thereafter becomes both primary benefactor but also unwitting victim of the patriarchal system of thought – of the hierarchical, one-up/one-down way of relating to others, and to one’s own self. As Terence Real states: “Both the roots of [man’s] pain and also his entitlement to run from it, inflicting it, instead, on those he most cares for, lie at the heart of patriarchy.” Or, as the late Black radical feminist scholar bell hooks (2004a) put it, boys learn “that the patriarchal man is a predator, that only the strong and the violent survive.”
The understanding here is that “Patriarchy is the single most life-threatening social disease assaulting the male body and spirit” (hooks, 2004b) - that men are ourselves oppressed by the unspoken patriarchal code. We are “taught that a boy should not express feelings” (hooks, 2004b), and it is this learning that seems to underpin many of men’s presenting problems in therapy, for not only do we often not know how to express our feelings beyond acting out upon them, we also often appear not to know how to even feel them. hooks, b. (2004a). We Real Cool: Black Men and Masculinity. Routledge, New York. hooks, b. (2004b). The Will to Change: Men, Masculinity, and Love. Atria Books, New York. Real, T. (2002). How Can I Get Through to You? Closing the Intimacy Gap Between Men and Women. Simon and Schuster, New York Many neurodivergent people, with or without a diagnosis, can see “difference” as a lonely experience of not belonging (Humphrey & Lewis, 2008; Huws & Jones, 2008). Internalized oppression can lead some who have received a diagnosis to wish for a cure (Bagatell, 2010; Punshon et al., 2009). These are just some indicators of the pressures placed upon this demographic to adopt a “less than” stance toward themselves. A “less than” internalization can lead to all manner of difficulties for people, neurodivergent or not. While it’s likely that most therapy is generally geared towards addressing such internalizations, I believe ISTDP is a particularly effective modality with regard to interrogating the relationship you have with yourself and how that plays out in your relationships with others. But for neurodivergent folks, as with folks who feel similar pressures as a result of other aspects of their identity, finding safety and understanding with a practitioner is the important thing. When the risk of being harmed by someone you are going to for help and support is high, it takes genuine courage to reach out for help in the first place.
Bagatell, N. (2010). From cure to community: Transforming notions of autism. Ethos, 38, 34 –58. doi:10.1111/j.1548-1352.2009.01080.x Humphrey, N., & Lewis, S. (2008). “Make me normal”: The views and experiences of pupils on the autistic spectrum in mainstream secondary schools. Autism, 12, 23– 46. doi:10.1177/1362361307085267 Huws, J. C., & Jones, R. S. P. (2008). Diagnosis, disclosure, and having autism: An interpretative phenomenological analysis of the perceptions of young people with autism. Journal of Intellectual and Developmental Disability, 33, 99 –107. doi:10.1080/13668250802010394 Punshon, C., Skirrow, P., & Murphy, G. (2009). The “not guilty verdict”: Psychological reactions to a diagnosis of autism in adulthood. Autism, 13, 265–283. doi:10.1177/1362361309103795 Many people suffer from painful feelings about their own bodies. It’s an important thing to interrogate. We tend to blame our bodies for such feelings, but research has shown that attachment is closely associated with body image and dissatisfaction (Hui & Brown, 2013). Our body image develops through interactions with significant figures in our lives (Kearney-Cooke, 2002), and any body image issues tend to be sparked by early experiences of bullying, humiliation, and body image criticism by family members or peers (Boyda & Shevlin, 2011; Wolke & Sapouna,2008). Furthermore, an insecure attachment is associated with a greater investment in body image, greater dissatisfaction, and more negative feelings about the body overall (Cash et al., 2004).
ISTDP can help here, because it focuses on the causes of such issues by addressing attachment and our responses to it. This kind of work can facilitate a recognition of our conscious wish for affiliation and attachment with others, a conscious awareness of how we have learned to expect others to respond (Abbass, 2015) – and how we have learned to relate to ourselves as a result of this expectation. Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Boyda, D. & Shevlin, M. (2011). Childhood victimisation as a predictor of muscle dysmorphia in adult male bodybuilders. The Irish Journal of Psychology, 32, pp. 105–115. http://dx.doi.org/10.1080/03033910.2011.616289 Cash, T. F., Theriault, J. & Annis, N. M. (2004). Body image in an interpersonal context: Adult attachment, fear of intimacy and social anxiety. Journal of Social and Clinical Psychology, 23, pp. 89–103. http://dx.doi.org/10.1521/jscp.23.1.89.26987 Hui, M. & Brown, J. (2013). Factors that influence body dissatisfaction: Comparisons across culture and gender. Journal of Human Behavior in the Social Environment, 23, pp. 312–329. http://dx.doi.org/10.1080/10911359.2013.763710 Kearney-Cooke, A. (2002). Familial influence on body image development. In T. Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory, research, and clinical practice (pp. 99–108). New York, NY: Guilford Press. Wolke, D. & Sapouna, M. (2008). Big men feeling small: Childhood bullying experience, muscle dysmorphia and other mental health problems in bodybuilders. Psychology of Sport and Exercise, 9, pp. 595–604. http://dx.doi.org/10.1016/j.psychsport.2007.10.002 I am an able-bodied male-coded individual, and despite the fact that being able-bodied is in truth a transitory condition for every single person alive – that some form of disability awaits us all as we age (Potok, 2002) – ableism remains prevalent, a “common set of stigmatizing social values and debilitating socially constructed hazards” that disabled people have to live with and navigate that results in recurring experiences of “cultural devaluation and socially imposed restriction, of personal and collective struggles for self-definition and self-determination” (Longmore & Umansky, 2001).
The normative attitudes toward disability arise from the medical model which locates the disability in the individual (as a failure in their body) rather than in the failure of social structures to ensure accessibility for all. This is a capitalist logic at root, in that the cost of addressing disabled folks’ social marginalization and economic deprivation would be high, while their value to the capitalist machine, built as it is on the bodies of workers, remains low. And so we have the conception of disability as “pathological rather than political, clinical and not cultural” (Longmore & Umansky, 2001). The primary building block of this structurally oppressive edifice of thought seems to lie in the idea of normality - positing disability, or sickness, as a deviation from it (Baynton, 2001). This concept of normality is used to manage populations and situations, which brings us back to the present moment, one in which marginalized folks around the world were and continue to be disproportionately affected by the global pandemic, with people of colour the frontline workers among those most exposed, elderly folks in care homes a significant proportion of those tragically lost, and the disabled – which includes those who are immunocompromised and/or have what are known as “pre-existing conditions” – the most at continued risk. The vulnerable have been left to fend for themselves – with accessibility as high a priority for institutions as it ever was (meaning not very much at all). Herein lies the difficulty: it’s incredibly hard to convince people that they should care about other people. I may not be able to make anyone realize that it is good to care about other people, but I can certainly try to help people return to genuine care and compassion for themselves - in the hope that from such a place, genuine care and compassion for others might arise. With the well-being of my immunocompromised and high-risk clients in mind - as well as the basic issue of accessibility - I am therefore focusing on virtual (telehealth) sessions for now. If and when this changes, I am nevertheless decided to always retain this as an option for clients in the future. Baynton, D. C. (2001). Disability and the justification of inequality in American history. In Longmore & Umansky (pp. 33–57), p. 33. Longmore, P. K., & Umansky, L. (Eds.). (2001). The New Disability History: American Perspectives. New York: New York University Press, p. 12. Potok, A. (2002). A Matter of Dignity: Changing the Lives of the Disabled. New York: Bantam Books, p. 12. Cultural competence in therapy involves - but is not limited to - an awareness of someone’s country of birth, ancestry, their parent’s country(ies) of birth, languages spoken, Indigeneity, sexuality, gender expression, religion or spirituality, social behaviour and customs, physical and neurological differences, age and socio-economic status (Brooks et al., 2019). But such information is only useful if used to discover how an individual uniquely experiences these aspects of their identity (Dyche & Zayas, 2001).
Feminist and multicultural theorists indicate the importance of awareness and integration of the various intersections of a client’s identity to the development of an effective therapeutic relationship (Knox et al., 2003; Collins et al., 2010; Ecklund, 2012). Culturally competent therapy also requires a practitioner’s self-examination of their own reactions, a humility and openness to learning, the ability to use culture appropriately (and to ascertain when it is not related to the presenting issue), patience, empathy, and an awareness of the differential power status which, in cross-cultural therapy, can be significant (Dyche & Zayas, 2001; Yeung et al., 2018; Brooks et al., 2019; Lee & Neese, 2020). Awareness and incorporation of cultural differences in values, attitudes and behaviors (Interian & Díaz-Martínez, 2007) has been linked to better rapport, intimacy, disclosure, risk-taking, involvement, and therapy outcomes in marginalized clients (Henderson-Daniel et al., 2004; La Roche & Lustig, 2013; Graham-LoPresti et al., 2017). Treatment that fails to address contributing sociocultural factors in their lives may prove insufficient (Abrams, Hill & Maxwell, 2019). An exploration of intersecting aspects of a marginalized client’s identity, where relevant, and an awareness of the barrier to therapy different folks face, for example, may instead facilitate greater engagement among groups who often don’t get the support they most need (Abrams, Hill & Maxwell, 2019). As a member of such a group, and as someone for whom the idea of going to therapy was for the longest time simply unthinkable, I am determined to bring the healing power of this work to those so often failed by the mental health industry. Abrams, J. A., Hill, A. & Maxwell, M. (2019). Underneath the Mask of the Strong Black Woman Schema: Disentangling Influences of Strength and Self-Silencing on Depressive Symptoms among U.S. Black Women. Sex Roles, 80, pp. 517–526. https://doi.org/10.1007/s11199-018-0956-y Brooks, L. A., Manias, E. & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26, pp. 383–391. https://doi.org/10.1016/j.colegn.2018.09.007 Collins, S., Arthur, N. & Wong-Wylie, G. (2010). Enhancing Reflective Practice in Multicultural Counseling Through Cultural Auditing. Journal of Counseling & Development, 88, pp. 340-347. https://doi.org/10.1002/j.1556-6678.2010.tb00031.x Dyche, L. & Zayas, L. H. (2001). Cross-cultural empathy and training the contemporary psychotherapist. Clinical Social Work Journal, 29 (3), pp. 245–258. https://doi.org/10.1023/A:1010407728614 Ecklund, K. (2012). Intersectionality of Identity in Children: A Case Study. Professional Psychology: Research and Practice, 43 (3), pp. 256–264. doi: 10.1037/a0028654 Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S. & Hayes-Skelton, S. A. (2017). Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Disorder: A Case Paper. Cognitive and Behavioral Practice, 24, pp. 459-471. https://doi.org/10.1016/j.cbpra.2016.12.003 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. doi:10.1002/jclp.20014 Interian, A. & Díaz-Martínez, A. M. (2007). Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients. Cognitive and Behavioral Practice, 14, pp. 84—97. https://doi.org/10.1016/j.cbpra.2006.01.006 Knox, S. Burkard, A. W., Johnson, A. J., Suzuki, L. A. & Ponterotto, J. G. (2003). African American and European American Therapists’ Experiences of Addressing Race in Cross-Racial Psychotherapy Dyads. Journal of Counseling Psychology, 50 (4), pp. 466–481. doi:10.1037/0022-0167.50.4.466 La Roche, M. & Lustig, K. (2013). Being Mindful About the Assessment of Culture: A Cultural Analysis of Culturally Adapted Acceptance-Based Behavior Therapy Approaches. Cognitive and Behavioral Practice, 20, pp. 60-63. doi:10.1016/j.cbpra.2012.04.002 Lee , H. Y. & Neese, J. A. (2020). Mental and Behavioral Health of Immigrants in the United States. Academic Press, pp. 157-178. https://doi.org/10.1016/B978-0-12-816117-3.00008-7 Yeung, A. S., Trinh, N-H. T., Chen, J. A., Chang, T. E. & Stern, T. A. (2018). Cultural Humility for Consultation-Liaison Psychiatrists. Psychosomatics, 59 (6), pp. 554-560. doi:10.1016/j.psym.2018.06.004 When I first arrived in this country I realized I had become complicit, just by virtue of my being here, in the ongoing genocide of the First Nations people that belong to this land. One of the reasons for my becoming a therapist was to make some kind of sense of my being here, on this land: the intention was, from the beginning, to ensure a significant percentage of my work is with the people who belong to this land – here in Vancouver, this primarily means the people of the Squamish, Musqueam, and Tsleil-Waututh First Nations.
Both sets of my grandparents were born colonized subjects, and I know all too well the internalizations that result; how heavy sits the Crown. I have to work in opposition to that; it’s the only thing that makes sense to me, to work with these and other marginalized populations and facilitate the undoing of the internalization of external forms of oppression, the undoing of all the frozen moments of trauma that creep into the body and contort it. Sadly, many of the systems in place that provide support to Indigenous folks also function under the oversight of the same enterprise that has its boot on their necks. Coping with the consequent feeling of incongruence this creates in me means keeping my eyes, ears and heart open in order to learn how this enterprise operates - so that I can make better decisions about how to be of service to this demographic and thus be a useful part of the healing journey being undertaken by the communities here. While I include feminist, existential, and client-centered thinking in my approach to the work of therapy, my focus is on the role of unconscious forces in an individual’s response to trauma. My belief is that all of us experience trauma, even if the worst thing we have experienced was simply the painful separation of birth itself. I believe that the ultimate goal of therapy is the removal of all obstacles to the processing of the emotions that are locked inside the body, whether these have arisen as an adult, perhaps due to systemic causes, or in early childhood, as a result of attachment trauma.
A vast majority of presenting problems in therapy can be traced back to - or can have some active component involving – attachment issues. Anxiety provoking emotional states are created in us as children when we experience obstacles to our innate desire to bond to a primary caregiver (Abbass, 2015). As adults we bring this early formation of expectation for other’s behaviour to our relationships; it informs how we view ourselves and also the form and expression of any psychological problems we might experience (Kernberg, 1980). While many of the strategies and coping mechanisms we develop in response to our early attachment experiences originally function as the best available option for survival when we are young, they can become the prime source of psychological suffering as we become adults (Abbass, 2015). They can cause somatic disturbances (Abbass, 2015), anxiety, depression, personality disorders (Abbass, Town, & Driessen, 2012), and interpersonal problems (Solbakken & Abbass, 2015). It is important to be clear that this is automatic and unconscious behaviour, not something we are actively choosing to do. Psychodynamic theory understands the unconscious as having a major role in internal conflict and pathology and maintains that a resolution can be achieved through the therapeutic encounter - through two equally meaningful presences in the room who both share a commitment to addressing the anxiety, defenses, resistance, and complex feelings that arise during the work of therapy. ISTDP therapy (Davanloo, 1990, 2000), focused as it is on attachment and an individual’s unconscious reactions to it, can facilitate an understanding of and healing from what often remains hidden from view because of the general focus we tend to otherwise have on dealing with symptoms rather than dealing with their causes. It makes sense that getting to the roots is the only way to ensure the weeds you want removed from your garden cannot return. Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Abbass, A., Town, J. M., & Driessen, E. (2012). Intensive short-term dynamic psychotherapy: A systematic review and meta-analysis of outcome research. Harvard Review of Psychiatry, 20 (2), 97-108. doi: 10.3109/10673229.2012.677347 Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Kernberg, O. (1980). Internal World and External Reality. Aronson: New York, NY. Solbakken, O. A. & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant disorders. Journal of Affective Disorders, 181, 67–77. doi: 10.1016/j.jad.2015.04.003 The suggestion that early childhood experiences shape adult functioning paved the way for attachment theory, which underpins the modern psychodynamic approach to therapy. John Bowlby (1958, 1969) developed attachment theory, maintaining that experiences with primary caregivers determined personality development, and Mary Ainsworth later furthered this work with her “Strange Situation” experiments (Ainsworth & Bell, 1970; Ainsworth, 1973).
In these, a child and its mother entered a room in which there was a person unknown to the child. The mother then left the child there, with the stranger, a situation a child would experience as dangerous. Their reactions were observed. After a few minutes, the mother returned, and observation of the child’s behaviour continued. The observed behaviours eventually led to the classification of four different attachment styles. Secure children would cry when left with a stranger, but then when the mother returned they would reconnect with her and would be soothed until they could self-regulate. Some children, though, seemed unconcerned by the mother’s departure - they acted as if the stranger (a real and present threat) didn’t exist, completely ignoring them, and then when the mother returned, would stay disengaged. These were described as insecure-avoidant. Others would cry when the mother left, but when she returned they could not be soothed by her, and were never able to self-regulate. These were described as insecure-resistant, or sometimes as insecure-ambivalent. The fourth kind would display odd, irrational behaviour when the mother left, like hitting themselves, and these were described as insecure-disorganized. Attachment theory went on to inform individual psychodynamic therapy approaches such as ISTDP (Davanloo, 1990, 2000), as well as both family and couples therapy approaches. Psychodynamic therapies such as ISTDP pay specific attention to the effect of early relationships with primary caregivers - to the child’s (sometimes pre-verbal) understandings and internalizations that resulted from these relationships, and how these manifest in individual attachment styles. These early patterns of relating to ourselves and to others can persist into adulthood, and go on to affect our lives and relationships. In extremely general terms, secure children often become autonomous adults, avoidant children often become dismissive adults, resistant or ambivalent children often become preoccupied adults, and disorganized children often become fearful adults. Why is any of this relevant to you? Because no matter what problems bring you to therapy, what is behind them, what is driving them, is likely something related to your relationship with others, and ultimately, to your relationship with yourself. Imagine a child who has been abandoned by one or both parents. Their unconscious, infant understanding of the situation may have led them to view themselves as somehow being repulsive - as having repulsed the abandoning parent. This might show up in adulthood as an impulse to please others for fear of ever being rejected again, or it might show up as a pattern of rejecting connection first before you yourself can be rejected once again. Your internal system – the way you make sense of the world and your relationships in it - might be centred upon the unconscious sense of somehow being less-than, of somehow lacking in inherent value. A person might respond to this by turning their feelings in upon themselves and becoming self-punitive, for example, or might turn their feelings outward, onto others, and become abusive. Attachment can thus be seen to have a very real effect on every aspect of your life, and without healing, perhaps through therapy, can also become generationally active - getting passed down in one way or another to your descendants. Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (3, 1-94) University of Chicago Press: Chicago. Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67. Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39, 350-371. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. Basic Books: New York, NY. Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Our personal boundaries are naturally occurring demarcations - between us and others, between okay and not okay - that we can become aware of by learning to listen better to the cues in our own bodies. Professional boundaries are different, of course, because they also take into account demarcations assigned by external factors or bodies - by the demands of a job, or an industry, for example.
In the context of psychotherapy, the relationships between client and therapist are vastly different to those we might have with our friends and family. The psychotherapy relationship involves the provision of a professional service, and a failure on either side to respect the unique set of boundaries that exist in this context will actively hamper the therapist’s ability to provide that service, and ultimately, their ability to help the client learn to sense, understand and enforce their own boundaries. If a therapist can’t walk the talk themselves, then what use is talking to them about walking, really? My personal history is the reason I became a therapist. My earliest experiences led to damaging internalizations which therapy was able to allow me to understand and to begin to heal from, and this same facilitation of healing is what I aim to bring to others. This impacts the way I approach therapy; I operate from a psychodynamic lens - the way of working which provided the best framework for understanding my own self. I bring the strength of my own experience as a client to my work - I have moved through that process all the way to the experience of love for myself, inside my own body. It was both a life-changing moment to feel this feeling, and one filled with grief - to realize that in all the years before that moment, I had not. I believe this is of critical importance for a therapist - to have been on the path too, in your own way, in order to be able to gently encourage others to traverse the path that lies before them.
I was a child of the South Asian diaspora, born in London, England, abandoned by my father and separated from my mother for long periods of time after she took me to live with my grandparents in another city while she returned to work in London. These early losses - of any genuine sense of a homeland, and of both parents - were bereavements to child-me. I was not to understand this, however, until forty years later - in therapy.
As a person of colour in the age of late stage capitalism, having lived the aftermath of the colonial experience, having undergone the emotional castration required of the male-coded by psychological patriarchy and then having found my way back to myself, to recovery and healing - and now, recognizing that there is work to be done out there, the work of healing, through therapy - I believe that this work is built upon the foundation of unconditional positive regard, for others, and for myself. Because without this unconditional love and compassion for my own self, what chance is there of putting its healing power at the service of others? Being grounded in a place of unconditional love and compassion for my own self is not and will never be a fait accompli, but instead is a continual doing, a lifelong practice to go hand in hand with the learning and doing of this other practice - of being with clients, in session. This lifelong practice touches each of the five domains of life: the physical, emotional, cognitive, social, and spiritual aspects of existence. For me, the emotional and the spiritual are all but the same thing, for feeling, as I have come to understand it, is the live wire, the manifestation of the animating force in all things, the current through which that most imminent of information - the life force itself - is carried. The physical, and the cognitive domains both, to me, reflect this central domain: the physical being the flip side of that same coin, the material manifestation - and the cognitive being the play of its shadow on the wall. As for the social domain, well - integrating this aspect has been integral to my journey. Once I began to understand the socio-political-historical context of my life, I discovered the harm that had been done to me and the harm that I was perpetuating. This understanding has taught me to walk the path with heart, by which I mean to walk the path with care - for myself, and for others. My intention now is centred around non malfeasance - to do no harm, to live an anti-oppressive life and to try to be a force for good in this world. This has entailed divesting from people and situations with and in which the barriers to living this way are too great. This has also entailed continuing to do the work of learning about such harms, in order not to perform them - to continue to hold myself accountable, to continue to learn about and engage with the political, and to understand through this how best to live with compassion for others. Living with care, both for myself and others, equates to living in accordance with my values. And living thus means feeling, for feelings are the information of living, and a heightened awareness of my feelings is a heightened awareness and connection - to life itself. Ultimately, all that any of us brings to our lives, our relationships, and our work - is our own self. Self-care, meaning self-awareness, is therefore a non-negotiable practice, without which we can be of no use to ourselves or to those we care about. But too many of us learn - often unconsciously and in response to painful experience - not to care for ourselves. We may have discovered that our own needs were not as important as those of the people around us, growing up – and therefore developed an internal way of operating that puts ourselves last. Therapy can be a proving ground – a space in which to learn about this unconscious system that causes so many different symptoms and difficulties, and a space in which to unlearn it. "Trauma has become so commonplace that most people don't even recognize its presence. It affects everyone. Each of us has had a traumatic experience at some time in our lives, regardless of whether it left us with an obvious case of post-traumatic stress. Because trauma symptoms can remain hidden for years after a triggering event, some of us who have been traumatized are not yet symptomatic."
"Some of the frightening and often bizarre symptoms suffered by traumatized people include: flashbacks, anxiety, panic attacks, insomnia, depression, psychosomatic complaints, lack of openness, violent unprovoked rage attacks, and repetitive destructive behaviors." Levine, P. A. (1997). Waking the Tiger: Healing Trauma: the Innate Capacity to Transform Overwhelming Experiences. North Atlantic Books: California, CA. Anxiety is a fascinating topic, one that I have learned is integral to the work of therapy. There are many different perspectives upon and ways of understanding anxiety, and I have found the framework provided by psychodynamic psychology in general and ISTDP therapy in particular to be paradigm shifting. What is most important to communicate, I think, at the beginning of therapy, is the difference between fear and anxiety. Fear is a response to an external, clear, and present danger, while anxiety is the activation of this same fear system in response to an internal stimuli. It’s the difference between a tiger jumping out at you and the idea of a tiger jumping out at you. One danger is happening, the other is imagined, predicted, or expected. But our internal reactions in the absence of an external stimuli can be just as powerful – more so, in fact, given that they can perpetuate and effect our bodies in the absence of any clear and present danger out in the world to provoke them. The internal stimuli that cause our individual experiences of anxiety depend very much on how our internal systems are constructed, and this depends upon the things we have experienced. The question is, are we aware of what gets us anxious, and if so, what do we do with that? Developing insight and experience of this is exactly where ISTDP therapy can come in.
|
Thoughts on Counselling, Therapy, and Mental HealthArchives
August 2024
Categories
All
|
RSS Feed