Bringing the social and psychological together
A common critique of mainstream psychotherapy models is that they take little account of social and cultural forces and of their effect upon psychological structures and relational processes. This is a significant limitation in terms of culture competence. Many minority and marginalised groups continue to see mainstream therapy and mental health services as irrelevant. More concerning is that some may come to experience the therapeutic process as one which exposes and weakens them into powerlessness and; which renders invisible the power of the social context and its related wounds and traumas. It is not unusual for therapists and other helping professionals to feel overwhelmed and helpless in relation to the idea of actively working with social and cultural forces within the therapeutic encounter.
However, any genuinely emancipatory and culturally competent approach to therapy must strive to make visible the impact of oppression and help support service users’ efforts to free themselves from its destructive power relations. Relations that exist structurally, socially and psychologically for people who continue to be othered, marginalised and oppressed. More culturally and socially informed formulations may therefore offer tools to validate marginalised groups’ experience of the world and thus contribute to change. Although extremely useful, I have personally been frustrated by purely social formulations which have not commonly highlighted deriving psychological correlates and thus have located themselves within a level of analysis and intervention which may arguably be outside the remit of mainstream psychotherapeutic practice. This post is an attempt at bridging the gap. It provides an introduction to a preliminary psycho-socio-cultural formulation framework (figure A), its rationale and some possible questions to aid reflection.
Figure A: Draft diagrammatical formulation of the cycle of oppression.
Description of the formulation framework: The cycle of oppression.
At the centre of the draft formulation is a cycle of oppression. This cycle is made of four interrelated components varying in proximity to the present or to the ‘here and now’. Those components are: discrimination and oppression, inequality/access to material resources, proximal images/discourses and, distal and intergenerational narratives and events. The oppression cycle is posited to impact on both worldviews and on psychological functioning so that another cycle of psychological correlates is located outside it. The proposed deriving psychological processes are status anxiety and evaluative stress, the internalisation and replication of oppression, the (cognitive) salience of historical traumatic narratives/events and finally the sense of cultural mistrust or paranoia and (affective) distance to the dominant culture. The formulation thus firmly puts the influences of the social and cultural at the centre of psychological functioning.
Discrimination, oppression and cultural mistrust
Perception and experiences of oppression such as discrimination and harassment in the workplace (or in other life domains) are commonly reported amongst all members of minority groups. The link between such experiences and chronic stress, poor psychological wellbeing and ill physical health are well established. Perceived and actual discrimination can elicit what has been termed cultural paranoia, a healthy and adaptive response to experiences of oppression. Nonetheless, cultural paranoia can give rise to feelings of hopelessness, helplessness and bias against members of the dominant groups. It can also produce hyper-vigilance and fear.
It is thus likely that those who are experiencing it to a high level, will be in some form of distress. From the therapeutic perspective it may be helpful to consider how cultural paranoia may impact on trust and on the working alliance. Mental health services are a microcosm that, it can be argued, represents the social world. A service user who expects that he/she will be discriminated against within services or by therapists and/or that his/her account of such experiences will be dismissed, silenced or pathologized will understandably be guarded and reluctant to disclose relevant difficulties. A degree of hostility may become apparent if the therapist is seen as a representative of the dominant culture, the state and/or authority.
How does the Service User (S.U). locate himself/herself, his/her immediate family and distant family culturally and historically?
How does the S. U. define oppression and discrimination?
To what extent has the S.U. experienced oppression and discrimination?
How is sense made of the above?
What part do such experiences play/played in current/past psychological distress?
What has the S.U. found useful in managing such experiences?
What is the S.U. experience of power and powerlessness?
Social/material inequality, status anxiety and evaluative stress
Social inequalities have a significant impact on our psychological wellbeing. On a basic level they perpetuate the uneven distribution of protective factors and of stressful life events. Evidence suggests that more unequal societies tend to suffer from poorer mental health. England is one of the most unequal countries in the world. As consumerism is reaching new heights, the gap between the rich and poor is increasing. The relationship between mental health distress and social inequalities is bi-directional so that each has the potential to exacerbate the other. Additionally, although causality and directionality is not always clear, most marginalized groups tend to be socio-economically disadvantaged.
The psychological consequences of inequalities are central to the psychological functioning of those who are economically and materially disadvantaged. Wilkinson and Pickett (2009) argue that the impact of income inequality is psychologically mediated by ‘status anxiety’ in that inequality creates social hierarchies which increase status competition, stress and thus poor psychological health. Yet, another psychological mechanism that seems relevant is social-evaluative threat (SET). SET is believed to occur when a central component of our identity is, or could be, negatively evaluated so that we fear rejection. Within such potentially rejecting situations our fundamental need for social acceptance is threatened and a discrepancy between our actual and our ideal self is created giving rise to feelings of worthlessness, reduced relational value and/or shame.
How is respect and disrespect framed and conceptualized?
Are there significant debts?
To what extent does the S. U. feel pressure to conform to consumerism?
Is there a discrepancy between the actual economic situation and the idealized one?
Is there access to well established friendships and social support networks?
Is there shame and stigma associated with the socio-economic situation?
Images, discourses and the internalisation/replication of oppression
Unsurprisingly a proportion of minoritized individuals will internalize oppression. Internalized oppression can affect relationships within and between minority groups and between minority group members and those who are from the dominant group. This internalisation may manifest in mistrust toward the in-group, idealisation of the dominant culture, distancing from minoritized identities or the holding of stereotypical views about members of the in-group. Further, internalised oppression can, In extreme cases, lead to low self-esteem, self-hatred and even violence towards members of the in-group.
Assessing internalised oppression can be difficult because it is associated with high levels of shame and stigma and may therefore not be readily disclosed nonetheless; careful questioning may elicit such processes. Thus, any recurrent negative statements made about the in-group(s) may need further probing as may any negative emotion evoked by questions about the subjugated identity. Various standardised questionnaires exist to assess internalised oppression which may be useful when the therapeutic relationship is firmly established. Acculturation and stages of identity development may also influence the relationship with the dominant group (in addition to the one which may be formed with the therapist) and whether the therapeutic values and norms may be acceptable.
What community/group(s) does the S.U. feel most affiliated with?
Are there difficulties with fitting-in or with belonging?
What is the relationship with members of the in-group(s)/out-group(s) like?
Are there weak/strong cultural or other ties with members of other minority identities?
Is there a history of immigration or displacement?
Is there evidence of shame and stigma associated with the culture of origin?
Historical and intergenerational context and distal narratives and events
Many theorists have put forward concepts that aim to capture the psychological impact of historical trauma on oppressed groups. For example, Alleyne (2004) has proposed the concept of ‘The internal oppressor’. The internal oppressor is theorized to be a psychic part of the self which can become activated when members of oppressed groups are confronted with oppressive situations in their day to day lives so that painful and emotionally charged historical events gain salience in their awareness. Examples of such painful historical events/processes may include the Holocaust for people of Jewish origin, imperialist processes (eg. slavery, colonisation) for other members of minority ethnic groups or the pathologization of homosexuality for some sexual minorities. In essence, the ’internal oppressor’ triggers a process of interpretation of contemporary oppression in light of historical trauma and injustice. This amplifies the distress experienced.
Experiences of oppression can also be reinforced or triggered by public images and media portrayals. Marginalized groups’ representations in the media tend to be distorted. Some groups are particularly prone to misrepresentation e.g. Black males, those who claim benefits, travellers, those with mental health problems and Muslims. A number of studies have identified patterns in media representations of marginalised groups including an overall underrepresentation, an over-emphasis on negative associations (e.g. criminality, unemployment…) whilst at the same time relatively few positive associations. Consequently, public portrayal of minorities tend be one-dimensional, negatively framed or problem focussed. Biased representations leave out significant aspects of minoritized communities’ lives, contributions and experiences.
What historical and contemporary narratives has the individual been exposed to?
What impact have such narratives have/have had?
Are there alternative/competing stories?
How are negative images/discourses managed?
Has there been exposure to positive role models from the subjugated identity group?
Is there shame and stigma associated with negative images/narratives?
This post is a first attempt at putting together a formulation framework that is based on a social explanatory model but which also identifies possible deriving psychological processes upon which potential psychological interventions may be based. The framework is not married to any school of psychotherapy. It simply aims to offer a possible starting point to reflect and consider relevant socio-cultural forces, their possible psychological impact and potential interactions. I do not see praxis and social change based epistemologies as incompatible with psychological interventions particularly if they are located within a social model of psychological distress. In fact I believe that both are necessary to facilitate resistance and liberatory efforts. The diagrammatic formulation is based on common themes and theories related to oppression and inequality as well as some relevant empirical findings. Although the framework may be most useful when applied to racialized minorities, it may equally be helpful to support other marginalised groups. I welcome comments and feedback which will allow the improvement and further development of the tool.
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What to learn more? Please see…
Alleyne, A. (2004). Black identity and workplace oppression. Counselling and Psychotherapy Research, 4(1), 4 – 8.
Dickerson, S. S., Gruenewald, T. L., & Kemeny, M. E. (2004). When the social self is threatened: Shame, physiology, and health. Journal of Personality, 72, 1191–1216.
Hutchinson, E. O. (1996). The Assassination of the Black Male Image. New York, New York: Touchstone.
Rowlingson, K. (2011). Does income inequality cause health and social problems? York: Joseph Rowntree Foundation.
Wilkinson, R. and Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin.
Wilkinson, R. and Pickett, K. (2010). The Spirit Level: Why Equality Is Better For Everyone. London: Penguin.