Culturally Biased Therapy? (Part 2) Injustice and depression

In a previous article problematising Cognitive Behavioural Therapy (CBT) from a racialised perspective, I proposed that the epistemic assumptions underlying the model were capable, at group level, of subjecting people of colour (POC) to violence in part, by reproducing discourses of inferiorisation which help maintain the status-quo and thus, white supremacy.  In the present piece, I wish to continue to reflect on such assumptions focusing in particular on the conceptualisation of depression and its implications for people whose existence is plagued by inequality and injustice. I will draw in part, from my lived experience and posit that the invisibilisation of injustice or the pathologisation of injustice related wounds or responses, are further acts of violence which again disproportionately affect people of colour and reproduce social hierarchies.

Mental health inequalities                                                                   

Racial inequalities within mental health services need little introduction. They have been the subject of hundreds of studies over decades which have consistently found that Black, Asian and minority ethnic communities, as a group, are more likely to be diagnosed with ‘mental health problems’ and are more likely to be admitted to psychiatric hospitals. Further, such groups are more likely to experience poor outcomes from ‘treatment’ and are similarly more likely to be ‘treated’ coercively. More to the point here, we also know that people of colour are more likely to disengage from mainstream mental health services and to find them irrelevant or inappropriate. This state of affair is undoubtedly the interplay of various factors, including structural racism. And, in particular, mainstream mental health services’ continuing difficulties in providing support that is acceptable and accessible to racialised ‘minorities’.

The picture for depression is less clear. The depression of people of colour is arguably still both poorly understood and poorly recognised by health professionals. Yet, economic and social factors and the increased occurrence of adverse life events and trauma in this group likely increases the incidence of depression. There are on-going concerns over the lack of statutory support for some racialised groups when they experience depression or low mood. The dominance of bio-medical frameworks and their associated individualistic interventions often fail to translate into service uptake for people of colour. Part of this disconnect, I believe, is epistemic and so we must return to the assumptions related to the nature and origins of wellbeing and of psychological distress of mainstream/dominant models, namely here, CBT.

 A cognitive model of depression

Beck’s cognitive theory remains one of the most influential when it comes to formulating depression. The model is composed of three elements as represented in figure a).  The diagram proposes that a person’s belief system when they experience depression, is underscored by a cycle of negative view of the self, negative view of world and negative view of the future. Each component of the model is posited to interact with and to strengthen the others so that attributions of events, for example, are believed to originate from dysfunctional beliefs about the self, the world, and the future and in turn, negative beliefs about the future maintain negative feelings about the self and the world. The cycle is believed to be fed by dysfunctional thoughts and behaviours which ultimately maintain depression.

Many have clearly found the model useful to make sense of depression. I’ve always struggled. Firstly because, of the assumption of irrationality or dysfunction rather than adaption. Further, the triad, is too removed from contextual factors which may provide the fuel, if not be the genesis for the triad, rendering it both highly individualistic and pathologising in its emphasis. And more critically, I think there is something quite perverse which is done; in the name of therapy; to marginalised groups when the violence they experience in the world is invisibilised by people who at the very least, may be charged with benefitting from the said violence.

The impact Injustice

I have been doing equality and justice focused work for the past fifteen years or so. Fifteen years. That’s a long time for someone still in their thirties. About half my life…If I take into account my lived experience; I have been doing this stuff for most of my life. There is no single part of my existence that has been untouched by injustice, one way or the other. As a child, I remember being very upset by unfairness. Almost at soul level. I was an unusually observant child. I cried many tears over things most children do not concern themselves with, most were equality related. And there was much to cry about for a child attuned to the world around her. I understood injustice left marks. I could see it on the slumped shoulders and almost vacant gaze of neighbours in the cité. One of the psychological costs of exclusion. It was in the way they walked and moved too, as though lifeless. I could see it in the eyes of my parents as they fought low expectations and navigated racialised xenophobia. They did not need to name it. 

I have recognised this embodiment clinically, this imprint on the soul. It is unmissable to the trained eye. To the sensatised body…It led me to the conclusion that the need for justice may well be anchored deeply within us. Social determinants of heath are getting increased recognition in relation to mental health inequalities. And while their distributions among different groups are known to affect health outcomes, there’s been little theorisation as to how they inflict harm psychologically.  Injustice appears to me to be a unifying factor. I would suggest that it is through our lived experience of injustice that most social determinants are mediated internally, that they take hold and lodge themselves within us. I do not think it is coincidental that the experiences that most accurately predict psychological distress such as bullying, discrimination, sexual abuse, poverty even bereavement seem to all involve a breached sense of justice.

This breach of the principle or expectation of justice in the world seems therefore to be something that profoundly distresses us. It is capable of transforming us and our outlook on life. Reflecting upon my own clinical work, I do not believe that I have ever met a single person in distress who was not struggling with injustice. One way of the other. From the persecuted asylum seeker who feels god’s fury has turned onto them despite them devoting their entire life to religion, to the child who cannot comprehend why they are the one being picked on at school or who was born ‘different’. From the parents struggling to say goodbye to a dying child to those have been laid off because of ageism or sexism. From those whose historical trauma is constantly reproduced in the oppression they experience at work, to those whose body was objectified in the most degrading ways. Injustice automatises us. Injustice despairs us. Injustice wounds us. Deeply.

Injustice and depression

I was once told in a CBT class that seeking justice was pathological. That ‘demanding fairness’ was considered dysfunctional within CBT. I know many therapists believe this. But still…Imagine hearing this as a matter of fact, from a white man when your body is black and female. Just let this sink in. So I just want to say that as a black woman, the dysfunction to me, lays in adjusting and adapting to injustice and socialising the people who have suffered unspeakably at its hands into accepting it. The dysfunction is telling marginalised bodies that it is healthy, mature and desirable not to ‘demand’ justice while reaping the benefits of such manufactured powerlessness and apathy. I want to propose that maybe, just maybe, the dysfunction resides in the invisibilisation of the impact of injustice.

Let me also suggest that perhaps it is not pathological to be destabilised and affected by injustice in the world but that it is beautifully human and, that each time we socialise ourselves into accepting injustice we cut ourselves off from parts of our humanity, we normalise social inequality, we add an additional layer of protection to an already solid status-quo. Have you never wondered why children learn to say ‘it’s not fair’ and to comprehend injustice before they can say or grasp much else in the world? Perhaps this tells us something about us as human beings. Perhaps this is why people tend to experience distress or mourn or occupy space differently when they’ve been hit by injustice. And because some of us find ourselves at the intersection of various axes of oppression, we get hit more often. More deeply. More systematically. Our resources to remain unharmed, constantly tested. Sometimes they give. 

Injustice model of depression 

                                                

Those reflections led me to the above model (figure b). The injustice model naturally starts with and focus on the impact of injustice. It proposes that injustice leads a transformed a) sense of safety b) sense of security about the future and that both those components are mediated by an increased sense of ontological insecurity. By ontological insecurity here, I simply mean living in an embodied condition of fear, or dread, of threatening uncertainty in relation to one’s being in the world. Being able to maintain a sense of justice is central to our ontological equilibrium as human beings. It makes us feel secure both in the world and with others. It helps us trust ourselves and thus, trust others. It allows us to make predictions about the future. To have agency. Injustice shakes all of this. It is not therefore surprising that feelings of melancholia, of dread and helplessness can be triggered by injustice.

To conclude, there is nothing within people of colour’s cognitions or within marginalised bodies more broadly, that render us inherently pessimistic, prone to ‘dysfunctional beliefs’ and thus more likely to experience depression or ‘mental health problems’.  This is implied when intrapsychic formulations focus on some purported dysfunctions in the evaluation of the world at the expense of the harm which is done onto people. As though we were all gifted the same world.  The injustices we face also exist outside of our cognitions, at least in my worldview. They are material. They are sustained, for too many of us they are structural.

And, when injustice is done onto us and we recognise it as such, our self-image often shifts, our relationship with the world and with ourselves are often hit. Our sense of  belonging and being in the world can become shaky. This is more than a matter of  ‘viewing’ the world differently. This is not a matter of glasses being half full or half empty. I frankly find that this suggestion smacks of unpacked privilege. And arrogance. Our world is transformed by injustice. We are transformed too, possibly even epigenetically. 

It took me a while to try and articulate my reflections on the subject. When knowledge is embodied it can be difficult to translate it into words and to share it with the world, in way that speaks to others. Or perhaps this is my anxiety. So this is that first attempt. I ran a poll on Twitter earlier in the month, asking POC who had experienced low mood, which model (between the cognitive model and the injustice model) they felt best captured their experience and as the results below suggest, my lived experience seems to have resonated. The only validation I needed. And so, I am hopeful. I am hopeful that the model has the potential to help engage those who have traditionally felt alienated. Those who have felt invisibilised by mainstream therapy models. I believe this is how we start to heal. By being seen. 

I welcome feedback. 

Twitter poll results



Thank you for reading.
 

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