psychotherapy

Trauma Informed Care & people of colour

“If you are silent about your pain, they’ll kill you and say you enjoyed it”                

                                         Zora Neale Hurston

There are different kinds of wounds. Not all pain is deemed legitimate. Oppression causes trauma. Amidst the (fairly) obvious, debates around what really constitutes trauma as laid out in criterion A of the Diagnostic Statistical Manual (DSM)’s diagnosis for Post Traumatic Stress Disorder (PTSD); are alive and well. Criterion A now requires that an individual has been ‘confronted with: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence’ in order to qualify as having experienced trauma. In contrast with the DSM-IV and previous versions, the DSM-V notably includes sexual violence but not racial violence…troublingly evoking the fight for racial justice.

Looking back in history, (white) women’s rights have always taken precedence over the rights of people of colour. For example, in the US white women were afforded the right to vote in both state and federal elections in 1920 but, it was only in 1954 that people of Asian heritage could vote and; well into the 60s that measures specifically designed to bar African Americans from voting (e.g. voting taxes, literacy tests or intimidation) were rendered unlawful. The recognition of racial violence and injustice historically takes much longer than the recognition of sexual violence. It is important to bear that in mind. With some luck, we may get some intersectional thinking within mainstream mental health systems within 50 years.

Still…many of us continue to exist under the weight of racial (and intersectional) violence and more critically; continue to be affected by smaller, less extreme but repeated traumatic experiences. They rarely involve threat to life or to the integrity of our body but, they nonetheless create threat to livelihood, affect life course and limit life chances. They may not cause us to be confronted with overt violence, all the same, they create unsafeness and insecurity, pain and, a sense of futility and resignation or helplessness. Often too, they lead to internalised silencing or self-censorship due to repeated experiences of denial, invalidation or minimisation.

I am amongst those who believe in speaking of our pain.  As marginalised people when we are silent when violence is done to us, we offer a hiding place to perpetrators and to oppressive systems. Oppression and abuse often create a felt sense of shame. And, shame thrives in silence. This is also how oppressive systems reproduce themselves, they locate the pathology, dysfunction or anomaly within those they harm. We do the master’s work when we internalise these (projective) beliefs. Moreover, when one cannot speak of the violence they experience or have experienced, they are done violence all over again. Silence is violence. Often.

Insidious trauma

There is nothing new in considering oppression as a traumatic agent, nothing new at all. Feminist scholars have long critiqued DSM conceptualisations of trauma. Many have advocated for a theoritical expansion so as to locate the experience of trauma within socio-political contexts. The concept of insiduous trauma is born out of this scholarship. Insidious traumatisation (Root, 1992) is centred on the daily ‘subthreshold’ traumatic stressors marginalised people experience which, when taken cumulatively, amounts to trauma because they are constant reminders of one’s precariousness and unsafeness in the world. Some feminists have sought to include insidious trauma within PTSD criteria or put forward conceptualisations of oppression-related psychiatric disorders.

Understanding insidious traumatisation is vital. Nevertheless, I am not sure that some sort of pathologisation parity is required or would be helpful. Nor that pathologising responses to trauma more generally is desirable. This is not because I uphold a hierarchy of suffering or injustice or, because I think, insidious trauma necessarily produces dissimilar physical or psychological reactions to more ‘classic’ traumatic events or experiences. I am simply not convinced that the legitimisation of the psychological harm of racial violence should be via an extension of the DSM/psychiatric classification systems; systems that are based on alleged ‘deviation’ from unpacked and unproblematised norms (and let’s be real which themselves have a long history of doing violence to marginalised groups and indeed may easily be charged with actively living up to that legacy) when being deemed ‘abnormal’ and treated as such in the world is, by definition, the root cause of insidious trauma.

Trauma Informed Care?

When a traumatic event is extreme or when we are able to identify a specific event, it is easier to see and recognise the need for support and care. When the damage is done covertly or more subtly over months, years or decades or; when it is part of the fabric of society culturally or ideologically, it can be much more difficult to attend to our suffering or to legitimise the need for support; even to ourselves. Such violence becomes the norm and our responses the pathology, our inability to cope. Smaller but repeated acts of denigration, of discrimination, of othering; constant reminders of structural inequalities and injustices do culminate into significant psychological distress. The evidence is there. There is nothing abnormal or deviant in survivors. The deviance lays in the violence.

There has been a global push towards what is often referred to as Trauma Informed Care (TIC). Various definitions of Trauma Informed Approaches (TIA) exist; all have at their core, a will to configure services and/or care around the developmental impact of trauma on all level of human functioning including on the psychological, neurological and on social development. TIA, further; seeks to ensure all social systems understand the impact of trauma on families, groups, communities and other social systems. TIC may be less stigmatising and, there are many benefits to understanding how trauma can affect attachment, worldviews and more generally people’s experience of the world and thus how structures can retraumatise.

I remain cautious though, when it comes to uncritically embracing the approach. I am not sure there is a huge conceptual difference between envisaging people as traumatised rather than as ‘mentally ill’.  For starters, most proponents of the medical model would probably argue that both propositions are not mutually exclusive. Indeed, it is precisely what has been proposed of late ‘there is something wrong with you… (in your brain, your emotional responses, your personality, your perceptions, your cognitive or relational processes etc…) because of what you have been through’. Thus, saying or implying, you are damaged because of trauma is no more humanising as a narrative, to me, than saying or implying you are damaged because of faulty brain structures.

Both explanatory models locate the disturbance or pathology within the individual.  In other words, you are still saying to me that there is something wrong with me as opposed to, there is something wrong with the way that I have been treated and everything ‘right’ in the way I have responded to try to survive. Further, and more importantly, the main focus remains on ‘treatment’ rather than on prevention, at least not on holding structures of power to account.  I have seen very little of this within TIA. ‘What has happened to you’ is infinitely more compassionate than ‘what is wrong with you’ no doubt, better still is asking ‘what has happened to you’ then, turning to oppressive systems and those with more social power; to ask ‘what are you doing to stop harming people’ or ‘how are you abusing your power’. Much more difficult questions of course but, necessary ones to balance the focus here and not lay our gaze exclusively or even primarily, onto individuals who survived violence or try to survive the harm done onto them but onto those who abuse their power, individuals and systems.

Trauma Informed Care and oppression

Psychiatry and mental health systems do not own distress or trauma. Or how it is defined. Or how it is or should be experienced. Trauma is not patented by the American Psychiatric Association (APA). Our experience of the world does not cease to exist simply because a group of white American men at the APA, or dominant systems more generally have decided, the daily violence we suffer is not that traumatic or worthy of a name or of a mention in their (conceptually and empirically flawed) book. Or because mental health systems, by and large, continue to struggle to make themselves relevant to so many of us.

I note that despite the recognition that racism constitutes trauma within most TIA I have come across and, the expressed link between trauma and historical and cultural contexts as one the principles of TIC,  I am still to see a single intervention within the framework specifically addressing the damage of whiteness within any mainstream mental health system in the UK. This, I find quite ironic. Racism reproduced at cultural-symbolic level is a source of trauma too. This invisibilisation or disinterest is consequently quite rich.  There is thus no evidence that TIC would be more relevant and/or more centred on people of colour’s needs or experience. Although the potential that it could is certainly there.

Although I am still ambivalent but open about TIC in relation to people of colour and their experience of oppression particularly, I do believe that we could benefit from using insidious trauma to make sense of our lived experience and to render visible and legitimate, the psychological effects of racial oppression. Although here too, the danger of individualising social trauma by narrowing analytical lenses looms very near indeed, constant efforts are required to avoid this process. Sill, by claiming the term, irrespective of dominant groups or systems’ approval, we are choosing self-definition. We are too, asserting our right and power to define reality. We are choosing to centre our experience of the world and hopefully to orientate ourselves towards self-care. And, to be clear, self-care in my book absolutely entails organising and resisting. History, teaches us that it makes little sense, to seek social approval for our struggles before taking action. Eventually, we tend to be proved right.  TIC and particularly, oppression-focused TIA may well prevent more debilitating manifestations of oppression-related or insidious trauma in people of colour, but the evidence base is simply not there and, I cannot say I have seen a rush for it.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Root M. P. (1992). Reconstructing the impact of trauma on personality. In Brown L. S., Ballou M. (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229-265). New York: Guilford.

Thank you for reading.

If you have found this article useful or interesting, please spread the word. All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections. If you wish to repost this article, please see the contact section for further details.

 

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The cycle of oppression: A psycho-socio-cultural formulation (DRAFT 1).

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.

photo (1)

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?

Conclusion

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.

Thank you for reading.

If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.

 

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.

The Elephant in the room: Race Representation, Symbolism and Silenced Wounds.

The first time I sat foot on a psychiatric ward was just under 10 years ago.  I was engaged in doing Community Development and Community Research work within Medium Secure Units (MSU) in London.  This was my first day on a MSU and indeed my first time visiting any kind of psychiatric hospital. Following a brief introduction to the all White psychology team by the clinical lead and consultant forensic clinical psychologist (a White man); I was taken round the ward where a multi-ethnic, but still mainly Black staff base, composed the nursing team who was in turn, overseeing the care of a virtually all Black inpatient/clinical population. Upon entering the ward, I was so overwhelmed by the sea of Black faces staring at me in utter stoicism, that I had to work very hard to contain my urge to cry.

The visit felt surreal and oppressive in an almost suffocating way and; this had nothing to do with the (respectful) way I was being treated by staff. At the time, I was not entirely sure why this sight had provoked such a strong response in me.  I had some knowledge of the extent of race inequalities within mental health services and had also been briefed on the clinical population upon my induction. Yet, something happened in my very first few moments on the ward which took me by complete surprise. Although this ‘Elephant’ remained at the back of my mind as I did further work on the Unit, I became somewhat desensitised to its presence, particularly as the subject was hardly ever discussed with colleagues.  Hence, what I set out to do in the present post is to try and make sense of my experience and to consider some potential clinical implications.

The power of symbolism and representation

As human beings we all make use of symbols to categorize, convey and extract meanings from events and social interactions. From a systems perspective, to start with, the staff composition mirrored traditional power distributions so that at the top of the hierarchy was a White man and at the very bottom of the pyramid of power, were of course the Black staff, followed by Black patients. Thus, at team level, there was a representation of social inequalities in relation to income across staff roles.  Further, the Psychologist role is one of authority that socially occupies the sphere of expertise and; in the context of MDUs; as the role encompasses the assessment of patients’ readiness for release, another layer of power is therefore inherent to the role.

The meaning attributed to the role of the patient (or more accurately patient-offender) and that of the Psychologist cannot be interpreted outside of the racial make-up of the ward.  Connotations and associations whether consciously accessible or not; firmly remain when it comes to race dynamics.  Certain images have the power to tap directly onto this rich symbolic heritage.  Indeed, looking through history, one would not have to search for very long for many constructions of Black people as dependent and as psychologically, socially and intellectually deficient to surface (debates around such constructions are to some degree continuing today). Consequently, and in the context described, the sight of a virtually all Black patient population having been assessed as needing treatment, rehabilitation and indeed control cannot but evoke the historical inferiorization and pathologization of Black people.

Projection and Identification

Returning psychoanalytically to what had happened in my ‘here and now’ experience of the ward, Projective Identification may offer an alternative and viable framework to make sense of the dynamics.  In that line of argument, it may be notable that as the detained Black men appeared to display no feeling and emotion, I experienced an overwhelming sadness and a sense of suffocation. Such feelings appear consistent with experiences which may be triggered by compulsory detention, restraint and freedom deprivation. Thus, it could be envisaged that through my experience, I was acting out the patients’ s disowned and/or unacceptable feelings and wishes which had been projected into me.

There is a long psychoanalytical tradition of viewing racism as a mechanism by which dominant groups project intolerable aspects of themselves into racial minorities.  From an internalised racism perspective, those projected qualities can be said to become accepted as one’s own. The imagery evoked by the racial representation clearly echoes the worst things Black people are all too often socialised to believe about themselves. From a psychoanatytical standpoint, the projections from dominant groups. The Ward context may thus evoke the same images that often give rise to many identity difficulties and other internal conflicts amongst some of us. Thus, whilst working toward ‘Recovery’, Black mental health service users may be exposed to the very painful dynamics that may be be part of their parcel of suffering and that may have contributed to bringing about and/or exarcebating their psychological distress.

Working with the Elephant in the room.

Taking on the role of mental health patient, in the current context, may also means psychically, taking on a role which is consistent with racial stereotypes and which may be experienced as buying into the constructed racial hierarchy which naturally part of the self may resist. From that perspective, it may follow that the role of mental health patient may be an extremely conflictual one for many Black men which may bring to the fore feelings of inferiorisation, marginalisation, exclusion, subjugation, distrust and possibly self-loathing. Although I have not come across many Black mental health patients/service users who have described their experience using symbols, systems representation and psychoanalytical concepts as frames of reference, the sense of suffocation and oppression I experienced has recurrently appeared in my sessions with Black service users as did their experience of being stereotyped on psychiatric wards.

There is ample research evidence suggesting that Black mental health service users have the most conflictual relationships with their clinicians, that they are the most dissatisfied group of all mental health service users and that they continue to report experiences of racism (including racism within services) but; despite these well-established findings; it appears that the Elephant in the room remains too overbearing to acknowledge and to work with for many of us. The dearth of discussion, clinical and empirical attention to the extent of the impact of race dynamics in relation to the psychological functioning and the service use, experiences and outcomes of racialized minorities seems to me to be of particular concern.  Not only because it may be part of the reproduction of existing hierarchical structures that perpetuate the invisibility of race and of White privilege, but also because it prevents opportunities for race related wounds and institutional suffering to be seen and addressed. I believe it may well have been these wounds and suffering I was apprehending and reacting to on my first day on the ward.

Thank you for reading, If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.