Microaggressions are a public health crisis

In clinical psychology, microaggressions are defined as brief and relatively commonplace daily verbal, behavioral, or environmental indignities and incidents, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color.

Individuals may engage in acts such as avoiding eye contact on the street or making assumptions about someone’s intelligence or mental state. This ‘subtler’ type of discrimination negatively impacts health outcomes. Microaggressions have been described as “death by a thousand cuts.”

Microaggressions tend to be harder to identify than overt racism, more difficult to confront or address, or both, because victims of microaggressions may have different perceptions and racial realities than those who enact them.

An emerging body of research has found that people of color experience an array of microaggressions, ranging from being assumed to be a criminal, being presumed to be cognitively inferior, being exoticized, or being treated as a second-class citizen. From locking of a car door when approached, to stepping away from someone in an elevator, being singled out by security at an airport, a supercilious tone of voice from those in authority positions, to being trailed around the store while shopping… these actions are injurious to the mental health of those who are being aggressed against and they have a cumulative affect on medical and mental health.

The connection between microaggressions and health
An alarming set of data shows that perception of racial discrimination from doctors is associated with reduced trust in mental health professionals/physicians, as well as reduced adherence to treatment regimens among Black American adults suffering from chronic disease. In fact, individuals who perceive their doctors as engaging in microaggressions generally do not return to treatment. With anyone.  See Dr. Siddique’s series of seminars: Minority Mental Health: Everyday Traumas and Microaggressions

Lack of trust in providers due to discrimination is also related to lower levels of screening for cancer, heart disease, and diabetes in Black Americans. Racial discrimination is linked to unhealthy behaviors such as overeating, consumption of fatty and fast foods, and decreased exercise. Repeated exposure to discrimination has also been linked to substance use, including marijuana, alcohol, and tobacco among Black American teens and adults.

The connection between microagressions and mental health
Research on microaggressions provides strong evidence that they lead to elevated levels of depression, anxiety, and trauma among minorities. In several large studies, depressive symptoms were the link in the relationship between racial microaggressions and thoughts of suicide.

Finally, one recent study showed that Native/Indigenous Americans diagnosed with type 2 diabetes experienced racial microaggressions from their mental health care and medical providers. Among those sampled in the study, a correlation was found between microaggressions and reported histories of heart attack, depressive symptoms, and hospitalizations.

What to do?
So, as professionals in health care, how can we work to minimize the physical and psychological harm of overt racism and microaggressions? First, workplaces and health care training programs (such as medical and clinical psychology training programs and nursing schools) can provide better training to employees and students. Such training must include information on the impact of racism and microaggressions on health outcomes and should also increase awareness of one’s own biases. Training should include dialogues and language designed to promote mutual understanding.

This should be facilitated by training experts and focus on the impact of overt racism and microaggressions. Supervision matters, with peer groups, clinical directors, instructors, and program heads. As I have spoken and written about elsewhere, intake processes for new patients very rarely assess for contextual and racism factors in the past.

Active inquiry about microaggressions in the daily and overall life of our patients is mostly missing and absolutely crucial.

Second, health care institutions can create online resources for employees, students/interns, and patients. For example, The New School University’s Health Services created a microaggressions site that assists students with understanding the nature and impact of microaggressions.  As a student, intern, and resident of several excellent programs, I received no training in this area. I had to cobble it together and seek at my own mentors. This should become absolutely mandatory for training and continuing education requirements.

Third, policymakers should consider creating policies that address IRL microaggressions. Similar to sexual harassment policies, racial microaggressions policies can be created to protect individuals/students/employees from experiencing micro-aggressions.

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