Tag Archives: microaggressions

On MLK Day 2023: With Gratitude to Dr. King, from a Desi Doctor

In February 1959, Dr. Martin Luther King, Jr. arrived in India for a five week trip to learn firsthand the South Asian history and strategies that informed the US battle for Civil Rights. Nine years after Gandhi‘s death, Dr. King wrote that he was deeply struck by direct observation of the Indian caste system and the parallels in American conceptions of race. Over 60 years later, caste-based discrimination continues in India, and, exponentially, in Muslim communities In India.

If you get a chance, read Dr. King’s words about his impressions of India, just profoundly beautiful.

Related: Caste book summary by Isabel Wilkerson

South Asian health professionals in North America need to express gratitude for the activism that has reduced racist structures but also to acknowledge the privilege afforded to us by education and profession. Indian, Pakistani and other South Asian physicians and mental health must lead that charge. Asian physicians make up the second-largest majority of all health professions within the United States. South Asian doctors fall around the 15% range. Of these, for example, greater than 60,000 physicians and approximately 10 to 12 percent of entering medical students are estimated to be of Indian heritage in this country.

Like many of our first and second-generation colleagues, our parents were primarily part of a migration from India, Pakistan, Bangladesh, and Sri Lanka. It began around 1965 and increased through the early nineties, thanks to relaxed immigration legislation and increased employment opportunities, many brought about by the Civil Rights Act of 1964, the Voting Rights Act of 1965, and The Fair Housing Act of 1968. The large number of South Asian immigrants who arrived during those years did so as either recent university graduates, or with the scholarship or family funds to obtain an education here on U.S. soil. As a result, South Asian immigrants have been prominent in fields that require extensive and often expensive training, such as medicine and technology.

We the first and second generation children of immigrants can use our education and position to advocate for change. The first thing to do is speak out against racism within our own communities. Although this statement often angers my South Asian community, it would be dishonest to state that we did not witness growing up with elderly community members, outwardly spewing racist propaganda; particularly condemning engaging in romantic relationships or close friendships with Black women or men. I work with a large number of Desi clients, and many feel they must keep their personal lives secret from family, a practice which is painful and ego-dystonic.

Related, see Dr. Siddique in The Meaning of Difference, McGraw Hill.

As healers, South Asian medical and mental health professionals, must be part of solutions to tackle health inequities for our Black patients. Health disparities in medicine are prevalent in all fields of medical practice. Coronavirus is still claiming the lives of Black Americans at a rate almost 2.5 times greater than Whites or Asians. Black men continue to have a substantially lower life expectancy. As a health community, we must set the goal to help narrow the disproportionate gap in Black Americans’ deaths from coronary artery disease, stroke, diabetes, and cancer. At the least, we should take our skills and funds to contribute to organizations that will help abolish the health inequities that we see daily in our line of work.

South Asians have endured discrimination. Our names are mispronounced, our office lunch mocked, we are stereotyped as doctors or convenience store clerks on many popular shows. We continue to endure micro aggressions from patients, administrators, and supervisors based on who we are. Of the utmost importance now is that we take some of the burden for fighting for persons of color away from our Black colleagues and patients, so they can take a timeout or at least rest.

Additional reading:
Microaggressions are a Publc Health Crisis.
Why Representation Matters: Media and Mental Health

South Asian Mental Health

1 in 5 South Asians in the United States report experiencing a mood or anxiety disorder in their lifetime, with women reporting higher levels of distress than men. Obviously, these numbers, in general, are vastly underreported, as South Asians often express greater stigma toward mental illness than other groups. Stigma toward mental illness is a major barrier to getting a diagnosis or help.

South Asians commonly experience psychological distress as physical symptoms. Mental health problems may manifest as somatic, such as sleep troubles, bodily pains, headaches, fatigue, and stomach problems. When this occurs, it increases the likelihood of being undiagnosed and untreated since mainstream models of medical treatment may focus attention on physical symptoms instead of potential underlying causes, including systemic, familial, social-emotional, and historical.

Medical and mental health professionals must address the following areas in addition to presented physical symptoms. Issues that impact the mental health of South Asians may include:

Stereotyped Roles
The “model minority” myth is a microaggression known as “ascription of intelligence,” where one assigns intelligence to a person of color on the basis of their race. South Asian students are often perceived to be nerdy, academically rigorous, and driven to pursue fields in medicine, science, and technology. At home, a student earning less than stellar grades may be regarded as lazy or incompetent by family members, rather than needing support or accommodations.

The Perpetual Foreigner
This occurs when someone is assumed to be foreign, exotic, different. Some questions that perpetuate this stereotype include “Where are you from?” “Where are you really from?” “Your name is too hard to pronounce so I’m going to call you Sam,” and “How do you say (or write) _____ in your language?”

South Asian clients often tell me that they cringed in school when called upon, hearing their name mispronounced repeatedly. Others report that they could not eat their lunch in front of others without comments from peers about their “weird food.” Ramadan and fasting can be a challenge for Muslim students, particularly when faced with the social aspects of school lunch, participation in sports, and gym class. For South Asian girls/women in particular, the experience of fetishism is not uncommon. For example, in college, this writer was frequently asked questions about the Kama Sutra on dates, or inquiries about harems. When these occurrences become commonplace, feelings of isolation and loneliness may occur in routinely being treated as an outsider.

Trauma
First-generation immigrants, particularly from global conflict areas, may experience trauma. This trauma can be passed down to their children and subsequent generations. South Asians with a history in the US may have compounded trauma due to racial discrimination. Of note, South Asian parents are frequently unlikely to speak up or address bullying of their children in the school system or in social settings. This may include a lack of awareness, lack of access to resources, and a desire to be under the radar.

Stigma
According to statistics by the American Psychological Association, South Asian Americans are the least likely racial group to take actions on their mental health and are more likely to reach out to friends and family, if at all. Lack of knowledge or stereotypes regarding mental health, learning disabilities, and psychiatric disorders contributes to this dearth in treatment.

Expectations
Criticizing appearance, comparing successes, chores and family obligations, and an emphasis on academic and financial success create an often unrealistic set of expectations. Children of first-generation immigrants may also be expected to serve as cultural and linguistic liaisons for older family members in addition to frequently serving as a caregiver for younger children, all while attending school.

Religious intolerance
Religious minorities, for example Muslims and Sikhs, are often discriminated against for their appearance and beliefs, bearing the brunt of racial profiling due to Islamophobia. Some clients report being called a terrorist ‘in jest.’ There is also religious intolerance between groups, such as Muslims and Hindus; Ahmadi Muslims and Sunnis, and Sikh-Hindu conflict which carries forward to US immigrants.

Lack of data
Empirically validated research studies on mental disorders have historically not included participants of South Asian descent. For example, there are no large studies on bipolar disorder or schizophrenia which included significant samples of South Asian patients/participants. In addition, psychology and mental health concerns are rarely discussed in families, places of worship, and medical offices. See Cultural Competency with Muslim Parents.

Embolden Psychology is dedicated to culturally competent practice, social justice, and psychoeducation.

References, Dr. Siddique in:
Siddique, H: The Meaning of Difference, sixth edition (2011). Rosenblum, K.E. and Travis, T. C. (Editors), McGraw-Hill.
Mental health and stress among South Asians. Journal of Immigrant and Minority Health (2019), volume 21.

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.

Systemic Racism and Mental Health

Currently participating in the Maryland Psychological Association(MPA) annual Ethics Conference. I was able to speak about systemic racism and mental health. With clients: nurturing diversity awareness gently, but also insisting on it.

Takeaways from Dr. Siddique:

  • It is our obligation as mental health professionals to speak about systemic oppression, environmental context, and racism as an integral part of our intake process and treatment planning. This is a required need of our ethical guidelines, as recently endorsed by the American Psychological Association.
  • Microaggressions by clinicians can be a negative part of the psychotherapy process, without training and awareness. The research shows that BIPOC patients who experience their therapist as invalidating generally do not return to treatment. Ever.
  • We must get supervision from peers, consultants, and our own therapy in order to help others and to get a true understanding. Don’t assume that you know.
  • Developing psychological rapport and alliance is the most important way for us to work with our clients, as shown by psychotherapy research.

Resources
Coping with Racial Trauma
BlackLine provides a space for peer support and counseling, reporting of mistreatment, and affirming the lived experiences to folxs who are most impacted by systematic oppression with an LGBTQ+ Black Femme Lens.

My Personal Readings to Challenge Oppression.
DiAngelo, Robin (2018). White Fragility: Why It’s So Hard for White People to Talk About Racism Beacon Press: Reprint Edition.
Helms, Janet E. (2019). A Race is A Nice Thing to Have: A Guide to Being a White Person or Understanding the White Persons in Your Life. Cognella Academic Publishing.
Kendi, Ibram X. (2019.) How to Be an Antiracist. One World Publications.
Nadal, Kevin L. (2018). Microaggressions and Traumatic Stress: Theory, Research, and Clinical Treatment. American Psychological Association.

Mental Health and Black Patients: Survival and Stigma

The Black community suffers from a high rate of mental health concerns, including anxiety, PTSD, and depression. Black people experience direct traumatic stressors (including being heavily policed or being the victims of physical and verbal attacks), indirect stressors (such as the effects of viewing the video of the killing of George Floyd and others), and intergeneration-ally transmitted stressors (from traumatic stress passed from one generation to the next).

Access and availability of mental health care
Despite these challenges, however, Black people are far less likely to seek care. Statistics show us that about 25% of African Americans seek mental health care, compared to 40% of white Americans. Unequal access to health care is one major contributor to this disparity. The lack of cultural sensitivity by health care professionals, feeling marginalized, and the reliance on family, community, and spiritual support instead of medical or psychiatric treatment are others.

The incidence of psychological difficulties in the Black community is related to the lack of availability and access to appropriate and culturally responsive mental health care, prejudice and racism inherent in the daily environment of Black individuals, and historical trauma enacted on the Black community by the medical field. Moreover, given that the Black community exists at the intersection of racism, classism, and health inequity, mental health needs are often exacerbated and mostly unaddressed and unfulfilled.

History of exploitation and stigma
In Black communities, reluctance to seek both physical and mental health care can often be attributed to a general distrust of the medical establishment. This distrust is not without merit: historically, African Americans have been misdiagnosed at higher rates than white patients, and black communities have been exploited by the U.S. government and medical community in the name of medical research. Seeking mental health care is often viewed as a weakness, running counter to possibly a survivalist mentality born from systemic oppression and chronic racism.

Dr. Martin Luther King, Jr. suffered from bouts of severe depression from his teenage years throughout adulthood. He attempted suicide three times, but refused to go into long-term treatment, even though urged to do so by his inner circle of friends and advisers. He stated that he did not want the Civil Rights movement and his work to be tainted by the stigma of mental health problems. Today, the mental health stigma remains.
Culturally responsive mental health treatment

Culturally responsive mental health treatment is one way of addressing the disparities in psychological wellbeing in the Black community. Culture, a person’s belief, norms, values, and language, plays a vital role in every aspect of our lives, including mental health. Being culturally responsive is a mental health provider’s ability to recognize and understand the role of culture, both the client and clinician’s and the ability to adapt the treatment to meet the client’s needs within their cultural framework.

When meeting with mental and medical health providers, it is essential for clients to ask questions to gain a sense of their level of cultural sensitivity. Many people often feel nervous or guilty about asking these hard questions, but providers usually expect and welcome questions as this helps them better understand the patient and what’s important to them. If they become defensive, that provides important information as well. 

Here are tips Black clients could do to seek out culturally responsive providers:
Experience and training
Ask the provider questions about their treatment approach and if they provide care that is culturally sensitive.

Awareness of intersections
Seek attention from someone who is aware and affirming of your intersecting identities (social categorizations such as race, class, and gender, that are overlapping and interdependent systems of discrimination or disadvantage) and your cultural background.

Ability of the provider to ask questions and be mindful of their own gaps in knowledge and experience

Sidebar: I have to note another statistic that I frequently discuss when I am teaching seminars on this topic. The stats are that Black clients enter therapy with a sense of optimism. Microaggressions can occur in the very context of the therapeutic space. If they remain unaddressed, most often clients will just go away rather than complain. Research also shows that people who drop out of therapy are much less likely to go back.

Additional information on research on developmental psychology and microaggressions can be found here.

(Stats included are from Department of HHS 2017; APA 2019; Mental Health America).

Minority Mental Health: Everyday Traumas and Microaggressions

Just a few words about the presentation that I’ll be giving to the Association of Practicing Psychologists (APP.org), Montgomery & Prince George’s Counties on November 17th.  The topic is Minority Mental Health: Everyday Traumas and Microaggressions and its being offered as part of their Continuing Education series.

APP is a professional organization for practicing psychiatrists, and as such they are approved by the American Psychological Association to sponsor continuing education for psychologists. This workshop is for licensed psychologists who want to better describe, discuss and assess the psychological stressors that clients may struggle with in the context of everyday micro-aggressions or racism.

I’ve been told by the organizers that my workshop is almost sold out already. I’m gratified to know that so many of my colleagues are committed to cultural diversity and minority mental health. And I look forward to giving similar workshops, with/for APP and other organizations in the future.

 

                                                              

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