by Jennifer Pearlstein & Alice Hua, University of California, Berkeley
Given recent mobilization in response to police killings of Black people, we as clinical scientists are reminded again of the extensive evidence documenting the detrimental effects of racism on mental health (Carter et al., 2019; Paradies et al., 2015; Pieterse et al., 2012). We are trained in principles of cultural humility (Asnaani & Hofmann, 2012), which we believe requires knowledge and acknowledgment of racism and other identity-related stress and trauma contributing to mental health. Here, we aim to (a) illustrate the importance of identity in understanding stress, trauma, and mental health through a vignette and (b) provide suggestions for implementing culturally informed case formulation to clinical work. Vignette details, including the client’s name, have been altered to protect client confidentiality. We hope to highlight the importance of understanding identity – in all its dimensions – in clinical case formulation.
Carla was a cis-woman El Salvadorian refugee in her 20’s and was seen by a White disabled cis-woman also in her 20’s. Carla’s marginalized experiences led to persistent depression, anxiety, and post-traumatic stress symptoms. At 6 years old, Carla immigrated with her family seeking political asylum in the United States. She had difficulty fitting in at school due to culture shock, a language barrier, and bullying from peers. She also witnessed and experienced extensive violence from family and from her local community, leading Carla to devalue herself.
During the intake, the clinician initiated the first of many conversations about culture and identity. Carla named her mistrust of White providers and her desire to work with a clinician who is a person of color. The clinician shared that while she is not a person of color, and lacking that lived experience, she has been marginalized as a disabled woman. The clinician articulated that if they were to work together, she would strive to understand and honor Carla’s unique perspective, guiding Carla to elaborate about her experiences.
To help improve mood and prepare Carla for exposures, sessions focused on skill-building related to mindfulness and emotion regulation. As Carla became more self-aware, she identified sources of her feelings of worthlessness, realizing extensive social and cultural contributions to her self-schema. For example, Carla’s socialization as a Latinx woman impacted her schema that women should selflessly sacrifice and serve as caregivers, contributing to her tendency to over-extend and have difficulty with assertiveness. The concept of intersectionality was created by Kimberlé Crenshaw to develop a more nuanced understanding of how interlocking systems of oppression marginalize individuals (Crenshaw, 1989). Multiple systems of oppression – racism, sexism, xenophobia – intersected to impact Carla and her repeated marginalization. These systems shaped identity-related schemas regarding her view of herself and how she was expected to behave, which were compounded by violent assault and social rejection, and maintained her depression, anxiety, and post-traumatic stress symptoms. Acknowledging racism, sexism, and xenophobia as forms of trauma enabled Carla to recognize her repeated trauma was not her fault, empowering her agency to improve her own mental health, and to serve as an advocate for others.
As demonstrated above, recognizing systems of oppression that shape client and clinician identities, and explicit discussions of these identities, influence the therapeutic alliance and are important considerations for case formulation. In addition to establishing culturally informed case formulation for any given client, intervention also necessitates an ongoing process of the clinician’s self-reflection and education. French and colleagues (2020) have detailed a framework of radical healing that advances beyond individual-level approaches to coping with racial trauma (French et al., 2020). They articulate that a clinician’s deeper understanding of history and oppressive systems is critical to delivering effective interventions that are not only culturally sensitive, but also fully contextualize the client’s experiences of being marginalized, which can facilitate resilience and healing.
We also believe that deep and ongoing self-reflection and education are crucial for culturally-informed case formulation and intervention. We have found the following questions helpful in our own reflection and growth as clinicians.
- Am I showing interest in what clients have to say and how systems of oppression have impacted them?
- Am I providing space to process, grieve, and express thoughts and emotions related to racism and other systems of oppression?
- Am I making assumptions about my own understanding of my client’s lived experiences?
- Am I pathologizing my client’s experiences? Do I understand the sociopolitical and cultural context for my client’s stress and trauma?
- What is my own relationship with Whiteness and systemic racism? What is my relationship to other identities and related inequities?
- Am I labeling and discussing the role of my own identities in supervision and clinical work?
________________________________________________________________________________________
References
Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of clinical psychology, 68(2), 187-197. doi:10.1002/jclp.21829
Carter, R. T., Johnson, V. E., Kirkinis, K., Roberson, K., Muchow, C., & Galgay, C. (2019). A Meta-Analytic Review of Racial Discrimination: Relationships to Health and Culture. Race and Social Problems, 11(1), 15–32. doi:10.1007/s12552-018-9256-y
Crenshaw, K. W. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. University of Chicago Legal Forum, 139, 139–167.
French, B. H., Lewis, J. A., Mosley, D. V., Adames, H. Y., Chavez-Duañas, N. Y., Chen, G. A., & Neville, H. A. (2020). Toward a Psychological Framework of Radical Healing in Communities of Color. The Counseling Psychologist, 48(1), 14-46. doi:10.1177/0011000019843506
Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., … Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-analysis. PLoS ONE, 10(9), 1–48. doi:10.1371/journal.pone.0138511
Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1–9. doi:10.1037/a0026208
Disclaimer: The views and opinions expressed in this newsletter are those of the authors alone and do not necessarily reflect the official policy or position of the Psychological Clinical Science Accreditation System (PCSAS).