This post originally appeared in All Kinds of Therapy, written by Emily Miranda. You can find that post here.
Any seasoned wilderness therapy staff knows the importance of students remaining well-hydrated. Being that our bodies are comprised of so much water, drinking plenty of it every day helps keep students’ bodies functioning properly; it helps with regulation of body temperature, aids in removing toxins, helps acclimatize the body to new altitudes, prevents headaches and even irritability (both can be signs of dehydration) and helps the skin and hair maintain moisture and deliver essential nutrients to the cells. So, when I was working in a wilderness therapy program in Utah, and one of my students was refusing to drink water, suffice it to say I was concerned. As the staff and I were processing how to support this student being safely hydrated, while still meeting her need for a sense of choice, one of the staff mentioned, “well, she’s not drinking enough water, but she also is asking for lotion because her skin is dry. So, she’s really not making the connection that if she were more hydrated, she wouldn’t need lotion.” This may come as a surprise, but hearing that comment, I felt even more concerned.
This time, not about my student asking for lotion, but the staff making an assumption that my student’s request for lotion was about some sense of “entitlement” and “lack of awareness”. While wilderness staff are trained to observe a student’s behavior and to look for ways that the student might be manipulating, newer staff may be unaware of the nuances of behavior and unable to make accurate therapeutic interpretations. In this instance, instead of seeing this student as an individual, her request was generalized and therefore pathologized as “entitlement”. I felt grave concern about her being viewed this way because she is Black. I am aware that it’s absolutely crucial in this instance to see her as an individual. Her dark skin has a lower pH than white skin, contains less glutathione, the melanin is packed more tightly, among other things… suffice it to say it is different than white skin and therefore needs different care. Yes, she may not be sufficiently hydrated, but this does not mean that she doesn’t need lotion. If I ignore this difference, I further the message that people who are marginalized often experience; the feeling of being invisible--and therefore unimportant. So, I can address the physical need for her to be well hydrated and the therapeutic implications of her refusing to drink water, while still being multiculturally aware and attentive to her need for additional hygiene products in order to maintain healthy self-care. In addition, I can name my awareness of these nuances, so that my student knows I’m seeing her as an individual, and not generalizing her behavior. These things aren’t mutually exclusive of one another, and being aware of all of them is holistic therapeutic care. Any good clinician knows that the therapeutic experience should be a reparative one, so if I choose to stay silent, I further the wounding and no repair work is done.
This is one small example of an instance in a therapeutic setting where the need for multicultural awareness is tantamount to the individualized treatment that we promise to deliver. Every parent who sends a child to treatment makes an overwhelmingly difficult decision to do so. It is a painful process to make a choice to send a child to the hands of strangers, with a hope that healing can and will come. And every one of those parents wants to know that their child will truly be “seen” and “heard” for the individual that they are. This dynamic is even more poignant for students who have marginalized identities, and particularly in this instance, a Black student in a therapeutic setting that is predominantly white. It is absolutely imperative that clinicians see each student in the larger context of family, culture, community and society, in order to truly be individualized in their treatment approach. And in this approach, they must be willing to consider that behavior that might be deemed a ‘mental illness’ or ‘pathologized’, is in fact, behavior that is actually about wellness for that individual.
For examples, the Diagnostic and Statistical Manual of Mental Disorders (DSM) at one time named homosexuality as a mental health diagnosis, and has labeled gender dysphoria as Gender Identity Disorder but with continued research and practice, we know now that people who identify as gay, lesbian, bisexual, transgender or queer are not, in fact, “sick” and treatment approaches such as reparative therapy/conversion therapy have been proven by research to be harmful. We also know from research that self-harm and suicidality are among the highest in people who identify as Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Asexual, or Intersex (LGBTQAI). If we only conceptualize suicidal ideation and self-harming behavior through the lens of clinical depression, rather than as a normal response in reaction to aggressive community behavior such as hazing and bullying (or worse), and also in response to more passive harmful messages of not seeing themselves represented in the media or casual comments (microaggressions) such as, “that’s so gay” --meant as an insult-- we are missing a much larger boat. Similarly, when clinicians see withdrawn, aggressive or irritable symptoms in people of color (POC) and automatically label it as “depression” rather than seeing it with keen eyes and wondering if it in fact is racial battle fatigue or race-related stress, we not only wrongly label typical/expected emotional reactions in a student, we also wrongly label the individual with the “problem”, rather than seeing the structural and institutionalized oppression that is truly the fault of the larger society and culture.
This experiential conflict is well stated in an APA article by David and Nadal [David, E. J. R. and Nadal, Kevin (2013) , A Colonial Mentality Model of Depression for Filipino Americans. Cultural Diversity and Ethnic Minority Psychology Journal, 19 (3), 298-309.]:
Many cultural and ethnic minorities have extensive experiences of being oppressed, which they may eventually internalize. However, psychology has yet to actively incorporate various forms of internalized oppression (e.g. colonial mentality [CM]) into the etiological conceptualizations of psychopathology. Using a sample of 248 Filipino Americans, the author tested more complete and socio-politically informed cultural model of depression symptoms. Results with structural equation modeling showed that conceptual model that includes CM better explained depression symptoms among Filipino Americans than the model without CM and revealed that CM had a significant direct effect on Filipino Americans’ experiences of depression symptoms. It is argued, through this illustrative case of depression symptoms among Filipino Americans, that incorporating the psychological effects of oppressive historical and contemporary conditions into our conceptualizations of ethnic minority mental health may lead to a more culturally accurate etiological understanding of psychopathology among historically oppressed groups.
The world of mental health treatment has far to go in incorporating these perspectives into the framework. The DSM 5 (the most recent version of the DSM for psychiatric diagnoses) does not incorporate concepts such as racial battle fatigue, race-related stress, or diagnostics that reflect the emotional and psychological toll of bullying, for example. Because our students are individuals within this larger context of family, community, and society, it is the duty of the clinicians to have an awareness of the complexity of the struggles that our clients face, and to conceptualize that some of these struggles may not be just within the individual psyche of the student themselves but to truly see the student in the context of the environment and the pressures and challenges they face.
When a family member is exploring programs to place their teen or young adult, it is absolutely your right as a parent, family member, or guardian to ask your biggest concern --insert your biggest bias/fear here-- (for example: “Do your staff have much experience working with Black children in the wilderness?” or “Will your staff use gender neutral pronouns when communicating with my child?” “Will your staff be accepting of my gay child?” “Do your staff and the clinician understand that my child has different hair and skin care needs than white students?”) Please do not shy away from asking the questions that matter to you most. If the program answers your question in a full, complete, and direct way you can gain a sense of their values, their training and awareness and how they implement those. If they stumble and struggle in articulating their awareness of being able to see your child in a broader context, and all the identities they hold, you have valuable insight and ask can more questions. Sometimes, this might mean speaking directly to the clinician who would be working with your child, who can speak more immediately to their awareness and training, as well as how culture and identity will be considered in the therapeutic context. It is unquestionably your prerogative to ask for this; you’re placing your most precious person in their hands and want to feel a sense of relief, hope, and reassurance that this person will truly be “seen” and heard”; to see your child holistically.
- For an article related to Racial Battle Fatigue, Race-related Stress, and Critical Race Theory see: http://rci.rutgers.edu/~wocfac/WOC/resources/challenging_racial_battle_fatigue.pdf
- For an article related to the Effects of Bullying Lesbian and Gay Identified Youth see: http://bjsw.oxfordjournals.org/content/39/8/1598.full.pdf+html
- For an article about racial justice in mental health see: http://www.blackgirldangerous.org/2016/01/why-racial-justice-needs-to-include-mental-health/
- For an article related to Transgender mental health see: http://www.npr.org/sections/health-shots/2016/03/23/471265599/probing-the-complexities-of-transgender-mental-health