Microaggressions and the Therapeutic Relationship

[MUSIC] Welcome to the Clinical Console, a podcast from the National Register of Health Service Psychologists, examining timely psychological trends and excellence in clinical practice. I'm Dr. Samuel Lustgerton. I'm thrilled to have Dr. Ryan C. Warner with us today. Dr. Warner is a licensed clinical psychologist and the founder, CEO of RC Warner Consulting. As a consultant, he assists teams to develop cultures of inclusion, leadership development, diversity training, and wellness enhancement. His website can be found at RCWarnerConsulting.com. And today, we'll be discussing the impact of microaggressions on the therapeutic relationship, clinical effectiveness, and strategies for preventing discrimination at work. Ryan, thank you so much for being with us here today and welcome to the program. I'm glad to be here, Sam. Thank you. Absolutely. Absolutely. No, I want to jump right into it. We've got maybe about 25, 30 minutes, and I want to make the most of it today. As I listen to and have the opportunity to look back at your slides from a webinar that you gave for the National Register not too long ago, around this very topic of microaggressions and unconscious biases, it made me think about my own childhood as a white person. I grew up in highly segregated suburbs in Pennsylvania, shout out to Pittsburgh, Mount Lebanon territory, and then I moved to a very white part of Colorado, a suburb of Denver. Somehow, I took away this very simplistic idea that racism looks a certain way, that it has a physical violence traditionally against black bodies. But over time and in training, but also I recognize that I've got more work to do, but over time I recognized that this was pretty narrow. It was insufficient and in some ways contributed to that injustice. I've been really excited to speak with you here today so that we can all expand our understanding. And recently, because of your webinar, I wanted to maybe expand on some of these topics and highlight them a little bit further around microaggressions and unconscious biases. There's so much to cover here. So I wonder if we can start with the basics. Could you share a little bit about what microaggressions are with our listeners today? Yes. So I would define microaggressions as subtle, covert forms of discrimination directed towards marginalized populations. So ultimately, when we think about microaggressions, the first thing that may come to mind are racial microaggressions. However, it's important to know that microaggressions could be related to other facets of identity and culture as well. There are gender microaggressions, microaggressions related to religious background, sexual orientation, etc. However, microaggressions was originally coined in a, I believe, around like 1960 by a black psychiatrist by the name of Chester Pierce. Have you heard of Chester Pierce before? I have not. No, tell me about it. Yes. So he actually coined his phrase around you in 1960. And ultimately, he initially defined microaggressions as black, white, racial interactions. They're characterized by white putdowns and done in an automatic, pre-conscious fashion. However, since that time, since that initial definition is developed, you know, to other areas of diversity and and culture as well. So I just want to put that out there that, yes, there are racial microaggressions, but there's also other types of microaggressions as well that can be impactful for certain populations. Yeah. And so I really appreciate you highlighting that piece and some of the origination of where these terms come from around microaggressions. I'm wondering just so that I get a better understanding about it, what these tend to focus on or what they tend to sound like, just so that we're aware of what's micro about it or what does that mean to be aggressive? So oftentimes, we may think about initially like verbal microaggressions, right? You say something that is covert, you know, under the surface subtle, you know, microaggressions that I've experienced over and over and over again is, oh, well, you don't look like you have your PhD or people are coming up to me and assuming that because I'm six four and I'm a black male with the athletic builds that I happen, I have to be an athletic team or sports team or basketball player, right? Those are some examples of verbal microaggressions, but there's also environmental microaggressions. So for instance, if you go into the office of your therapist and maybe you identify with the marginalized group and you look in the wall and you see nobody who looks like you or maybe you see a confederate flag, a picture of a confederate flag in the office, right? You may not feel that you're you're wanted or your views are going to be heard, you know, in that setting, right? So it can be verbal, it can be bar mental, it could be, you know, through policy, etc. But I just want to throw that out there as will that it doesn't always have to be verbally conveyed. I think that's a really important point that you're highlighting that the spaces around us, what's on our walls, what's in our offices can all convey some of these messages and potentially microaggressions that they all are signaling something to those that walk in our offices. And in fact, Ryan, as you're talking, it even makes me think about the consequences of so many of those things on training too and trainees that come through our graduate programs and what kinds of messages they're receiving from faculty and professors and those that are in those offices too. Yeah, the training, but also just look at the websites. I know when I was applying to PhD programs, maybe how long has it been? Six years or so? Sure. When I was applying, I was looking at these top tier universities, right? And they say that we really value diversity. We want all voices to be heard. But then I look at the images on the websites and there's nobody who looked like me. And so that can also contribute to some detrimental impacts, especially for individuals who do not feel that their voice sometimes is heard by certain people. So what we put on our websites, the curriculum that we teach in our programs, what we have in our walls and our offices, as clinicians, there's a lot of different things that we should try to be more aware of. So we can create more inclusive environments for all people. Ryan, as you talk about even your own personal impact of receiving these remarks, microaggressions, I'm also thinking about in general, for those that we serve as clinicians, when we walk into the room and we're working with all sorts of folks, whether they have marginalized identities or minoritized identities or not, I'm curious what we know about the consequences of moving about life, receiving these kinds of remarks, receiving microaggressions. What does this do? And how does this impact those we serve and the places we work? It's a great question. So I can speak on the personal aspects of it and also what literature and research indicates as well. So personally, just a few years ago, when I was going through various rotations within my doctoral program, I usually experience microaggressions on a frequent basis from my supervisors. And one specific example, I remember one of my white female supervisors asked me, when she said to me one day, she said, Ryan, I would never guess that you would be in this doctoral program. And I looked at her and I asked her, I was like, what do you mean by that? And she indicated, oh, well, there's not a lot of people who look like you in the program. So I would never have thought that you'd be a PhD student. And when she told me that, at first, I didn't know how to respond. But then when I experienced microaggressions over and over and over again, especially in my previous academic experiences, when I would go to these top tier universities and I would sit in the classroom and I would look around and I would see no other black males. And people would always come up to me and ask if I'm on the sports team or be surprised that I would tell them that I'm actually here on an academic scholarship and not an athletic scholarship. When I received constant facial expressions of surprise, I started to feel that maybe I shouldn't be here, or am I smart enough to be in this setting? Am I smart enough to continue to be in these environments that don't feel that I'm wanted. And ultimately, that impact in my will be, it impacted my motivation. It led to me questioning my abilities. And then that also motivated me, though, to learn more about how I can support other to look like me. So I started to share some research, you know, I did some research studies and start to look at the data and say what is the research show about the impact of microgressions on marginalized groups? And what literature tells us is that when individual experienced microgressions on an ongoing like over and over again, then ultimately that impacts their well-being, right, that leads to higher rates of depression, higher rates of suicide, and leads to them having difficulty with retention in their workplaces as well as in higher education institutions as well. So with that, there's data that shows that yes, this has an impact, but sometimes it's so subtle and it's subjective, right? So it's hard to identify a time as well. If there are evidence-based, you know, empirically driven measures out there to be able to measure that, etc. But from my day to day, just in our workplaces and in their putic settings, it's hard to sometimes identify, and I think that's what makes it really tricky. Right. And you know, up until now, even though I know we've brought up the phrase of like unconscious biases, we haven't talked necessarily specifically around what that is. And I'm wondering how unconscious biases shape or change our clinical practices. How does that impact what we do? Yeah, so as a person who knows that as human beings, we all have bias. It happens bias doesn't make you a bad person, right? No one wants to be racist or sexist or or discriminate, discriminate on anyone's backgrounds, right? Especially as helping professionals, we all want to support, you know, everybody, right? No matter what their backgrounds are, and no matter how they identify it. But I think that oftentimes, you know, we're not aware of that bias that we may hold or the preferences that we may lean towards, then they can impact our patients and our clients that we work with. Okay. There's actually a study that came out, I believe, in 2017, and it interviewed about 120 individuals who identified as Asian American. And I believe 70% of those participants who identified as clients in a therapeutic setting, 70% indicated they experienced a microaggression, whether it be a racial microaggression or gender microaggression, within the therapeutic setting, within the past month, when the survey was administered. So that's huge, right? 70% of these Asian American clients and patients indicate experiencing, you know, that event from their therapist. Okay. So reading that study, I start to look at how do I, as a clinician, you know, create an inclusive environment for my patients, right? Because we see patients from all different backgrounds. And I want to ensure that they feel respected, that they feel that they can come to me and share what's on their mind, you know, in a non-judgment to wait. And I don't want to inadvertently harm, you know, do harm to my patients, right? So I started to reflect on the biases that I may have, whether the biases related to individuals of different sexual orientations or genders, etc. And there was kind of hard for me to reflect on that. You know, I mean, there's different, yeah, it's kind of hard because, you know, at first, I asked myself, "Oh, I'm not a bad person for having, you know, this judgment about this particular group." You know, and ultimately, when I was able to be non-judgmental to myself and realize that it's okay to have bias, but it's not okay not to do anything about it, that's what pushed me, you know, from that reflection to action and looking at my environment in the therapeutic setting to figure out what can I do, you know, to create that inclusivity for my patients. I want to give a specific example about, you know, maybe a mistake that I made, you know, in theory, actually recently. So there was actually a patient who came in and this individual indicated that he came in due to relationship issues, okay. And when I asked him about his spouse, I noticed that I used the term "wife," okay, at first. And he corrected me and said, "Well, actually, Dr. Warner, you know, it's not my wife, it's actually my husband." And right there, I realized that, you know, well, I made a mistake and I apologized and I had that discussion with him. And he was like, "You know, I get that all the time because I don't, you know, identify, I don't look on that outside like a traditional quote unquote, you know, gay male, you know, I don't, you know, abide by those like traditional or stereotypical mannerisms, you know, etc." And he said, "I get that all the time. People always assume that I'm married to a woman." And I have to always correct people. And sometimes that's taxing, I mean, and it's kind of impactful when I have to repeatedly correct others, right? But we were able to engage in that discussion and that dialogue. And at the end of the session, he indicated that he was so appreciative that I was open to learning, that I was open to raising my hand and say, "Hey, I made a mistake." And that actually made us closer, that actually improved our therapeutic alliance and promoted optimal treatment outcomes, right? So I want to give a specific example that I think sometimes we do that a lot. We may assume some of the sexual orientation or maybe their gender pronouns, right, etc. And sometimes just asking our patients, what they prefer to go by, could be the first step, you know, with enhancing that therapeutic alliance. So we can best meet their needs. Right. Right. I think that that's an important illustration you've given us, too. Oftentimes when I'm in the therapeutic context, I'm really fearful of having a rupture. I mean it, Ryan. Like, I'm really, oh god, what if I say the wrong thing? What if I do the wrong thing? I'm fearful of the rupture ending things. Like really becoming the end of our work. Someone doesn't want to come back. Like, or I do something so awful that it really disrupts the clinical process or the effectiveness of the work that we do. I really appreciate your example because I think that there's a humanity piece to it, but there's also a really incredible skill that you're sharing there that there are opportunities for repair as well and an opportunity seemingly for conversations, at least with some folks, to be able to talk about the impact of comments like that on their lives in a new way. Yes, definitely. It is is obviously easier said than done, right? However, if we're able to be vulnerable, you know, similar to our patients coming in to be vulnerable with us. And if we're able to safely, you know, inappropriately disclose as well, you know, like I was able in that situation to say, you know, I noticed that in the past, I've done that a lot. I've assumed that individuals will be married, you know, to the opposite gender. And I was able to convey that to my patient. And that appropriate self disclosure, I was able to actually enhance, you know, our relationship, right? So it obviously depends on the situation. It depends on the specific circumstance. But research shows that when we're more culturally aware, and when we are able to engage in that dialogue about culture, about diversity within the therapeutic setting, then actually improves therapeutic outcomes. And individuals of different backgrounds may feel more comfortable coming to us. You know, throughout our conversations today, and honestly, before our conversations today, this question has been bouncing around in my head, you know, how do I get better at this? How do we get better at this as health service psychologists? And I'm really curious about this question too, because in some ways, I've been thinking about how unconscious biases are unconscious. We don't see them until we see them. Or, you know, and in many ways, I'm wondering, how can we recognize something that we are unaware of? Great question. So the first thing that comes to mind is, number one, just do an environmental scan of your current connections. Okay. So if you have a social media, look on your Twitter, look on your Instagram, look on your Facebook. Who are the people that you're connected with? Are they people of the same background as yourself? Are they all health service psychologists? Are they all individuals with higher educational degrees? Are they all individuals who identify with your racial-ethy background? If so, then maybe it's time to branch out. Maybe it's time to connect with individuals of different backgrounds. Right? Because as human beings, we obviously gravitate towards people who are in our end group, right? Who share very similar background as ourselves. Okay. And however, that can add times, impact our ability to learn from the cultures of others. Okay. And in turn, contribute to additional bias that we may have. So if we're simply just able to connect with other people, whether that be individuals from different careers or different childhood upbringings, who hold different political views and ideologies than ourselves, you know, then that can improve our ability to be more aware of different cultural backgrounds. Okay. So that's, that's number one. Number two, we have to constantly engage in continual education. So I'm not talking about going to one Black History Month event a year, okay? Right. Or going to one LGBTQ rally, okay, or going to one training about diversity. I'm talking about engaging an ongoing dialogue, ongoing education, ongoing training, okay. So that could be watching a TED talk or watching a movie that maybe necessarily you wouldn't have watched in the past, okay. Or, you know, being able to reach out, you know, to others outside of your in-group, you know, engaging dialogue with them about their cultural background or maybe about a holiday that, holiday that they celebrate that you may not be as familiar with, you know, being inquisitive and trying to learn from the experience of others can also be helpful as well. And lastly, I have a specific systemic approach that we can implement within a therapeutic setting to improve our ability to feel more comfortable engaging in that dialogue with our patients. So I'm not sure if you would like to share it. Yeah, I would love to hear it. Okay, cool. Yeah. So this framework is actually created by Dr. Dan McRoughert. She's a psychologist and this framework, I talked more about, I spoke more about in the National Registered webinar that I recently did. However, I just want to briefly go over the framework. So it's called Let Up, okay. It is a framework, ultimately, that helps us provide more culturally effective care when working with individuals of different backgrounds. So I'll give you an example. Say for instance, maybe your patient, maybe you experience some microaggression yourself as a therapist, okay. Maybe your patient or client says something that didn't really sit right with you about a particular group that you have a strong, deep, emotional connection with, okay. So the first thing that we do as humans is we are defensive at first, okay. So we may experience a visceral reaction, right. And ultimately, we may disagree with that person. And sometimes in the therapeutic setting, we may try to hide that. But ultimately, this Let Up model is a way that we can engage in productive, effective dialogue with maybe a co-worker or a patient or client that can improve the relationships with others. And the probability that we can have some type of productive outcome. So Let Up first stands for Listen, okay. So when we experience that visceral reaction at first about a statement or maybe environment microaggression that we witness or observe, observe, we need the first listen. We need the first listen to not only the other person, if it's verbal, for instance, but also internal, okay. We need to listen to our internal processing. So what emotions are coming up? How is your body responding to that statement or that microaggression that you experience or observe? What are some of the things that I'm sorry to interrupt? What are some of the things that might pay attention to in my body? Sometimes like, are there physical sensations, are there emotional things that might be acute that say, yeah, yeah, that's something that's come up for you. So I know for me, when I experience microaggressions in a therapeutic setting and outside of the therapeutic setting, the first thing that comes up to me is my thoughts. So I think that that person is trying to offend me, those negative cognitions, that person is trying to offend me or that person is totally ignorant and they have no clue what they're talking about. And then my heart may be start to be fast. I may become kind of anxious because it's making me uncomfortable. So I need the first listen to my thoughts and be more aware of my thoughts, my emotions and the behaviors that I'm engaging in. Does that answer your question? Oh, absolutely. Yeah, thank you. Yeah. Okay, cool. And then the next step I need to take is the E, which is empathize. Okay. So we need to be able to empathize with that other person if we're engaging in just say one-on-one dialogue. Because oftentimes, when we become offended, the first step is to not say, think about, okay, what may be going through that person's mind, okay, or maybe that person may not have a be having the best day today. Or maybe that person just not culturally aware. Okay, sometimes those thoughts don't come to mind, right? So we need to first try to sit in that person's shoes and empathize with that individual. Okay. The next thing we need to do is tell our story. So after I'm able to listen, listen internally and externally, I empathize, you know, try to sit in that person's shoes and then I need to tell my story. Okay, and this is where appropriate self-disclosure is important. So in that example, if you think back to the example that I provided, when I made a mistake, you know, and I assumed that my male client was married to a female or a woman, right? I was able to tell my story and I say it that I often noticed that I make mistakes like that, you know, and I was able to share my personal experiences. Okay, in our appropriate way. After I tell my story, I need to then engage in understanding. Okay, so understanding ultimately helps us be able to be more aware about how the microaggression that was committed, how that may impact others. Okay, so if Rayba tried to understand, you know, we need to be educated about the impact of microaggressions and we need to be open to learning from that person's experience. Lastly, we need to psychoeducate. Okay, so say for instance, you know, I heard a microaggression. I was able to listen, empathize, tell my story, engage in that appropriate self-disclosure, try to understand where that person is coming from and then lastly, provide that psychoeducation, right? So, for instance, with that, I want to ask you actually, Sam, can you think of an example maybe in your life in which maybe you provided some psychoeducation after you experienced or observed the microaggression? Do you think of example? You know, there are a few that come to mind, but, you know, one of the ones that impacted me when I was in graduate school and so I can kind of own this as my own is an individual in a class. We were talking a little bit about all of our identities. It was a multiculturalism class and each reflecting on identities that we hold and I have a Jewish ethnic background and the person asked a question, no malicious intent behind it, but asked the question, why do Jews always have so much money or why do Jews always control so much of the money? And I recognized that in that moment, it really activated me. I'll be frank with you, Ryan, I don't know that I had the right response in that moment around psychoeducation, but I think as I was in that moment and as I think back to it, it was an opportunity missed in some ways, you know, an opportunity missed to provide a little bit of psychoeducation of that, you know, there are a number of stereotypes that are portrayed in the media and historically that, have to do with that and that it may be hurtful for some groups to hear such a comment like that. And it might impact their ability to connect. So their response right there is a perfect example of educating, engaging in that last step, that psychoeducation, right. Talking about that remark that was made is often a stereotype that may be portrayed in the media, you know, except, and right there when you're able to convey that, they may open their other person's eyes to realize, oh, I don't realize that's a stereotype, that may not be true of all individuals. Okay, however, you made another point in which sometimes it's hard to do, right. It's hard to have that response to be able to engage in psychoeducation, you know, especially when you may feel offended or you may shut down, right. And that's why I think the let up model is so powerful because before we respond, we have the first listen, we have the first try to send that person's shoes, we have the then tell our story, right. So if you were able to gauge in that self-disclosure, that could have been helpful as well in that moment. Then understand that that person may not realize that they committed their microaggression. They may not realize what they said can be hurtful for some people. And that's why that psychoeducational piece at the end, you know, could be helpful with providing that additional awareness. So I think that was a great example and I think that sums up, you know, how powerful, you know, how helpful the let up model can be, you know, not just in a therapeutic setting, but also maybe in the workplace as well. Ryan, even as you asked me to kind of go through it and kind of rolls through that experience that I had in the past, even for me, it's getting me questioning like, well, yeah, how could I do this better in the future? And like, what does this look like for others, too? When I hear things happening that don't necessarily involve me and don't necessarily have to do with my identities personally, but what is my role and how do I, how do I, how do I play a role? What, what can I do in those moments? And it's getting me kind of questioning like, wow, I feel like I can use this in those moments too a little bit more to kind of fuel how I then respond. And I often like to convey a quote and it goes like this, silence is compliance and only enhances and encourages is injustice in the world. Oftentimes we feel that if we're silent and don't say anything then it will go away. Especially when covert subtle remarks happen. But say for instance if you're out of society and you see someone being harassed or physically abused then sometimes we make feel that we need to stand up, we need to say something because it's overt, it's out there, right? Everybody sees it. However we also need to do the same when covert remarks and covert environmental microgressions may occur as well. Okay? Because even though it may not be so obvious research shows that it still has significant impacts. Impacts and individuals will be impacts on their self-esteem leads to less productive therapeutic outcomes, right? So it still does have an impact but just in a different way. So I just want to leave you with that as well that yes is hard, yes there's a lot of barriers that are speaking up. We can have a entirely another discussion about that. But if we're able to just first try to learn from that experience and we're able to engage in continuous education, reach out to other individuals who may not be like us and hold different ideologies and beliefs than ourselves, then that's going to improve our cultural awareness so we can best serve our patients. Thank you so much, Ryan. You know as I think about this conversation today it has flown by and I so appreciate you disclosing with us and sharing a little bit about your experience and also pushing me a little bit today to get better at this because I really want to and I think we all have to be asking that question of like how do I get better at this? How do I do this better for our clients, for our colleagues, for those that are coming through their training programs as well. Thank you for taking the time to share your expertise today. But before we go I just want to ask it one last question. Where can listeners go for more resources or even find out more about your consulting? Yes, so you can first visit my website at www.rcwannerconsulting.com. You can also Google my information, Dr. Ryan C. Warner and there should be blog posts and different podcasts that you can look into. You can also email me at [email protected] as well if any questions comments or feedback come up. Great, great. Well thank you so much Ryan and listeners thank you for tuning in. I'm Dr. Samuel Lustgarten and this has been the clinical consult, a podcast from the National Register of Health Service Psychologists. If you enjoyed this content be sure to check out Dr. Ryan C. Warner's recent clinical webinar on unmasking microaggressions in a clinical setting which is available on the National Register's website. And for more content on this topic make sure to listen to a previous clinical consult, episode titled Multicultural Competence and Telepsychology with guest Dr. William Ming Lu. As a reminder all episodes provide general information for discussion purposes only and don't serve as formal clinical advice or continuing education.