We need to address colorism in the therapy room if we hope to start healing as a nation

When I was in second grade, a classmate approached my desk.

“You’re brown,” he declared, his face contorted with repugnance. I turned and we locked eyes. He was brown like me, maybe a shade lighter. I was shocked. In cursing my brown skin, he was proclaiming his hatred of his own, the complete opposite of the pride I was raised to feel in my heritage.

This entire exchange lasted only three seconds, yet it held the expansive weight of generations of American colorism, a form of discrimination based on the darkness of one’s skin tone. It’s related to racism but also distinct: while all Black people experience discrimination due to the racial category in which they fall, for example, the magnitude, prevalence, and end result of that discrimination will differ greatly by skin tone. The ubiquity of colorism impacts all people of color, cutting across groups of racial and ethnic minorities in America.

This entire exchange lasted only three seconds, yet it held the expansive weight of generations of American colorism, a form of discrimination based on the darkness of one’s skin tone.

That childhood moment followed me into my adult career as a clinical psychologist specializing in trauma, where colorism comes up regularly with my BIPOC clients, but not with my white ones. And after a traumatic year for everyone that disproportionately caused suffering in minority communities, from police violence to COVID deaths to anti-Asian hate crimes, conversations about colorism must be part of the healing process, even -- especially -- in majority-white spaces.

We cannot be anti-racist without being anti-colorist, and we cannot grapple with colorism as a society unless white people -- who make up the majority of mental health professionals here -- join the conversation.

Colorism research has consistently demonstrated that lighter-skinned people of color are privileged in areas of income, education, and housing, even when controlling for other variables. For example, lighter skinned people of color earn more money, complete more years of schooling, and live in wealthier neighborhoods compared to darker skinned people of the same ethnicity. In America, people will opt to hire a lighter skinned person before a darker skinned person of the same race (Hunter, 2007). Most people are not even conscious of this preference for lighter skin; it is deeply ingrained in the systematically racist foundation of American culture.

We cannot be anti-racist without being anti-colorist, and we cannot grapple with colorism as a society unless white people -- who make up the majority of mental health professionals here -- join the conversation.

I’ve found that my work with BIPOC clients deepens when colorism emerges in the psychotherapy process. It’s an experience of mutual understanding about the social/interpersonal/economic consequences of colorism. We talk about how colorism has impacted their life, their relationships, their view of self and others. We talk about the similarities and differences of our appearances and how that impacts the relational dynamics in the therapy process. This is undergirded by a shared knowing around the peril that comes along with existing in non-white skin in America.

With white clients, the dialog of colorism seldom emerges. What surfaces more frequently is a mixture of them sharing their anti-racist activism and expressed white guilt around race.

Psychology as a discipline is attempting to reckon with a past whose theoretical foundations were built by white, Western European men...

But whether or not white clients speak openly about colorism, it’s present in the room, and it’s an ethical responsibility for therapists to acknowledge how psychological theory, research and clinical practice has been impacted. Psychology as a discipline is attempting to reckon with a past whose theoretical foundations were built by white, Western European men, the majority of the burden has been shouldered by BIPOC clinicians. Just last year, a group called Disrupt the Silence, including BIPOC and white clinicians, formed to speak out and change the status quo. But it’s still a reckoning that primarily exists in therapeutic relationships that include BIPOC therapists and clients.

I imagine that it’s easy for white therapists to avoid talking with their white patients about being white, but they need to start doing it. In her 2019 paper, “Whiteness on the Couch,” clinical psychologist Natasha Stovall writes, “The couch in my therapy office is occupied mostly by white people. We talk about everything. Except being white.” She asserts that the field of psychology essentially reflects “the psychology of whiteness.”

Creating space for these conversations in therapy feels like a duty, as if not doing so would represent a form of collusion with racist power structures.

But the current political climate and barrage of news stories spotlighting racist behavior, narratives and hate-crimes puts issues of race and colorism front and center for all of us. Creating space for these conversations in therapy feels like a duty, as if not doing so would represent a form of collusion with racist power structures.

We’ll never create a more just society unless everyone addresses their complicity in upholding its current structure. That includes therapists.

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Millions of pregnant parents have past sexual trauma. We need to support them better

When Nicole* came to see me, she was pregnant with her second child. Nicole, a survivor of childhood sexual abuse, was terrified about giving birth again. And she felt completely alone with her fears and feelings.

Twenty percent of women are sexual assault survivors. Another 20% are survivors of childhood sexual abuse. More than 80% bear children. There is significant overlap between these demographics, and the numbers cut across all racial, ethnic, and socioeconomic groups.

But there is a lack of quantitative research about how sexual trauma affects people’s childbirth experiences; issues that primarily impact women regularly receive less scientific funding than those that impact men. The limited literature that does exist suggests that the overlap carries unique risks during the childbirth process. The changes to childbearing bodies during pregnancy, the frequency of invasive prenatal exams, the loss of control and the pain of labor can cause dissociation, flashbacks and re-experiencing the original trauma (LoGiudice, 2017).

Twenty percent of women are sexual assault survivors. Another 20% are survivors of childhood sexual abuse. More than 80% bear children. There is significant overlap between these demographics, and the numbers cut across all racial, ethnic, and socioeconomic groups.

Pregnancy and labor are arduous -- and, potentially, traumatic -- enough without bringing past horrors into the mix. That’s why it’s time to establish cross-disciplinary universal guidelines around providing trauma-informed obstetric care to survivors of sexual assault. That means medical and mental health professionals need to work together to create and maintain evidence-based best practices that will keep survivors from being triggered or retraumatized while giving birth.

Before we can create these guidelines, we urgently need to devote more resources to learning about how a sexual trauma history can reappear pre- and postpartum, and about the risk and protective factors for survivors. We also need to know more about how to prepare survivors for pregnancy and childbirth, and how to interact with them to help them stay calm enough to engage consciously in the labor process without experiencing retraumatization.

Nicole, a survivor of childhood sexual abuse, was terrified about giving birth again. And she felt completely alone with her fears and feelings.

Here’s what we do know: Women with childhood sexual trauma are more likely to find childbirth terrifying (Leeners et al., 2016), which can re-trigger the emergency survival strategies -- fright, freeze, flight, or fawn -- that helped them cope with their original trauma as it happened. The nervous system may go on alert, causing the person in labor to experience hypervigilance and stress about every unfamiliar sensation they feel; or they may dissociate from the situation altogether, checking out of their bodies in an attempt to psychologically escape.

These nervous system responses can happen in people with known trauma histories, but the birthing process can also cause unconscious memories of sexual violence to reemerge.

As an EMDR therapist who works frequently with perinatal parents, I teach survivors how to stay in what is called the “window of tolerance,” where they can stomach being in the present moment rather than responding with either an over- or underactive nervous system. Together, the client and I focus on resourcing, a stabilization process that involves accessing internal strengths, allowing someone to tolerate remaining present and “calm enough.” This sort of cooperative strategizing is crucial to prepare childbearing individuals for the emotional labor of birth.

For example, Nicole told me she wanted to feel confident and present, and to believe that she would be “OK” when she is giving birth. Since she mentioned her sister as someone who embodied these characteristics, we resourced this for her in our work together. I prompted her to imagine her sister in her mind’s eye, to note all of her senses as she held this image of sister in mind. Keeping this image in mind during the treatment process allowed Nicole to internalize the sense of calm and solace that she associated with her sister to bring into the birthing process. It’s a concrete, repeatable process that minimizes anxiety for many of my clients.

Every professional who comes into contact with pregnant or perinatal people should approach their patients through a trauma-informed lens, starting with sensitively, carefully assessing patients’ history during the very first visit.

How to help pregnant people access inner strengths is the sort of knowledge that shouldn’t -- but currently does -- start and stop in the mental health community. The relationship between patients and prenatal providers is essential, because negative reactions to trauma symptoms from an authority figure can cause a further psychological injury. Every professional who comes into contact with pregnant or perinatal people should approach their patients through a trauma-informed lens, starting with sensitively, carefully assessing patients’ history during the very first visit.

The best solution to grappling with sexual assault and abuse, of course, would be to eliminate it altogether. But in the meantime, protecting new parents from older traumas needs to become the standard of care, incorporated into everything pre- and post-partum caregivers do.

*This is a composite of multiple clients over multiple time periods to protect client confidentiality.

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We need to start talking about birth trauma

Imagine this: there are two people in labor at the same time at a hospital. Both of them planned vaginal childbirths. But their labors didn’t go smoothly, and the well-being of their babies dictated that both undergo emergency caesarean sections.

Both ultimately delivered healthy babies, but that’s where the similarity of experience ended.

Their postpartum journeys were drastically different: One parent healed from the surgery and went on to enjoy the child’s infancy; the other healed physically but started having flashbacks shortly after leaving the hospital. She couldn’t hold her baby without reliving how scared she felt moments before the baby was first handed to her, after a hastily assembled emergency surgery, where medical staff were so focused on the task at hand that the patient felt like an object rather than the vulnerable, terrified person she was in that moment.

Birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment.

For a significant minority of people who give birth, the experience ends up more like the second scenario than the first one: as many as 45% of parents who went through labor -- laboring parents are primarily mothers, but not all people who give birth identify as women -- report that the experience was traumatic (Alcorn, O’Donovan, Patrick, Creedy, & Devilly, 2010). And 9% of people who give birth will go on to develop symptoms of post-traumatic stress disorder (PTSD).

Birth trauma, as defined by Cheryl Tatano Beck DNSc, CNM, is caused by an event or series of events during labor and delivery that involves the birthing person experiencing an actual or perceived threat of injury or death to the parent or unborn child -- or by a birth experience that leaves them feeling stripped of their dignity. Beck writes that “birth trauma lies in the eye of the beholder,” meaning that the parent may experience terror, helplessness, powerlessness, or horror while, from the perspective of medical staff or partners, the labor was uneventful.

Like the physical effects of childbirth, which are regularly underdiagnosed and treated, leaving new parents to suffer for years with treatable injuries, birth trauma is widespread but cloaked in a stigmatized silence that prevents people from seeking treatment. And without treatment, it has the potential to destroy the joy of the postpartum period with shame and self-blame.

By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years.

As a trauma therapist specializing in perinatal mood and anxiety disorders, I see this all the time. By the time patients seek my help, they have been dealing with full-blown PTSD or other mood symptoms for months, even years. They talk about feeling like they were assaulted in front of their entire family during nonconsensual cervical exams, or of doctors deploying forceps with such force that they were dragged down the hospital bed. Other experiences that can cause birth trauma include a prolapsed cord, a baby needing the NICU, severe postpartum injury, like tearing or hemorrhaging, and a prior history of trauma, like sexual assault/abuse.

In fact, birth trauma has major similarities to sexual assault: both involve women feeling objectified, violated, stripped of dignity, and unable to escape. And – no surprise – both come with a tragic societal stigma around talking about the experience, which makes millions of people suffering from a common experience feel isolated and alone.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance...

This shame-based silence is a tragedy, because both types of trauma are treatable with trauma therapies, which are especially effective if the trauma event is addressed early. Trauma therapy helps undo the painful sense of aloneness, helping people feel connected, and providing a window for them to reclaim their vitality. When taking care of a newborn, sleep-deprived parents need all the vitality they can harness.

We need to continually push to destigmatize birth trauma to create a culture of nonjudgement and acceptance, allowing sufferers to feel empowered to reach out for help.

If a new parent is experiencing flashbacks, a feeling of numbness, hypervigilance, or detachment, remember: it’s not your fault, and it doesn’t have to be this way. Help is out there.

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How today’s trauma can affect future generations – and how to stop it

We are currently living through a confluence of mass trauma events: a global pandemic; oppressive forces of white supremacy; a dangerously partisan political environment; an escalating climate crisis. Mounting evidence suggests that once some of these disasters ebb, the trauma they have inflicted can have lingering effects, even on future generations.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

In the United States alone, 23.2 million people have been diagnosed with COVID-19, and more than 385,000 people have died from it, making it the country with the highest number of deaths worldwide, growing daily.

On top of that, the past year has seen multiple killings of Black people by police, leading to historically large and widespread protests against the ongoing legacies of racism in America, generations of racism brought to bear.

Undergirding all this is an ever-escalating climate crisis that wreaked extreme storm damage across the gulf just as COVID made it dangerous to house climate refugees en masse.

The trauma risks to frontline workers, especially healthcare workers during COVID, have already been documented. But the effects 2020 will have on the rest of us are still playing out, and research suggests that those effects may echo far beyond the current generation.

Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees, torture victims, and combat veterans, among others.

There is growing recognition in psychology of secondary trauma, where a person experiences post-traumatic stress disorder symptoms via proximity to someone else’s harrowing experience. That is, you don’t need to experience a potentially traumatic event directly to suffer psychological symptoms from it, because learning about terrible things happening to loved ones can trigger reactions akin to experiencing it first-hand. Past studies have indicated an association between parental PTSD and secondary trauma in offspring of refugees (Sangalang & Vang, 2017), torture victims (Daud et al., 2005), and combat veterans (Dekel & Goldblatt, 2008; O’Tool et al., 2016), among others.

In other words, the current and future offspring of people living through today’s panoply of horrors may well suffer from it even without their own memories of events.

A recent research paper published in Traumatology further supports the grim notion that traumas have the potential to affect the children of those who have survived them (Payne & Berle, 2020). The paper is a meta-analysis -- the study of multiple research papers at once, looking for larger trends across data sets -- of prior studies on PTSD in children and grandchildren of Holocaust survivors. The researchers found that children, but not grandchildren, of survivors are more likely than the general population to display trauma symptoms.

It’s unclear how trauma is passed from one generation to the next. Trauma could be hereditary, perhaps through stress hormones, or children may internalize their parents’ trauma through observing behavioral and emotional patterns. Trauma may even be passed down through how parents communicate or interact with their kids. The authors recommend that future studies parse these possibilities further. Regardless, the paper further strengthens the case that if parents suffer from PTSD, their children are more likely to have symptoms, too.

We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

This growing problem has a solution: As we navigate this historically troubling era, we must prioritize systematic screening for – and increasing access to – trauma treatment, notably for the people of color who have long been shut out of our current system. PTSD is treatable, and no one should have to suffer when there are evidence-based treatments that actually work and can prevent trauma’s passage to survivor offspring.

What’s more, working through trauma has additional benefits -- treatment opens a person up to experiencing posttraumatic growth, an experience of positive psychological change as a result of going through a challenging event. People I’ve worked with who have experienced this talk about having increased resilience, empathy, and improved relationships. We can’t always stop terrible things from happening to us, but we can, with help, go from strength to strength.

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Moral injury and COVID: how to protect our front-line healthcare workers

COVID-19 rates are soaring nationwide, setting new records nearly every day. Recent reports show that doctors have learned a lot about how COVID operates in the past eight months – leading to briefer hospitalizations and fewer deaths. But as hospitals reach and then exceed capacity, doctors, nurses and other healthcare workers are again facing situations where resources are dangerously stretched.

These conditions can lead to moral injury, a form of psychological distress that results when someone’s actions, or inactions, violate their ethical code, or when they feel unprepared to face decisions or situations before them. Moral injury was originally described vis-a-vis the military: think soldiers on the front lines, forced to make decisions that will cause civilian casualties.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens. Which of two equally sick patients gets the last available ventilator? Who gets admitted first when there aren’t enough beds for everyone? When does saving the life of a milder COVID case trump using resources on a severe one when there aren’t enough supplies to do both? All doctors take an oath to avoid doing harm, and the pandemic’s strain on medical resources has made that vow difficult to uphold.

Moral injury is not, in itself, a mental illness, but it can contribute to PTSD, depression, or anxiety. And since doctors already have a suicide rate twice that of the general population – one doctor commits suicide every day in the US – it’s vital that hospitals prioritize helping their staffs process pandemic treatment experiences before, during, and after each COVID spike.

Today, our front line is the healthcare profession, and COVID has forced an ongoing stream of Sophie’s choices, where the options get more dire as the pandemic worsens.

According to a recent paper published in the British Medical Journal, psychological support is key for ensuring that what researchers called potentially morally injurious events (PMIEs) become a foundation for increased psychological resilience rather than a risk factor.

A few studies that have come out recently looking at healthcare workers during COVID-19 point to strategies for supporting them through the pandemic, including:

Prepping healthcare workers for the moral quandaries they are going to face during the pandemic: We know that preparing staff for the job and its associated challenges reduces the risk of mental health problems later on.
Checking in with staff who are “too busy” or routinely “not available” to process experiences in a group setting, since avoidance is a core symptom of unresolved trauma.
Making time to reflect on the extraordinarily difficult experiences healthcare providers are facing to create a meaningful, rather than traumatic, narrative.
Taking practical steps to manage anxiety, such as limiting time spent consuming news.
Encouraging healthcare workers to seek support from trained peers and/or professionals when necessary.

Healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience post-traumatic growth...

It is important to note that most people who endure traumatic events like PMIEs will recover on their own and will not require professional support. Even most healthcare workers struggling with the hard emotional fallout of moral injury during COVID have the capacity to eventually experience “post-traumatic growth,” a strengthening of resilience, self-worth, and values after living through extraordinarily difficult circumstances. But making sure there are supports in place when healthcare workers need them will help ensure that PMIEs won’t contribute to wearing down exhausted front-line workers all the more.

The pandemic has dropped us all in largely uncharted waters, both medically and psychologically. But it’s becoming clear that current conditions, rife with potentially morally injurious events, are putting our healthcare providers at unprecedented risk. What we do know is how to help protect them, and it must become a top national priority.

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How the just world hypothesis worsens the trauma of sexual assault survivors

People tend to mistake their own perceptions for universal reality. When it comes to politics, that tendency leads to our current hyper-partisan political environment, where people tapping into different media ecosystems may as well be living on different planets. When it comes to race, we see a cohort that cannot recognize the way white supremacy is structurally woven into the way society operates.

And when it comes to sexual assault, it means that onlookers overlook the gender inequality that pervades our socio-political system and instead blame the survivor for enduring a traumatic event that happened beyond their control.

This is the Just World Hypothesis in action -- the flawed idea that people get what they deserve.

“In a rape case, the Just World Hypothesis states that people can’t handle the cognitive lift of the fact that something unjust happened to the rape victim,” wrote Culda , Opre, and Dobrin in a 2018 paper published in Cognition, Brain, Behavior. They went on to say, “So to preserve the ‘you get what you deserve’ mentality, it’s necessary to view the victim as flawed in some way.”

Sound familiar? Her skirt was too short. She drank too much. She was asking for it.

This is the Just World Hypothesis in action -- the flawed idea that people get what they deserve.

The Just World Hypothesis is another shade of the prosperity gospel - that people become wealthy because they deserve to, never mind that most of those people are white, male, and cisgender. It allows lucky people to look at the world and divine that their lives are fortunate because they deserve what they get, not because they are at the top of a racist, sexist hierarchy designed to keep them up and everyone else down.

In American culture, it might be even more pronounced, as our milieu idealizes the American Dream and the concept of controlling our future. As a general rule, Americans have a hard time with the idea that bad things happen to good people (white Americans definitely struggle with this concept).

No matter what we want to believe, the world is not a just place, and sometimes terrible things happen to people. And nobody, no matter how they operate, ever deserves that plight.

Victim blaming: doubling down on harm

Though people engage in victim blaming to psychologically distance themselves from the idea that they are vulnerable to becoming victims themselves, it ends up compounding the trauma of sexual assault survivors.

The problem is, victim blaming takes the focus and responsibility off of the perpetrator and shifts it onto the survivor, thus silencing her – 90% of adult rape victims are women – and increasing her feelings of isolation. Victim blaming can also be experienced as a "second assault" by the survivor, complicating the trauma.

Believe the survivor. People rarely make up stories of abuse.

In my clinical practice, I have seen how victim blaming deepens the shame, self-blame, and confusion that revolves around the trauma of sexual assault. This detrimental form of secondary gaslighting deceives the survivor into believing fallacies like “I’m worthless,” “It was my fault,” or “I’m making this up in my head.”

Changing the status quo

We must all do our part to push against victim blaming in society, starting with educating ourselves about rape-culture and the myths that perpetuate it.

Some common myths and realities around sexual assault include:

She's lying.

Very few people lie about being sexually assaulted. Research has found that approximately 2-10% of rapes are false reports (Lisak, Gardinier, Nicksa, and Cote, 2010). What’s more, there are countless examples of alleged sexual assault where victim blaming led to little or insufficient punishment for the perpetrator. The #MeToo movement is virtually built on that traumatic disparity.

She wanted it.

No one wants to be sexually assaulted. This myth conflates sexual assault with sexual desire. Sexual assault is a violent act motivated by the urge to dominate and humiliate. Additionally, sexual assault is NOT caused by the survivors’ drinking or drug use, clothing or makeup, flirting, or consensual past sexual encounters with the perpetrator.

Sexual assault by an acquaintance is less traumatic than assault by a stranger.

Sexual assault is traumatic whether perpetrated by a stranger or someone known to the survivor. An acquaintance assault can have devastating long-term consequences because the survivor may doubt their ability to judge who they can trust.

Each one of us must take responsibility for making sure that victim blaming becomes an unacceptable response to sexual assault and gender-based misconduct.

Beyond educating ourselves about victim blaming and rape culture, we must practice responding appropriately when someone close to us discloses they have experienced sexual assault, breaking the cycle of victim blaming and allowing survivors to start healing.

Here is what you can do:

Believe the survivor. People rarely make up stories of abuse.
Express compassion. If you feel outraged, sad, or shocked by the survivor's pain, share it with them. There is nothing more validating than a genuine human response. Make sure your feelings don't overwhelm the survivor’s.
Inform them of appropriate resources and options. Encourage them to get help to heal.
Respect the survivor’s timeline for healing. Trauma integration is a process that cannot be hurried.

Though victim blaming can be charitably understood as a self-protective impulse, allowing people to avoid the reality that something just as horrific could happen to them, that magical thinking does nothing, in reality, to protect those using it. But it does inflict tangible harm on assault survivors. Each one of us must take responsibility for making sure that victim blaming becomes an unacceptable response to sexual assault and gender-based misconduct.

Resources for survivors of sexual assault:

RAINN

The Safe Helpline

The Voices and Faces Project

It’s On Us

It Happen ed to Alexa Foundation