Transforming crises into fresh beginnings
Naji Abi-Hashem

Naji Abi-Hashem, PhD, MDiv, MA, DAAETS, is a clinical and cultural psychologist, public speaker, author, visiting professor, cross-cultural worker, consultant, ordained minister, and caregiver at large. He is a Lebanese American who is involved in international service, teaching-training, humanitarian aid, speaking, counseling, editing/writing, publishing, volunteering, global network consultation, pastoral care, and caring for the caregivers.

He was a staff psychologist with the Minirth-Meier New Life Clinics in Seattle, WA (1992-2004) and has served as a visiting scholar at the Graduate School of Intercultural Studies, Fuller Theological Seminary in Pasadena, CA (2006-2007), and the Graduate Theological Union in Berkeley, CA (2006-2008).

Naji is active in national and international organizations. He has made ~100 professional presentations and has ~100 publications in form of journal articles, book chapters, encyclopedia entries, and periodical essays. Currently, he is a Member Care International associate and a non-resident scholar at Baylor University’s Institute for Studies in Religion, an interdisciplinary research center. He usually divides his time between the United States and Beirut, Lebanon.

---

Ancient wisdom has conveyed that life is meant not only to be endured but to also be enjoyed, virtually as a well-integrated existential experience. Whether we are pursuing higher purposes and worthy goals in life or facing daily obstacles, struggles, and hardships, we respond in various ways. Our responses are usually shaped by a host of social factors and interpersonal dynamics.

The negative forces of life seem to impact us strongly and for a long duration. The degree of impact, and how deeply we are affected by a crisis or hardship, and what coping styles we usually employ, depend largely on our background and historical experiences, such as cultural heritage, age, gender, socio-educational status, types of community support, religious faith, value system, global worldview, and existential outlook regarding the potential hope for the immediate and far-away future.

From my cultural experiences, diligence, patience, and perseverance have been perceived as highly desired virtues, not only during- but also—after the crisis or adversity. These virtues require persistence and endurance, irrespective of the stressful events or the unfavorable circumstances. They are both innate qualities and learned skills. Naturally, life itself is a series of succeeding and failing, coping and surviving, gains and losses, clarity and confusion, triumphs and disappointments, comforts and calamities, pleasures and pains, purposeful planning and multiple setbacks, and ultimately, treasures and tragedies.

Thus, as sojourners, we, humans, normally face two types of struggles: The first type includes the expected range of challenges and difficulties, which is an integral part of the daily lifecycle. It requires pre-determined and focused efforts as well as demanding costs, as we move along the path, all the way uphill or upstream. These include the usual trials and errors, tests and oppositions, illnesses and infirmities, and the many attempts of trying over-and-over again and then spending time re-grouping afterwards.

The second type of struggle is represented by unexpected major losses and misfortunes, adversities and disasters, traumas and tragedies, especially those which happen rather suddenly. They throw us off-course and force us to contain our grief and mourning, while finding ways to press on, bounce back, and resume an at least semi-normal lifestyle and mode of functioning.

Therefore, as human beings, we are fortunate to have the ability to mostly absorb the shadows and negatives of living and then transform them into positive potentials, practical skills, learned lessons, and insightful wisdoms to use along the rest of the journey. Hopefully, we will be able to impart these nuggets of gold with others and also to pass them on to future generations.

ENDURANCE

Endurance can be viewed as the act and attitude of tolerating regular struggles and strife, problems and pandemics, disillusionments and disorders, agonies and adversities… Endurance implies mere sustaining and basic surviving. It requires a deeply built-in patience and stamina. It is the result of an empowered spirit and a core durability. Such dynamical fortitude has the potential to counter tendencies of dejection, depression, defeat, and disintegration

Simply put, endurance is the ability to withstand chronic stress and a prolonged tribulation without breaking down or giving up. It is also a skill that must be practiced in order to remain strong (like a bodily muscle), even when the system is really fatigued or has reached its level of saturation. Therefore, endurance is the quality of perseverance during unpleasant times and amid painful situations. It is also perceived as grit, which is a concept that combines both an energizing passion and a long-suffering patience in the pursuit of a long-term survival plan and, eventually, a betterment of the quality of life.

Now, if we want to chart possible developmental stages to describe such phenomenological experiences, the following sequence of steps can be helpful to consider as we conceptualize the progressive movements or the chain links for these phases-stages: a) moving from facing hardship and adversity to using our best coping skills and survival abilities; b) practicing necessary patience and endurance, with insightful forbearance, until the waves of crises fade out; c) mobilizing our resources and available capitals to make the best of the situation, with problem-solving skills: and; d) advancing forward to a wider space and upward to a higher ground so we transcend the previous level of mere operational and survival mode. This innovative and creative process is essential for striving and flourishing and can beautifully reveal a colorful inspiration of blossoming ingenuity, exactly like the shining of the horizon-sky after rain and the glowing of a rainbow after the storm.

RESILIENCY

This leads us next to talk about resiliency, which can be simply defined as tolerating an unfavorable situation, a temporary bouncing-back from a failure, or an incremental recovery from a traumatic event. However, resiliency is more than that definition and is rather a deliberate movement from a problematic and troubled condition, with open-mindedness and progressive mentality, into a wider space of aliveness and determination, coupled with a realistic plan for action to find ways to continue the gradual and healthy flow onward.

Resiliency is more than basic coping or mere surviving. It is both striving and thriving, simultaneously, in the midst of adversities and calamities. Actually, it is the tendency for positive coping in spite of the circumstance(s) and the ability for transcendence above and beyond the tangible trial(s). Simply put, resiliency is being robust and resourceful, leading the person, family, group, community, or institution toward further flourishing—all the while, without minimizing the nature or impact of the surrounding struggles or agonies. Resilient people inherently keep a keen awareness of the pain involved, yet at the same time, they are willing to pay the necessary price (although at times high) to endure, to survive, and to overcome; and eventually, to enjoy the new constructive modification and fruitful transformation in their personal life as well as in the life of their extended families and communities. That experiential reality is also true collectively for large organizations, assemblies, towns, cities, and even nations.

Resiliency involves the acquired skills and the combined efforts of accommodation, adjustment, alteration, and adaptation—and perhaps even more. These processes usually result in making the best of any given setting or situation, both on individual and communal levels, when people participate in utilizing their available resources, in fashioning potential new realities, and in maintaining an energetic sense of hope toward a better future.

Unfortunately, not all persons, families, or communities, who were exposed to severe adversities, traumas, or agonies cope or survive well. Some people, young and old, remain psychologically vulnerable and relatively weak following a calamity or tragedy, with obvious long-term psycho-social-spiritual damages and mental-emotional-physiological injuries. Such lingering symptoms and scars continue to interfere with their daily functioning and personal-communal wellbeing, perhaps for years to come.

Ultimately, resiliency is part of the maturation process and the growth journey, which manifests itself in realistically accepting both the present strengths/weaknesses and the bright-sides/dark-shadows of life. Also, it is the innate ability to dwell on the positive aspects and potential possibilities, without an intense focus on the negatives, unfortunates, and non-essentials (though fully aware of them). It is the ability to celebrate the warmth and newness of daily living without dismissing its coldness and oldness. To rejoice in the cheerfulness of others without minimizing their sadness, but rather genuinely share in their loss, grief, and anguish.

Therefore, resiliency demands a sound integration, a delicate balance, and a healthy reconciliation of the many polarities of life, including the joys and sorrows of the past, the opportunities and challenges of the present, and the hopes and fears of the future.

CREATIVITY

Creativity can be viewed as the process of inventing something new from a basic, monotonous, or permanent old. It is the manifestation of a fresh-innovation and an inspired-ingenuity. Creativity means progress, aliveness, and colorfulness. It involves re-imagining, re-establishing, re-inventing, re-calibrating, re-configuring, re-envisioning, and re-launching.

Creativity is the skill of discovering new possibilities and expanding horizons at every turn in life. It is the talent of extracting monotony out of the routine and implanting novelty and vibrancy into the ordinary.

Being creative requires depth, flow, and continuity. Also, it entails wisdom and sensitivity to build upon the beautiful richness and heritage of the past, yet at the same time, to break free from its rigid tradition and mental limitations—all done gracefully and diplomatically, in order to avoid a deliberate confrontation with what has been established, accepted, and practiced for a very long time.

Therefore, creativity is not waging a cultural war on the entire past (as if it is totally rugged or irrelevant), but gradually introducing new elements of designed-change and animated-beauty, to charm the repertoire of the old-system, without intentionally threatening it or causing a major drift and bitter schism with it.

Creative people remember that the present moment or the future landscape do not stand alone, freely floating in space, but they have roots in the past and hold enough historical context and anthropological grounding. As we celebrate the present, our creative minds ought to cherish the former and the older, because it is foundational and an integral part of our true-authentic present, which in turn, reflects our socio-cultural self, communal DNA, and tribal personality.

Invariably, the past represents our origin, heritage, reference, chronicle, and identity. When modifying and re-creating the present, as a way of exploring the possibilities of one existential moment, or when charting new paths in the middle of the here-and-now reality, the previous past and the distant future are both vividly alive and readily impinging on that present moment. Therefore, and to loosely borrow from the words of Carl G. Jung, the present moment is but a moment that is pushed by the past and pulled by the future.

Indeed, human nature is blessed with the ability to endure hardships, survive adversities, and assign a new meaning to intruding calamities. Therefore, humans are inherently equipped with a marvelous capacity and an ingrained talent-faculty to re-create new repertoires, plant new landmarks, and chart new paths, steadfastly and tirelessly, along the winding long journey of life.

When we are attuned to the Spirit of Creation, then we will become, to some degree, co-creators (or mini creators) of beauty, virtues, and values — like kindness, honesty, compassion, faith, fortitude, fidelity, prudence, generosity, integrity, and courage. We will be able to fashion fresh beginnings at every turn along the road. Surely, we will enjoy becoming the sort of artists who engage in crafting unique and delightful shapes-forms and adding much needed colors to the wide tapestry of life. And thus, significantly participating in the phenomenological experiences and elevated transcendences, almost as a Divine Expression reflecting the Imago Dei (image of God), of accumulating precious moments, generating meaning-making, designing exquisite attractions, expanding new horizons, and leaving enduring legacies.

Together, resilience and creativity seem to be two-sides of the same coin. They are interrelated, intertwined, and interdependent. Both inform each other and build upon each other. Each sphere continually shapes and feeds the other sphere. They appear to have combined and strong elements of emotional intelligence, cognitive intelligence, cultural intelligence, and spiritual intelligence—all of which constitute a mosaic tapestry of procreation, originality, determination, novelty, flexibility, steadfastness, freshness, beauty, and ingenuity.

References & Readings

Abi-Hashem, N. (1999, 2001, 2011, 2014, 2017, 2020); Al-Ghazali, A. H. (2011); Almedon, A. (2005); APA (2011); Aronowitz, T. (2005); Barker, P. A. (2019); Bonnano, G. A. (2004); Boyd, J. (2002); Davis, G., & Woodward, J. (2020); Engel (2007); Figley, C. R. (2012); Gonzalez-Mendez et al. (2020); Graham, L. (2018); Keith, K. D. (2013); Khosravi, M., & Nikmanesh, Z. (2014); Luthar et al. (2003); Maslow, A. H. (1943); Masten, A. S. (2001); McCann, J., & Selsky, J. W. (2012); Oppezzo, M., & Schwartz, D. L. (2014); Piirto, J. (2004); Psychology Today (2023); Richardson, G. E. (2002); Rubinstein, D., & Lahad, M. (2022); Schrag, B. (2013); Şimşek, A. (n.d.); Southwick, S. M., & Charney, D. S. (2018); Teachenor, J. W. (2022); Thorman, J. (2007); Titus, C. S. (2006); Ungar (2013).

Citation: Abi-Hashem, N. (2023). Endurance, resilience, and creativity: Transforming crises into fresh beginnings.Trauma Psychology News, 18(1), 10-17. https://traumapsychnews.com

Ani Kalayjian & Andrew Dolinear

Section Editor: Claire J. Starrs

The Association of Trauma Outreach and Prevention (ATOP) MeaningfulWorld is an international non-governmental organization affiliated with the United Nation’s Department of Global Communication. MeaningfulWorld offers mental health education programs and workshops focusing on empowerment, stress management, time management, creating a healthy workplace, preventing burnouts, mindfulness, resolving conflicts peacefully, emotional intelligence, and meaning making. In addition, our humanitarian outreach teams have implemented rehabilitation programs for survivors of traumatic events in over 48 countries and 26 American states. Over the last three decades, MeaningfulWorld has conducted humanitarian missions in 50 countries aimed at transforming trauma caused by human-made and natural disasters. Although the primary aim of such missions is to facilitate healing and post-traumatic growth in affected individuals and groups, the utilization of surveys, workshops and other engagement efforts has provided insight into the individual and institutional factors that influence the ways in which traumatic events are integrated, processed, discussed, and passed on, in various cultural contexts.

Horizontal Violence (HV), also known as lateral violence, is defined as internalizing the aggression of a perpetrator and displacing it onto others within one’s own group (Hastie, 2002). HV has been shown to emerge from oppression, discrimination, and colonization (Embree & White, 2010). The resulting preference for the oppressor’s kind (e.g., their race, religion, color, gender, etc.), leads to oppressed people making negative assumptions about themselves and their own kind. Therefore, in-group individuals may start behaving as the aggressor, feeling entitled and putting other group members down. This may include attitudes and behaviors such as envy, jealousy, distrust, one-upmanship, negativity, denigration and displacement of frustrations and anger. Instances of HV have been described in several communities that MeaningfulWorld has served. In the African American community in the Southern United States, this process is called the “Crab in a Bucket” syndrome, where in a bucket full of crabs, when one tries to climb out, another will pull it back down, and as the cycle endlessly repeats, it leaves all the crabs stuck in the bottom of the bucket. Thus, in a fitting allegory for the process of HV, members of the oppressed group, stuck in the proverbial bucket, preclude other members from overcoming their condition.

Brief Literature Review

HV has primarily been examined in studies focusing on workplace dynamics, particularly among nurses in hospital settings. Much of this research was conducted in response to instances of hostility observed among nurses despite ostensibly sharing similar experiences, goals, and workplace status. Studies point to HV prevalence rates among US nurses ranging from 25.3% (Sellers et al., 2012) to as high as 85% (Wilson et al., 2011). In their 2002 study in this population, Hastie (2002) described examples of gossip, verbal abuse, intimidation, sarcasm, elitist attitudes, and body language such as eye rolling, folding arms, and disinterest. Furthermore, nurses report experiences of HV as both the victim (25.5%) and the witness (29.8%) (Sellers et al., 2012).

Embree and White (2010) identify various antecedents to HV, such as organizational imbalance of power, personal oppression, lack of empowerment, and a professionally dysfunctional culture. Moreover, Bent suggests that, due to their difficult working conditions, nurses are being oppressed, as the nursing profession is marked by a continual struggle for autonomy, accountability, and control over the profession (Bent, 1993). Nurses

may, therefore, be responding to a sense of powerlessness associated with restricted autonomy and autocratic leadership, and feelings of powerlessness and insecurity may manifest as aggression either turned inward or outward in the form of HV.

Until now, the HV model has seldom been applied to understand intragroup conflict and hostility outside of the realm of nursing. One exception is within the Indigenous community, where such concepts as internalized racism and internalized colonialism leading to HV, have been examined (e.g., Canada, Bombay et al., 2014; Australia, Whyman et al., 2021). Indeed, Bailey (2019), examined lateral violence in Indigenous post-secondary students in Canada. Using open-ended interviews, Bailey found that in addition to the complex burden of historical trauma due to colonization and colonized institutions, Indigenous students reported experiencing acts of HV. Despite recent efforts by the government to address historic oppression, these acts, Bailey contends, continue to negatively impact attainment of community, power, and resources. Other studies on HV in Indigenous communities also argue this process affects well-being and sense of identity (Whyman et. al., 2021).

Of note, other groups for whom bullying within the workplace, including from peers, has been explored, such as amongst the military (for review see Stuart & Szeszeran, 2021), first-responders (for review see Walker & Stones, 2020), and academics (see Goodboy et al, 2020 for discussion), do not fit within an HV framework, as these are not groups that experience overall oppression and discrimination.

Horizontal Violence in the Field

As we have learned through three decades of humanitarian work, the HV framework can shed light on both individual behavior and attitudes, and intragroup dynamics in far reaching contexts. Indeed, it provides a useful structure to map the relationships between institutional or cultural prejudice, and oppressed groups. Throughout our missions, we have identified several ways in which HV is expressed, including:

• Minimizing positive behavior, and lack of validation
• Fear and avoidance of reporting HV behavior
• Isolation from others
• Lack of respect and support
• Organizational chaos
• Personal and professional bullying
• Distrust, envy, jealousy, and gossip
• Discrediting success
• Undermining strengths
• Division and conflict instead of collaboration and mediation

We have observed these dynamics in more than a dozen missions, including to the countries of Haiti, Sierra Leone, and Armenia. Although these countries have unique histories and cultures, they have each experienced periods of armed conflict, genocide and collective violence, leading to intergenerational trauma, which is compounded by continued societal injustices. As such, these events have had similar effects on intragroup cohesion and HV in these three locations.

In 2022, during our last mission to Armenia, many Armenians expressed a degree of hopelessness. For example, one individual, when taught the concept of HV, immediately recognized it in her own community and culture, and said to the first author that she believed it could not be changed, and that our intervention efforts on the ground were in vain. Examples of HV in Armenia that we observed included distrust, envy, gossip, jealousy, putting others down, disregarding others’ achievements, finding faults in others, and making disparaging public announcements about others without any corroborating evidence. Additionally, given the complex political situation in the Middle East, thousands of Armenians have been forced to migrate from Iraq and Syria back to Armenia, and we noted instances of HV expressed against these new immigrants who were competing for already limited resources.

Throughout numerous missions to Haiti, volunteers with MeaningfulWorld have observed the previously identified signs of HV daily. For instance, in a capacity building effort, we worked to connect local organizations working on peace-building, with the objective of ensuring a continuation of these efforts after our mission’s conclusion. However, local organizers often refused or failed to cooperate with one another due to a lack of trust and comradery. Instead, they reported wishing to continue working with our organization, despite our mission lasting only a few weeks. When first discussing signs of HV in workshops, many people dismissed the idea that such actions and attitudes could be indicative of a greater issue; however, after describing HV in detail, they generally laughed and told us “This is a Haitian disease, we all are infected by it.”

Intervention Utilized

According to the literature on HV, the first step in addressing it is to increase awareness of its prevalence, followed by proactively addressing its multiple components within each specific environment (Lewis & Malecha, 2011). In various contexts where we have encountered HV, MeaningfulWorld has utilized the 7-step Integrative Healing Model (Kalayjian, 2017; Kalayjian, & Diakonova-Curtis, 2019), in which various aspects of emotions are assessed, identified, explored, expressed, processed, validated, and finally re-integrated.

• Step 1: Assess Levels of Distress, Disagreement, or Conflict. Participants are given a written questionnaire that helps them define the kind of trauma, distress, or dispute they are working on.
• Step 2: Encourage Expression of Feelings. Each participant in the group is encouraged to describe their feelings about the trauma, or conflict from their own perspective and express feelings in the “here and now.”
• Step 3: Provide Empathy and Validation. Each participant’s feelings are validated by the mediator, group facilitator, and group members. Emphasis is placed on understanding others and putting one’s feet in the opponent’s shoes.
• Step 4: Encourage Discovery and Expression of Meaning. Participants are asked, “What lessons, meaning, or positive associations did you discover about yourself as a result of this dispute?”
• Step 5: Provide Information. Practical tools and information are shared on how to gradually integrate the conflict resolution information that has been provided, and care for oneself as a caregiver/mediator.
• Step 6: Nurturing Mother Earth. Participants are provided with practical tools for connecting with nature (Mother Earth) and ways to care for one’s environment.
• Step 7: Breath Work and Meditation. Participants are guided on how to use breathing, to create peace within, and to foster gratitude, compassion, faith, strength, and forgiveness in response to conflicts, with the objective of increasing self-empowerment.

This 7-step model is an integrative approach that incorporates modalities from multiple schools, including psychodynamic, interpersonal, existential, humanistic, and learning-theory, as well as third-wave approaches that encompass mind-body-ecological-spiritual practices. This model has been useful in addressing the behaviors associated with HV, by focusing on group-based exercises in developing emotional intelligence through empathy, while also treating the causes through forgiveness, mindfulness and meaning making. This intervention model has been utilized to address HV in multiple countries (Kalayjian, 2017; Kalayjian, & Diakonova-Curtis, 2019). However, research specifically examining the efficacy of the various components of this intervention, would greatly benefit future humanitarian missions in this area.

In sum, the prevalence of HV observed in numerous culturally distinct groups suggests the possible benefits of utilizing this framework in future research on collective trauma, intragroup conflict, and community building in oppressed groups. We believe such an analytic lens has the potential to better identify problematic behaviors and attitudes, as well as address their causes in individual and group settings.

ANI KALAYJIAN, EdD, President of Meaningfulworld, and Adjunct Professor of Psychology at Teachers College, Columbia University, John Jay College of Criminal Justice, multicultural and multilingual Psychotherapist, Genocide Prevention Scholar, International Humanitarian Outreach Administrator, Integrative Healer, author, and United Nations Representative. She was awarded Outstanding Psychologist of the Year Award by the American Psychological Association (2016, Trauma Division), a Humanitarian Award from the University of Missouri-Columbia (2014), the 2010 American Nurses Association Honorary Human Rights Award, and an Honorary Doctor of Science degree from Long Island University (2001) recognizing 30 years as a pioneering clinical researcher, professor, humanitarian outreach administrator, community organizer and psycho-spiritual facilitator around the globe and at the United Nations. In 2007 she was awarded Columbia University, Teacher College’s Distinguished Alumni of the Year. She has over 100 published articles in international journals, books, and is an author of Disaster & Mass Trauma, Chief Editor of Forgiveness & Reconciliation: Psychological Pathways to Conflict Transformation and Peace Building (Springer, 2010), Chief Editor of two volumes on Mass Trauma & Emotional Healing around the World: Rituals and Practices for Resilience and Meaning- on Mass Trauma & Emotional Healing around the World: Rituals and Practices for Resilience and Meaning-MakingMaking (Praeger, ABC-CLIO 2010), author of Amazon Bestseller Forget Me Not: 7 steps for Healing our Body, Mind, Spirit, and Mother Earth (2018), A Journey of Empowerment, Healing, and Transformation (2023), and a meditation CD called “From War To Peace” transforming generational trauma into healing and meaning-making.

ANDREW DOLINAR holds a MA Human Rights Studies from Columbia University and a BA in Sociology from The University of Illinois at Urbana-Champaign. He has worked on crisis response and conflict monitoring at Human Rights Watch in New York, and sentencing reform at Penal Reform International in Tbilisi, Georgia. Much of his career has focused on human rights issues in Eastern Europe and the Caucuses, in particular LGBTQ+ rights, transnational organizing, and conflict intervention. He currently serves as the Vice President of the Association for Trauma Outreach and Prevention at MeaningfulWorld.

Citation: Kalayjian, A., & Dolinar, A. (2023). Transforming horizontal violence globally. Trauma Psychology News, 18(1), 22-27. https://traumapsychnews.com

Multicultural Considerations for the Past, Present, & Future of our Field

Nicholas A. Pierorazio, Christina M. Dardis, & Bethany L. Brand
Section Editor: Claire J. Starrs

Dissociation is presently understood as a disconnection and/or disintegration in consciousness, memory, identity, emotion, perception, somatic experience, motor functioning, and/or behavior (American Psychiatric Association, 2022). Dissociation may range from being normative (e.g., absorption) to complex (e.g., dissociative identities). Complex dissociation is posited as traumagenic (Dalenberg et al., 2012), with dissociative disorders (DDs) arising from complex trauma in childhood (Chu & Dill, 1990). Complex dissociation is prevalent; up to 4% of the United States’ general population report it (Simeon & Putnam, 2023).

Understanding the role of culture within the study of trauma, dissociation, and DDs is difficult (Krüger, 2020b). Many studies define culture as one dimension of identity, such as nationality. However, culture is multidimensional and often nested below the surface of an individual’s experience. Specifically, individuals hold layers of identities (e.g., Black, woman, mother, writer) and exist within layers of systems that influence their meaning-making about trauma, its sequelae, and related healing processes (Brown, 2008). Research exploring the intersection between culture and dissociation has been nebulous, as is the history of defining and understanding dissociation itself.

A History of Dissociation Enveloped in Stigma

Just as psychological trauma is part of the human lived experience, dissociation is also intertwined with human history. While the first documented experiences of dissociation were noted before the 18th century, descriptions and conceptualizations of dissociation began to proliferate in the late 19th and early 20th centuries with the rise of psychoanalytic personality theories (van der Hart et al., 1989). Specifically, dissociation was theorized as a protective mechanism enabling the fragmentation of traumatic events from conscious awareness to reduce internal threat (van der Hart et al., 1989). Trauma and dissociation experts have continued to view trauma as an important etiological factor in the development of complex dissociation (e.g., dissociative identity disorder [DID]). This trauma model (TM) of dissociation has received empirical support (Dalenberg et al., 2012).

By the mid-20th century, dissociation was understood as occurring on a continuum from normative to complex, with individuals possessing an innate dissociative capacity (Spiegel, 1963). DDs were later integrated into the Diagnostic and Statistical Manual of Mental Disorders in DSM-III in 1980, including multiple personality disorder, renamed DID in DSM-IV, capturing the most complex form of dissociation: identity fragmentation (APA, 1980; 1994). The idea of dissociation on a continuum has persisted in the field, and professionals have begun to consider dissociation as encompassing a wide range of experiences and presentations (Şar, 2022).

However, despite strong theoretical and cross-cultural (e.g., Ross et al., 2008) empirical support for the TM of dissociation, some theorists strongly dispute it, in favor of the fantasy model of dissociation (FM; Dalenberg et al., 2012). The FM posits that individuals who are suggestible and fantasy-prone are susceptible to dissociating, which in turn heightens the likelihood of developing false trauma memories due to social influences. Proponents of this model further argue that therapists implant false trauma memories and DID in these vulnerable individuals (Dalenberg, 2012; Lynn et al., 2014). They also claim that dissociative individuals are prone to over-reporting symptoms (e.g., Merckelbach et al., 2015). Thus, FM theorists posit that DID is an iatrogenic condition, rather than a genuine disorder. In the 1990s, parents who had been accused of child sexual abuse and their supporters, formed the False Memory Syndrome Foundation, an advocacy group that vocally supported the FM (Olio, 2004). No studies in clinical populations strongly support this etiological model. Additionally, research has consistently found people with DID are not highly suggestible, nor prone to false memories or symptom over-reporting (Merckelbach et al., 2015; Vissia et al., 2016). However, FM theorists continue to deny the validity of the TM and the DD diagnoses.

The FM has greatly contributed to stigma regarding dissociation, especially DID, which is surrounded by myths and is misunderstood (Brand et al., 2016). People who experience complex dissociation are subject to re-traumatization by the same mental health systems that purport to serve them. People who dissociate face additional dissociation-related mental health treatment barriers. For example, a study by Nester and colleagues (2022) identified multiple significant treatment barriers, including providers’ limited understanding of trauma and dissociation, the fear of having their dissociation disbelieved, as well as more frequent treatment ruptures due to providers responding poorly to dissociation. Moreover, many of the participants also endorsed treatment barriers related to their minoritized identities, such as being unable to receive adequate dissociation-informed treatment due to racism.

Stigmatization also occurs in the media (Brand & Pasko, 2017). The media frequently engages in damaging misportrayals of dissociation, especially DID. Films such as Sybil (1976) have foregone clinical accuracy to make a spectacle of dissociation and DID. Even more recently, Hollywood productions like Split (2016) have sensationalized DID and portrayed the condition as inherently violent, contrary to the research literature. This historical stigma surrounding dissociation and DDs may represent a cultural dimension that compounds dissociative individuals’ trauma and dissociation, as many professionals continue to approach dissociation and the DDs through this stigmatized lens.

Dissociation as Cultural Context

The history of clinical conceptualizations of dissociation and the stigma around it provide context for how it has been studied. Quantitative approaches have allowed experts to obtain evidence about etiological factors and related treatment that has consistently supported the TM (see Dalenberg, 2012). However, academic debate has persisted in the field, despite strong empirical support for the TM. This dynamic of debate has been relatively exclusionary of those with lived experience, often leaving these individuals out of conversations regarding their own experiences, meaning-making, and treatment goals (Christensen, 2022). Furthermore, research has mostly been in Western contexts (Krüger, 2020b); although, there has been some cross-cultural research, highlighting cultural complexities around dissociation.

Myriad dissociative presentations are observed across cultures (Şar, 2022), indicating multicultural nuance for dissociation. For example, dissociative possession phenomena may be experienced more often in Eastern contexts than in the West. Dissociation may present as functional neurological symptom disorder, possession phenomena, and chronic mood disorders in Eastern cultures such as Turkey, Africa, and Asia respectively, as well as acute reactions to stress (e.g., ataques de nervios) in Latin American cultures, and as mass trauma (Şar, 2022). A greater cultural understanding of dissociation may be dependent on culture-specific clinical training and conceptualizations. For instance, episodes of psychosis are often characterized as dissociative in Turkey, whereas the dissociative nature of these same episodes may be overlooked in traditional Western conceptualizations (Lewis-Fernández et al., 2007). In one quantitative study, Douglas (2009) found that Black and Asian American students who reported higher dissociation experienced less distress. The author suggested dissociation may be more protective for Black and Asian American students than it is for White students. It may be that dissociation is a traumagenic reaction to cultural traumas, such as colonial violence (Dupuis-Rossi & Reynolds, 2018), institutional betrayal (Smith & Freyd, 2017), cultural betrayal (Gómez, 2019), and racial discrimination (Polanco-Roman et al., 2016).

In the greater mental health culture, discourse has historically marginalized contextual approaches to understanding psychological experiences (Ratts & Greenleaf, 2018), including trauma and dissociation. However, these processes are inextricably contextually situated. The few published qualitative studies have often aligned with post-positivist values, sacrificing important nuance to quantify experience. Professionals are beginning to call for more qualitative research in the study of trauma and dissociation, in particular to understand the ways in which culture and dissociation interact. Qualitative methodologies may be the strongest way to open doors for the exploration of such under-researched phenomena, and this research could broaden our understanding of dissociation and illuminate the sociological processes involved.

Trauma specialists have more recently begun investigating culture in relation to trauma and dissociation. Pierorazio and colleagues (2023) explored meaning-making about culture, dissociation, and the treatment of dissociative individuals in a reflexive thematic analysis study. Participants with lived experience of dissociation understood their dissociative and treatment-related experiences in the context of sociocultural processes, including through cultural aspects such as queer identity, race, stigma, and systemic oppression, among others. They conceptualized their dissociation as either catalyzed or buffered by their intersectional identities; that is, participants often understood their dissociation as worsened by the ways in which they are oppressed, and countered by how they held privilege. Some participants also decontextualized themselves from their culture (e.g., explaining they have no culture), which may itself be a dissociative disconnection from cultural identity.

Dissociation may even be cultural for those who experience it. Christensen (2022) suggested online spaces (e.g., dissociation support forums) for those who identify as Plural are cultural spaces with their origins in dissociation-related lived experiences. The author identified that in these online spaces, there is also some intersectionality with transgender and autistic populations. Many members indicate being Plural due to trauma (e.g., DID). However, there are also Plural people who identify as endogenic (i.e., Plural before birth and not due to trauma), and exogenic (i.e., Plural since some time after birth yet not due to known trauma). There has not yet been any empirical research specifically related to these online cultural spaces.

Contextual Dissociation in Mental Health Treatment

Evidence-informed treatment guidelines for complex dissociation include dissociation-informed phasic psychotherapy that emphasizes safety and stabilization (International Society for the Study of Trauma and Dissociation, 2011). This psychotherapeutic treatment for complex dissociation can be empowering within a multicultural framework; yet there remain calls to include those with lived experiences of complex dissociation in the revision of these guidelines (Christensen, 2022). There is also a call for the integration of social action, such as advocating against the societal denial of dissociation and changing social policies, alongside trauma- and dissociation-informed treatment (Pierorazio et al., 2023). Social action could address treatment barriers for people who dissociate. Considering the contextual nature of dissociation, mental health professionals working with people who dissociate should consider using culturally-responsive, trauma-informed, and social justice-oriented interventions (Dupuis-Rossi & Reynolds, 2018). For example, community-based, culturally-consistent healing methods may be most beneficial for possession experiences (e.g., Indigenous healing; Kirmayer et al., 2003). It is important for researchers, clinicians, and activists to understand that treatments should acknowledge the systems in which we live, validate clients’ lived experiences, and be culturally-relevant.

Future Directions for the Field of Trauma and Dissociation

Consistent with the calls for researchers and clinicians to hold a more contextualized understanding of dissociation, professionals in the field must learn to acknowledge the layers of identity, culture, and systems that can affect dissociation in complex ways. Stigma has complicated our progress in understanding dissociation from a multicultural perspective. A more contextualized understanding of dissociation may be reached by moving away from medical model conceptualizations. In particular, the assumption of universality regarding the pathological nature of dissociation may be harmful to the nuance of how dissociation is experienced.

There is a lack of research regarding dissociation-adjacent cultural identities, including being Plural. Research with multicultural approaches is necessary when considering these shifting cultures. Further, qualitative research may provide valuable insight into their implications for the budding understanding of plurality as a cultural identity. These methods would allow us to gain understanding from people with lived experiences of dissociation and/or plurality, voices that have historically been silenced. In the meantime, clinicians should consider empowering these voices by validating these cultural identities (Christensen, 2022).

Cultural traumas may precede complex dissociation; however, research regarding dissociation as a response to historical-cultural trauma is scarce. Further research should explore dissociation as a response to these traumas, such as institutional betrayals, cultural betrayals, intergenerational trauma, and other forms of insidious trauma such as microaggressions. To do so, exploration may begin with interdisciplinary and qualitative research through an intersectional, multicultural framework (Krüger, 2020a). Creativity and subjectivity may be essential resources to integrate into these approaches (Braun & Clarke, 2022), as well as in clinical practice. Truly addressing dissociation may require mental health professionals to push the bounds of what is generally accepted in psychology. Professionals in the field must explore the traumatic nature of oppression and its interaction with dissociative processes to fully understand dissociation and related healing.

NICHOLAS PIERORAZIO is a Research Assistant for the Treatment of Patients with Dissociative Disorders (TOP DD) Lab at Towson University. His research interests are trauma, dissociation, psychotherapy, and qualitative methodologies. He has worked on several studies in the TOP DD Lab and has spearheaded research examining multicultural considerations surrounding trauma and dissociation. His clinical experience includes working as a Mental Health Worker on a trauma disorders inpatient psychiatric unit.

CHRISTINA M. DARDIS, PhD, is an Assistant Professor of Psychology and Director of the Laboratory for Interpersonal Violence and Traumatic Stress Studies at Towson University. Her research interests include predictors and correlates of stalking and cyberstalking victimization and perpetration, the role of social support in interpersonal violence, empowerment self-defense, and intersections between gender and violence.

BETHANY BRAND, PhD, is a Professor at Towson University in Maryland and an expert in trauma disorders. Dr. Brand conducts research in five areas: treatment of dissociative disorders (TOP DD studies); methods for distinguishing dissociative disorders from malingering; the impact of training clinicians about trauma; investigating the trauma versus fantasy model of dissociation; and assessing the accuracy of textbooks’ information about trauma. In her private practice, she treats complex trauma patients and serves as an expert witness in trauma-related cases.

Jessica Krukowski, Ed St. Aubin, & Karen Robinson
Section Editor: Sydney Timmer-Murillo

Black women live in an intersection between two marginalized identities: their Blackness and their womanhood (King, 2019). Oftentimes the challenges Black men and boys face become synonymous with the entire Black experience (Patton et al., 2016). As a result, solidarity becomes asymmetrical, and the lived experiences of Black women and girls become marginalized (Johnson, 2013). Black women encounter a similar asymmetry with sexism. Sexism as experienced by White women and by Black women is not equivalent. Because the Black woman’s particular experience is not recognized, that experience of sexism is dismissed (Sesko & Biernat, 2010). Because the impact of racism and sexism have been historically explored separately, the unique intersectional forms of racist and sexist oppression Black women face are less understood and have remained invisible to larger social justice movements (e.g., civil rights, Black power, feminism/women’s liberation, workers’ rights, Me Too, Black Lives Matter; Coles & Pasek, 2020). This imposed invisibility has perpetuated the systematic silencing of Black female voices (Kota, 2020). As a result, Black women have been consistently underrepresented and historically overlooked in research, leaving a gaping hole in the scientific literature (Allen, 2018). Methodologies exploring stress and trauma in Black women are no exception. Presently, the body of stress and trauma literature has found pervasive effects on the mental health (Turner & Turner, 2021) and well-being (Harrell, 2000) of Black people, but the methods employed have not been conducive to understanding the lived experience of Black women in particular. Thus, it is imperative for researchers to provide the space for Black women to use their voices to guide future scholarship. Raising the voices of Black women will help to close this gap, adding a strength-based and intersectional lens.

Method

The sample consisted of Black women varying in age, income, and sexual orientation living in Milwaukee, Wisconsin; see Krukowski et al. (2022) for additional study methodology. The purpose of this mixed-methods study was to explore how the low-point narratives from Black women relate to quantitative measures of mental health and well-being. Written informed consent was obtained before completing a 90-minute, semi-structured, one-on-one life-story narrative interview (McAdams, 2015) which was audio recorded in real-time with a Black/African American female researcher trained in the interview protocol. The low point prompt requests that the participant describes in as much detail as possible the lowest point in her life. These women were asked what happened, when and where it occurred, who was involved, and what they were thinking and feeling. Participants were asked to recount why this particular moment was so difficult and what the scene may say about them or their life (McAdams, 2015). This prompt qualitatively elucidates experiences of stress and trauma without explicitly asking to recount a specific traumatic event.

Following the interview, participants completed an online survey battery including the Perceived Stress Scale (PSS), a 10-item stress assessment instrument to help researchers understand how various situations affect a participant’s feelings and perceived stress over the last month (Cohen et al., 1983); the Depression Anxiety Stress Scales (DASS), a 21-item scale with three sub-scales designed to measure the emotional states of depression, anxiety, and stress (Lovibond & Lovibond, 1995); the Psychological Well-Being scale (PWB), an 18-item instrument based on the participant’s attitudes about themselves and others which investigates quality of life as it relates to benefits gained through overall psychological health and stable self-concept (Ryff, 1989); and the Social Well-Being scale (SWB), a 15-item instrument that explores quality of life as it relates to benefits gained through understanding of self as a social being and maintenance of stable social relationships (Keyes, 1998). Each participant was compensated for their time. After data collection, all interviews were deidentified and transcribed verbatim. The low-point portion from each Life Story Interview was compiled. Other facets of the Life Story Interview were not considered for this project.

To ensure cultural responsiveness, there was a council of five Black female community leaders and academics who consulted the team at every step of the project’s design including identification of all measures used and the implementation of the study. Further, each of the interviews were conducted by Black women members of the research team and Black women were part of interpreting the narrative material participants told.

Results

There were 62 participants with both interview and survey data. A thematic scoring system was created to determine which women described an event that would meet Criterion A of posttraumatic stress disorder (PTSD) from the Diagnostic and Statistical Manual of Mental Disorders. Criterion A events are defined as ones in which a person is exposed to actual or threatened death, serious injury, or sexual violence either directly, as a witness, from a loved one’s experience, or from repeated or extreme exposure to adverse (disturbing) details of a traumatic event; Criterion A does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related (APA, 2013). Of the 62 responses, 38 women (61.3%) described an event that would qualify as Criterion A. Using independent samples t-tests, we tested whether there was a mean difference between women who described a Criterion A trauma and those who did not on six measures of wellness. There were no significant differences. What we get from these data is a constellation of how this group of women’s voices relate to mental health and well-being.

Discussion

This demonstrates that more than 6 out of 10 Black women from Milwaukee tell stories of the low point in one’s life narrative that meet the criteria for an event to be considered potentially traumatizing. Yet, when compared to those in this study whose low point did not meet Criterion A for trauma, there are no group differences on several indices of wellness.

While clinicians may work under the assumption that clients whose life experiences meet Criterion A are categorically different than those who do not with regards to psychosocial functioning, this study suggests a more nuanced reality. Practicing clinicians working with Black women from Milwaukee, and perhaps in other contexts, need to be mindful that there may not be an increase in their client’s mental health symptoms, or a decrease in their well-being when talking about life threatening or serious injuries that have happened to themselves or to people close to them.

We must remember that the methods and findings of this study are not the same as diagnostic work using Criterion A and that the description of the lowest point does not explicitly ask about trauma. It did, however, elicit responses that clinicians could consider traumatizing at incredibly high rates. These results can be used by mental health professionals to help guide appropriate treatment and intervention for the Black women they work with. This work underscores that if we want to understand individuals as a whole, we need to ask them about their lives. Lives are not checklists.

JESSICA KRUKOWSKI is a fifth-year clinical psychology doctoral student at Marquette University. Her clinical and research interests are rooted in exploring well-being using strength-based and translational methodologies. Upon graduation, she plans to pursue a community engaged clinical and research career aimed toward evidence-based social justice and policy reform.

---

ED DE ST. AUBIN is a Psychology Professor at Marquette University. His current research projects integrate qualitative and quantitative techniques, with an emphasis on empowering participants by prioritizing their self-defining life stories. Our work is community-engaged and based on a deep understanding of the impact that culture and structural power dynamics have on individual lives. Core concepts we explore include psychosocial wellness, meaning-making, identity, microaggressions, intersectionality, trauma, and generativity.

---

KAREN ROBINSON is the Interim Assistant Dean Graduate Programs and Associate Professor in the College of Nursing at Marquette University. Dr. Robinson’s program of research focuses on racial disparities in maternal-child health. She has centered her research around breastfeeding disparities by examining breastfeeding barriers for African American mothers. Specifically, Dr. Robinson is investigating how racism, implicit bias, and discriminatory behaviors towards African American mothers negatively impact breastfeeding outcomes within this population. She has also studied the positive effects of breastfeeding peer counselors and group prenatal care on breastfeeding outcomes. [See Dr. Robinson’s online profile.]

Citation: Krukowski, J., De St. Aubin, E., & Robinson, K. (2023). Exploring the wellness of black women who describe a criterion A trauma in their life story. Trauma Psychology News, 18(2), 22-25. https://traumapsychnews.com

In brief
Claire J. Starrs & Zaine A. Roberts

Religiosity has been shown to be related to indicators of well-being such as hope, optimism, happiness, and quality of life (Gonçalves, et al., 2017; Panzini, et al. 2017; Peres, et al., 2017), as well as lower distress, even in the face of major stressors, such as cancer, bereavement, and traumatic events like sexual assault (Ahrens et al., 2010; Gudenkauf et al., 2019). Studies have suggested various mechanisms for this protective effect, including through increases in meaning making (Steger & Frazier, 2005), social support (Ellison & George, 1992), self-regulation (Watterson & Geisler, 2012), and self-efficacy (Abdel-Khalek & Lester, 2017). With the rise of secularism in the 20th century, at least in much of the West (Bruce, 2003; Lambert, 2004), broader conceptualizations of religiosity have been considered, under the umbrella term spirituality. Currently, there is some consensus that religiosity captures more formal religious beliefs and values, and collectivistic practices that generally include a public and institutional sphere (Pargament, 1997). Alternatively, spirituality usually describes more humanistic beliefs and values, including feelings of connectedness to the self, others, nature, and the sacred (i.e., to something greater than oneself), and spirituality is typically a more private and internal experience (Chagas et al., 2023; Reed, 1992). These two dimensions are not necessarily separate, as spirituality can be present at any level of religiosity (Zinnbauer & Pargament, 2005). Studies specifically examining spirituality, although less numerous, have supported a protective effect, and supported mechanisms include increases in hope (Gibson & Hendricks, 2006), and meaning making (Salsman et al., 2011).

Coping can be defined as the internal and external resources that are mobilized to manage stressors (Haan, 1977). Coping includes both adaptive and maladaptive strategies, and there is substantial evidence showing that maladaptive coping is associated with higher distress, and adaptive coping with lower distress (e.g., Cukrowicz, et al., 2008; Jaser et al., 2005). At the intersection of religiosity/spirituality and coping, is religious coping (RC, Pargament, 1997). RC is multidimensional, including behaviors (e.g., prayer, meditation), emotions (e.g., comfort through spiritual connection), cognitions (e.g., cognitive reappraisal and reframing), and relationships (e.g., seeking pastoral care). As with general coping, RC can be maladaptive (e.g., interpreting stressors as a punishment from ‘God’ or karma), which has been shown to lower quality of life and increase depression, or it can be adaptive (e.g., finding solace in prayer) leading to less distress and more personal growth (Pargament et al., 1998). Difficulties in defining more secular spirituality have hindered equivalent examinations in non-religious persons. Although, the few existing studies have also shown protective effects. For example, Roming and Howard (2019) found that higher spiritual coping was related to higher life satisfaction in college students.

Black, Indigenous, and People of Color (BIPOC)

Religiosity/Spirituality has been shown to be important across minority groups, including in African American and Black Caribbean groups (Taylor & Chatters, 2010), Latinx communities (Campersino et al., 2009), and Indigenous Americans (Garroutte et al., 2003). Furthermore, despite overall growing secularism, a recent large study found that 41% of Black Americans and 30% of Hispanics reported that their faith had grown stronger during the recent COVID-19 pandemic, compared to 20% of Whites (Gecewicz, 2020). Protective effects include lower suicidality (see Gearing & Alonzo, 2018 for a general review) and decreased depression (see Braam & Koenig, 2019 for a general review). The principal mechanism that has been suggested for this adaptive effect in ethnic minority communities is high levels of RC, as they deal with ongoing minority stress (Bhui et al., 2008). Most studies have examined Black and Latino samples in the US (e.g., Sanchez et al., 2015), however similar effects have been found other minority groups, for example Adam and Ward (2016) showed that RC buffered the negative effects of acculturative stress leading to higher life satisfaction, in a Muslim sample living in New Zealand. Suggested explanations for higher levels of RC across minority communities focus on sources of minority stress such as disparities in access to health care, reluctancy to seek psychological support due to stigma, and the general low cultural competency of health care providers (Harris et al., 2021; Nair & Adetayo, 2019). In addition, there is a long history of medical racism, especially, cruel nonconsensual medical interventions and experimentation on Black and Indigenous persons, in countries such as the US, Canada and Australia, which fuels mistrust in mainstream healthcare (Starrs & Herne, 2021), whereas, spiritual and religious resources are widely available and generally free, making them considerably more accessible than many other mental health focused services.

LGBTQ+ Communities

The picture is more complex within the gender and sexual minority community. There are many studies showing increased distress in LGBTQ+ individuals related to discrimination, oppression and rejection stemming from religiously motivated homophobia and harmful clinical practices, such as conversion therapies (e.g., Newman & Fantus, 2015; SAMHSA, 2015), and this distress effect may be even higher in those with intersectional identities (Jaspal et al., 2021). Furthermore, there has been a recent rise in religious based discriminatory legislation against LGBTQ+ individuals, especially transgender youth, across several countries, which raises serious concerns about related decreases in health and well-being (Richgels, et al., 2021). Regarding intra-individual processes of religiosity and distress in LGBTQ+ individuals, research has mostly focused on internalized homophobia. Internalized homophobia refers to negative attitudes about homosexuality that are applied to the self (Meyer & Dean, 1998). Internalized homophobia has been associated with poorer mental health and suicidality (see Newcomb & Mustanski, 2010 for review). Furthermore, exposure to non-gay affirming religious settings has been shown to increase internalized homophobia, thus creating an additional stress burden for queer individuals (Barnes & Meyer, 2012). Research suggests that to resolve the internal conflict created by religious doctrine around homosexuality, sexual minority individuals adopt various strategies including changing religions, reexamining, reframing and/or rejecting certain teachings, abandoning religion either temporarily, completely or stopping attending formal services and turning to a more personal sense of spirituality (Leong, 2006; Schuck & Liddle, 2001; Yip, 1997, 2005). Another concerning issue highlighted by the research is that many gender and sexual minority individuals are reluctant to seek help in times of distress (Bivens et al., 1995; Schaefer & Coleman, 1992), especially for those in non-gay affirming environments. For example, Wolff and colleagues (2016) found that college religious affiliation was associated with poorer mental health outcomes for sexual minority students.

There is considerable evidence showing higher levels of suicidal ideation and attempts in gender and sexual minority persons than in cisgender heterosexuals (Haas et al. 2010; King et al. 2008; McDaniel et al. 2001; Plöderl et al., 2010). At the same time, research in community samples has shown that religiosity confers some protection against suicidality (e.g., Dervic, et al., 2004; Gearing & Lizardi, 2009). Studies examining this protective effect in LGBTQ+ samples are sparse. One exception is Kralovec et al.’s study in an LGB Austrian sample (2014), who found that religious affiliation was associated with higher internalized homophobia but with fewer suicide attempts and a sense of belonging to one’s religious community was associated with significantly less suicidal ideation during the last 12 months. These authors suggested that religion might therefore be both a risk and a protective factor against suicidality in religiously affiliated sexual minority individuals (Kralovec et al., 2014).

Multiple Minority Communities

Finally, given the findings supporting religiosity-spirituality as a resilience factor in BIPOC communities, an interesting additional area of research is studies with multiple minority members of the LGBTQ+ community. As with the non-intersectional research, findings suggest considerable differences by population, and that different components of religiosity-spirituality may be toxic for people with marginalized identities (Bliss, 2011; Hackney & Sanders, 2003). However, there is also emergent research showing protective effects. For example, one study showed that religious support, along with family and social support, negatively correlated to psychological distress experienced by Black sexual minority college students (Lefevor, et al., 2020). In a qualitative study, Singh and McKleroy (2011) analyzed the experiences of transgender BIPOC persons who had survived severe trauma (e.g., hate crimes) and showed that, cultivating spirituality and hope for the future was connected to resilience and increased well-being. And in a recent study, Currin et al. (2021) showed that young adults who identified as BIPOC and LGBTQ+ reported lower distress, higher resilience and hope, as well as significantly higher spiritual support than White LGBTQ+ participants.

Clinical implications

Although psychotherapy has sometimes been seen as incongruent with religion and spirituality, overall, the research suggests that it is a salient part of people’s social and psychological identity, even if that salience may be on the decline (Siddiqui & Kapoor, 2021). Furthermore, given the existing findings suggesting that R/S is especially important in certain ethnic, cultural and social communities, and that it is a significant contributor to resiliency and/or vulnerability in these populations, that are already dealing with heightened levels of minority stress, to not explore the subject and it’s impacts in therapy is problematic. Approaches that harness the aspects of spirituality that have been shown to be protective, in particular, the development of meaningfulness and trust, of values and connectedness with the self and others, should be prioritized. As well as, exploring and reframing those aspects that may be contributing to distress. Minority communities face high levels of stressors that are outside of their personal control, particularly those related to discrimination and oppression, and systemic economic disadvantage (Williams, 2019; Sutton & Perrin, 2016). As such, avenues of intervention that support growth and well-being beyond just those that focus on changing stressful events themselves are essential. Furthermore, research has shown that individuals who have experienced religious conflict, report several helpful resources including extended social support, such as reaching out to alternative LGBTQ+-affirming congregations and leaders, as well as books and online communities, that can provide emotional support through peers and role models, as well as appraisal support for validating their experiences (Schuck & Liddle, 2001; Mallari, 2023) Thus, therapist should be prepared to refer clients to external resources such as support groups, and gay- affirming congregations, when possible. One positive aspect of the lockdowns related to the recent COVID-19 pandemic, is that many R/S communities were forced to explore the use of online spaces, and recent studies have confirmed that these on-line groups can positively contribute to well-being (e.g., Keisari et al., 2022), thus extending the availability of resources that can be offered to clients who may be geographically isolated from supportive communities (e.g., LGBTQ+ youth in non-affirming environments). Finally, the majority of mental health professionals are not themselves members of the communities that they treat, for example in 2015, 86% of psychologists in the US were White (Lin, et al., 2018), as such, including some focus on spirituality in psychotherapy with minority clients could be an effective and culturally responsive approach for non-minority clinicians.

CLAIRE J. STARRS, PhD is a researcher in the Department of Psychology at the Université du Québec à Montréal (UQAM), and an adjunct lecturer at McGill University. Her research focuses on historical and intergenerational trauma, as well as risk and resiliency in diverse populations, especially LGBTQ+ communities. For more information, see her lab website: https://starrslab.weebly.com

---

ZAINE A. ROBERTS graduated from SUNY Potsdam with a BA, major in Psychology and Criminal Justice, and a minor in Human Services. He is currently a second-year graduate student in the Applied Clinical Psychology program at Penn State Harrisburg. Recently, he became the Vice President of their PRIDE organization where he works with the community to promote a safe and accepting campus environment for LGBTQ+ students. His research interests include youth, religion, gender and sexuality processes. He will be applying to doctoral programs in Fall 2024.

Citation: Starrs, C. J., & Roberts, Z. A. (2023).Religiosity/spirituality and wellbeing in BIPOC and LGBTQ+ communities: In brief. Trauma Psychology News, 18(3), 16-20. https://traumapsychnews.com

Elizabeth K. Lee

In the United States, approximately 1 out of 7 children is identified as having experienced child abuse within the past year (Centers for Disease Control and Prevention, 2022). In 2021, this equated to approximately 600,000 children (National Children’s Alliance, 2023). A recent report by UNICEF (2021), estimated that globally, around 80% of children aged 1 to 14 years, experienced some form of psychological aggression and/or physical violence by a caregiver within the past month. Moreover, perpetrators of child abuse are most often family members (Kurniawan et al., 2019), and maltreatment is often a pattern of repeated violence and/or neglect, rather than a single traumatic event (Warmingham et al., 2019). As such, chronic abuse and/or neglect can be conceptualized as complex trauma which, in children, has been associated with long-term mental health impacts such as PTSD and depression, low school engagement, and increased engagement in risky behaviors (Voisin & Berringer, 2015; Yearwood et al., 2021).

Child abuse and neglect are defined as physical and emotional mistreatment and/or lack of care, including physical and sexual violence, physical and emotional neglect, and forms of exploitation that result in harm or potential harm to a child’s health, survival, development, or dignity (World Health Organization, 2023). More recently, there is also an emerging consensus that witnessing domestic and family violence constitutes a form of emotional trauma that should be included under the umbrella of child maltreatment (e.g., UK Domestic Abuse Act, 2021). Of the different forms of abuse, emotional maltreatment and neglect are the most prevalent, and both have greater negative long-term impacts on victim-survivors compared to physical or sexual abuse (Naughton et al., 2017; Shi, 2013; Strathearn et al., 2020). In most US states, adults in specific professions (e.g., mental health providers, teachers, social workers, nurses) are, by virtue of their occupation, designated as mandated reporters, meaning that if they learn or suspect that a child is experiencing maltreatment, they are required by law to report it to child protective services (Child Welfare Information Gateway, 2022). In other states, all adults are required by law to report abuse or neglect. Laws regulating the responsibility of reporting also vary internationally.

Understanding perceptions of what constitutes maltreatment and the severity of its impact vary considerably across cultural groups (Nguyen-Feng et al., 2023). Cultural groups can be construed as individuals who share various identities that influence the way they view and interact with the world (Hook et al., 2017). This broad definition implies that multiple facets of identity influence perceptions of maltreatment, including socioeconomic status, educational status, immigration status, race, ethnicity, and religion, to name but a few. Throughout the world, sexual and physical victimization are generally considered to be the most severe forms of child abuse (Fakunmoju et al., 2013; Nguyen-Feng et al., 2023), although some studies also suggest that emotional maltreatment is as detrimental to development and mental health (Vachon et al., 2015). Furthermore, the degree to which the offender is viewed as responsible for the abuse, the offender’s relationship with the child, and the amount of harm inflicted on the child have also been found to shape perceptions of abuse (Qiao & Xie, 2017). For example, in a study examining public perceptions of child abuse conducted in China, Qiao and Xie (2017) found that it was only when a parent frequently caused serious physical injury to a child that it was perceived as physical abuse. This difference in definitions of physical abuse was also highlighted in a cross-cultural comparative study of mothers from the United States, Japan, and Korea (Son et al., 2017). Specifically, mothers from the US were more likely to view physical punishment as abuse than mothers from Japan and Korea. Interestingly, mothers from all three countries in this study agreed on definitions of emotional abuse and neglect. Within the United States, studies have shown that perceptions of what is considered as physical punishment vary by region, generation, socioeconomic status, and education level (Finkelhor et al., 2019; Hoffman et al., 2017). For example, Hoffman and colleagues (2017) found that older individuals of lower socioeconomic status and lower education levels endorsed the use of physical punishment more than younger individuals of higher socioeconomic status and higher education level. Moreover, regarding regional differences, those who live in southern US states have been found to approve of the use of physical punishment more than those who live in northeastern states (Finkelhor et al., 2019). Lastly, the use of corporal punishment as an educational tool was common and acceptable in most Western countries up until the 1970s, when it began to be denounced, leading to the enactment of gradual legal prohibitions (Zolotor & Puzia, 2010). However, it remains prominent in some cultures. For example, in a study of Korean immigrant mothers living in the US, Park (2001) found that although the participants reported negative attitudes towards physical abuse, they also indicated positive attitudes about physical punishment in the context of ‘correcting’ a child’s behavior. Furthermore, this was viewed by mothers as a form of showing love to their child, which the author suggests stems from the belief that using physical punishment for discipline helps children learn. Interestingly, the use of physical discipline in the context of child-parent conflict was not generally sanctioned by the mothers in this sample. Similarly, in a study examining the attitudes of Black mothers/caregivers regarding the use of physical punishment, Taylor et al. (2011) found that the majority of participants considered the use of at least some corporal discipline with their children to be both necessary and expected, particularly when the child compromised their safety, was disrespectful, or did not respond to other types of discipline. Furthermore, physical discipline was seen as both instrumental and effective, as well as culturally normative. Finally, in line with Park’s study of Korean mothers (2001), the Black mothers/caregivers in this study emphasized that they used physical punishment for the child’s own good, and that it was not intended to harm the child.

Given the complexity of the influence that culture has on the perceptions of, and the acceptability of child abuse, clinicians must be prepared to address child abuse in a culturally-informed manner. The first step in working with culturally diverse clients is adopting a multicultural orientation framework which includes cultural humility, cultural opportunities, and cultural comfort (Hook et al., 2017). Within this approach, the therapist does not simply attempt to achieve a finite level of cultural knowledge (i.e., competency) about the client’s cultural identity, but rather welcomes ongoing learning, and adopts an other-oriented perspective while working with clients (Hook et al., 2013; Hook et al., 2017). Cultural humility includes intrapersonal and interpersonal components. The interpersonal component is defined by the way in which the therapist maintains an open and curious stance regarding their client’s values and beliefs, especially when they differ from their own. Assuming a perspective of cultural humility in therapy is vital for therapists to be able to connect with their client’s most salient identities and to foster the therapeutic alliance. The intrapersonal component requires therapists to look inside themselves and reflect upon their own cultural identities including their biases, assumptions, and limitations. It is especially important for the therapist to consider their own perceptions of what constitutes child abuse and what parenting ‘should’ look like. Research has suggested that, despite their training, and research to the contrary (e.g., Vachon et al., 2015), mental health professionals tend to consider emotional abuse as less severe than physical and sexual abuse (Nguyen-Feng et al., 2023). Thus, part of adopting a cultural humility approach is recognizing that all the actors involved hold perceptions and values that are shaped by In sum, therapists who apply a cultural humility framework in their practice emphasize openness to their client’s beliefs and customs, as well as ongoing growth in themselves through self-reflection and autocritique (Hook et al., 2013). These are particularly important stances to adopt when working with culturally diverse clients who are engaging in child abuse, as they may feel judged and misunderstood by mental health providers, which could lead to a withdrawal from mental health and other supportive services, further jeopardizing the situation of the child. Moreover, refugee and migrant families may come from countries where the government does not get involved in family matters, and may already be reticent to work with healthcare professionals and the child welfare system (Earner, 2007). Studies support the effectiveness of adopting a cultural humility approach; for example, client’s perception of their therapist’s cultural humility has been shown to be a significant predictor of positive therapy outcomes (e.g., Owen et al., 2014).

Best practice recommendations for working with families and children who have experienced maltreatment include adopting a trauma-informed (SAMHSA, 2014) and strengths-based approach (Asay et al., 2014; Rashid, 2015). A trauma-informed approach is broadly defined by SAMHSA (2014) as consisting of six key principles: 1) safety, 2) trustworthiness and transparency, 3) peer support, 4) collaboration and mutuality, 5) empowerment, voice, and choice, and 6) cultural, historical, and gender issues. Therefore, when working with families, clinicians should consciously cultivate a sense of safety and trust, including by being transparent with their clients, approaching treatment as a collaboration and empowering their clients, as well as recognizing the cultural, historical, and gender issues that underpin their clients’ context. Moreover, a trauma-informed approach is based on four key assumptions wherein the clinician realizes the widespread impact of trauma (e.g., use of various coping strategies, distress and mental illness); recognizes the signs and symptoms of trauma (e.g., re-experiencing or avoidance); responds by integrating trauma knowledge into their practice (e.g., evidenced-based trauma practices); and actively resists re-traumatization of their client during the therapeutic process (e.g., triggering painful memories).

A strengths-based approach is based on the premise that everyone has talents, capabilities, and skills that can be harnessed to reach therapeutic treatment goals (Cox, 2006). Moreover, a strengths-based approach seeks to further foster existing family and child strengths, in order to improve well-being for the child and the family (Asay et al., 2014). When recognizing families’ strengths, it is also important to acknowledge how their culture has informed existing strengths, and how culture can be used to further enhance treatment. A specific culture focused tool that may be helpful in developing a working treatment plan in these contexts is Koramoa and colleagues’ (2002) continuum of child-rearing practices. This approach suggests that child-rearing practices and traditions can be viewed on a continuum comprising those that are undeniably harmful (e.g., female circumcision) to those that are beneficial (e.g., Inuit gentle parenting), and as such harmful practices can be targeted for elimination and those that are beneficial can be encouraged. One way a clinician may approach limiting harmful cultural practices is by suggesting alternatives, for example, age-appropriate time-outs could be suggested in lieu of physical punishments. The spectrum of child-rearing practices also includes harmless cultural practices, these should not be targeted for intervention as there is no justifiable reason to warrant their elimination. On the contrary, the therapist should work on understanding and respecting these practices as the objective of these interventions is the protection of children from maltreatment, not the homogenization of practices across cultures. Finally, Koramoa et al. (2002) also note that the clinician may engage in some evidence-based education in the case of practices that are potentially harmful (e.g., traditional scarification). Thus overall, a strengths-based approach, in conjunction with a trauma-informed framework is recommended as it consolidates what parents and children are already doing well, leading to increased self-efficacy, enhanced therapeutic alliance, and increased hope (Rashid, 2015).

In conclusion, clinicians working with children of diverse backgrounds should be aware of the various ways a child’s cultural context influences their well-being. Clinicians should adopt a cultural humility perspective by being aware of how their own culture influences their work and being open and non-judgmental with clients of different backgrounds. The continuum of child-rearing practices (Koramoa et al., 2002), in conjunction with the legal definitions of abuse in the clinician’s jurisdiction, may be beneficial in determining whether a child is being harmed. Finally, adopting a trauma-informed and strengths-based approach is recommended.

Biography/Positionality Statement

ELIZABETH K LEE: Mindful that this article provides suggestions on how to conceptualize cultural perceptions of childhood abuse, I wish to provide the reader with information on my background. I am a second-year Clinical Counseling Psychology Master’s student at the University of Minnesota Duluth, a Graduate Research Assistant, a Graduate Research Mentor, and the Research Team Coordinator in the Mind Body Trauma Care Lab. I was motivated to write this article because of my involvement in a past study exploring perceptions of childhood emotional abuse in the general public, psychologists, and college students, as well as my involvement in an ongoing study exploring perceptions of childhood emotional abuse across countries and cultures. I write this article as a White, heterosexual, cis-gender woman, born and raised in Minnesota, and a first-generation college student. I have six years of experience working with victim-survivors of interpersonal trauma, including youth, as an advocate, researcher, and practitioner. As a practitioner, I am drawn to trauma-informed, mindfulness-based, and embodiment-based approaches.

Citation: Lee, E. K. (2024).Navigating perceptions of child abuse with culturally diverse families in a trauma-informed a strengths-based way. Trauma Psychology News, 19(1), 18-22. https://traumapsychnews.com

Terri L. Weaver, Sophia R. McMorrow, Sydney L. Bell, Jeane Bosch, & Jintong Tang

The SARS-CoV-2 or COVID-19 pandemic was a cataclysmic global event that overwhelmed healthcare systems, profoundly impacted healthcare providers’ mental and physical health (Magill et al., 2020), and brought racism, cultural and systemic disparities into hyper focus (Singu, Acharya, et al., 2020). Damian Barr (2020) aptly articulated the differential sociocultural impact of COVID-19 in his oft-cited tweet, ‘We are not all in the same boat. We are all in the same storm. Some are on super-yachts. Some have just one oar.’ Macrosystems, including historical, societal, and cultural contexts, are vital when considering the confluence of identity with the COVID-19 stressor experiences of Asian American and Pacific Islander (AAPI) healthcare providers (Louie-Poon et al., 2022). These macro factors include sociocultural narratives that yoked COVID-19 to AAPI racial identity, conveyed heroic expectations for providers in concert with AAPI identity tropes, and conferred messages of inferiority steeped in historical legacies, instantiated in workplace dynamics, and internalized in identity.

Broadly speaking, both regulatory and cultural institutions can influence the uncertainty and risks that AAPI healthcare providers face, and ultimately the mental health and well-being of AAPI members. Regulatorily, the world has witnessed a remarkable upsurge in populism (i.e., the aggressive pitting of “the people” against “the elites”) since the Brexit referendum, the election of Donald Trump, and the riots at the United States Capitol. Populist political leaders have been actively promoting the connection between masculinity and politics (Boatright & Sperling, 2020). Trump’s slogan “Make America Great Again,” for example, appealed to patriotism and nostalgia by referencing a glorious golden past, the past when America was less diverse with forceful strong-man leadership. Populism is generally characterized by xenophobia and anti-intellectualism (Borins , 2018). Xenophobia refers to restriction on the movement of people (e.g., opposition to immigration) and restriction on the movement of goods and capital (e.g., opposition to globalization). Populists not only create an ideological difference between the “people” and the “elite” but articulate the “people” as insiders and “others” as outsiders, which considers entry of immigrants and foreign corporations as posing socioeconomic, cultural, religious, and political threats (Magistro & Menaldo, 2022). This can increase AAPI individuals’ fear of being “othered” and losing protections in such hostile institutions, leading to greater stress.

Culturally, AAPI members cherish the tight culture where societal institutions such as the family, educational system, media, and justice system restrict permissible behavior and provide greater normative guidance to societal members (Gelfand et al., 2006). Members of tight cultures, due to shared societal understanding, tend to develop psychological adaptations denoted by caution, self-monitoring or discipline, and predictability (Gelfand et al., 2006). In such cultures, individuals’ emotional appraisals or assessments of emotion-causing events are significantly guided by society’s normative expectations. “The nail that sticks out gets hammered down,” a Japanese proverb, aptly describes the greater conformity in tight cultures (Speake & Simpson, 2008). Accordingly, some AAPI members are afraid that if they openly share experienced discrimination and stress, they will be considered incapable, weak, and ultimately “hammered down.” As a result, AAPI members may hold cultural narratives that discourage help-seeking for such issues.

Racialization of COVID-19: Providing Care Amidst Asian Hate

Overt anti-Asian rhetoric soared with COVID-19, with some media outlets and politicians racializing COVID-19 as the “China virus” (Shang et al., 2021). Despite warnings to eschew subpopulation stigmatization during COVID-19 (e.g., World Health Organization [WHO], n.d.) perceived race and ethnicity was often associated with great stigma (e.g., Gutierrez et al., 2022). In this mixed-methods study, AAPI-identified populations had the highest odds of experiencing stigma (OR=6.96), and employment as a healthcare provider and/or first responder also significantly increased odds (OR = 2.50) of experiencing stigma. At the intersection of identity and healthcare occupation, AAPI healthcare providers shouldered an amplified burden reporting an increase in racism and aggression, including threatened and actual physical assault, threatened sexual assault and verbal harassment (Shang et al., 2021). In addition to overt discrimination, Louie-Poon and colleagues (2022) illuminated the covert, macro-level racism that is baked within the culture, history, and theoretical foundations of nursing, and perpetuated by institutions. For example, while nursing embraces a commitment to promoting social justice and upholding human rights, the theoretical foundations of nursing fail to integrate antiracist and intersectional concepts. Institutional instantiation of anti-Asian racism includes experiences where AAPI providers are relegated to inferior professional status, exposed to demeaning comments by colleagues and staff, characterized as foreigners, and limited in opportunities for advancement or positions of leadership (Louie-Poon et al., 2023). Thus, racialization of the virus resulted in otherness and hypervisibility of AAPI providers as a perceived health threat, activating stigmatization, discrimination and violence — all within an institutional environment awash with covert discrimination and exclusion.

Othering AAPI Healthcare Providers: Superhero Expectations Amplify Cultural Tropes

At the start of the COVID-19 pandemic, healthcare providers were lauded as “healthcare heroes” in mainstream and social media (Cox, 2020). Hospitals provided pizza and ice cream parties, celebrities dedicated performances to ‘modern day superheroes,’ and cities across the United States erupted into collective applause at dusk (Pangborn et al., 2021). Simultaneously, in their own social media posts, healthcare providers expressed anger and frustration about expectations to work without basic personal protective equipment (PPE) during long, physically demanding hours, to shoulder this treatment imperative despite individuals flouting virus mitigation (Pangborn et al., 2021), and to be superhuman without societal acknowledgement of any possible limitations in duty to treat (Cox, 2020). These hero expectations othered healthcare providers by providing accolades for extraordinary efforts without acknowledging the concomitant, cumulative toll of the work.

Such ‘hero’ othering is magnified for AAPI healthcare providers, when considering identity-related societal tropes. Certain Asian subgroups have been characterized as the ‘model minority,’ which is a singular, homogeneous identity characterization that dictates a mythic reality of people with lives devoid of suffering and expectation of silence in the face of trauma and adversity (Louie-Poon et al., 2023). Expectations for hyper-resilient individuals by virtue of role (hero) and identity (model minority) confer invisibility (see Louie-Poon et al, 2023 for an expanded discussion) for the actual lived experiences of these providers. This erasure of the discrimination realities as well as the unique experiences of diverse AAPI provider populations is instantiated in workplace dynamics that perpetuate inferiority, research designs that blur distinctions between subpopulations, and assessments of psychological distress lacking in cultural congruence and specificity.

Asian Invisibility in Workplace, Research, and Mortality

Anti-Asian institutionalized racism prescribes inferiority in the professional status of AAPI healthcare providers (Louie-Poon et al, 2023) with accompanying disparities in the occupational exposure landscape. Hawkins (2020) converged data from the Bureau of Labor Statistics (BLS) Current Population Survey (CPS) for 2019 with descriptive data regarding occupational risk and proximity for infections using their previous work. A greater percentage of AAPI and Black workers when compared with the proportion of white and Hispanic workers were employed in occupations with a substantial risk of COVID-19 infections. These occupational risks included work as respiratory therapists and registered nurses, and occupations with proximity to others, including physical therapists and personal care aids. Based on these omnibus findings, AAPI healthcare providers were disproportionately positioned by occupation type and proximity to incur greater risk for virus exposure.

Refining the examination, Escobedo and colleagues (2022) used a sophisticated, creative data compilation approach to examine COVID-19 mortality data within Asian subpopulations, generally, and those working in healthcare, specifically. Researchers found disproportionate deaths for Filipinx healthcare providers. Both the percentage of Filipinxs among Asian Americans and the percentage of Filipinxs in the healthcare workforce were positively correlated with a greater percentage of Asian American COVID-19 deaths. Healthcare occupation was a robust predictor as the percentage of Filipinx in healthcare predicted Asian American COVID-19 deaths even after controlling for age, poverty and population density. The legacy of the United States’ colonial control of the Philippines was posited as one pathway to disproportionate mortality.

Colonial mentality is a construct that refers to the internalized oppression that exists in the Filipino American community (David & Okazaki, 2006). It has been described as manifesting in several ways, including denigration of the Filipino self, culture, and body. This denigration includes feelings of shame, embarrassment, or resentment of being Filipino, as well as perceiving White physical features as superior and Filipino features as inferior. There is also discrimination towards those who are less acculturated due to feelings of inferiority, and tolerance and acceptance of historical and contemporary oppression. The latter is due to the perception of colonizers as ‘heroes,’ which can lead to the normalization of discriminatory actions or maltreatment from the dominant group. As such, colonial mentality could instantiate contemporary perceptions of Filipinx inferiority through present-day, institutional practices and internalization of lesser status within Filipinx identity. Internalization of inferiority could prompt efforts to prove worth by stepping forward to care for the sickest patients and suppressing agency for advocating for personal safety combined with institutional practices of unequal access to PPE and patient assignments that confer greater proximity to viral risk (Escobedo et al., 2022). These perceptions are consistent with the tolerance of historical and contemporary oppression and a sense of indebtedness to the colonizers, such as the United States. Some individuals may feel extremely grateful just to be in the United States and may not perceive actions towards them as discriminatory (David & Okazaki, 2006). These findings highlight the importance of interrogating Asian subpopulation experiences and their respective cultural narratives.

n terms of psychological outcomes, Prasad and colleagues (2021) described occupational stress findings from 20,947 healthcare workers who responded to the ‘Coping with COVID’ national survey. Stress was higher among nursing assistants, medical assistants, social workers, inpatient workers, women and persons of color (Black and Latinx workers) and those who felt institutionally devalued. While AAPI providers did not report elevated levels of stress, there was a considerable number of participants who reported elevated levels of stress but preferred not to disclose their race. Given the stereotypical AAPI identity-related prescription for silence and that the indicated identity (women) and occupational (nursing assistants, feeling institutionally devalued) stress predictors are representative of AAPI healthcare providers, it is plausible that AAPI stress responses were captured without race disclosure. For example, a study providing a general Asian/Pacific Islander race option, without subpopulation specificity, may lead respondents to select no response rather than a broad response that does not fit their identity. Cultural prescriptions and the stigma of disclosing emotional distress may have also led AAPI healthcare providers to decline participation in the study or to underreport their stress when they did participate and report race. These findings highlight the challenge of documenting objective (mortality) and subjective (morbidity) AAPI healthcare provider experiences using extant research methods. These gaps in knowledge, themselves, have been deemed forms of structural racism as they homogenize diverse AAPI communities (e.g., Escobedo et al., 2022) and rely on research epistemologies that may be culturally incongruent with the prescribed narratives for AAPI populations.

uture Directions and Limitations

Creating culturally informed, antiracist health care settings for AAPI healthcare providers is a public health imperative. At the macro and theoretical level, we support Louie-Poon and colleagues’ (2023) call to expose and dismantle covert racism embedded in the foundation of nursing including theory, pedagogy and institutional practices. Similarly, it is critical to develop and incorporate social justice research strategies and build community coalitions informed by AAPI scholars (e.g., Pheng & Xiong, 2022) to provide voice and representation of AAPI experiences. In terms of limitations of this review, while some members of our team are behavioral healthcare providers and engage in interdisciplinary research and clinical work in healthcare settings, we do not have a medical healthcare provider as an author. Therefore, our summary is subject to our potential biases as nonmedical providers. We have been intentional to include cited work by authors with identity and occupational proximity to this topic and encourage individuals to read their excellent, foundational scholarship.

Socio-ecological systems, including historical, societal, and cultural contexts, shape human identities and frame the exposure and impact of AAPI healthcare providers to COVID-19. Centering ecological and identity-based perspectives in the theory, research and practice of trauma psychology is a small but crucial step toward decolonizing the field.

ERRI L. WEAVER, PhD is a professor of clinical psychology at Saint Louis University whose research focuses on the ways in which aspects of identity and macro contexts inform sequelae following exposure to potentially traumatic events. Her most recent work includes collaborations with providers in critical care medicine to examine burnout and meaning making associated with pediatric patient deaths, with domestic violence advocates and community leaders to examine bias within built systems of care for Black women experiencing intimate partner violence, and with nursing and sociology to examine the impact of conducting trauma-related research on the researcher. She maintains a trauma-focused clinical practice and a forensic practice, serving as an expert witness in civil and criminal litigation.

SOPHIA MCMORROW graduated with honors from Saint Louis University with her bachelor’s of science degree in psychology. She currently works as a clinical research assistant at Washington University in St. Louis where she applies a neuroimaging system called high-density diffuse optical tomography for neuromonitoring infants in the critical care unit and to investigate the developmental underpinnings of Autism Spectrum Disorder. She aspires to earn her PhD in clinical psychology and pursue a career in research.

SYDNEY BELL is a Clinical Psychology doctoral student and graduate research assistant in the Saint Louis University Violence and Traumatic Stress laboratory. Sydney has experience in community-based public health research including a multi-site study aimed at reducing opioid overdose deaths in high-risk communities, and a qualitative study on community access to intimate partner violence services for Black women. Most recently, Sydney has assisted in a series of studies examining Pediatric Intensive Care Unit provider trauma exposure and wellbeing.

JEANE BOSCH, PhD, MPH, is a clinical psychologist with the National Center for PTSD (NCPTSD), Dissemination and Training Division. She is an Implementation Facilitator and Evaluation Lead for the Tech into Care program at NCPTSD. Her primary focus is to expand the reach of VA mental health apps to improve care for veterans. She provides training to VA staff and the community on the integration of apps into care and offers support to those implementing this practice at the individual or program/facility level. Dr. Bosch is also trained in evidence-based treatments for PTSD, such as Prolonged Exposure and Cognitive Processing Therapy (certified), and has worked with diverse populations, including female veterans, particularly those with a history of military sexual trauma.

JINTONG TANG, PhD, is Mary Louise Murray Endowed Professor in Management, Research Institute Fellow, and Director of the Emerson Leadership Institute at Saint Louis University. Her research has appeared in more than 80 refereed journal publications and more than 100 refereed/invited conference proceedings. She has received multiple Best Paper Awards/Finalists at the Academy of Management and United States Association for Small Business and Entrepreneurship Conferences.

Citation: Weaver, T. L., McMorrow, S., Bell, S., Bosch, J., & Tang, J. (2024). COVID-19 and Asian American and Pacific Islander healthcare providers: The importance of an ecological lens when examining stressor exposure and outcomes. Trauma Psychology News, 19(1), 24-30. https://traumapsychnews.com

Rochelle L. Frounfelker & Tej Mishra

Section Editor:
Claire J. Starrs
Opinions expressed by the authors are their own and not necessarily those of APA, Division 56, or any member of the editorial board.

Mental Health of Older Refugees

The most recent data from the United Nations High Commissioner for Refugees (UNHCR) indicates that the number of civilians forcibly displaced from their homes due to war and political violence reached over 117 million in 2023 (UNHCR, 2024). A subset of forcibly displaced individuals is considered refugees. UNHCR defines a refugee as someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (UNHCR, 1951). Forced displacement due to conflict and persecution has been shown to have negative effects on mental health. For example, compared to the general population, refugees have higher rates of depression, anxiety, and PTSD (Blackmore et al., 2020; Morina et al., 2018). Researchers have identified individual, family, community and macro level pre- and post-resettlement factors that contribute to the poor mental health outcomes of displaced populations (Fazel, 2018; Gleeson et al., 2020; Mesa-Vieira et al., 2022; Porter & Haslam, 2005; Scharpf et al., 2021).

The majority of research on the mental health of refugees has studied effects of displacement in youth and younger adults, and little is known about the mental health trajectories of aging refugees. This is important, as older individuals may be disproportionately vulnerable to adverse mental health outcomes in the context of past exposure to war and political conflict (Porter & Haslam, 2005). Processes of migration and aging are conceptualized as entwined trajectories that heighten vulnerability to adverse mental health outcomes (King et al., 2019). For instance, there are experiences that are common among the majority of older adults, regardless of migration status, including concerns over maintaining functional capability, quality of life, and access to care, that may negatively impact mental health (WHO, 2018). In addition, older refugees are disproportionately burdened by historical traumas experienced before and during flight from country of origin and displacement, as well as post-resettlement socioeconomic stressors, both of which impact current mental health among war-affected populations (Miller & Rasmussen, 2017).

Older refugees often receive limited attention from national and international aid providers (Ridout, 2016; UNHCR, 2016), even though they are more likely to experience physical and psychological distress compared to younger refugees (Bazzi & Chemali, 2016; Strong et al., 2015). Studies on the impact of forced migration on the elderly have found both pre- and post-migration experiences contribute to negative mental health outcomes (Lor et al., 2022; Mistry et al., 2021; Mölsä et al., 2017; Virgincar et al., 2016; Yang & Mutchler, 2020). Critiques of psychosocial services for older refugees include a lack of cultural specificity and failure to consider the age-specific needs of the population. Typically, services are an extension of those provided to general adult refugees, and do not address age-related accessibility barriers, such as physical limitations, language skills, or intergenerational struggles (Ahmadinejad-Naseh & Burke, 2017; Ridout, 2016; Virgincar et al., 2016). Interventions are frequently based upon and promote more Western-oriented coping strategies that may be more suitable, familiar, and comfortable for older American-born populations (Chenoweth & Burdick, 2001).

Bhutanese with a Refugee Life Experience

In the mid-1980s, the Bhutanese government stripped citizenship from ethnic-Nepali Bhutanese and deprived them of various basic rights including land ownership and access to education (Rizal, 2004). Pressure to leave the country intensified, with Bhutanese authorities threatening violence and carrying out rape, murder, and torture of the ethnic-Nepali (Giri, 2005; Hutt, 1996). This persecution culminated in the forced displacement of over 100,000 ethnic-Nepali into Nepal in the early 1990s (Hutt, 1996). UNHCR provided relief to Bhutanese refugees in Nepal starting in 1991 (Hutt, 2005), where they lived in refugee camps until third-country resettlement commenced in 2008 (Reiffers et al., 2013). In the past 15 years, over 90,000 ethnic-Nepali Bhutanese refugees have relocated to the US (Embassy, 2016). Ethnic-Nepali Bhutanese were exposed to a range of traumas and stressors in Bhutan and Nepal. They were incarcerated and tortured by government authorities as a way to pressure individuals, families, and entire communities to leave the country (Van Ommeren et al., 2001). Once in Nepal, the refugees suffered hardships that significantly impacted their wellbeing (Martin et al., 1994). Over a decade after forced expulsion, UNHCR reported overall poor quality of health programs and services in camps, including concerns over a lack of qualified health care personnel and coordination of services for survivors of interpersonal violence (Unit, 2005). Post resettlement has increased attention to the mental health of Bhutanese refugees given the disproportionally high rate of suicide in this group, which is roughly double the rate in the US (Brown et al., 2019; Cochran et al., 2013; Meyerhoff et al., 2018). Research indicates that Bhutanese also face resettlement challenges and stressors related to language barriers, cultural loss, lack of social support, and economic strain (Brown et al., 2019; Im & Neff, 2020; Meyerhoff et al., 2018).

Project Bhalakushari

In 2017, a Bhutanese community in the Northeast US began collaborating with researchers to explore the mental health of older adults. In the spirit of building a community partnership, we named this research to Project Bhalakushari, based on the Nepali term bhalakushari meaning a casual conversation. The goal of the project was to learn about the older adults’ past experiences in Bhutan and Nepal, and their current lives in North America. Project Bhalakushari is a mixed methods study that aims to understand the impact of forced displacement and immigration on the long-term mental health of older Bhutanese, and, ultimately, to inform downstream multi-level interventions that address their psychosocial functioning. We adopted a community-based participatory research approach (CBPR) as outlined by Israel and colleagues (Israel et al., 2018), in which community partners are actively involved in all aspects of the research process. Community members partnered with researchers to develop research proposals and secure funding, participate in data collection and data analysis, and disseminate study findings to the community and relevant stakeholders. To date, several additional Bhutanese communities have collaborated, including in Springfield, Massachusetts, Ottawa, Ontario, and recently in central Pennsylvania through the Bhutanese Community in Harrisburg (BCH), a self-help community organization. Since 2017, academic partners have included researchers at Harvard T.H. Chan School of Public Health, McGill University, Boston College’s Research Program on Children and Adversity, and, most recently, Lehigh University’s College of Health. The study has received funding from the Harvard T.H. Chan School of Public Health, the Research Institute of the McGill University Health Centre, the Canadian Institute for Health Research, and is currently supported by the National Institute on Aging (1R01AG089038-01). The current NIA-funded objective is to explore the longitudinal mental health outcomes in this population over three waves of data collection.

Project Bhalakushari was motivated by concerns from within the Bhutanese community for the psychosocial wellbeing of older adults. In their country of origin, the Bhutanese lived in remote villages with communal farming, which promoted strong social bonds with relatives and neighbors. After displacement to refugee camps in Nepal, this culture of togetherness was maintained through time spent mingling and helping each other during times of distress and disasters. However, this highly interconnected lifestyle deteriorated after US resettlement, especially for the more elderly individuals of the community who no longer worked outside the home. Furthermore, in combination with the American cultural ideal of independence, elderly community members had fewer opportunities to engage in social interaction with their peers.

Resettled Bhutanese families generally live in multi-generational homes, often with three generations living together. Elderly individuals report feeling that there is a deterioration in the fabric of the family and of their own value within the family, primarily due to spending most of their time home alone or solely with a spouse while the bread earners, typically sons and daughter in-laws, go out to work (Prasai et al., 2024). The role of the elders in the family has changed dramatically, from being the provider and head of the family in Bhutan and Nepal, to being in the back seat in the US, due to language and other barriers such as lack of transportation (not being able to drive) and challenges in obtaining employment (Frounfelker et al., 2020; Prasai et al., 2024). Their adult children, who are adapting to the American way of life, are dealing with their own stressors including adjusting to American society (workplace, school, etc.), managing the perceived and expected responsibilities of preserving ethnic-Nepali culture and tradition, and taking care of young children brought to the US or born as US citizen. The elder generation is strongly impacted by these changes, in part because they don’t have the opportunity to spend time outside of the home (Prasai et al., 2024). Understanding how current social and family dynamics, as well as past experiences, shape the current mental health of resettled elderly Bhutanese is important for both researchers and health care providers to identify and adapt evidence-based mental health interventions that will effectively address their needs and be culturally relevant.

To date, our research highlights the relationship between pre-resettlement trauma, current stressors, and mental health. Past traumas, including imprisonment and torture in Bhutan and threats to physical wellbeing in Nepal, have been shown to have a lasting negative impact on symptoms of depression and anxiety in older Bhutanese, both directly and via mediating pathways such as current physical health and economic stressors (Frounfelker et al., 2021). We have found that individuals with higher exposure to pre- and post-resettlement trauma and stress, as well as those who experienced deprivation and loss in refugee camps in Nepal, show more severe symptoms of PTSD than those with less past and current trauma and stress (Frounfelker et al., 2023). Furthermore, social support has been shown to be an important moderator of the relationship between trauma, stress, and mental health outcomes (Frounfelker et al., 2021). Qualitative findings highlight the importance of social support and meaning-making as coping mechanisms with pre- and post-resettlement experiences by older Bhutanese to overcome challenges and stressors throughout their refugee life experience (Frounfelker et al., 2020; Prasai et al., 2024). Our findings reveal that the elderly long for social time and interaction, to share their joy as well as their pir (sorrow) with their friends.

Culturally-informed Research and Services

Culturally-informed care is increasingly recognized as an important component of effective mental health services and treatment for refugees (Baarnhielm, 2016; Greene et al., 2017; Im et al., 2021; Reis et al., 2020; Wylie et al., 2018). Developing culturally-informed services requires detailed investigation into how specific populations conceptualize mental health and the mechanisms that promote psychosocial wellbeing and healing (Kirmayer et al., 2014; Raghavan & Sandanapitchai, 2020; Ungar, 2014). Thoughtful attention has been given to understanding the ethnopsychology of ethnic-Nepali Bhutanese and how this informs adjustment and coping for this population in refugee camps and post-resettlement (Chase, 2012; Chase et al., 2013; Kohrt & Harper, 2008; Kohrt & Hruschka, 2010). Nepali words such as dukha (sadness), chinta (worry/anxiety), dar (fear) and pir (sorrow/anguish) are commonly used when describing emotional responses to trauma (Kohrt & Hruschka, 2010). A common idiom of distress is that of tanaab (tension/stress), and the concept of coping in Nepali is best translated by tannab samaadhaan garnu (solving tension) (Chase et al., 2013).

Our work builds on this by exploring culturally-specific protective processes related to social support among older resettled Bhutanese. There is a well-established association between social support, social connectedness, and mental health outcomes in aging adults (De Main et al., 2023; Gabarrell-Pascuet et al., 2022; Newman & Zainal, 2020; Santini et al., 2020; Schwarzbach et al., 2014; Turner et al., 2022; Xiao et al., 2022). This evidence extends to some immigrant and refugee populations (Brown et al., 2009; Ekoh et al., 2023; Hawkins et al., 2022; Kim et al., 2020; Lee et al., 1996; Miyawaki, Liu, et al., 2022; Park & Roh, 2013; Wong et al., 2007). Among refugee populations, family, religious, ethnic/cultural, and host community networks may all play a pivotal role in providing support and promoting resilience of individuals in this age group (Tippens et al., 2023). At the same time, the circumstances of forced migration can lead to a reduction in social networks and social supports among older adults (Ekoh et al., 2023), suggesting that mental health interventions should prioritize promoting social connectedness. However, there is considerable cultural variation in expectations about social relationships, forms of social support, sources of social support, and appraisals of social interactions (Kim et al., 2008; Makwarimba et al., 2013; Miller et al., 2017; Mojaverian & Kim, 2013; Stewart et al., 2008). As such, it is critical to understand culturally-relevant pathways and mechanisms by which social support promotes or diminishes mental health among distinct aging refugee groups. With the support of NIA funding, we plan to qualitatively investigate how older resettled Bhutanese, their caregivers, and health care providers understand social support and its role in promoting the psychosocial wellbeing of aging adults.

In addition to geographic isolation, the limited availability of healthcare services in rural Specific to resettled Bhutanese of all ages, there are established relationships between social support (concrete and emotional) and refugee wellbeing, for example, social support from family and friends has been shown to play an important role in protecting against negative mental health (Ao et al., 2016; Chase & Sapkota, 2017). Interpersonal support (both familial and community) is critical for older Bhutanese to cope with past traumas and current stressors, acting as a moderator in the relationship between exposures and depression and anxiety (Frounfelker et al., 2021; Frounfelker et al., 2020). This idea of interpersonal support becomes even more culturally relevant within the context of intergenerational families and normative support mechanisms in Nepali culture. In Nepal, over 80% of older adults reside with family members (Chalise, 2021; Joshi, 2019; Singh et al., 2021). Culturally, caring for elderly parents is regarded as the responsibility of children, with primary caretaking assigned to sons and daughters-in-law (Khanal & Chalise, 2020; Kharel, 2023; Shrestha et al., 2021). To our knowledge, there is currently no data published on patterns of family caregiving arrangements among ethnic-Nepali Bhutanese in the US. However, we believe that, with rare exceptions, older Bhutanese in the US also live in multi-generational households, with family members acting as primary caregivers. This is important in terms of understanding the relationship between family caregivers and older adults with a refugee life experience. There is a robust body of literature highlighting the mental and physical health needs of individuals who are caretakers to older adults (Schulz et al., 2020; Schulz et al., 2016). Evidence suggests that witnessing the physical and psychological suffering of a relative can increase caregiver risk for psychological and physical morbidity (Monin & Schulz, 2009; Schulz et al., 2017). Recently, there has been increased attention on mental health of caregiver/care receiver dyads (Jiang et al., 2021; Liu et al., 2023; Meyer et al., 2021; Monin et al., 2023). In longitudinal studies, caregiver symptoms of depression were associated with care recipient mental health and cognitive functioning (Jiang et al., 2021; Liu et al., 2023); in one study, this relationship was reciprocal (Monin et al., 2023). However, currently there is limited information on these dynamics among immigrant and refugee populations (Miyawaki, Meyer, et al., 2022). This is a significant shortcoming, as family members play an important role in providing care for older immigrant adults, particularly among some minority groups, such as Asians Americans (Knight & Sayegh, 2010; Miyawaki, 2016; Raj et al., 2021; Weng & Ngyuen, 2011). Foreign-born Americans and Asian populations are more likely than US born Americans and Whites to live in multigenerational households (Cohn & Passel, 2018), prompting a call to include Asian Americans in family caregiving aging research (Yellow Horse & Patterson, 2022). The current phase of our research in Project Bhalakushari will include enrolling dyads of older Bhutanese and a loved one/caregiver to track longitudinal mental health outcomes and identify the relationship between older adult and caregiver mental well-being over time.

Conclusion
Our ultimate goal is to develop a preventive, community-based psychosocial intervention for older ethnic-Nepali Bhutanese that leverages both family and community-level resources to promote resilience (Weine, 2011). This population experienced and survived expulsion from Bhutan, refugee camps in Nepal, and third country resettlement. It is critical that this generation not be left behind and forgotten as a casualty of the refugee life experience. Furthermore, we encourage other researchers, mental health providers, and policy-makers to address the dearth of research and evidence-based services for aging refugees more broadly, given the high level of need in this population.

Rochelle Frounfelker, ScD, MPH, MSSW is an Assistant Professor in the College of Health, Lehigh University, PA. She is a social epidemiologist with her doctorate in Social and Behavioral Sciences from Harvard T.H. Chan School of Public Health. Her primary area of research is addressing mental health disparities among refugees and other war-affected populations. She conducts community-based participatory research with refugees that address mental health throughout the lifespan, ranging from preventing mental health problems among children and youth to promoting the psychosocial wellbeing of aging adults. A focus of her work is on adapting and implementing interventions that incorporate and privilege local understandings of mental health and wellness and leverage culturally relevant strategies for coping and healing.

Tej Mishra, MPH is the Executive Director of Bhutanese Community in Harrisburg (BCH), a community based non-profit organization serving Nepali speaking former Bhutanese Refugees. As the Executive Director, Tej has led important initiatives such as fostering and improving community relationship with law enforcement, research collaborations with universities to address public health issues of the community, and led the organization to become a refugee resettlement affiliate of one of the national Refugee Resettlement Agencies. Tej has a master’s degree in public health from BU and has worked as a Surveillance Epidemiologist for the Massachusetts Department of Health, and later for the District of Columbia Department of Health. His experiences also include mental health research, notably in the Community-Based Participatory Research (CBPR) framework. He’s collaborated on CBPR projects as a research staffer at Harvard University, and later as a CBPR research consultant at Boston College, McGill University, and more recently as a community partner through BCH with Lehigh University.