Therapy for Social Change Podcast

It is often said that the dominant culture of the United States is “individualist.” This is a tricky term, because the concept of individualism has its own history and context and is leveraged in many ways in our popular and political cultures.

I think that when the dominant white culture of the U.S. is said to be individualist, it has a flavor of Cold War ideology to it: the U.S., globally, stands for the rights of individual actors, preserved from the kinds of statist interventions associated with communism, collectivism. “We” are free because we prioritize the individual; cultures that focus on the collective, the communal, abridge the freedom of individuals to create their own lives, hold their own moral codes, garner the rewards of their own hard work and merited success.

I name this narrative white because there are so many peoples in the U.S. who come from families and cultures that do prioritize the community, and that have multiple models of how individualism and communalism can dance with one another rather than cancel each other out.  So to say that the U.S. is individualist is itself a work of ideology: it flattens the reality of all the peoples who live here and the richness of how they see the world.

I’m wanting to challenge individualism because so many people tell me they feel despair, hopelessness and overwhelm when they consider the ways violence infuses our culture and our systems. They tell me they just want to check out. They don’t think there’s anything that can be done: it’s too late, too hard, they’re just one person, how can any one person make a difference when everything feels just so immense. I understand these feelings, and I also think these feelings are being reinforced by individualism: either there’s a bad guy who is responsible for all of this, who needs to be locked up, or there’s a good guy who is a hero who is going to tell us all what to do to make it better.

In my last post I wrote a bit about how PTSD became a diagnosis. This week, I’m going to talk about how the diagnosis shapes trauma treatment, and why there can be a gap between the way a clinician approaches trauma treatment–what they think is most likely to bring people relief–and what the survivor might hope for, in terms of reckoning with what happened.

The naming of PTSD as a disorder, rather than a syndrome, meant that the Diagnostic and Statistical Manual III, published in 1980, had to include a list of symptoms that clinicians could use to determine if a survivor of a traumatic event had PTSD. By drawing the clinician’s focus to symptoms—their severity, persistence, increase, or decrease—the diagnosis implied that the work of treating PTSD, like any other medical condition, was to reduce or eliminate altogether the patient’s symptoms. (I’m using the word “patient” here because evidence-based trauma treatments are often provided in clinical settings that are rooted in a medical model.)

Though mainstream, evidence-based treatments like Cognitive Processing Therapy and Exposure Therapy are quite different in their approach to trauma, for example, what they have in common is a focus on symptom reduction.

There’s an intrinsic tension between the clinician’s focus on symptom management and the survivor’s focus on meaning. The question trauma evokes in the survivor isn’t “how do I stop the symptoms?” It’s “why did this happen in the first place? How could a person do that? What if I hadn’t gone out that night? What if I hadn’t agreed to be part of that group? What if I hadn’t married that person? Why did I participate? Who am I, now that I know what I and others are capable of doing?”

The anthropologist and historian of science Danielle Carr, who is currently an Assistant Professor at UCLA’s Institute for Society and Genetics, published a piece in the most recent issue of New York Magazine profiling therapist Bessel van der Kolk’s trauma work, academic career, and the ways trauma has become “America’s favorite diagnosis.” As most of the folks reading this newsletter likely know, The Body Keeps the Score has been a New York Times bestseller now for 250 weeks, a fact that stuns even van der Kolk himself.

When I read the 126 comments on Carr’s piece, I was surprised to see how many readers found Carr “snarky,” and thought she was not persuaded of their suffering. They also took the profile to be a verdict about trauma therapy—whether it works; whether it’s silly; whether trauma survivors are victims; whether it’s the brain or the body that is the ultimate source of trauma symptoms. Though Carr does briefly survey these questions, she does so to locate van der Kolk in the history of psychiatry and to explain why he’s shifted from a person who used to rely solely on psychodynamic and pharmaceutical approaches to trauma and who now is more interested in neurobiology, yoga, and somatics, today’s popular interventions.

But as Carr’s title indicates, her abiding interest is less in whether trauma is “real”; whether somatic practices bring relief; whether van der Kolk was rightfully censured for bullying behavior by his former place of work; whether he’s a trauma god or a narcissist, and more about what it means that the term “trauma” has become such an important public concept, at once malleable and vague, ubiquitous and scorned, capable of explaining at once highly personal experiences and at the same time large cultural and political events, such as immigration, refugee camps, economic inequality and social injustice.

PTSD is perhaps the only category in the Diagnostic and Statistical Manual that locates distress outside the self, the mind. It is inherently social, because an act of violence is the impetus for the traumatic event. That said, the wording of the diagnosis is cautionary: it avoids the word “cause” when it discusses the relationship between a traumatic event and the eventual presentation of PTSD symptoms in the person. To this day, the category of PTSD accounts for acts of interpersonal violence—even combat happens between groups of people—but does not account for vectors of structural violence like patriarchy and white supremacy. 

It is no surprise that the American Psychiatric Association took a dim view of those who sought recognition for the syndrome. It was only after more than a decade of effort on the part of activists and clinicians that the APA ratified and published in the DSM III the diagnostic category of PTSD. In doing so, it transformed the syndrome into a diagnosis and stripped the veterans’ distress of its social and political context. PTSD was a diagnosis that a clinician could identify and differentiate from other diagnostic categories by parsing its set of symptoms. In order to validate those symptoms as universal, rather than particular to any political context, the kinds of trauma out of which PTSD could emerge was broadened to include not only combat, but also rape, childhood sexual abuse, assault, car accidents, and natural diasasters (with Mother Nature acting as a kind of vengeful self). 

The DSM III was a repudiation of psychoanalysis, which had been the organizing framework of the DSM II, and a turn toward making psychology and psychiatry more scientific, more in line with medicine. The focus of the subcommittees who gave us the DSM III—out of which the current DSM arises—was to regularize diagnosis, eliminate diagnostic unreliability across clinicians, which was rampant, and buttress the fields of psychiatry and psychology from the critiques of the anti-psychiatry movements of the 1960s and 1970s. All of the diagnoses in the DSM III were scrutinized and regularized in an effort to make psychology more legitimate from a scientific standpoint. The publication of the DSM III in 1980 coincided with Regan’s presidential campaign and what would become the successful containment of the protest movements of the 1960s and 1970s.

What’s interesting about this moment in time, and about Carr’s piece in NY Mag and her opinion piece in the NY Times, is that we are again in a moment of mass protest that is asking hard questions about structural violence. You can feel today the unresolved tension between the two frameworks for understanding trauma that animated the political advocacy for veterans in the late ‘60s. You can hear the people who are in treatment, arguing over the methods they’ve tried—somatic, pharmaceutical, psychodynamic, polyvagal, EMDR-–and you can hear voices like Brooks, who sounds exactly like the APA members who fought hard to delegitimize the arguments about veterans’ suffering. It’s this fight that gives rise to arguments that “everyone is traumatized” and that the term is thus evacuated of meaning. 

Imagine a change you’re wanting to implement: an exercise habit, a meditation practice, a weekly phone call with a far-away friend. Or maybe you want to “subtract” something: sugar or caffeine; screen time; criticizing others. What happens when you picture yourself making this change? What words do you hear in your head? What do you see, as you imagine yourself doing this new thing?

A common response to these fears is either to give up in advance, or to summon a call to discipline to make the change stick. No excuses. Just get up a half-hour early and work out; just go to bed and read; just stop complaining—your negativity is poisoning the air.

There’s a cruelty here, underneath these exhortations. “It’s not that hard” can quickly devolve into “What’s wrong with you? Anyone could do this.” Or, “Why are you so weak, so self-indulgent, so unable to take care of yourself, so incapable of doing the thing you’ve tried to do, over and over, for years?”

If we want to change the broader culture, we have to find ways to engage change beyond discipline. If we want to do more than make small changes in our individual lives, we’ll have to build our resilience, our uncertainty training, because before we can even embark on change, we have to slow down enough to notice when discipline is in play.

It’s more than hypocritical to be invested in cultural transformation and to think I can get there through domination and efficiency—it’s demoralizing; it’s staggering; and, when I’m being kinder to myself, it’s evidence of just how steeped I am in the methods of self control.

When I look at the goals I actually stick to, it’s not because of my discipline, or because I’m a hard ass. It’s because of love. It’s hard to write that sentence. It feels squishy and vulnerable and naive. But I don’t mean love like “I love it!” I mean love like protection, fierceness, like coming back over and over again, when you don’t know what you’re doing, because you care enough to stay in it. Love that’s so immense that your daily frustrations and uncertainties and general laziness are just no match for it.

Toughness is about walling things off, including our relationship to our own pain. But being in contact with structural violence and oppression requires entering the pain of others, as well as our own. It requires an enlarged capacity for holding grief and outrage—the feelings we instinctively recoil from. But these feeling states arise out of our love. If we didn’t feel so much love, so much connection, we couldn’t suffer and grieve when others are in pain. To stay connected to that love can power us into that space of possibility. Even if we can’t yet envision its fullness, we’ve already touched a tiny version of it in our everyday encounters with all the forms of Being in our world. When you are wanting to change, even a small thing in your own life, ask yourself first to find its source in love.

Examines the question of how evangelical churches struggle with childhood sexual abuse, and what we might do to stop it.

In the interim, I thought I’d tell you about something cool that’s happening with Pride this year in Portland, Oregon. Like many cities, Portland celebrates Pride in June. Pride happens in June to honor the Stonewall uprising of June 28, 1969. But this year, the committee that plans the Pride parade changed the date. We’re having our Pride parade in July. 

The committee announced it was moving the parade to make room for full celebration and respect for Juneteenth, commemorating June 19th, 1865. The main idea behind this shift is that members of the queer community shouldn’t have to choose one aspect of their identities over another.

What’s notable about both Pride and Juneteenth is that they are celebrations of resilience and at the same time ways of collectively naming the presence of structural violence and oppression. They establish moments when people who are most directly targeted by violence can join with those who are present in solidarity, to reinforce the commitment to collective social transformation.

The committee noted a second reason for the switch—Father’s Day. In the past, the parade was intentionally timed to happen on Father’s Day because historically many gay people have been exiled from their families of origin when they come out. If you know the slang term “family,”—as in, “Do you think they’re family?”—that’s because the chosen family of queer culture promises to hold you, all of you, no matter what. But Portland (or some of the city at least) is experiencing a cultural shift. There’s all these gay people who want to spend Father’s Day with their dads, because their fathers accept and love them. They don’t want to choose between their families. Also, we’re a tiny place, and now our drag queens can go to San Francisco to perform and clean up, and then come back here and make some more money in July.

So there’s this moment of expansion happening here in Portland, updating our Pride. The problem is that since there’s no gay bat phone in Portland, a lot of people didn’t get the memo that the Pride parade isn’t ‘til next month. Plus, no one said what we’re supposed to do about the Pride events that normally happen on the same weekend as the parade. Does everything move? Do we celebrate, sort of, for two months?

I’m curious to see how Portland learns to celebrate Juneteenth as a city, in a way that doesn’t commodify the day or appropriate its history. I’m wondering what the energy of Pride will feel like in July. I hope we will still be fierce, still be in solidarity with the rest of the country, the places where gay rights and bodies are more explicitly under assault. I hope it won’t be tepid, or ghostly, or feel like it’s less necessary because there are some gay people here who don’t experience explicit homophobia and violence. Mass celebrations are powerful: they create solidarity, they create relief, they demonstrate to the dominant culture the masses of people who do not necessarily want “inclusion,” if inclusion means being incorporated into a culture that was created without them. 

After I got home it occurred to me that perhaps I was off base, thinking there was something exceptional about raising the subject of whiteness on San Juan Island. After all, is what I am describing so different from dynamics that might occur in a small rural town that is largely white? Or in an affluent white neighborhood in a city, cordoned off from its working-class neighbors by its price? An island has particular needs for its community to function, so everyone can survive. But there are conceptual islands everywhere.

At the end of the day, no matter where we live, don’t we all depend on a small group of people for our survival? What happens if that small group is largely white and we identify as white? Don’t many of us feel a curl of fear rise up when we prepare to raise the subject of white power to other white people; wonder if we’ll be socially shunned for making people uncomfortable?

What is insidious, I think, is the idea that having conversations about white identity and whiteness in a therapy session will inexorably lead a client and a therapist to engage in public resistance to those structures that maintain self-segregating environments, especially among white people.

Therapy is designed to help a person remove, or at least contest, the emotional blocks that impede change. It is a space in which avoidance, denial, anger, terror, repression, and anxiety are welcomed and made visible. It’s a place to practice allowing the energy and the heat and the sweat of fear show up and crest and then drop back. It’s a place to figure out what risks need to happen to support growth.

Because therapists are experts at welcoming these emotions, and because these are the very emotions that keep white people from raising the subject of white identity and whiteness with their friends, their bosses, their neighbors, it would seem that therapists are uniquely positioned to be able to help our clients, and ourselves, name the forbidden so that we can move into action to collectively resist structural violence and oppression.

But here’s the thing: I’ve been thinking about the fact that therapy, itself, is part of white culture. We all know that the majority of therapists are white women; the majority of counseling and social work professors are white women; the psych research subjects are mostly white university students; the majority of therapy clients are white women; the licensing exam is written so that white candidates will pass it at far greater rates than Black candidates.

In white culture, therapy can perform the role of mitigation: it can save a community from facing discomfort, the very discomfort that it is essential it face, in order to repudiate power and privilege. When white people’s friends get too obsessed with their ex, or come to parties and get wasted, week after week, or can’t get out of bed in the morning, someone will likely ask them if they’ve gone to therapy yet. Though many people still see therapy as the place you go to deal with your personal problems, and don’t yet see white supremacy as a “personal problem,” I wonder if, as white supremacy does start to be recognized as a problem for white people as well as everyone else, if that, too, will be something that therapists deal with in private.

The individual, “identity-based” approach

Clients who do not have a strong self-concept that they are racialized as white—by which I mean they do not have a regular practice of seeing themselves as a white person, moving around in a world that is coded by race—may unconsciously see themselves as “not racialized” and by contrast see people who are coded as non-white as having to cope with “having a racial identity.” 

If a person without a strong sense of white identity is in therapy, they are unlikely to bring up the topic of whiteness, white supremacy, or their own racial identity in session. They may also associate the term “white identity” with “white identity politics” that is, white nationalism and white separatism.

In this context, the social work professor Lisa V. Blitz writes in “Owning Whiteness: The Reinvention of Self and Practice,” it is likely the therapist who will have to open the conversation about white identity with the client, signaling that it is part of the context that shapes the client’s life, as much as other elements of identity, family, relationship and personal interests. Blitz writes that she uses Janet E. Helms’ model of white racial identity development as a lens through which to interpret both her own and her client’s awareness of white identity, to better understand the therapeutic dynamic and how white identity is being enacted in the session.

Somatic Practice

If you’re a therapist who is trained in somatics, or who uses body scans or embodied attunement in your sessions as a form of grounding, or if you are a therapist who raises transference and countertransference in sessions, you can use a somatically-rooted approach to bring up the subject of whiteness or white identity in a session.

Often, when a white person even names the fact that she is white to another white person, a hum of tension can show up in the room. A person can feel wary: how will the other white person respond? Will she be offended? Will she feel accused of some nameless, vague offense? Is she being tested? There can be a sense that the therapeutic alliance is being threatened with a rupture. 

Resmaa Menakem, who designed an entire somatic framework to aid people as they engage the “charge” that occurs when race and racial violence are named, sees the survival response as automatically triggered in the body, regardless of the level of political or intellectual sophistication and practice of the person, because these subjects are embedded in generational and historical violence that pervades not only the culture, but the epigenetic transfer of embodied knowing, even at the cellular level. From this perspective, it is only sensible, if not kind, to proceed at a pace that allows the body to metabolize the charge, to not  rush “past” but rather stay “in” the body’s signals to fight, flee, or fawn in response to a perceived threat.

Structural Analysis

A third approach to talking about whiteness and white identity is to start with the larger structures that work together to attach the idea—and even at times the “ideal” of—“American” identity to white identity, and how the dominant culture teaches all people who live in the United States to see white culture not as a specific, racialized way of being, but rather as the “norm” to which all Americans consent to live by in order to participate in society. 

By talking about how systems work together—where they reinforce certain stories about what it means to be a white person, or what it means to be an American, and where those stories are challenged—the client and the therapist can distinguish between whiteness as a structure and white identity as an aspect of self. The field of psychology will often label an aspect of self a “personality trait” that is available to be changed. In contrast, an identity position, like “being white,” pre-exists the individual, and impacts the way the individual is perceived and read by others who are steeped in the same dominant culture. The individual does not “choose” their whiteness; they do not consent to the meanings that whiteness carries, but they must nevertheless live with those meanings and what those meanings confer in their material world.

This week I want to talk about the Liberation Health Model.

The word “liberation” in the model honors and acknowledges the work of liberation theology, out of which grew liberation psychology, a way of thinking about healing that was practiced by Ignacio Martín-Baró, a Spanish-born Jesuit priest who trained in psychology at the University of Chicago. Martín-Baró was concerned that the individualist focus of therapy could encourage people to adjust to the status quo. Psychology’s attention to individual behavior, and the ways behavior is seen as an expression of the individual’s consciousness, keeps both the problem, and the solution to the problem, inside the arena of the self.

The work of psychology, Martín-Baró wrote, should be that of concientización, a term he took from the philosopher and educator Paolo Friere. Friere, who was born in Brazil, is responsible for a way of teaching he named pedagogy of the oppressed—he wrote a book of the same title, which outlines his method.

Friere argued that the pedagogy of educational institutions was based on what he called the “banking method.” The educator, standing at the front of the classroom, is literally positioned by the architecture of the room as the holder of knowledge, the one who has more standing than his students. The teacher “deposits” his wisdom into the empty heads of his students, who are willing and passive receivers of his deposits. 

Inspired by Friere, Martín-Baró argued that psychology could also take as its goal that of concientización. Liberation psychology allows us to ask an important question: if the banking model teaches people to be passive receivers of knowledge, could we see the practice of therapy, of social services, of “helping professions” as that of creating a similar power dynamic between therapist and client, expert and patient?

This complex interpersonal dynamic is why overt conversations about power can be so crucial to the work of liberation psychology. The therapist is situated, institutionally and structurally, as the one who knows; the client is situated as the one with the problem. The “collaboration,” between them, if it occurs within this framework, is that of the therapist gently educating the client about the best way to proceed, working hard not to dominate, but at the same time, “helping.”

I think that if the mental health practitioner opens the scope of conversation as he suggests, the idea that there is one answer, one intervention, one diagnosis for a mental health condition, goes out the window. This means that both the therapist and the client have to become comfortable with ambiguity, uncertainty, fear, and loss. They have to grieve, together, the suffering that so many people are enduring. And in that lack of clear direction, of a simple solution to a problem, collaboration between the two becomes a necessity, rather than a concession the therapist makes to the client at her own discretion.

So when you see the word “liberation”—liberation psychology, liberation health—you want to think about people coming together to discuss the social context that influences their world, and to help one another see and describe the structures of violence and oppression that make it difficult for them to access and engage their individual and collective power. By doing so, they will be encouraged to stop blaming themselves for “failing”; they will start to question the source of their shame; they will stop, as Martín-Baró put it, “acting like a dominated being or a dominator.”

When Dawn Belkin Martinez, a social worker from the United States, started practicing, she wanted her work to include attention to power, culture, and context. Since she couldn’t find the training she was looking for in the U.S., she went to train with Friere. Luckily for her, when she came back to Children’s Hospital Boston where she was working, the people there were very interested in what she learned, and encouraged her to design a model of healing that drew on Freire’s method.

If any of you reading this are already practicing with this model, please let us know how it’s going in the comments section. What struggles have you encountered, using this approach? What has surprised you about using it?

Also, here are some questions I use myself, when I’m trying to broaden my scope of inquiry about a problem, whether it’s personal or collective:

* Whose knowledge (What is the source of the information; what “counts” as knowledge?)

* Whose power (Who is said to be in the power position; is power circulating through the group, or is it concentrated in a hierarchical orientation?)

* In what context (What are the unacknowledged assumptions about the problem and the best way to fix it? Where does the problem begin and end? What happens if the context is made larger than the individual or the group?)

* To whose benefit? (When you think about the proposed solution to the problem, who will gain from having it solved in this way, and whose needs are excluded?)

* To what end? (What is the ultimate goal of the solution? Is it a temporary solution? Does it silence further conversation and analysis? Is it open-ended or closed?)

From my perspective, perhaps the most effective impact of these events is psychological. After the Dobbs decision came down I wrote about the ways the law is an act of psychological warfare. I see the Kacsmaryk decision as an effort to recontain the political force and energy that has arisen to overturn Dobbs and return rights to pregnant people. I don’t think it’s a coincidence that his decision came down two days after Wisconsin voters elected a justice to their Supreme Court, Janet Protasiewicz, who is going to return abortion rights to that state.

I see these events as efforts not only to attack particular identity groups, but also to split collective movement-building efforts by eroding trust among them. These actions press on historical conflicts between identity-based groups, reminding them of the people they shouldn’t trust, the people who refused to organize with them in the past, the people who wouldn’t stand up for their rights and instead focused on their own needs. 

In a climate of fear and confusion, it's crucial to distinguish between what is anticipated and what is known.

And yet, despite these countermoves, and regardless of whether any of these actions ultimately succeed in their efforts, the psychological blow has already landed. Terrorizing and exhausting a majority of citizens is itself an action. It is one that people who work in mental health are particularly well-suited to address. 

We have the tools to help people distinguish between their anticipation of an attack in the future and the actual threats they face in the present. We have the capacity to help people slow down and attend to their somatic responses. We can help people notice the ways a context of imminent but unverified threat may be impacting their capacity to focus, to attend to themselves and those they love. 

We can notice an increase in shame, self-blame, hopelessness, and despair, and work with it not only individually but by contextualizing these feelings as in part responses to collective stress.  We can come together, knowing that there is no clear distinction between therapists and trauma survivors, clients and practitioners, activists and healers—that we can contract into isolation and despair, or acknowledge and work through the ways we may be rehearsing and reinforcing our own lack of trust. We can remind people of their curiosity, creativity, spirituality, community, and other sources of personal and collective power.