Podcast: How Identity Impacts Mental Health

Jenn talks to Dr. Chase Anderson. He discusses the application of identity to mental health and shares stories about his personal discoveries during medical school and beyond. Chase also offers tips to encourage and support others in discovering their identities.

Chase Anderson, MD, MS, is a child and adolescent psychiatry fellow in the Department of Psychiatry and Behavioral Sciences at the UCSF Weill Institute of Neurosciences. His clinical interests include advocacy for LGBTQ+ and underrepresented minority (URM) populations.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks, and thanks for joining us for Identity and Its Relationship With Mental Well-Being. I’d like to officially introduce myself. I’m Jenn Kearney, and I’m a digital communications manager for McLean Hospital. I hope that wherever you are joining us from today, you’re doing well.

Over about the next 50-ish minutes, Dr. Chase Anderson will share how identity applies to mental health, and how we can encourage and support others in discovering their identities. And he and I will chat about microaggressions, biases and more.

If you are unfamiliar with Dr. Anderson, Chase is a child and adolescent psychiatry fellow in the Department of Psychiatry and Behavioral Sciences at the UCSF Weill Institute for Neurosciences.

He completed his psychiatry residency at the Massachusetts General Hospital and McLean Hospital Adult Psychiatry Residency Training Program. And his clinical interest include advocacy for LGBTQ+ and URM populations. Chase, thank you so much for joining, and please feel free to take it away.

Chase: Thank you Jenn so much for having me and thank you McLean for inviting me back. This is really, it’s an honor to be with all of you, and it’s an honor to be with all the participants and talking about this.

So as Jenn said, we’re going to go through a presentation first and then do questions after. All questions are on the table. I am here to help out, I’m here to listen, I’m here to educate as much as possible.

So, what I’ll be presenting on is the impact of identity, how it impacts and affects mental health, what it means to be a minority and especially how can we help. This is by me yours truly as well as it’s actually a modified presentation that I did with one of my colleagues at MGH.

He’s still there his name is Mark Fusunyan, and he’s really wonderful. And we did this project for our QI project on Blake 11, which is our psychiatric unit at MGH. And this talk is expanded and changed over time as I’ve given it different places.

So quick overview is we’ll be going through several different parts, the first part is what is identity? What does it mean? How is it used? What does it mean in today’s society? Part two is the identity. How is identity related to minority stress?

So, we’ll dive into some terms and we’ll talk about different things that we really should be thinking about, especially for minority mental health. And then part three, we’ll go into what is minority stress? How is it play out in America? How does it play out in healthcare?

Part four will be some anecdotes of minority stress. And then part five is how do we help? How do we grow? Because I always want to spin hopeful.

That’s basically a part of what I do is let’s build the awareness of things. And then how do we maybe make things better for other people? Part six is future directions of thoughts. So just some questions to leave all of you with. And then part seven is the Q&A.

So first, what is identity? What does that even mean? Typical definition is it’s the fact of being who or what a person or thing is. More than that identity is the way that you think about yourself, the way the world views you, and characteristics that define you.

What we’ll go into more and more as time goes on is that identity is fluctuating, it can change from one month to the next, it can change from one hour to the next.

You can take on labels and take off labels as you choose as well as society actually puts labels onto people as well, and that’s what will lead to minority stress in some situations. Identity can be shaped by your culture and societal labels.

So, I am African American and gay. However, I also identify as a dreamer. Like I like to figure out how do we help people dream a little bit better and a little bit brighter. My friends call me a “phoenix unicorn.”

So, all labels for all different things. It helps us with decision making and community building. So, we’ve seen that different cultures have different labels, and they are also sometimes stigmatized because of certain labels that are placed on them.

African Americans are sometimes called certain things or known certain ways however, that’s not thinking about how do they define themselves. Identity is often a good thing, but can it also be a bad thing? The short answer is yes.

The long answer is the drive to protect our identity can sometimes prevent us from being open-minded and compassionate and it can be polarizing. I think, especially with what’s happening with George Floyd, with what we’re seeing with coronavirus and our present government and how they are interacting with people who are of Asian descent.

Identity is becoming more and more of a thing that people are talking about as well as again, it is polarizing sometimes, and we have to come at this from a point of understanding.

Identity can also impact our mental health. If we don’t identify as being someone with good qualities, then we can identify as lazy and if we actually do that, there are studies that show that when you internalize those labels, they start to become part of you.

When African Americans are told that they do worse on exams they actually do 10 points lower, even if they wouldn’t have if they had never heard that. Identity can also impact our mental health if others aren’t open-minded and compassionate about how we identify ourselves.

That’s a really big point of thinking about especially in America today, how are we speaking to people? How do we impact their mental health with the words that we use? And then let’s go into how identity is related to minority stress.

So, one of the big things that I want to do with this presentation is that I noticed through residency and through medical school that, we aren’t even using the proper words yet for the minority experience. Psychiatry is a lot about how do we talk to people? How do we help people?

But when we talk about minorities and we talk about culture and their culture, we aren’t even using the proper terminology in a lot of ways. So, a lot of this talk is to give you terms that you can think about and try to incorporate, and so that you can relate to people a little bit better.

So, the typical definition of minority stress, the one that first came to being is the process through which stigma directed towards sexual minorities, influences health outcomes. However, the definition is much broader than that.

When it first came out this applied to sexual minorities such as people who are LGBT, however, a lot of other groups have taken this on and actually identify with this term minority stress. So, people came up with this thing called minority stress theory, which is the more elegant explanation.

And its individuals from oppressed social groups experiencing excess stress and negative life events, because of their non-dominant status or statuses, which can lead to or exacerbate mental health problems. These affects are unique, socio-culturally based and long lasting, which means they’re additive.

The way that somebody has described it is that when somebody experiences one instance of minority stress, it’s like a paper cut. But when you’re experiencing that every hour on the hour, every day of every life that you have, then it actually you’re bleeding all over the place and you don’t know how that happened.

And so, you’re just very raw and open. I personally think of it a little bit differently. So, if any of you have ever seen “Sailor Moon,” I really love the show. And there’s this thing where they have the shine that is basically encapsulates who they are as a person.

And I think that every time that minority stress happens, it’s a little bit of a crack inside of your shine. And this also relates to institutional discrimination. So, disparities that systematically favor certain groups.

We see this with housing, with red lining, where African Americans could only live in certain places with schooling where kids of certain socioeconomic standing can only go to certain schools and other people can’t, things around employment as well as health injustice. So how does minority stress play out in America? How does it play out in healthcare?

In terms of some statistics just to give you some numbers so you know that this is real and it’s not just one person sharing an experience, in terms of racial statistics in America, study by psychologist Randy, as well as others showed that major lifetime discrimination 48.9% of African Americans versus 30.9% of Caucasians stated that they experienced major lifetime discrimination.

And then in terms of day-to-day discrimination. So, in that sense that 44.4% versus 8.8%, then it’s a little bit flipped in this situation where 8.8% of people who were African Americans said that they hadn’t experienced lifetime discrimination. So that’s a pretty small number.

That means that there is over 90% of people who are African American who have experienced discrimination in their lifetimes.

In looking at pay discrepancies 57 versus 32, versus 31, versus 25, verses 13% of people, and that’s listed out as African American, Hispanic-Americans, Native Americans, and Asian-Americans versus Caucasians, mentioned or stated that they had experienced pay discrepancies, even though they were at the same level of training, had gone through the same education and things like that.

So, there’s a pretty big gap that we’re seeing. So, this is just a handy chart that I actually use. So, to bring it really back home, then in terms of racial disparities, they were looking at people who said that they had experienced discrimination. And if you look at the top bar where it says white, so yes regularly was only 3.82% versus black Americans which was 11%.

And then if you look down in terms of totals and you look across all groups compared to Caucasian people or white people, all minority groups had experienced discrimination at a higher rate. How does that play out for LGBTQ Americans?

So, in terms of youth identifying as LGBTQ, all sexual minorities reported higher rates of violence victimization, the way they classified that was feeling unsafe forced to have sexual intercourse, threatened with a weapon, they were bullied at school or online.

So basically, anything that had made a person feel unsafe in terms of being bullied at school with gay males, 27.7% versus 14.6% so that they had been bullied.

When they’re doing those comparisons, it’s gay males versus people who identify as heterosexual. That doesn’t only apply to actually being bullied, but it leads to higher rates of substance abuse.

So, lesbians reported higher use of cigarettes and marijuana use, the prevalence of cocaine, heroin, methamphetamines, ecstasy, and inhalants were higher among all sexual minority groups.

And the numbers are pretty staggering with 13.4% versus 1.7% for gay males versus heterosexual males. So, these things of minority stress the way that minority stress plays out in America, it has a significant impact it’s not only on mental health, but it’s on substance use, it’s on how people see themselves, it’s how they relate to others, it’s how they feel about themselves.

So again, words have power. The prevalence of suicide attempts is also higher with lesbian and gay individuals at 24.3% versus 13.1%. So again, this is people who identified as lesbian and gay versus people who identified as heterosexual.

For bisexual people it was 28.3% versus 23.2%. And then people who identified as unsure this is one of the studies that they’re still looking into. So, people said I’m not sure about my sexuality, they were actually at a decreased prevalence of suicide attempts at 12.4% versus 14.9.

One of the big drawbacks of this study is that they did this in school children and people who had filled out this survey, in a lot of cases there actually were high dropout rates. And then so we might actually be underestimating the prevalence of suicide attempts in LGBT populations.

And since the 2016 election I think we can all envision what has happened, but we’re seeing more people coming to the emergency room with suicidal thinking. We’re also seeing higher rates of bullying in schools. We’re also seeing higher rates of people just reporting that they have depression.

One of the things that has happened inside of coronavirus too, is that Asian-Americans for the first time are actually reporting higher rates of depression as well. That’s coming from multiple factors, including minority stress that they’re experiencing from colleagues, from staff, from people in America, from seeing things online.

So just something to think about even in election, in and of itself can cause significant damage to minorities. In terms of statistics for Asian American sexual minorities.

So, when you look at the actual previous studies we saw that there was poor mental health outcomes for people who identified as sexual minorities, however, those studies were mainly done in Caucasian or white LGBT people.

So, research demonstrated when they did this in American sexual minorities, that external racial stressors among Asian Americans resulted in greater psychological distress.

A study by Dr. Dawn Szymanski as well as PhD candidate at the time and Mi Ra Sung at University of Tennessee showed that Asian American, LGBT people experience rejection, prejudice, and discrimination from inside of the LGBT community.

This is something that isn’t talked about as often where people feel as though if you’re LGBT and within your own community of LGBT people, you are safe. However, there’s actually a lot of discrimination that can happen against racial minorities inside of the LGBT community.

They noticed increased internalized heterosexism. The way they described that is its actually internalized homophobia because of violating traditional Asian values, such as harmony and complementarity.

And so, when somebody comes out or feel, or is LGBT, they don’t want to disrupt the status quo of the cultural environment that they’re in and coming out is seen as a disruption.

Among the 314 LGBTQ people of color that they studied, 58 of them were Asian American. There were higher rates of depression, perceived distress, and also a need for acceptance.

And this heterosexism or internalized homophobia comes from within as well as it also is enacted in the general society, and then people take that in, and it becomes part of their fabric, and it becomes part of their identity.

So again, things that are on the outside can very much be written into the core of who we are. They also talk about this really interesting term of ethnosexual mythologies.

So, I think the best way to describe that is that when somebody is a sexual minority, what you can see sometimes is, oh I love your black skin, or I don’t date black people, or I love people who are from China, things of that nature so basically some people think those things are compliments, but they are actually reducing somebody to a skin color.

Also, Asian American sexual minorities have to deal with competing identities, where they are Asian-American, they are also LGBT, they also are part of America. One of the things they do speak about too and we’ll touch more on this later is this idea of resilience.

So how do you build yourself back up? How do you find a community that fits you? How do you figure out a way to move forward? Especially during minority stress. In terms of minority stress this really interesting term comes up of intersectionality.

And so, it’s known as the interconnected nature of social categorizations, such as race, class, gender, which created an overlapping interdependent systems of discrimination or disadvantage, not always disadvantaged and we’ll get into how some things are helpful, but it can be a disadvantage.

So, an example is I’m African American and gay identify as many other things however, those are the things that many people see. So, during the day I can be called the N word, or I can be called a slur for sexual minorities, and that’s two hits already in a day.

And just imagine that happening throughout the day as well as throughout the year, and you begin to maybe get a little sense of how intersectionality can play a role in being a disadvantage. However, I also have seen intersectionality be really powerful.

So, I get really nervous when I’m walking around police people, especially with what’s been happening lately. So, I play up that I am gay, and I walk in a different way, and I actually changed my voice a little bit, just so I’m seen as less of a threat.

I also did so inside of a hospital system when African Americans are seen as not as intelligent. So, I played up being gay and that gay people are seen as more intelligent than African American. So sometimes it can be really adaptive to use. There comes a point where this thing called an intersectionality paradox comes into play.

And so, an example is an African American woman with higher education levels, actually show decreased rates of depression. However, we need to think about were they able to always go to like a historically black college? Are they supported by their family? Are they socio and economically advantaged?

One of the things is that I am known as very well off financially, and I have to recognize that that’s part of my intersectionality as well. Me being well off financially and having a dad who is a physician and a mom who did science work, was actually very protective and also put me on a track with my education.

There’s also this thing known as the multiple jeopardy perspective, it’s also known as the multiple disadvantages approach, and it’s also known as the multiple hierarchy stratification. So, an example is an Asian-American bisexual female in America is given what is called three hits for what’s deemed as low status in America.

The reverse is somebody who is white heterosexual and male would be assumed to be the jackpot in America, where they have three high status traits. However, in all of this, I think one of the things that sometimes we lose when we talk about race is that there’s a lot of nuance to this and it means that we really need to look at identity and experience because I’m African American and gay.

I technically somebody one time was like, “Oh, it’s like a wonder you made it to 30 and you haven’t been in jail yet.” And I was like, “I actually, I know, it’s a moment.” But I thought about it and my family background, my identity actually was very much a shield and it actually helped me in a lot of ways.

So, we always need to think about those things as well. Each person is nuanced. So, what’s missing in all of the things I’ve talked about so far.

So, I looked on PubMed, Google, even Wikipedia, as well as PLoS One and ResearchGate, in a lot of the studies that have come out so far, this is changing as time is going on and as people start talking more and more about this, but LGBTQ research is often lumping people like one category together.

It doesn’t speak specifically about like African American lesbians, it doesn’t speak about gay people, it doesn’t speak about bisexual people, it puts them all as LGBTQ and it puts them under one umbrella, and then they compare that to heterosexual people usually.

There isn’t enough nuance to the study yet. There’s also a dearth of research about intersectionality in and of itself, women as minorities when using the model, because women in a lot of workplaces actually do experience minority stress and we don’t talk enough about that.

They also usually think about certain racial groups, but they don’t encapsulate all of them, it’s usually white versus African American versus maybe Hispanic or Asian-American, they don’t actually dig in as much to the other minority groups that exist in America.

And one of the other populations that is actually frequently overlooked are the elderly population. So just something to keep in the back of your mind that we’re talking about a lot of different things with minority stress, but our elderly populations are also minorities in some ways.

How does this play out with regards to patients? One of the things that we’ll be diving into is I spun this a little bit from a healthcare perspective. However, all of these things are adaptable to America at large, they also are adaptable to your workplaces.

So, I’m giving you terms to start thinking about and think about how does this play out in your daily life? How does it play out in terms of how you interact with people? How does it exist in the hierarchy that you exist within?

So, a couple of terms before we dive in a little bit more microaggressions, I think a lot of us have heard that especially nowadays with what’s going on, broadly defined as behaviors that ambiguously disempower racial minorities.

So, and also, I want to say, because I’ve seen this on Twitter from somebody else, microaggressions do not feel like microaggressions to people who are experiencing them. So always keep that in mind. There are three categories of microaggressions.

They’re microinsults, where they’re explicit acts of racism where they say that somebody else has lesser worth because of their identity, or skin color, or sexual orientation. They’re microinsults, where you didn’t earn your position.

That’s something that I heard when I was in medical school when somebody I had won class president through popular vote, and somebody who said you won president because you were black and gay. I heard that were there certain amount of spots reserved for gay people in medical school and that’s why I got in.

So those kinds of things happen, and they start to hit at who you are. Microinvalidations is the third of the categories. And it’s saying that we are all the same and that’s actually just not true in America right now, we are all different and that’s why it’s beautiful. And we need to think about that.

They’re also healthcare microaggressions, which originate from a verse of racism where somebody says, I’m not prejudice, I don’t have racist tendencies. We all have racist tendencies. I’m sitting here with implicit biases.

We all sit there with them and it’s how do we enact them? How do we speak about them? How do we move forward with them and respectfully towards other people? Out of all of these terms actually comes this other term that I really love, even though it’s really sad in a lot of ways and it’s known as institutional betrayal.

And basically, what happens is a person is told so often and they have microaggressions that happen so frequently, and those microaggressions are not dealt with appropriately, and so this person begins to experience what’s known as institutional betrayal.

We are seeing that actually on a bigger scale in America right now with African Americans thinking about the institution of America and Asian-Americans thinking about the institution of America, and how many are not responding in the way that they need to, in order to actually mitigate what’s happening to the said minorities.

And in 2007 Constantine looked at the impact of racial microaggressions on the mental health of African Americans.

And what was seen at the time was that the experience of African Americans were often minimized where it’s basically, “Oh, like it’s not that bad or it’s okay, like you’re fine, it’s not a big deal,” or over identification which is the reverse where, “Oh, I know exactly what it’s like to have gone through what you went through.”

A lot of these things actually your subtle gaslighting that goes on with people and people who are minorities. And so that person who is a minority starts to think, am I crazy for thinking these things? They’re doing a lot of studies on how PTSD and these microaggressions play out for minorities as well.

In terms of patients continuing along. In 2017 FitzGerald looked at vignettes to examine the influence of patient characteristics on attitudes, diagnoses, and treatment decisions. Nearly all of the studies, the 35 out of 42 articles actually found evidence of implicit biases in the healthcare system.

These were around race, age, socioeconomic status, mental illness, weight, having AIDS, brain injured patients, intravenous drug users, disability, social circumstances, and gender. So again, we all have implicit biases it’s that we need to recognize that.

And what was really interesting is that they saw the same levels of implicit bias, then when compared to the wider population, the way I like to think about it in the way I imagine it is that the hospital system is a microcosm of the macrocosm that is America.

So always thinking about like, we’re just in a smaller setting, we’re having the same rates of discrimination that are happening. One of the things they also saw was that when physicians were less certain of coronary artery disease for middle-aged women who were African American, they were more likely to receive a mental health diagnosis compared to men.

And in this situation, intersectionality can play a large role in protection versus being a single minority. So, it goes back to that example that I was using before, where I play up that I’m gay to make people feel less threatened by my being African American.

And this happens in a lot of different populations where sometimes people will play up one aspect of their personality and wear a mask in some ways, to make sure that they cover for something that might not be seen as “as good” by society.

It’s not something that is ideal but it’s something that is protective. And talking next about residents as well as medical students, as well as fellows and people in medical training. So again, I’m speaking specifically to residents, however, all of these things are applicable to minorities and people in America.

Leisy in 2016 looked at bullying which are repeated acts or practices directed at one or more workers, unwanted by the victim done deliberately or unconsciously, but clearly cause offense, humiliation, and distress, and may interfere with job performance and or cause unpleasant working environments.

Some of the examples that they cited were unjustified criticism where, because of your identity or because of who you are, you are criticized because of those things.

I have experienced times where people will mention my hair color, I used to dye my hair but coronavirus so like, you know, not doing that right now, but I didn’t wear a tie, or my clothing is more colorful and that’s part of my expression of myself.

And sometimes those things can be criticized without actually asking why I wear those things, or who I am as a person. Humiliation in front of colleagues, intimidatory use of discipline or competence procedures. A lot of minorities have to go through remediation because they’re seen as difficult, even though they were bringing up a situation that was very real for them.

Undermining personal integrity as well as shifting goalposts. To explain shifting goalposts a little bit, it’s almost like if you’re on a football field and you know that you need to get to the end zone and you’re almost there and the end zone moves, it’s like that.

You will never reach that end zone, and you will never get that promotion, you will never be seen as good as your colleagues. And so that’s what shifting goalposts mean. 69.8% of residents in the workplace had actually experienced workplace abuse. That number should be shocking to people and make people pause for a second, that’s a huge number of people.

The most common form of abuse was verbal in nature. And then some types of resident mistreatment and themes where there’s a lot of hierarchy we also see that in America. So again, everything I’m talking about is applicable to America as well. We have a hierarchy in America is whether we want to recognize it or not.

You sometimes hear that certain minority populations are preferred minority, whereas others are not. Silence, incognizance, fear. 79% of residents were afraid to report when they had an issue. Acceptance and denial. So, what happens during that is it’s part of gaslighting where people start saying, “Oh, well it’s me, I’m the problem,” or “Oh, I like obviously did this, it’s my fault.”

One of the other things is legacy of abuse. So, residents who experience abuse, then we’ll be more likely to go on to abuse other residents later on. So, we are perpetuating a cycle and how do we stop that cycle from happening? Leisy also talked about, there’s actually very interesting data around what happens when people experienced mistreatment?

And they looked at individual and systemic and there’s actually a cost to a system and a cost to the individual.

So, to the system there were higher rates of medical errors, harming patients, as well as disillusion of care. 67% of witnessed disruptive behavior or people who witnessed disruptive behavior, felt it actually contributed to adverse events for patients, some causing minority stress and causing these things leads to decreased productivity.

So, if people want to think about it from a purely economical standpoint, decreasing minority stress will increase productivity at your work. So, if we wanted to just think about money, you will make more money. Like I know we should think about other things, but we have to get down to that kind of basic level.

There’s also cost to the individual. With higher burnout rates, thoughts of desertion. So, people actually wanted to leave residency sometimes.

You see that in other systems as well, where minorities come into the system and they are a tasked with heading diversity efforts, they are tasked with speaking up about diversity, but they receive very little praise and they actually are usually harmed for speaking up, and so they think about leaving.

Higher rates of depression as well as stress, they’re looking into if PTSD symptoms actually happen in residency, they’re also newer studies coming out with minority stress and how it plays out with symptoms that are very similar to people who have PTSD.

So, people have nightmares, they’re hyper aware, they’re scared to go to work, things of that nature. There’s also higher rates of substance use for residents as well as suicidal ideation. Again, these map very closely to the general population.

That’s why I talked about how the hospital system is a microcosm of the macrocosm of America. 20% of people studied so they would not pursue medicine again and several actually would advise others not to pursue it.

And so, we have a problem right now. We have a problem with how we treat residents, how we treat people inside of the hospital system, and we have a problem with how we treat people in America, and how do we change that a little bit?

So, I’m going to share an extra some anecdotes. So, these are things that I gathered from people when I was building this presentation with Mark, and we actually got stories from people. Some of these are going to be a little shocking.

So, I just wanted to preface that. And I’m glad that we have the slides so we can slow down for a second and stop and say like, some of these things will be disconcerting however, these are things that everybody needs to know they happen.

And I also want to give a warning to people who are minorities, who might not want to see this part. So just that heads up. So blank voice and concern that a black patient was dangerous because they were listening to rap music loudly while pacing the unit.

An elderly Hispanic man admitted for dementia, psychosis, so seeing and hearing things as well as paranoia. The treatment team was rounding with the patient in the ICU. Patient became very agitated and angry because in his psychosis, he believed that I had assaulted him at a facility where he lives.

The Spanish interpreter reported that the patient was making racial statements and wanted me to leave the room. Not knowing how to correctly respond, the resonant gave me a look that seemed to suggest that for the sake of the interview, I should leave.

Feeling shocked by the resident’s response and lack of response from the attending, so somebody higher up in medicine, I felt I had to do what was being asked. Needless to say, I felt unsupported, stigmatized, and invalidated. I believe the resident and or attending should have told the patient that was part of the team and would need to stay.

So sometimes it’s not only speaking up for setting limits with the patient, but it’s also protecting people in the room around you. Some other anecdotes. So, this came from other experiences that residents experienced and other people in medicine.

Differences in attending evaluations when colleagues state that the person had worked twice as hard and was twice as good but was seen as not doing as well or was tasked with the whole shifting goalposts thing. People who are minorities being interrupted by attendings when others who are not minorities were not interrupted.

Minorities being told their answer was wrong when they are citing directly from the reading that they had been tasked with. There’s also this thing known as the minority tax.

And so that goes back to when minorities come into a system, they are tasked with being the head of diversity, being on the front of the webpage, being the spokesperson for diversity, however, they are often not listened to and actually they end up leaving those institutions usually, or those places.

Tokenization is another aspect to the minority tax in some ways and it’s “Oh, well, since you’re African-American can you do this for us? Because you clearly know how to deal with this.” When everybody should be learning about these issues and talking about these things. Tokenization is also reducing a minority to their skin color and reducing their fully fledged identity to one aspect.

Residents feeling and sometimes made to feel as though they are the problem when they bring an issue to the fore. I think we’re seeing that in America in a lot of ways right now, black lives matter was actually seen.

This is the first time in history that black lives matter is seen and supported by more white people than disapproving of it. It’s the first time it’s ever flipped previously was more white people disapproved of black lives matter than approved of it.

So, a lot of those people who were involved in black lives matter were told, “Oh, it’s you?” Or like, “Why are you bringing up this issue? Why are you talking about race? You talk about race too much, race isn’t a thing in America, you have a black president,” it can run several thousand different ways.

And then also an attending saying he had worked with other African Americans before and they had worked so well together, when checked this was not true for those African Americans. So sometimes people have a very distorted view of how they actually interact with minorities.

Some other anecdotes wait staff being told by a patient that they could finish the food left on a patient’s tray. Wait staff being told instead of asked what to do in a room. Constant misgendering of transgender patients and saying when rooming them, “Well they’re not actually a female, we need to think about the safety of other patients who have trauma from men.”

A sign-out emails, so a sign-out email is basically things to do overnight and things to think about for patient care. I’m saying that because a person had trauma with African Americans in the past do not room with a black person, instead of moving that person.

Staff sometimes saying that clearly that person has a personality disorder, so of fixed and inflexible way of thinking in some ways and noting that it often occurs with LGBT patients.

So, one of the other things to bring up in this situation is that minority populations are often over in misdiagnosed, especially one example is African Americans are often over-diagnosed with schizophrenia, which is where you see and hear things that aren’t there or have paranoia, and sometimes that paranoia for those African Americans is reality based.

They live in bad neighborhoods, or they’ve experienced minority stress their whole life, so they actually are justifiably paranoid about things. So, it goes back to we always need to actually be thinking about a person as an individual and their actual stories. Hearing that a patient is difficult or aggressive and sure enough they are a minority.

When looking at notes and seeing how race is bought into the one-liner for specific patients. So, a lot of the times what we do in the hospital system is we say like a 33-year-old with a past medical history of depression and anxiety here for suicidal thinking.

However, a lot of one-liners can say a 33-year-old African American male which already causes implicit biases to start springing up for people and how you will triage them, and how you will think about them. Staff and patients noting how there are no pictures of minority physicians on the walls.

So, think about in America and the statues that are all across America of Confederate statues. That is basically again a microcosm of the macrocosm. So, we’ve talked about a lot of things and I want to make sure that we think about how do we grow? How do we help?

I cannot give you all the answers and you shouldn’t be wanting that from me, because we shouldn’t be tasking minorities with all of these things, because a lot of the times it’s not the minorities who caused issues and we need to work together as a team, and we also need to think about how do we not put the onus on the minorities to fix this for us?

However, because I’m in a place where I feel comfortable doing this, and I know how to do this in a lot of ways, I will leave you with some things and we’ll talk through some of that just to get us thinking about it. And again, I can’t fix racism in like one talk I tried you can’t.

So how do we grow? And how do we help? We ask there is a caveat to this when asking a minority, a person who is of minority status about their story, ask for their consent to talk about it first.

Because some days I do not want to talk about race, I want to talk about “Sailor Moon,” I want to talk about charmed, I want to talk about K-pop, I want to talk about like exploring San Francisco, sometimes I do not want to talk about like how has your experiences of black male back in Boston?

And I’m like, I’m here in a different place I don’t want to talk about it. Sometimes I do not have the mental capacity to talk about it. However, I used to always feel the onus to talk about it because I knew it helped people.

However, there’s also Google and reading books and people can do that research on their own, so when we come to the table, we were having a much more nuanced conversation and I know that I am not just holding you the whole time, we are holding and supporting each other.

So always ask, but also preface it by saying, these are the things I know about race and I am here for you to help. However, I know you might not want to talk about these things but know that I am somebody who will listen.

So, part of that is educating ourselves. I will be very upfront and honest. When I first started residency, I did not know much about transgender health. My colleague Jack Turbine who is at Stanford now you should read his stuff if you can it’s really wonderful.

He actually showed me some readings that I could do as well as we talked about trans-health and things like that. So, when I actually met my first patients who were transgender, I actually came in with a better sense of like how to interact, how to think about things, and I also had the right vocabulary.

So, educating ourselves as a big part of that. We also protect minorities. That’s one of the big things we need to think about because as we talked about, minorities come to institutions and they try to help, and they actually know exactly how to help.

But if that’s not implemented and they’re not protected when there are people who speak out against them implementing said help, they leave, it’s not safe.

So how do you actually protect minorities in those situations? And then we also become actual allies. There are dangers of false allies where somebody says I’m not racist. However, they actually then will enact racist behaviors or do things that are actually very racist in some ways.

So, when we think about allyship, it’s always a verb and it’s always ongoing and changing. We have to come at this through humility, from seeking to understand and truly converse. We also believe minorities when they bring these issues forward. And we also ask. How do we heal?

So, when I was doing this talk for the first time with Mark, one of the big things we noted was that there wasn’t a lot about how do we actually help minorities heal. And that’s something that we don’t talk enough about.

But Leisy actually in 2016 talked about some tools. So, education and awareness in and of itself was actually shown to decrease bullying. In team-based care at all levels reduces the hierarchy. thinking about that in America?

How do we make it so we’re all on the same page, we’re all in a group together? And it’s not one person leading, it’s everybody leading in their own way, and leading together. Also, good leadership is really important. It prevents, and also protects, and helps define culture.

And then inner-physician support, so I’m going to say inner-human support. So, what kind of things in your workplace are set up to have mentors? How are people who are African American coming into your system that might be new for them? Where are the mentors that they can find?

It doesn’t have to be somebody African American, but it can be somebody who is understanding of them and will listen to them. How do you foster community? Also, confidential mental health services I think everybody should have a therapist.

I think it’s just useful. However, how do you implement that and where your place of work? How do we bring that into America? We’re seeing as coronavirus goes on that psychiatry is rising as a field in some ways, but how do we make sure everybody has a psychiatrist or therapist who needs it.

Also, development of curriculum that tackles the hidden curriculum. In medicine hidden curriculum is basically this thing where, it’s all the things that you do during your day, but there’s an underlying current of like the minority stress and like racism and other things.

So how do we talk about that? How do we bring that to light? Also standardizing feedback and reporting methods. And then in the worst-case scenario, how do we make sure that that minority can go somewhere else that is safer for them?

That’s the worst-case scenario after everything else hasn’t worked, with something we do sometimes need to think about. Also, again, how do we heal? Recognize name and understand our attitudes and actions. Again, we all have implicit biases and that goes along with identifying our own implicit biases.

And diversity training is also important not just in terms of how to talk about these issues, but also what is the history of this? Like I remember when I first started doing these things, I didn’t know about minority stress, I didn’t know about African American history or red lining, I didn’t know about like stonewall and things like that.

So how do we build that history, so we don’t repeat the same patterns. We also need more research around this. And then thinking about a patient’s actual social risk factors and needs and diversifying the healthcare workforce there’s a caveat to this too where we need to not bring in minorities to an unsafe situation and expect them to fix things for us.

Some further reading is actually reducing health, racial, inequalities, and health. And it’s by David R. Williams it’s a really good article. It’s a little bit longer but it has a lot of tips and tools.

So, some future directions of thought we’re almost at the end. So, then we’ll get to the Q&A. What are some ways that we can protect people of minority status when they enter institutions where minority stress happens? How do we do further research into minority stress and female and other URM populations?

One of the big things I really noted is that nobody had looked at how long does it take for somebody to recover from minority stress? And they would obviously have to think about what are the levels of minority stress? How have they impacted this person? And what does healing look like? What does recovery look like?

Because if we go back to the imagery of that shine or that star inside of our hearts, like I have a lot of cracks in mind from the past seven years, they’re healing but they will never completely be gone, but it doesn’t mean that I haven’t recovered.

So how do we think about what recovery means to people? What are some ways in which people do and don’t recover? What aids in that recovery? And how do they protect themselves in the future when entering a work environment, or environment in general that’s unsafe for them?

And how do institutions facilitate productive conversations? What is our role on speaking to these topics to a larger audience? So, like how do we inside of our small little spheres then take that out in the world because we are all advocates, and how do we advocate for people?

And then also just standardizing study methods in terminology. That’s what a big part of this talk was about, was standardizing terminology for us.

Jenn: So, we are going to jump into the Q&A section understanding there’s about 10 minutes left in the hour. So, our first question that came up Chase was actually, how can we handle microaggression from other disciplines especially mental health providers?

An example would be medical doctors who minimize and dejustify other clinicians, such as psychologist who are MDs but are treated like second class providers.

Chase: Yeah, that’s an excellent question. I think that’s something that I’ve seen a lot and that is something that’s actually pretty painful to see when people across different disciplines don’t actually interact with each other in a healthy manner.

One of the things that I have seen work best is actually sitting down at a table with them again, hard with Zoom right now. But I think when I first come into a place, I try to figure out what is the team like? Who will I be working with?

And then sitting down with them and saying, “Hey, like here’s my story.” And I don’t even really talk about medicine I just say like, here are the things that I really like to do, and this is how I think about things. And so that person has a baseline and we actually build a bond and a friendship.

So then when that person comes to me, they’re like, “Oh, Chase listens to psychologists.” And like we shared our stories with each other because I think one of the big things in all of this is it always comes back to a person’s story because we all have a lot of common threads between us.

Somebody as a psychologist, they want to help people with mental health issues. I want to help people with mental health issues. So how do we get to that crux in that common thread? And that usually starts out with like the very beginning of how do you set up the intro to each other?

Is your group like your MD group? Introducing you to this psychologist that you might be working with. Is your group introducing you to the PT students? Are your like PT students reaching out and being like, “Hey, like we haven’t met the MDs yet. Is there a way to do this?”

So, we can all come to the table a little bit together and actually have a seat at that table together? Hope that helps.

Jenn: I think that’s helpful. What does lying about identity do to somebody’s mental health?

Chase: Nah (laughs).

Jenn: (chuckles) I know the second question is like, “Oh, we’ve got eight minutes left.” (laughs)

Chase: (indistinct) I can get those. This is great, excellent question too. I will spin it from personal perspective. I came out in fifth grade, which was very early back in the day. Now kids are coming out and they’re like two, when they’re like, “Hey, I know.” And you’re like, “Alright like sure.”

And they actually do know but I remember coming out and my family is super accepting, it’s super supportive at the beginning it wasn’t. My mom and I got along really well, my sister and I did too, my dad was always super supportive of how well I did in school and everything else.

I think he was very scared for me as a black gay male growing up at the end of the AIDS crisis. And we’ve actually had discussions about this. He’s one of my best friends now. However, I kind of went back in the closet at home where I’d be like, “Oh, Halle Berry is so hot.”

And I mean yes, like she was very attractive however, I was just like it took so much mental energy, and it felt like I was constantly going through back flips all the time with hoops that I couldn’t see. What ended up happening because of doing all that for so long.

I came out again junior year and people always kind of figure it out at school sometimes, or I would tell them in person, but it took so much energy that I became suicidal. I’m totally fine now, I’m self-disclosing right now basically. But it got to the point where I hated who I was, I didn’t think I was worthy of living, and I felt like I was a waste of space.

And I remember going to MIT and I come out again and I found the supportive environment where people were like, you being black and gay are some of the most beautiful things we’ve ever seen, and you were going to be a game changer.

And I got to say that to my friends who also felt different, and I got to see people rise. So, it holds you back. It’s basically like building a cage around yourself to keep people out, but also that society’s building a cage around you.

And we as a society can just help people be themselves a little bit more and it took away parts of me that I had to reclaim later. So, doing really well now, by the way. But yeah, so that’s what it does to people by lying sometimes it’s a lot.

Jenn: Yeah and I’m sure that you know especially if you feel like a dichotomy between who you can be when you’re around people that you feel like they’re family, even if they’re not blood relatives versus your actual family it can just be something that’s just ongoing undue stress too.

Chase: Yes yeah its constant minority stress inflicted on yourself.

Jenn: Which I have to say I think you’re a game changer, but that’s just my personal opinion. (laughs) So, our next question is actually twofold. Should we stop identifying patients by race? I wonder if it would be better to identify someone as a 33-year-old male versus 33-year-old African American male.

The second part of it is, is it appropriate for medical professionals to discuss race with patients, as it applies to prescribing medications or identifying prevalent symptoms or diagnoses.

Chase: Wonderful questions, so our class and other classes actually above us I think, and lower the classes who came after us, we in residency started doing this thing where we dropped the identifying like race inside of our one-liner.

Because one of the things we talked about as a group was, why are you including that one-liner? Does it actually talk about the person? Or are you doing it because we are taught to think about people as little boxes, and I hear African American female and I think sarcoidosis.

However, I could have said 33-year-old female with sarcoidosis, and it already triggers a lot of implicit biases. So, I think what I have started doing, and this is something I started doing during residency too is I always make sure to ask somebody how do you identify?

And is your identity port important to you? In what ways? I started incorporating basically questions about minority stress in my note template so when it would continue on to other residents, you could see like I didn’t put in the one-liner because it wasn’t necessarily there.

However, it is necessary to their care overall and seeing them as a full human being. So, I recommend not using it. And if you do use it, think really closely about why am I using it? What is the purpose of this and how other people read it?

How will somebody who might have biases against certain people read it before they even go into the room with this patient. Do you mind remind me of the second part?

Jenn: Sure, so the second part was, is it appropriate for medical professionals to discuss race with the patient, as it applies to medication or identifying prevalent symptoms or diagnoses?

Chase: I think it’s always appropriate. Again, it needs nuance, and it needs understanding. And I think I as a psychiatrist, I will admit that I was at fault at the beginning where I was scared to bring up race and diversity and other things with my patients, because I had experienced my own problems with diversity, and it was hard to talk about anymore.

But some of the people I worked with being female had caused minority stress, being African American, being gay. And I became a much better psychiatrist once I started saying, “Hey, like,” I mean obviously I had more eloquence than I’m going to use.

And I was like, “I’m African-American and gay.” And that comes with some things in America. You were also different in certain ways. Let’s talk about it. I actually saw almost all of my patients have this reaction where they’re like, it was just the sigh of like, finally, somebody I can talk about this with.

So, with medications and things like that, I’m thinking about like, we prescribed this in this way for certain populations because of this. First always think about is that actually accurate? Or did we just prescribe this to certain populations for certain reasons that were actually racially based.

But once you figured that out then saying to patients like we have seen in African American patients, that this works better because of this, I think that’s an important conversation to have, because it shows that you’re thinking about race, you’re handling it well, and you’re thinking about their care in a way that is informed, and also shows that you’re informed.

Jenn: I know that we are just about at the hour. Do you have a few more minutes because--

Chase: I do.

Jenn: We have a few questions that came in that I think are really wonderful. The first one is actually really lovely. Someone asked were there any bright spots in your training classes or experiences that were both sensitive and thoughtful about identity?

Chase: Yes, so I think you will notice that a lot of my presentation was building awareness and awareness is hard. I would love to just do like conversations about like, these were the amazing things about residency.

In my like last seven years I had a lot of amazing things and in med school I had a vice dean who really helped me as class president, and actually was like, she was Caucasian and female, and like we were nothing alike.

But she actually when I told her about the things that were happening, she emailed me back and was like, you are an asset to Feinberg and we will help you in every way that we can.

And she really took that on and helped me and others like make things better there. In residency I have to speak so highly of my classmates. My colleagues are magical like I love them. They are on par with how I feel about my friends from MIT who I’m still friends with.

I’m going to get a little emotional but my colleagues in residency are my family in a lot of ways. I remember when I first started experiencing things in residency and the first thing somebody said was, you’re not alone and we’re going to be together through this. And that really was a game changer.

It made residency better for me than medical school had been. Again, I’m in a different place now because of how some things went. However, I am really glad and fortunate that I had that experience with all of them to see how people can bond together.

They kept me going through residency and I have best friends from there one of them just got engaged and like, I expect to go to that wedding. But I think as a whole, I’ve had a very charmed life and privileged life. I didn’t expect that I would be 30 years old and where I am today.

And I am happy where I am today. Doesn’t mean that things didn’t happen along the way, but there always been people to help and show me how we can do better. So, then I can in turn, always help people do a little bit better too.

Jenn: I think that’s a really bright spot that we can take away from a really heavy discussion too. So, thank you for such a thoughtful answer. This one I find really interesting someone wrote in saying, I think the word minority is a microaggression that teaches people they come from a lesser position. What are your thoughts?

Chase: Yeah, I think I struggled with that a lot too, because I don’t think of myself as minority I think of myself as a person. However, our society and just society in general has an obsession with labels. One day I envisioned that like when kids are LGBT, they just go up to somebody and they say, “Hey I’m into guys and I’ into girls,” not like I’m gay and like that becomes this label.

I think we’re not there yet. But I think a lot of people are thinking about that. For me, it doesn’t feel necessarily like a microaggression, but it does feel like an othering in some ways, it is one of those labels that I have taken on because I will use it and I will use it appropriately before somebody else uses it inappropriately.

But I think language again, should be shifting and changing as we grow. I agree with that.

Jenn: Somebody wrote in saying as a lesbian, I find myself having a hard time accepting the notion of non-binary and pronouns that people are using. What thoughts do you have about my bias?

Chase: Yeah, I think so what I always think about is when I first started watching RuPaul’s Drag Race, like I actually had biases against people who dressed up in drag and I was like, I don’t get it what? And I think part of it came from when I first came out, somebody asked me like, “Oh, do you want to dress up as a girl now?”

And I just remember that as a stigmatizing moment. And so, whenever my own personal biases come up and also thank you for sharing that ‘cause that’s like a very vulnerable thing to share. I always think about where is this coming from?

How am I enacting it? And also, am I enacting it because I don’t understand it, and I don’t have the education around it yet. Like when I talked about interacting with patients who were transgender, I didn’t know as much of the verbiage yet.

I didn’t know about their stories in what a lot of them have to go through just to even get in the door of a psychiatrist. So, doing reading on my own and also like we have a LGBT book club thing on Twitter, and it’s called Reading Rainbow, and we’ve been reading stories and memoirs.

I know it’s so good. Stories and memoirs by other people who are LGBTQ authors, and it’s been just so illuminating to hear other people’s stories. I always think again go back to the story and also think about why do I have this bias? Is it because of what I’m hearing in today’s society?

And also, do I not have the understanding about how my biases might affect people, but we all have them, and it’s just, how do we learn from them? So, thank you again for sharing that.

Jenn: Do you have time for three more questions?

Chase: Yeah, I’m totally here for it.

Jenn: Okay, perfect so one of my biases that I actually wanted to ask you myself is how did we unearth and address our implicit biases? Because I know I’ve got them, we’ve all got them, but I want to work on eradicating them.

Chase: Yes so excellent question. I think one of the things that I started doing was when I interacted with somebody new, I was like, what is your snap judgment? That’s what I always call it in my head. I’m like, what is your snap thought about this person?

Like if I met somebody, I actually had implicit biases against other African Americans because I grew up very privileged, and when somebody didn’t speak in the way that I did or wasn’t as eloquent as so as I thought they might, should or should be biases actually came up.

College helped me unlearn that in a lot of ways. And I was like, “Oh, that’s not cute.” But I think always thinking about, what is your snap judgment when you meet somebody that helps you really think about like, what are my implicit biases? We can’t always get rid of them. However, it’s much more of like it’s an awareness.

It’s almost like meditation in some ways where like, oh, I’m going to have this snap judgment however, I now recognize that which decreases the thing that you’re not going to act on it as readily as you might have if you hadn’t known about that.

As well as there’s a stop gap then of like, “Oh, I will have this bias, but I have a breath and now I can interact with this person as a person because I can hold onto that a little bit.”

So, I think that’s how to think about it. When you first meet somebody or you hear like transgender, what is the first thought that comes to your head or African American we all have automatic thoughts that come up.

So, starting to think about some people even write them down of like, they will write down a word and then whatever word association comes with that. And then start thinking about, how do I actually think about people and how do I create a little bit of a breath where my implicit bias does not portend my behavior.

Jenn: I think that’s incredibly helpful. And when you actually asked about African American or transgender, the first things that came to mind for me were people and then under supported. And I was for that snap judgment, that’s a little bit of a relief, but then what do I take away from that information?

And like what I’m thinking how can I actually apply that to be a better person and a better ally of more communities on the ones that I’m a part of.

Chase: Yes, I agree.

Jenn: So second last question is, how do you bring up acts of minority discrimination perpetuated by somebody who has minority status? So, the example they gave us within the LGBTQIA plus community, there’s often the lesbian and trans erasure or reductionism.

Chase: Yes yeah, that is a huge thing. And thank you to whoever pointed that out, because it happens with racial minorities, it happens with--there’s this term of we eat our own. And you would think that every LGBT person would be like, I have suffered discrimination, I will not enact this against other people.

However, there’s a race to not be the bottom or what’s seen as the bottom group. It’s not right because if we don’t work together all are going to be in the bottom group, and we have bigger things to worry about right now, but it does come up.

And I think the way to bring it up is asking, and this is something that I’ve had to do with people interacting with transgender people, or people who identify as transgender. When I interact with gay people who bring up those biases they’re like I don’t get it.

And I’m like, why are you not taking the time to get it? And then I also actually am very blunt sometimes, I think you all know I can be eloquent, but I also if you see my Twitter I can be very pointed in some ways. And I will tell somebody, you are enacting biases right now and I want to know why.

And I also sometimes say to people you have probably, or I will ask as a question to maybe bring them in a little bit and like not trap them, but like bring them into the conversation a little bit more. I will say, what are your experiences as a gay person with discrimination?

And like, just that question starts them thinking about their own experiences. And then I’ll be like, “Wow it sounds like you’ve gone through a lot of things,” like imagine being transgender or somebody who identifies as a lesbian and you’ve gone through not only those things, but also like your own gay community maybe saying things, it like makes them pause for a second.

And that’s what we’re doing is making people pause right now. We’re not always in the healing phase of things, but like, if you can make somebody stop that kind of comment will stick so.

Jenn: So, my last question is how can we support others or ourselves we’re struggling with identity and intersectionality.

Chase: Yeah, I really love that question. The first thing I want to say is, you are beautiful for your intersectionality, it’s a gift. I’m not just saying that because I also have intersectionality, but I think it is one of the best gifts.

An example is that there was black men Twitter and gay men Twitter at the beginning, and now what I’m seeing as time is going on is like the black gay people on both sides are like bringing that together a little bit and the communities are interacting more.

You have a power to build bridges, but it’s hard. Like I still struggle with it sometimes of like, do I? And I’m just learning to relax a little bit around those kinds of things, but how do you want your life to look like? How do you want to build bridges between those two parts of yourself or three parts or four parts?

And I think one of the big things when I was struggling was my friends from MIT actually saying like, this is a gift. It’s a gift to be seen as different and also a gift to be in two different worlds that may be actually overlap in a lot more ways than you think.

A way to talk to yourself about it is not only thinking about how you’re a gift, but also exploring those parts of your identity. I think sometimes we’re so bogged down by society is saying that things are wrong, or people are wrong, and you don’t get to see like, how do I want to be right? How do I want to be seen as right?

And so, one of the best things for me has been like, “Hey, I’m gay,” this comes with all these facets. “Hey, I’m African-American,” and I have never explored as much of that. Like, “Oh and I’m also black and gay.” So, like how does that come together? So that’s how I would recommend that in finding your community of people.

Jenn: Chase, thank you so much for taking the time to chat with me today about identity and the parallels between our mental health and how we identify ourselves. I have found this session to be so refreshing and so inspiring, and I hope folks joining felt the same way.

This actually concludes our session, so thanks so much for tuning in and until next time, be nice to one another, but most importantly, be nice to yourself. Thank you again and take care.

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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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