First Responders, National Holidays, and Couples Therapy

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We frequently hear ambulance sirens in our neighborhood, as the sound echoes throughout the streets of our Boston suburb and into our second-floor apartment, but they generally pass by, directed toward a hospital, fire station, or in a worst case, a scene of an emergency.

One afternoon this summer, the siren wails grew nearer to our house, nearer, until the flashing lights of ambulance vans and a fire truck parked outside our front door. I watched the following scene from the second floor, a la Jimmy Stewart: two men carefully yet efficiently strapping my landlord onto a gurney, a woman negotiating calmness to the landlord’s hysterical wife and direction to her even-tempered daughter. A team of paramedics receiving the gurney in the back of an ambulance van and quickly attaching my landlord to a number of monitoring devices, gauging his heart rate and blood pressure. Within about 10 minutes, they drove away, sirens blazing through our often impassable streets, where they dropped him off, whisked him into care of emergency room, and sped toward the next emergency, where I only imagine this stressful process of quick resuscitation and calming of family members got repeated dozens of times throughout an 8-12 hour shift.

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On Saturday, September 27th, communities throughout the nation shared end-of-summer picnics and gatherings in honor of First Responder Appreciation Day.

We’ll cut you some slack if you missed it. Only 19 states (including Massachusetts, but not including bigger states like California, Texas, New York, and Florida) have passed legislation identifying September 27th as a state holiday, signifying the overlooked, often thankless tasks of law enforcement officials, firefighters, EMTs, and others that arrive to scenes of emergency and tragedy offering order, support, and compassion to immobilized victims and communities.

Currently, the House of Representatives has a bill, sponsored by Massachusetts’ own Michael Capuano, that would require the President to designate 9/27 as National First Responders Day. This bill was introduced into the House at the end of February, where it has remained in the Committee on Oversight and Government Reform for the last seven months. Some legislators and civilians, including Andrew Collier, brother of Sean Collier, the MIT police officer who was killed on duty while tracking the Tsarnaev brothers following the Boston Marathon bombings last April, have attempted to press the House into moving this bill along. Andrew Collier writes on change.org, a site that invites citizens to support legislative petitions:

“We ask that our elected officials designate a national holiday to honor the brave professionals in the emergency response fields, including Police, Firefighters, and EMS. We’ve witnessed the bravery and heroism of these men and women time and again – running into the Twin Towers on 9/11; heading toward the sound of gunfire in Colorado, Connecticut, and too many other recent tragedies; and facing danger for our protection in every community, every day. We are now reminded of their bravery again after the tragic events that took place in Boston, Cambridge, and Watertown, MA.”

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Researchers at Johns Hopkins report that first responders who are exposed to traumatic events increase their possibility of experiencing post-traumatic stress symptoms, including physical ailments, avoidance, and flashbacks. First responders are also more likely to develop substance use addictions as they attempt to wash away the memories of seeing someone severely injured, having one of their colleagues killed, or seeing a dead body.

Too often, our first responders suffer in silence. Unfortunately, a stigma around receiving professional help exists in many first responder communities, as some risk losing their job or ranking following a PTSD diagnosis. Global News, a Canadian news source, reports that 23 Canadian first responders have committed suicide since April, a disturbing trend amongst many nations.

Anita DeLongis and David King, professors of psychology at the University of British Columbia, recently explored the internal suffering of first responders in the context of intimate relationships. In “When Couples Disconnect: Rumination and Withdrawal as Maladaptive Responses to Everyday Stress”, an article published in August’s Journal of Family Psychology, DeLongis and King evaluated the interactions patterns of 87 intimate relationships involving paramedics. The authors identify the term “rumination” as the passive, internal process of repetitive thinking about problems, and label burnout, the depletion of emotional and social resources, as the end result of perpetual rumination. Many first responders avoid burdening their partners with the stressors and chaos of their job, but still struggle to truly leave work at work.

DeLongis and King asked these couples to keep journals of their conversations at three points during the day: one hour after waking up, immediately after work, and before bed. They discovered days with greater work stress also involving greater levels of rumination during times before bed. Rumination seldom involved discussions explicitly about work, but carried over into worries about other areas of life, including finances and social obligations. Partners attempted to assuage the increase of worry in one of two ways: either by pursuing and trying to find solutions to eliminate the worry, often through criticism, or by distancing completely. DeLongis and King also discovered that paramedics struggling with burnout had a greater tendency to withdraw entirely, creating an impenetrable wall around their anxiety, exhaustion, and feelings of worthlessness. Partners’ responses, regardless of whether they pursued or distanced from their partners, seemed to exacerbate the process.

Working with emergencies creates an inordinate amount of stress for first responders, particularly when an outlet to discuss occupational stressors in a supportive environment fails to exist. DeLongis and King remind us, in line with other research, that first responders who found that safe outlet in the context of their intimate relationship reported a significant higher quality of intimacy, connectedness, and empathy from their partners.

Couples therapy can provide an opportunity to improve connectedness and intimacy by providing a space to share stories of stress, burdens, disappointment, and heroism. First responders experiencing high levels of stress and burnout may perceive that they have limited emotional energy to engage with their partner, or that if they do engage, their partner will share some of their negative self-thoughts and distance or not understand them. We’ve discovered, through creating a safe space to share experiences, that partners often move closer to their first responder when learning of their anxieties and vulnerabilities, providing compassion, empathy, and support for their significant other.

Star-Crossed Lovers and the Stress of LGBT Couples

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From forth the fatal loins of these two foes,
A pair of star cross’d lovers take their life,
Whose misadventur’d piteous overthrows
Doth with their death bury their parents strife.

Romeo and Juliet, Prologue

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Image from fanpop.com

Montague and Capulet. Tristan and Isolde. Cyclops and Phoenix. Any time a mortal tries to fall in love with a vampire. (Or for that matter, any time someone riffs off the vampire/unrequited love theme and creates a story that makes us scratch our head as to how it remained on the NY Times Bestseller list for over a year.)

The socioeconomic and personality gaps (and ensuing conflict) between these couples draws us into their narratives. We want to see Romeo overcome all odds to connect with Juliet and stick it to those snooty Capulets. We connect with heroes who are misunderstood and castigated, and root for them to find happiness and show the world that they’re much more than what their races, social classes, and disfigurations might suggest. We are captivated by degrees of difficulties: The more barriers a relationship has, the more we root for them to triumph.

Unfortunately, as William Shakespeare suggests in the killing of his protagonist teenage lovebirds, relationships fraught with external conflict, coming from parents, friends, and/or society at large, often struggle to survive.

Ilan Meyer, professor of sexual orientation law and public policy at UCLA, identifies the minority stress model, where socially devalued groups expect the constant discrimination and mistreatment they experience to exist in future relationships, leading to negative appraisal of self and other and attempts at hiding the status of minority. (Meyer researched LGBT couples who have a greater ability to conceal their identity as a minority than, say, an African-American person, although this model extends to racial/ethnic minorities as well.)

Recently, Kristi Gamarel of the City University of New York and others expanded Meyer’s minority stress model to encompass the experience of both partners, asking, “How do the external stressors of an LGBT person transfer over to the partner’s experience?” In the article “Gender Minority Stress, Mental Health, and Relationship Quality: A Dyadic Investigation of Transgender Women”, published in August’s Journal of Family Psychology, Gamarel and other researchers interviewed 191 transgender women who were in intimate relationships with cisgender (or non-transgender) men, almost 80% of whom were also racial minorities.

Transgendered individuals provide an interesting contrast to other LGB couples because they have higher rates of poverty. Related, the National Center for Transgender Equality reports that at least 25% have lost a job either during or shortly after the process of sexual transformation, and 75% have experienced occupation discrimination, including sexual harassment, refusal to hire/promote, and privacy violations. A national survey reports that two-thirds of transgendered people have been victimized by assault. Poverty creates its own set of relational stressors; Gamarel and company estimated that low income increases the odds of her research participants reporting depression by 65%. (Research included being screened through an evidence-based depression scale.) In this study, 43% of transgendered women and 47.5% of cisgendered male partners met the criteria for depression.

Studying depression in couples can prove challenging because of the chicken-egg dilemma: Did a couple enter into a relationship already suffering from depression, or did they develop depressive symptoms throughout the course of their relationship? Depression is too complex to answer that question simply. However, Gamarel and company created a qualitative questionnaire to assess for relationship stigma, including the following questions:

  • How uncomfortable do you feel holding hands in public?
  • How uncomfortable do you feel going out to bars (straight or gay bars?
  • How frequently have you actually been harassed when w/ partner in public?
  • How often do you experience difficulty introducing your partner to friends/family?
  • How often have you had to hide your relationship from other people?
  • How often do you feel there is something wrong/feel self-conscious about being in this relationship?

Predictably, many couples reported feelings of self-consciousness, that they were doing something wrong both in and because of their relationships. Sadly, the researchers also determined that partners experienced higher risks of depression the longer they stayed in their relationship. After awhile, as Gamarel and associated suggest, partners lose the ability to distinguish the difference between pressure from the negative messages from outside forces (i.e. family members and friends) and pressure from within the relationship. Work with minority (racial or sexual) couples must have conversations about discrimination and the potential for transference–the expectation that one’s partner will treat you with the same negativity and contempt that others have treated you.

Innocence, African Americans, and Couples Therapy (part 3 of 3)

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Couples therapy seems to be a middle-class, White person construct. There are a lot of reasons for this that we’ll discuss at various points on the blog, including financial and geographical. (Most private practitioners, for example, have offices in middle/upper-middle class communities with a lower concentration of racial diversity.) Nevertheless, for whatever reasons, therapy, especially couples counseling, seems to be utilized less frequently by African Americans.

Dr. Clifford Broman, a professor of sociology at Michigan State, recently evaluated racial demographic data of therapy participants in his article, “Race Differences in the Receipt of Mental Health Services in Young Adults,” published in a 2012 edition of the journal Psychological Services. Broman created a longitudinal project in which teenagers were asked to assess their therapeutic experiences over a seven year period (1994-2001). Almost 5,000 young adults participated in the project, which involved reflecting on the process of therapy through a Likert scale format in 3 periods (1994, 1998, and 2001). 55% of participants were White, and 20% were Black. He discovered that Blacks with prior therapeutic experience were less likely to currently seek services, whereas other racial groups maintained an interest of pursuing counseling. He also discovered that Blacks with higher education were less likely to receive services than those with lower education; the opposite was true for other racial groups. Perhaps education symbolizes a victory over systemic injustice, a representation of strength and “overcoming the odds”, and the acknowledgement of an educated Black person that therapy is needed implies that reverting to a place of weakness and subjugation.

In couples counseling, one of my goals is to develop intimacy through the witnessing of vulnerable parts, under the principle that “if my partner will accept my weakest, most needy parts, he/she will be more willing to accept all of me.” This principle counters our natural survival strategies, which rely on variations of physical and emotional strength. Dr. Phillip Goff, as we discussed in previous blog posts, suggests that Black youth are more likely to be perceived by peers and authorities as aggressive, angry, and more culpable. This social perception reduces the possibility that others see Black people (and that Black people perceive themselves) as innocent, empathetic, and child-like, and transforms into adult identity and couple formation.

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Picture taken from essence.com

How can we get Black couples to buy into vulnerability models of couples therapy if they’ve had to/been forced to see themselves strictly through labels of “strength”? I wanted to use this blog post to make five suggestions, with the help of research established by Georgia State’s Dr. Makungu Akinyela, who writes about couples therapy with African American couples in the book Re-Visioning Family Therapy: Race, Culture, and Gender in Clinical Practice.

1) We must ask couples about racism as part of our assessment. Dr. Ken Hardy, one of the editors of “Re-Visioning Family Therapy”, encourages therapists to connect with systemic injustice by asking “What happened to you?” When did each person experience racism for the first time? What has racism prevented you from achieving your goals? Ask these questions in the context of the couple rather than the individual, and learn about how these messages of racism affect couple interactions.

2) Cultural competency needs to come from an African-Centered model. Dr. Akinyela explains that cultural competency is often strictly evaluated in relationship to Western culture. When I ask about racism, there’s always the shadow of the dominant discourse of White culture: how do your experiences fail to fit into the mores and norms of Caucasian families? While these questions are important, Akinyela encourages therapists to ask about the influences of African culture: its practices, ethics, and interpretations of mental health.

3) We must focus on the process of storytelling. Akinyela writes that African cultures center around musicality and oral narratives, as opposed to Caucasian cultures, in which stories are written and read. He encourages therapists to ask questions about the metaphors that these couples produce (Akinyela reminds us that metaphors drive African storytelling) and the rhythm and timbre of conversations.

4) Assess for the importance of spirituality. Akinyela writes, “We understand spirituality as that experience of connectedness and relationship that is expressed in the customs, rituals, music, and traditions of Black people. Spirituality is also understood and expressed as an honoring of elders and ancestors and a respect for the collective history and past of descendants of Africans enslaved in America” (p. 358).

5) Identify working models of strength and vulnerability for both partners. One of the challenges with always being strong is that others aren’t allowed to help. It may be scary for partners to accept the influence of the other, particularly if doing so also increases the risk of irrational culpability (such as the treatment of Black youth as adults.) When do we expect the other person to be strong, and how can we revel together in the sharing of narratives that disprove the racial legacies of powerlessness? But also, when are we allowed to ask for and receive help from the other, and what emotional process coincides with asking for help?

Innocence, African Americans, and Couples Therapy (part 2 of 3)

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As we discussed in the latest post, Dr. Phillip Atiba Goff of UCLA led four different studies that evaluate how race affects the way we ascribe traits of innocence to people, particularly children. (The Wire provides an excellent summary of Goff’s research procedure and results.) In one of the projects, Goff tested two pools of people: mostly-white university students and police officers. The research team discovered that both test groups perceived Black children as approximately four and a half years older than their actual age. It’s one thing for idealistic university students to create this perception about people only a few years younger. The stakes increase when authority-wielding police officers carry the same perception.

Let’s say a 15-year-old African-American boy is caught shoplifting, and the store owner decides to get the police involved. If this study is true (Goff evaluated over 100 police officers, a moderate pool sample, and remember, 4.5 years is an average overestimate, which means it’s possible that some police officers may have assumed Black children were six or seven years older), the police officer assumes that the Black teenager is no longer a minor. The teenager lacks protection that minors receive. Perhaps the police officer addresses the teenager with more assertive, aggressive non-verbals that he/she would use with actual adult offenders, rather than a parental tone of voice. Perhaps the police officer is more prone to using physical force or stricter punishments; after all, we’ve learned that approximately 60% of children sentenced to adult facilities are African American.

The Department of Education reached similar conclusions about teachers in a 2012 quantitative study involving data from 72,000 schools: 46% of students who have been suspended more than once and 39% of students who were expelled were Black children. (Black children made up 18% of all children in this study.)

One could make the argument that Black children are more likely to come from families in which chaotic, abusive interactions reign, developing a more intense anger which transfers into relationships with peers and authorities, resulting in harsher forms of punishment.

Regardless of the reason, Black children appear to lose the perception of themselves as innocent through familial and larger systemic interactions. Anxiety seems to coincide with the recognition of lost innocence, including increases of anger, defensiveness, and “defiant” behaviors throughout adolescence and adulthood. This creates a significant challenge for Black couples.

Most relationships begin with a clean slate–partners connect with greater ease during the initial relationship stages due to an increased sense of innocence and security in the other. Attachment theory suggests that couples develop problematic interaction cycles as they learn/perceive/fear that their partners are untrustworthy. Partners are viewed as no longer innocent, but as guilty of numerous transgressions, and partners will either distance themselves (i.e. shutting down, limiting communication) or overpursue their partners (i.e. criticism, nagging) as a way of rectifying this internal conflict. Couples therapy involves re-engaging the distancing partner and softening the stance of the pursuing partner through the process of witnessing emotionally vulnerable moments and reestablishing a sense of understanding and innocence in the other.

What if you enter a relationship lacking that initial sense of innocence? How many Black people enter romantic relationships with the notion that others perceive them to be guilty of something? (If we follow the conclusions of Goff’s study, we can logically assume that a significant number do.) If larger systems (schools, law enforcement, etc.) perceive that I’m inherently guilty of something, how long is it going to take before I believe that my romantic partner will perceive the same?

I explain to my couples, “Some of the issues have everything to do with your relationship and some of the issues have nothing to do with your relationship, they just get superimposed onto your relationship because of proximity.” Black couples have chapters in their stories that white people seldom confront: the legacy of racism.

Many Black individuals seem to survive this legacy with language of strength–I’m going to fight through these injustices, or develop a thick, impenetrable wall around myself that lets you know I won’t be bothered by racist rhetoric. I’m wondering if couples therapy can do the opposite: if it can provide a safe place to explore and share narratives of systemic injustices with the goal of identifying the other as vulnerable, emotionally weary from the experience as “Other”, and ultimately, innocent. In the next blog, we’ll explore some ways this can happen.