Ethnocultural Allodynia

Abstract

The authors introduce and define ethnocultural allodynia as an abnormally increased sensitivity to relatively innocuous or neutral stimuli resulting from previous exposure to painful culturally based situations. Ethnocultural, gender-specific, and cognitive-behavioral techniques are used in clinical vignettes to illustrate the pervasive ethnic, racial, and gender effects of ethnocultural allodynia in the lives of people of color. Therapy components for the treatment of ethnocultural allodynia are described, including psychoeducation regarding racism and its sequelae, racial socialization, inoculation, and racial stress management.

In medicine, allodynia refers to an exaggerated pain sensitivity in response to neutral or relatively innocuous stimuli, which results from previous exposure(s) to painful stimuli.¹ For example, in patients suffering from allodynia of the trigeminal nerve, even a very soft touching of the facial skin with a cotton swab or tissue may result in excruciating (and often protracted) pain. Although enhanced pain sensitivity—hyperalgesia—acts as a normal part of the body's self-defense mechanism by helping to protect against repeating a situation that might cause further injury, this pain sensitivity is abnormally enhanced in allodynia to the point of losing adaptive benefits.

In psychotherapy with people of color, we have observed an analogous phenomenon—ethnocultural allodynia—which we define as an abnormally increased sensitivity to ethnocultural dynamics associated with past exposure to emotionally painful social and ethnoracial stimuli. Ethnic and sociocultural emotional injuries can cause profound changes in the sense of self, altering object relatedness through an increased sensitivity to loss. Although clinical observations suggest that traumatic sequelae of racial insults may include disorders of the self² in addition to cognitive and physical disturbances, research is needed to empirically examine these effects.

We propose that ethnocultural allodynia can result from both historical and contemporary racial trauma. Because racism is an organizing theme in the lives of African Americans³ as well as other people of color, being an ethnic minority in the United States increases the likelihood of developing ethnocultural allodynia. Relative to Whites, African Americans of all socioeconomic levels report more frequent and intense exposure to the stress of racism.⁴ Direct and vicarious racism can range from hate crimes⁵ to systematic discrimination in the legal, educational, housing, and medical systems. Racism has now been recognized as a major violation of human rights.^6,7

Exposure to racism can result in psychological affliction, behavioral exhaustion, and physiological distress.⁸ For example, racial victimization has been associated with increased cardiovascular reactivity among African Americans.^9,10 Paradoxically, seeking treatment may increase racial stress because of the insidious racism and sexism permeating the U.S. healthcare system.^11–15 As part of this system, mental health care has been documented to foster and support racial bias through the disproportionate prescription of certain psychotropic medications, such as antipsychotics.¹⁶ Depressed African-American Medicare patients have been found to be less likely than their White counterparts to receive antidepressants, and when these were prescribed, Whites were more likely than African Americans to receive selective serotonin reuptake inhibitors (SSRIs) as opposed to tricyclic antidepressants.¹⁷ This is a critical difference, since using SSRIs may provide specific benefits for African Americans who, due to racial differences in pharmacokinetics, may be more sensitive to side effects of tricyclics than Whites.¹⁸

Ethnocultural allodynia may be exacerbated by aversive racism, a condition whereby Whites harbor preconscious or unconscious negative racial feelings and beliefs toward people of color, while perceiving themselves as being fair, egalitarian, and thus nonracist. In aversive racism, both liberal and conservative Whites discriminate against African Americans (and probably against other visible people of color) in situations that do not implicate racial prejudice as a basis for their actions.¹⁹ The existence of aversive racism has been empirically demonstrated by using response latency measures of bias.²⁰ These cognitive psychology experiments have found that many Whites who appear to be nonprejudiced in self-report measures actually have pervasive negative attitudes toward African Americans.²⁰

Aversive racism is an extraordinarily complex phenomenon involving unexamined biases such as colorblindness, blaming the victim, “loving minorities,” avoidance, and patronizing.²¹ While colorblindness allows the denial of racial and cultural differences, blaming the victim ignores the responsibility of the perpetrators and of the sociopolitical system that sustain racism. “Loving minorities” depicts individuals whose underlying racist feelings are often belied by self-righteous assertions to the contrary. For instance, the declaration “I'm not racist because I love Chinese food, Latin music, and Black comedians” may conceal unexamined racism. Likewise, patronizing behaviors such as dysfunctional helping (e.g., raising one's voice when talking to individuals whose first language is not English) or offering aid that is inappropriate or unneeded, may represent attempts to camouflage racism. Avoidance is a subliminal racist response whereby Whites do not question why they restrict their socialization to other Caucasians even after encountering African Americans in their daily lives. Although experiencing token social exchanges with people of color, many Whites subliminally confine their nontrivial socialization to other Caucasians. In contrast, immersed in the White society through mass media exposure, most Blacks find themselves in unavoidable hierarchical social interactions with Caucasians, and thus are less likely to engage in avoidant racism.

Unexamined forms of racism such as microaggressions can cause and aggravate ethnocultural allodynia. Microaggressions consist of assaults that visible people of color confront due to their race and color—such as being ignored by clerks in favor of White customers, being mistaken as service personnel, and other racial injuries.²² Indeed, many African Americans probably suffer from endemic ethnocultural allodynia. In a study assessing racial discrimination, Thompson Sanders²³ found that 28% of African American participants indicated that they had confronted significant racial discrimination during adulthood and 17% reported that they had experienced discrimination during both childhood and adulthood. In a subsequent report the same researcher²⁴ reported that 33.8% of the participants had experienced discrimination within 6 months of the study.

Ethnocultural allodynia wounds healthy narcissism and impairs coping because racism often causes confusion, disillusionment,²⁵ and racial mistrust. Systemic racial mistrust may be a historical sign of ethnocultural allodynia whereby collective and historical sociocultural trauma sensitize some people of color into perceiving neutral organizational behaviors as signs of institutional racism. Consider the example of the group of sociologists of color who met with their professional association's president to request representation at an international meeting. The president responded that funds were unavailable, but offered assistance in seeking external funding. Charging racism, the sociologists withdrew from the process, even though several other non-minority groups were unrepresented due to lack of funding. The sociologists' reaction is characteristic of color consciousness or the perception that all problems are caused by racism.²⁶ The non-minority groups followed up on the president's suggestion, securing funds and participating at the meeting. An example of collective ethnocultural allodynia, this response by the sociologists of color prevented them from securing external funds to attend the meeting and to further promote their agenda.

Many people of color experience acute, episodic, and/or chronic racial stress. While episodic racial stress includes exposure to both direct and vicarious racism, acute racial stress comprises regular racial injuries, and chronic racial stress entails cumulative and transgenerationally transmitted racism-related experiences.²⁷ Chronic exposure to discrimination often causes posttraumatic stress disorder (PTSD) in people of color.²⁸ In PTSD, emotional flooding and disorganized behavior is triggered by subtle clues, reminders, or even mini-instances of what has been suppressed.²⁹

Ethnocultural allodynia is consistent with Herman's³⁰ description of complex PTSD, a diagnosis that focuses less on individualistic subjective PTSD symptoms and more on relational issues, dissociation, somatic symptoms, and alterations in one's worldview in terms of trust, hope, and meaning. Moreover, racial trauma changes identity, group relational capabilities, and worldview.⁶ To illustrate, Manuel, a successful Mexican-American dentist, became extremely anxious when a community clinic decided to eliminate pro bono services to Latino children. Manuel reminisced in therapy: “This event reminded me of the way I felt when my kindergarten sweetheart told me that she could no longer be my girlfriend because her mother told her that I was Mexican. I was so devastated that I asked Mami why Whites hated Mexicans.” The community clinic incident acted as a flashback to Manuel's earlier racial trauma, triggering somatic symptoms (backaches and headaches), accompanied by feelings of rejection and abandonment. Mistrusting Whites, Manuel questioned the clinic's commitment to the Latino community. As a consultant to the community clinic, he doubted his own professional expertise. “To them I am just a dirty Mexican.” When Manuel interpreted the cessation of medical services as a conspiracy against immigrants, his wife Mariana asked him to see a therapist. Suffering from ethnocultural allodynia, Manuel reacted to the clinic's financial distress in a way that appeared clinically disproportionate, a hypersensitive response to previous ethnocultural assaults.

Because of the pervasiveness of racism, many people of color are socialized to be vigilant in ambiguous social situations²⁸ in order to preserve dignity and self-respect.³¹ Racial vigilance increases intuition, fostering the development of a “sixth sense” for detecting racism.²⁵ The racial sixth sense can misfire, however, resulting in a lowered threshold for the perception of racial indignities with the development of ethnocultural allodynia. Whether ethnocultural allodynia is an adaptive response, a racial intuition, or a maladaptive response to racial trauma depends on the specific context. The therapist's role is to help patients discern the specific context and develop appropriate racism-specific coping responses.

The following clinical case illustrates the impact of ethnocultural allodynia in an African-American woman's psychotherapy. We use a cultural and gender-specific formulation in the detection, recognition, and treatment of this behavioral allodynia.

CASE REPORT: THE YELLOW CHAMELEON

Nancy is a 45-year-old African-American divorced lawyer who has a 27-year-old daughter. The older of two daughters, Nancy lives with her parents, a retired policeman and an elementary school teacher.

History of present illness. Nancy presented to therapy after a heated argument with a colleague. “I am concerned about my temper and don't want to lose my job,” she stated during the initial clinical appointment. Her friends who recommended therapy worried that Nancy was suffering from depression beneath her anger. To calm herself, Nancy began taking St. John's wort but complained that it was ineffective. She agreed to a psychopharmacological consultation and subsequently began a trial of an SSRI. Nancy acknowledged difficulty in her stress management and entered individual psychotherapy.

Dr. S., a White woman specializing in employment problems, saw Nancy in psychotherapy. When the patient inquired about her experiences in treating patients of color, Dr. S. replied: “I treat all kinds of people, regardless of their color.” Nancy interpreted this as a colorblind response and terminated therapy. Consequently, her psychopharmacologist, a White man, recommended another therapist, a woman of color specializing in multicultural mental health. Nancy agreed to “give it a try.”

Past psychiatric history. Nancy reported no previous personal or family psychiatric history.

Cultural formulation/cultural identity. Nancy described herself as a “high yellow” African-American woman. While completing a multigenerational genogram—a diagram of extended family relationships, kinship networks, and historical links³²—Nancy revealed that her paternal grandmother was a White Cuban immigrant. All other relatives were African Americans. “I guess I can be called a quadroon—a Black with one White grandparent,” she observed. Being able to pass as White, Nancy called herself “a yellow chameleon”: “When I am with Whites I look White, but when I am with African Americans, I look Black.” Prevalent among some multiracial individuals, this process refers to racial backgrounding or the ability to blend with the race of the people in the background. In other words, an African-Japanese man may “look” more Japanese when he is with Japanese people, while “looking” more African American when he is in the company of African Americans.

Socializing predominantly with African Americans and Latinos, Nancy was nonetheless concerned about dating African-American men because “they treat me like a trophy.” Regarding White men, she declared, “I don't want to go there.” Indeed, Nancy's first marriage to a White Jewish man ended in bitter divorce. The union produced a daughter, Marina, a 27-year old biracial lawyer who married a Puerto Rican physician. Nancy's second major significant romantic relationship was a 5-year-old common law marriage to José, a Black Dominican man. This relationship ended when José moved back to the Dominican Republic for unclear reasons.

Cultural explanations of Nancy's illness. Clinical examination revealed that Nancy was depressed in reaction to the anniversary of the termination of her engagement to Charles, an African-American lawyer whom she accused of wanting a wife who “could pass as White.” Nancy identified an argument with Charles regarding the movie Jungle Fever, in which an African-American lawyer left his Black wife for a White woman. Upon the anniversary of her breakup, Nancy became upset, wondering whether she had overreacted to the incident. “Just because Charles could understand the protagonist's behavior didn't mean that he was going to leave me for a White woman,” Nancy conceded.

Nancy identified her light skin as the cause of envy and resentment from other African Americans. “At best, they are ambivalent towards me,” she noted. Nancy seemed to have internalized such ambivalence, compounded by her ability to pass. In exploring cultural idioms of distress, Nancy revealed that she feared people's envy. She disclosed that six months before the breakup with Charles, a Tarot card reader had predicted that Charles was going to leave her for a White female colleague. The psychic identified envy as her rival's motivation. Nancy remembered that her Cuban grandmother declared that envy could cause sadness and depression in its target. However, when the therapist directly asked her whether her depression was caused by envy, Nancy replied: “I don't think so, but I don't doubt that envy causes suffering.” She later confessed that she had had a dream in which her dead grandmother, a practitioner of santería (Afro-Caribbean folk religion), asked her to wear an amulet to ward off envy. “Sometimes I wear it, sometimes I don't,” Nancy admitted.

Cultural factors related to the psychosocial environment and levels of functioning. Nancy's parents provided instrumental and emotional support. However, their deteriorating physical health was a major concern for Nancy. Indeed, she enhanced her caretaker role by residing with her parents. Nancy welcomed this change since she identified taking care of others as paramount to taking care of herself.

Active in African-American professional associations, Nancy was proud of her community activism and public interest commitment. Although these activities provided a support system, they also exposed her to adversarial interactions with mainstream institutions. As a lawyer, she was often assigned the spokesperson role. Within this context, Nancy acknowledged an oversensitivity to racial and gender insults. “I die small deaths every day,” Nancy replied when exploring her history of racial and gender affronts.

Examining her ethnocultural trauma revealed a catastrophic injury during adolescence. Nancy related that her high school discouraged Black candidates for prom queen. “Everyone knew that it was a no-Black-candidates situation.” A new student, Nancy passed as White, had her hair chemically relaxed, and ran for prom queen. Confident of winning, she stated that she wanted to come out of the racial closet at the moment of being crowned and thereby shame her White classmates. “I never denied my race, but I tried to pass because as the queen I was going to announce to the world that Black is beautiful.” Nancy declared. Unfortunately, she was racially outed by an “envious White prom queen candidate,” resulting in Nancy's public humiliation. While Whites accused her of being an impostor, Blacks saw her as a traitor.

Nancy experienced subsequent gender and racial trauma as being neither “White enough or Black enough.” For many African-American women, looking White can be a cause for devaluation from their family and peers.³³ Being a “yellow chameleon” further landed Nancy in a professional racial limbo, lacking the support and solidarity of either Blacks or Whites. As a White-looking Black, she benefited from affirmative action but was not White enough to be promoted past the racial and gender glass ceiling. “At work I am promoted to where most Blacks are not, but as a non-White woman I can't get into the upper echelon,” she complained.

Levels of functioning and disability. Nancy's functioning at her job was outstanding. Notwithstanding her argument with a colleague, she was widely respected and admired. Moreover, her immediate supervisor and the head of the firm stated that she was an invaluable asset. Nonetheless, Nancy's interpersonal relationships had deteriorated, causing concern among her friends and significant others.

Cultural elements of the clinician–patient relationship. Nancy's clinician was a Puerto Rican female therapist (first author). The ethnic, racial, and gender similarities helped to cement the therapeutic alliance. “I grew up with Puerto Ricans in New York and as a high yellow Black, people thought I was Boricua,” Nancy stated. Boricua (literally meaning a native from Borinquén—Puerto Rico's Taíno name) is a term many Puerto Ricans use to designate each other. Consequently, Nancy developed a positive transference toward the therapist, equating her with her Cuban grandmother: “You have a similar accent to my grandmother's.” The development of this positive alliance seems consistent with research indicating that African Americans in same-race clinician–patient dyads describe the clinical relationship as more participatory than those in race-discordant therapeutic dyads.³⁴

Coinciding with Nancy's disclosure of her early gender racial trauma, she confessed to her therapist why she decided to adopt the clinician's hairstyle. “We both have suspicious hair—not clearly good or bad. After our first meeting I went to my hairdresser and had it cut short just like yours,” Nancy explained. This therapeutic racial mirroring seemed to facilitate Nancy's disclosure of past gender and racial insults. While discussing her passing as White during high school, she said: “You understand what I mean by chemically relaxing your hair.” Addressing this comment was a turning point in treatment. Instead of using a psychodynamic interpretation, the therapist took at face value Nancy's words, a strategy that further cemented the therapeutic alliance. Hair issues are extremely sensitive and complex among African-American women since “good” (straight) hair often denotes attractiveness and “bad” (kinky) hair signifies unattractiveness.³² The complexity of hair texture also involves internalized racism in that “good” hair implies White beauty standards, while kinky hair relates to African beauty standards. The African-American mental health literature has consistently argued that since hair texture is central to African-American women's self-image and sense of well-being, it requires exploration as a reality issue.^32,35,36

Overall cultural assessment for diagnosis and care. Assessment and treatment combined an ethnocultural and a gender-specific approach with cognitive-behavioral techniques. Nancy's cultural identity, trauma, loss, and grief were explored and addressed. Assessment included an ethnocultural trauma inventory, examining Nancy's racial and gender wounds. Such inventory involved the examination of racial injuries in Nancy's life as measured by the Schedule of Racist Events.³⁷ The inventory provided data for the therapeutic desensitization by unfolding Nancy's hierarchy of exposure to racist events. Following the empirical research demonstrating that stress inoculation training produces greater improvement in symptoms of posttraumatic stress disorder than supportive therapy,³⁸ cognitive-behavioral techniques were used to desensitize and inoculate Nancy against gender and racial stress. Using the data from Nancy's Schedule of Racist Events, the therapist asked her to imagine racist events with negative emotions. She then taught Nancy progressive muscle relaxation for the systematic desensitization process. Guided imagery was used in the inoculation process. A therapeutic emphasis on identifying the rational responses to racism from irrational responses facilitated Nancy's ability to differentiate between functional and dysfunctional reactions to racism. Additionally, the ethnocultural allodynia treatment involved Eye Movement Desensitization and Reprocessing (EMDR) techniques for racial trauma,³⁹ in particular the safe place exercise and the light stream technique.⁴⁰

A pivotal aspect of the clinical work was racial psychoeducation or the provision of information regarding racism, its causes and effects, and coping mechanisms. Psychoeducation also included the examination of personal, group, and societal dynamics in order to understand the different psychological stages that the victim/survivor faces. As part of psychoeducation, internalized racism was explored as promoting ethnocultural allodynia through the reenactment of racial victimization. This experience was a painful but helpful process for Nancy. Moreover, using the therapeutic relationship was crucial at this healing stage. At one point, Nancy's positive transference turned negative: “My grandmother was racist, even though she married a Black man,” Nancy cried out while questioning her therapist's commitment. Working with the transference, the clinician racially resocialized Nancy. Racial socialization involves teaching cognitive skills in the accurate identification of racism, modeling of appropriate responses, and emotionally supporting the management of feelings of difference, rejection, and confusion generated by the racist experience.³³ Similarly, therapeutic racial resocialization entails facilitating the understanding of racist injuries, teaching cognitive-behavioral skills to cope with them, and working through negative feelings associated with racial and sexual discrimination. The clinician's availability, consistency, care, and acceptance were essential during Nancy's racial resocialization. Eventually, Nancy worked on reconciliation with her grandmother's racism and with her own internalized racism.

Defining and identifying ethnocultural allodynia was a central area of psychoeducation, increasing Nancy's awareness and critical consciousness. According to Paulo Freire,⁴¹ critical consciousness is an empowering approach promoting a change of mentality, improving the capacity to critically analyze oppression, and increasing the ability to choose among alternatives. Examining Nancy's choices helped her to recognize and understand the strategies used against racism and to evaluate their effectiveness. Making conscious decisions required analyzing both external and internal realities, as well as placing Nancy's racial coping within a context. Having addressed her internalized racism, psychoeducation promoted racial socialization aimed at distinguishing racial threats from neutral ones. Therapy allowed the discussion of appropriate responses to diverse situations, including strategies to address racism while identifying dysfunctional responses such as allodynia. This training enhanced and fortified Nancy's adaptive coping with racism and sexism. The racial stress inoculation training augmented Nancy's sense of mastery and agency. Repairing a damaged self-image while reducing ethnocultural allodynia, this treatment helped Nancy to enhance her self-esteem and self-determination.

EPILOGUE

Nancy's narrative highlights the relevance of ethnocultural and gender factors in therapy. The ethnocultural and gender-specific formulation helped to diagnose and treat Nancy's ethnocultural allodynia, allowing the unfolding of core therapeutic issues. Trust, acceptance of self and others, internalized racism, fragmentation, and integration were some of the topics catalyzed in this culturally relevant and gender-specific therapy. Clinical intervention incorporated racial socialization coupled with racial stress management and racial inoculation training. Psychoeducation regarding ethnocultural allodynia was a crucial element in healing that was particularly helpful to Nancy. Three months after terminating treatment, Nancy called her therapist's answering service: “Today I heard a White man call a Black man ‘nig—r.’ For the first time in my life, I did not experience this as a fatal wound.”