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Internalized Oppression, Psychopathology, and Cognitive-Behavioral Therapy Among Historically Oppressed Groups E. J. R. DAVID Department of Psychology University of Alaska Anchorage Abstract

In recent decades, clinical psychologists have increased their efforts to make Empirically Supported Treatments (EST) more culturally appropriate and effective for various minority groups. Parallel to this development, greater attention has also been paid to identifying various political, social, and cultural variables that may influence the development of psychopathology and improve culturally specific treatment methods. The current article reviews the historical and contemporary experiences of oppression by various minority groups and proposes that internalized oppression is one important variable that may influence psychopathology development among members of such groups. Furthermore, I make suggestions with regard to how clinicians may culturally modify one popular EST - Cognitive Behavioral Therapy (CBT) to conceptualize and address internalized oppression. It is hoped that this paper will (1) increase awareness of minority groups' historical and contemporary experiences of oppression, (2) inspire greater awareness of how internalized oppression may influence psychopathology, and (3) generally articulate how CBT may be applied to address internalized oppression within racial and ethnic minority communities. Send correspondence to: E.J.R. David, Ph.D.; Department of Psychology; University of Alaska Anchorage; 3211 Providence Drive, SSB214; Anchorage, Alaska 99508; Email: [email protected]

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Introduction A large and controversial debate regarding evidencedbased practices (EBPs) in mental health began during the 1990s (Norcross, Beutler, & Levant, 2006). Shortly thereafter, the American Psychological Association's Society of Clinical Psychology (Division 12) established a task force to identify and publicize a list of empirically-supported treatments (EST) (e.g., Chambless & Hollon, 1998; Chambless, et al., 1996). In the seminal Evidence-Based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions edited by leading scholars in this debate (Norcross, Beutler, & Levant, 2006), the most pressing issues surrounding EBPs in mental health are explored in detail. One of the fundamental issues in the controversy according to the editors and other scholars (e.g., Sue & Zane, 2006) is the lack of attention being paid to how validated or supported these practices and treatments are for non-White or non-Western individuals. Indeed, various researchers have commented that there is not one EST for ethnic minority populations (Bernal & Scharron-Del Rio, 2001; Chambless, et al., 1996; Sue & Zane, 2006; Zane, Hall, Sue, Young, & Nunez, 2003). Consequently, there has also been a recent push toward making psychological treatments more culturally appropriate and, thus, more effective for nonWestern or non-White individuals (e.g., Sue & Zane, 1987). One notable example of such an effort is Hays' and Iwamasa's (2006) edited text Culturally Responsive CognitiveBehavioral Therapy: Assessment, Practice, and Supervision. Without a doubt, the parallel and related issues of establishing SSTs and improving the cross-cultural appropriateness of psychological interventions have been two of the fastest growing and most vibrant areas of clinical psychological research over the past two decades. Due to the increased attention on establishing SSTs and making such interventions appropriate and effective for

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various minority groups, efforts toward examining factors that contribute to treatment outcomes has also grown. Intervention outcome research has typically focused on three major sources that contribute to observed variance in treatment outcomes: (1) client characteristics and behavior (e.g., values, acculturation, fatuity characteristics and dynamics); (2) therapist characteristics and behavior (e.g., values, preference for certain treatments); and (3) treatment features and procedures. Treatment outcome research has focused on the separate as well as interactive effects between variables from these three sources. Major reviews have found that client and therapist variables tend to account for relatively more variance in intervention outcomes than treatment features (e.g., Bergin & Garfield, 1994; Wampold, Mondin, & Ahn, 1999). Moreover, Norcross and Goldfried (1992) found that client, family, and environmental factors accounted for the most variance (40%) in the observed improvement among psychotherapy clients, with therapist and relationship factors (30%) and treatment features (30%) splitting the remaining observed variance in treatment outcome. Various culture-related factors among non-white groups (i.e., client characteristics) that may potentially influence the implementation and, consequently, the effectiveness of, these so-called empirically-supported treatments when applied to non-white individuals have been proposed. These client characteristics include differing attitudes and cultural beliefs about mental health, unfamiliarity with the English language, family factors, and unfamiliarity with American values, among others. Research with Asian Americans, for example, has found that: (1) shame and stigma felt by relatives were associated with greater delays in family efforts to seek treatment for the patient (Okazaki, 2000); (2) adherence to Asian cultural values was a negative predictor for general willingness to seek treatment (Kim & Omizo, 2003); and (3) significant differences exist between Whites and Asian

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Americans with regard to how each group conceptualizes family roles (e.g., Strom, Park, & Daniels, 1987), self-concept (e.g., Arkoff & Weaver, 1966), ethnic identity (e.g., Atkinson, Morten, & Sue, 1988; Phinney, 1990), life stressors (e.g., Abe-Kim, Takeuchi, & Hwang, 2002), and mental health and illness (e.g,, Sue et al., 1976; Tung, 1985). Hall (2001) defined Culturally Sensitive Therapies or treatments (CSTs) as interventions that are tailored to address and incorporate the clients' cultural contexts. Thus, when clients ' cultural characteristics such as those outlined in the previous paragraph are taken into account in the application of an intervention, such an intervention is often regarded as a CST. This approach is becoming more widely used in the treatment of various cultural groups, and research suggests that this method is effective (Flaskerud, 1986; LaFromboise & Howard-Pitney , 1995; Lau & Zane, 2000; Malgady, Rogler, & Costantino, 1990; Zane, et al., 1994). Despite the increased attention paid to culture-related client variables, however, one client characteristic that has yet to be recognized as influencing the development of psychopathology and treatment efficacy is internalized oppression. Internalized oppression and its variants have the potential to influence ethnic minority clients in various clinical contexts. For example, internalizing the stereotype that members of one's social group are not as bright as others may activate stereotype threat, which may affect anxiety (Osborne, 2007) and performance during assessments (Steele & Aronson, 1995). Furthermore, internalizing the notion that most people and institutions of the majority culture cannot be trusted results into cultural mistrust, which may influence help-seeking attitudes (Whaley, 2001a) and the development of paranoia (Whaley, 2001b). To this end, in the succeeding paragraphs I describe internalized oppression in more detail and how it may influence the development of psychopathology among various historically oppressed groups. Next, I present some ideas for

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how cornponents of one of the most popular ESTs - Cognitive Behavioral Therapy (CBT) - may be applied effectively to conceptualize and address internalized oppression. It is hoped that these suggestions for keeping an eye for one important client characteristic (i.e., internalized oppression) among members of historically oppressed groups and how to apply a popular EST (i.e., CBT) in a more sociopolitically and culturally appropriate manner may contribute toward improving the cultural sensitivity and effectiveness of the field's interventions with racial, cultural, and ethnic minorities. Historically Oppressed Groups Racial and ethnic prejudice and discrimination, along with their associated injustices, are ubiquitous in the United States (e.g., Dovidio, Glick, & Rudman, 2005). Thus, many non-white individuals in this country have experienced some sort of oppression, both historically and contemporarily. For instance, African Americans' (population: 36.0 million; McKinnon, 2003) early experiences in the United States have been tainted with brutal acts of oppression (e.g., slavery) and their current daily experiences in the country continue to consist of both overt and subtle forms of oppression (Carter, 2007; Speight, 2007). American. Indians and Alaska Natives (population: 4.3 million; Ogunwole, 2006) have experienced and survived colonialism, attempted genocide, and boarding schools that intended to eradicate their culture. Furthermore, various stereotypes (e.g., the drunk Native; American Indian mascots) for American Indians and Alaska Natives continue to persist to this day. Among Asian Americans and Pacific Islanders (population: 12.2 million; Barnes & Bennett, 2002; Grieco, 2001), it is often forgotten that they have experienced severe forms of racism throughout American history such as the Japanese internment during World War II, the increased anti-Asian sentiments during the Korean War, Vietnam War,

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the fear of Chinese communism in the 1990s, the aftermath of September 11, 2001, and the scapegoating of South Asians and Filipinos for American companies' decisions to outsource work abroad (Mio, Nagata, Tsai, & Tewari, 2006). Furthermore, Filipinos (2 nd largest Asian ethnic group in the United States; population: 3.4 million) experienced a long period of colonialism under the Western nations of Spain and the United States, and Filipino Americans continue to face various forms of contemporary oppression with 99% having racist experiences on a daily basis (Alvarez, Huang, & Liang, 2006). Lastly, it is undeniable that Hispanic/Latinola Americans (population: 37.4 million; Ramirez & de la Cruz, 2003) have also experienced various forms of racism, discrimination, and other forms of oppression (e.g., stereotypes, colonialism) throughout history, with the current debates on immigration reforms revealing the persistence of anti-immigration and anti-Hispanic/Latinola sentiments held by many in the American society. Indeed, among many minority individuals, the harsh and painful histories of their social group in relation with the United States continue to be of significant importance in how they experience the American society today. Furthermore, despite the United States' increasing progress toward multicultural and multiracial diversity, minorities' daily experiences in the country continue to consist of interpersonal, institutional, overt, and subtle messages telling them that their group, and thus them as persons, are inferior to the majority (e.g., Sue, et al., 2007). Thus, it is very likely that such historical and contemporary stressors continue to influence their psychological experiences. In terms of their mental health, the Surgeon General's report on Mental Health: Culture, Race, and Ethnicity (U.S. Department of Health and Human Services, 2001) highlighted the finding that minorities experience mental disorders at a rate that is similar to or higher than the majority White population, For example, high rates of depression have been found

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among Hispanic/Latino/a Americans, American Indians and Alaska Natives, and Asian Americans, and high rates of anxiety arnong Asian Americans, Hispanic/Latinola Americans, and African Americans have been reported. Examining these findings in the context of other research suggesting that minorities have low rates of service utilization (e.g., President's Commission on Mental Health, 1978; President's New Freedom Commission., 2003), the Surgeon General concluded that a high proportion of minorities have unmet mental health needs. Consequently, the Surgeon General recommended the incorporation of historical, political, and cultural factors in the implementation of mental health activities (i.e., interventions, research) targeting minorities. Internalized Oppression and Psychopathology Among Historically Oppressed Groups One psychological variable that is highly shaped by the historical, political, and cultural experiences of minorities is internalized oppression -- a condition in which an oppressed individual or group come to believe that they are inferior to those in power. The colonial model described by Frantz Fanon (1965) provides a theoretical framework for understanding the psychological effects of oppression on the oppressed. The first phase of colonialism is the entry of a foreign group into a territory with the intention of exploiting the territory's natural resources, including its inhabitants. The second phase is the imposition of the colonizer's culture on the colonized, disintegration of the indigenous culture, and recreation of the indigenous culture as defined by the colonizer. Such a cultural transformation of the colonized culture is intended to differentiate between the colonizers' allegedly superior or more civilized ways of life and the colonized people's assumed inferior or savage ways. Once a distinction has been established between the colonizer and the colonized, the

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third phase begins with the colonizer having to nobly monitor, tame, train, and civilize the colonized people through a process of tyranny and domination. Accomplishing the first three phases eventually leads to the fourth phase, which involves the establishment of a society where the political, social, and economic institutions are designed to benefit and maintain the superiority of the colonizer while simultaneously subjugating the colonized. Thus, colonialism is a specific form of oppression. The major psychological effect of colonialism is internalized oppression. Fanon (1965) argued that the constant denigration of the colonized under colonialism often leads to self-doubt and feelings of inferiority. Memmi (1965) added that the creation of a colonizer-defined cultural identity for the colonized often leads the colonized to eventually believe such an inferiorizing identity. Freire (1970) further contended that because of the inferior connotations attached to their cultural and ethnic identities, the colonized might develop a desire to rid themselves of such attributes by trying to emulate the colonizer as much as possible. Thus, the colonized may begin to act and dress like the colonizer because the colonizer's ways are seen as superior. Furthermore, the colonized may eventually feel a sense of gratitude and indebtedness toward the colonizer for civilizing and enlightening the colonized (Rimonte, 1997). The link between one's self perception and psychological distress has long been established (e.g., Sandura, 1997; Rosenberg, 1965). However, one's self-concept is not just composed of the individual or personal self Instead, selfconcept is composed of both a personal and a collective component and each component can be associated with either positive (or pleasant) or negative Or unpleasant) attributes (Tajfel & Turner, 1986). If personal self-esteem is the extent to which an individual evaluates his/her personal self positively, collective self= esteem is the extent to which an individ-

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ual evaluates his/her social groups positively (Luhtanen & Crocker, 1992). Furthermore, obtaining and maintaining positive personal and collective selves are essential for psychological health (Crocker, Luhtanen, Blaine, & Broadnax, 1994). One important social group for ethnic minority individuals is their ethnic or cultural group, The extent to which such individuals evaluate their heritage group is one aspect of their collective self-esteem. For members of historically oppressed groups, centuries of oppression may have resulted in internalized oppression, which in turn, may negatively influence their collective self=esteem. Given that various personal characteristics are intrinsically tied to their social group membership (e.g., skin color, language, etc.), internalized oppression also has the potential to negatively influence their personal self-esteem, Such a negative regard toward one's heritage ethnicity and culture, as well as one's personal characteristics, may adversely affect one's psychological well-being and mental health, which may partly explain the high rates of psychological disorders found for various minority groups (U.S. Department of Health & Human Services, 2001). In the succeeding paragraphs, 1 will briefly discuss internalized oppression as experienced by four major racial groups in the United States, with a focus on the experiences of specific subgroups within each racial group to serve as prototypical examples. Among African Americans, Thomas (1971) theorized that internalized racism leads to identity confusion and to the development of a self-inferiorizing identity. The Black Identity Development Model (Nigrescence Model) (Cross, 2001; Cross & Vandiver, 2001) also argued that internalized oppression may lead African Americans to highly value the dominant culture and simultaneously devalue their own, which could lead many to hold anti-Black sentiments. Consistently, Harrell (1999) also argued that internalized oppression may lead members of this group to develop self-hatred and behave

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in self-destructive ways. Tatum (1994) further proposed that internalized oppression is another possible explanation for the high rates of crime among African Americans, arguing that such behaviors are self-destructive responses to a society wherein opportunities for social mobility are limited because of one's race (also, see Carter, 2007 and Speight, 2007 for a recent review of the mental health implications of racism among African Americans). It has also been demonstrated that oppression is negatively related to African Americans' physical and mental health (Landrine & Klonoff, 1996; Kolonoff, Landrine, & Ullman, 1999). More recently, stress associated with cultural adaptation (i.e., acculturative stress) such as environmental experiences that affect the sense of well-being (Berry, 2003) have been found to be associated with depression among African Americans (Walker, Wingate, Obasi, & Joiner, 2008). Furthermore, Walker and colleagues (2008) also found acculturative stress and ethnic identity -- the extent to which members of an ethnic group positively value their heritage - to be moderating the link between depression and suicide among African Americans. The colonization of Native Americans and the concomitant efforts to destroy and recreate indigenous Native American cultures as exemplified by the boarding school era, attempted genocide, and geographic displacement has arguably denied many Native Americans a deep connection with an indigenous cultural identity and spirituality (McBride, 2002), The internalization of such oppression likely evokes profound feelings of cultural isolation and distress, potentially creating a diathesis for sundry dysfunctional behaviors (e.g., increased rates of substance abuse, domestic violence, depression, suicidality, etc.). Duran and Duran (1995) and Brave Heart (1998) also argued that internalized oppression is passed on intergenerationally by continued oppression, lack of opportunities to critically and accurately understand history, ensuring that later generations experience similar difficulties. The int-

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ergenerational transmission of the psychological consequences of oppression has also been observed among Jewish holocaust survivors and their children (e.g., Major, 1996; Sorscher & Cohen, 1997) and Japanese American internment camps survivors and their children (e.g., Nagata & Cheng, 2003). Although it would be a gross oversimplification to assert that the groups we categorize as Asian American are somehow homogeneous, it is fair to say that some commonalities exist in terms of how these various groups are affected by discrimination. Thus, while it is beyond the scope of the present paper to discuss how racism affects every Asian American subgroup, it is possible to capture some common themes by utilizing a representative example from which we might make some generalizations to other groups. For this purpose, I have chosen to discuss the experiences of Filipino Americans. It has been argued that, among this group, ideas of superiority, pleasantness, or desirability have been associated with anything American or Western - a condition of internalized colonialism popularly referred to as Colonial Mentality (David & Okazaki, 2006a; 2006b; Root, 1997; Strobel, 2001). David and Okazaki (2006b) conceptualized Colonial Mentality (CM) as "...a perception of ethnic or cultural inferiority that is...a specific consequence of centuries of colonization" and that it " ...involves an automatic and uncritical rejection of anything Filipino and an automatic and uncritical preference for anything American" (p. 241). Behaviors such as discriminating against other Filipinos who are perceived to be "too Filipino" and using bleach or other skin-whitening products to whiten one's appearance are believed to be manifestations of CM (David & Okazaki, 2006a; 2006b). Scholars have speculated that CM is prevalent among this ethnic group (Bergano & Bergano-Kinney, 1997; Lott, 1976; Revilla, 1997) and psychiatrists Tompar-Tiu and Sustento-Seneriches (1995) also hypothesized that CM may possibly contribute to

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the high depression rates (27.3%) they found for this population. David and Okazaki (2006b) tested this hypothesis and found CM to be uniquely contributing. to Filipino Americans' depression symptoms above and beyond the contributions of self-esteem and status (sex and socioeconomic) variables. More recently, David (in press) compared a model of depression without CM to a model that includes CM using structural equation modeling and found that CM is positively correlated with depression and that CM has a significant direct effect on depression symptoms among Filipino Americans. Furthermore, the CM model was able to explain approximately 63 of the variance in reported depression symptoms. Among Hispanic/Latino/a Americans, the implicit effect of skin color on determining important life factors such as employment, income, and self-concept that exists in American society has been argued to be especially problematic for this ethnic minority group - a group that is "characterized by a rainbow of skin colors and diverse physical attributes" (Hall, 1994, p. 307). Hall argued that colonization and its "domination model of assimilation" (pp. 309-310) leads many Hispanic/Latino/a Americans to believe that light skin is the most advantageous, attractive, and desirable skin color. The internalization of such a skin-color ideal consequently results in a perceived necessity to become as white as possible in order for social mobility. This desire to shed one's natural, but socially undesired, physical traits has been argued to lead many Hispanic/Latino/a Americans to use "beauty" creams and other products such as bleach in order to whiten their skin (Hall, 1994). Indeed, according to Hall, many Hispanic/ Latinola Americans "will value and internalize all aspects of the mainstream culture - including the idealizations of light skin color - at the expense of their culture" (p. 310). Empirically, using a Mexican American sample, Codina and Montalvo (1994) found that darker skin color and loss of Spanish culture (i.e., lan guage) was associated with hi gher

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levels of depression. More recently, acculturative stress was found to be associated with depression symptoms and suicide among Hispanics/Latinos/as (Hovey, 2000a; 2000b). A specific Hispanic/Latino/a American ethnic group that has received some psychological research attention in terms of their experiences of internalized oppression is the Puerto Rican population. Puerto Rico was colonized by Spain in 1493, was sold to the U.S. in 1898, and remains an American territory to this day. The effects of centuries of Spanish and American colonialism on the psychological experiences of Puerto Ricans are remarkably similar to David and Okazaki's (2006a; 2006b) description of the psychological consequences of Spanish and American colonialism among Filipino Americans. For instance, Varas-Diaz and Serrano-Garcia (2003) found that it is common for Puerto Ricans to experience identity confusion, feel ashamed of their ethnic and cultural identity, feel inferior about being Puerto Rican, and not have national pride. Furthermore, they also reported that Puerto Ricans despise the stereotypical and mythical perceptions often imposed on them by mainland Americans, including Puerto Ricans in the mainland U.S. Finally, they also found that negative emotions such as shame, anger, desperation, and disillusion were associated with what the researchers called "the Puerto Rican experience" (p. 112). A similar psychological phenomenon relating to loss of identity has also been observed among the Chamorro group in the currently U.S. colonized island of Guam (Perez, 2005). Internalized oppression has also been argued to be common among members of sexual minority populations. For example, Meyer (2003) argued that both distal (e.g., discrimination) and proximal stress processes (e.g., concealing one's sexual orientation) affect LGB individuals' mental health. He further proposed that the most proximal of the stressors (on the continuum from the environment to the self) is internalized homophobia -- a form of internalized oppression in which

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LOB individuals eventually re-direct negative homophobic societal attitudes toward themselves. Even in the absence of direct and explicit discrimination, he argued that internalized homophobia could harm LGB individuals' self-regard. Empirically, it has been shown that internalized homophobia is related to negative psychological outcomes (Williamson, 2000). In sum, the literature reviewed above suggests that members of historically oppressed groups may eventually internalize the oppression they experience. Internalized oppression, in turn, has the potential to influence how members of such groups perceive their personal and their social group's characteristics. Furthermore, internalized oppression also has the potential to influence how members of historically oppressed groups perceive and regard the social group in power, or those whose personal characteristics resemble those of the allegedly superior group. Such perceptions of one's self, environment, and others have been shown to have important implications on the psychological well-being and mental health of historically oppressed groups. I now turn to a discussion of internalized oppression as it relates to cognitive-behavioral theory and provide a few examples of how CBT may be applied to address internalized oppression. Internalized Oppression and Cognitive-Behavioral Therapy CBT is the most popular form of psychotherapy today (Norcross, Hedges, & Prochaska, 2002). However, an overwhelming majority of the literature on CBT involves only people of European American identities (Suinn, 2003). Furthermore, CBT is often criticized for being value-neutral and its overreliance on science, logic, and rational thinking makes it appear to be valuing dominant cultural perspectives (Kantrowitz & Ballot', 1992). Also, CBT's strong emphasis on changing internal factors (e.g., cognitions and behaviors)

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has been viewed as potentially reinforcing the notion of victim blaming and limits its ability to consider and change external and cultural factors (Hays & Iwamasa, 2006). However, such limitations of CBT are not insurmountable, and a closer look at its major tenets reveals that CBT may be highly appropriate for various ethnic and cultural minority groups. First, CBT emphasizes the need to tailor interventions to the unique contexts of individuals. Second, CBT works toward empowering the client by recognizing the client as the expert regarding his/her experiences. Finally, CBT pays attention to and utilizes the client's strengths and support systems. Indeed, CBT has been shown to be culturally-modifiable and effective for various minority clients (for examples, please see Hays & Iwamasa, 2006). Using cognitive-behavioral theories, internalized oppression may be conceptualized as a sett of self-defeating cognitions, attitudes, and behaviors that have been developed over time as one consistently experiences an unjust and oppressive environment. Furthermore, internalized oppression may be conceptualized as a distorted view of one ' s self and of others that is a consequence of how one experiences his/her environment. One of the most basic tenets of CBT is that thoughts that occur most frequently and are most easily accessible in memory are the ones we tend to believe. Historically oppressed groups have been, both in subtle and overt ways, consistently receiving the message that they are inferior to the dominant group, Eventually, members of historically oppressed groups may no longer need the dominant group to perpetuate such inferiorizing messages; they begin telling themselves in overt and subtle (and automatic) ways. Consistent with the literature on cognition and culture (Hong, Morris, Chiu, & Benet-Martinez, 2000), members of oppressed groups may eventually internalize the oppression they experience in such a deep way that it creates within them a cultural knowledge system that is characterized by automatic negative

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cognitions and perceptions of their heritage group. Recently, David and Okazaki (under review) used the implicit association test and lexical decision priming task among multiple samples of Filipino Americans and found empirical evidence supporting the notion that members of this group have automatically associated undesirable, unpleasant, and negative thoughts with the Filipino culture and desirable, pleasant, and positive thoughts with the American culture, suggesting that oppression has been internalized deeply enough by members of this group for a distorted cognitive system to be developed and automatically operate. Consistent with cognitive behavioral theories on psychopathology (e.g., Beck, Ruch, Rush, Emery, & Shaw, 1979), underlying such automatic thoughts, attitudes, (e.g., "Lighter skin is more attractive or desirable") or behaviors (e.g., discriminating against less-Westernized members of the same racial group) are maladaptive general beliefs (e.g., "Being White or American is better than being Black/Asian/ Hispanic/Latino/a/Native") that have been developed from previous experiences (e.g., colonialism, slavery, boarding schools, contemporary oppression). Such thoughts and beliefs contribute to the creation of dysfunctional self-schemas (e.g., "I'm Black/Asian/Hispanic/Latino/a/Native, therefore I am not attractive and I am inferior to Whites") that may lead to psychological distress and various psychopathology. For historically and contemporarily oppressed groups, the experience of centuries of ethnic and cultural subjugation may have created a general belief that the indigenous cultures of these groups are somehow inferior to those of their Western colonizers. Such a belief may underlie the automatic selfdeprecating thoughts and behaviors that many members of these groups display today. Such automatic negative cognitions and behaviors are likely damaging to the self-esteem and may contribute to the development of various forms of psychopathology, including depression and anxiety.

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Internalized Oppression and Depression

Internalized oppression may lead to depression in the following manner: A person internalizes the idea that he/she is worthless, stupid, or undeserving due to his/her group membership (cultural, ethnic, racial, or other social group), an idea that has been consistently imposed and reinforced by the person's experiences with his/her environment. Furthermore, because of the negative connotations attached to one's social group, the person may eventually distance and isolate himself/ herself from other members of the social group, many of whom may be significant characters in the person's life. Moreover, given that it may be impossible for these individuals to completely rid themselves of their respective group identities (i.e., their status results from society's view of their physical characteristics, gender, etc.), the person may develop what cognitive-behavioral psychologists call learned helplessness (Peterson & Seligman, 1984). That is, persons may develop the attitude that there is nothing they can do to rid themselves of the negative attributes they possess because it is intrinsically linked to their social group. This is consistent with what Peterson and Seligman (1984) called having a pessimistic explanatory style, which is the tendency to perceive the assumed inferior characteristics of their group as permanent or stable (e.g., "I will never be able to completely rid myself of my dark skin"), personal or internal (e.g., "It's my fault or my ethnic groups' fault"), and pervasive or global (e.g., "All of the characteristics of my ethnic group are inferior"). Thus, the person may altogether "give up" and stop trying to improve the adverse situation. Such feelings of inferiority, isolation, and helplessness, in turn, may create within the person a sense of guilt or self-blame for being a member of an allegedly inferior social group. The combination of such feelings of worthlessness, isolation, guilt, and lack of rnotivation may contribute to the development of a rnajor depressive episode,

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dysthymia, or an anxiety disorder. CBT may be utilized to address internalized oppresssion, which may be contributing to the experienced depression, in the following manner: Homework may be assigned testing the client's distorted core belief that the social group to which he/she belongs possesses mostly (if not all) undesirable characteristics (in CBT terms, magnification of negatives and minimization of positives regarding one's social group). The client may be asked to list the characteristics of the social group that are desirable or positive. The client may also be asked to speak with other members of the social group (e.g., elders, community leaders, etc.), attend events of the social group (e.g., powwows, etc.), or conduct literature search (e.g., books about the social group's history, culture, etc.) to help facilitate the identification of positive social group characteristics. Furthermore, the distorted or inaccurate core belief that he/she is worthless may be challenged by asking the client to list positive attributes that he/she possesses. The list of positive attributes may be generated by the client or the client may ask relatives, friends, co-workers, or other people to provide positive attributes they think the client has. One of the main purposes of these tasks is to make more positive information about the client and about the client's social group more frequently available and salient to the client, which may eventually challenge the negative automatic cognitions about himself/herself and about his/her group that the client had developed over time. Another goal of such tasks is to encourage the client to interact with other members of the social group in order to reduce the client's sense of isolation and improve the client's appreciation of the social group. Finally, it is likely that as the client learns more about the social group's history, he/she will learn more about the oppression of his/her social group. This may contribute toward the identification of where inferiorizing messages are coming from and the eradication of the self-blame that has been developed. This cognitive re-


structuring is challenging because minority individuals will likely continue to have experiences that reinforce the inferiority of their heritage groups. However, the realization that such inferiorizing messages are inaccurate and the increased salience of positive messages about one's heritage group may provide minority individuals the needed tools to resist the internalization of the inferior messages that are perpetually reinforced by society. It is likely that a more accurate perception (i.e., a cognitive system consisting of both positive and negative attributes) of his/her personal characteristics and of his/ her social group's characteristics may reduce, and eventually eradicate, the feelings of depression that the client has for being a member of the social group. Internalized Oppression and Social Anxiety

Internalized oppression may lead to social anxiety in the following manner: A person internalizes the notion that he/she is incapable of performing a particular task due to his/ her social group membership, a notion imposed on him/her repeatedly and a notion that he/she had eventually learned. Thus, this person may experience heightened levels of anxiety when faced with performing such a task and may choose to completely avoid the task altogether. If this task is significantly important to the person's personal, professional, educational, or overall functioning, then the avoidance of such a task due to the excessive anxiety the person feels over such a task warrants a diagnosis of social anxiety. For example, given the stereotype about Asian Americans that members of this group are not good at sports, then an Asian American who repeatedly hears such a message may eventually believe it. Consequently, this person may experience heightened levels of anxiety when performing various athletic tasks and may leam to avoid being in such situations altogether. The person may believe that if he/she does not do well in these athletic

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events, other people will judge him/her negatively. Given that he/she believes other people have an a priori tendency to assume that Asian Americans are not good at sports, he/she believes it is more likely for other people to judge him/her negatively because he/she is Asian American. If participation in sporting events is a significant part of this person's personal, professional, or overall functioning (e.g., the person is married to someone who enjoys playing in community leagues and would like the Asian American individual to participate; the person's job has a company sports team that is viewed by the company as an essential tool for improving company morale and efficiency, etc.), then this person warrants a diagnosis of social anxiety. CBT may be utilized to address internalized oppression, which may be contributing to the social anxiety, in the following manner: Homework may be assigned testing the client°s developed core beliefs that Asian Americans are not good at sports and that others are more likely to judge his/her athletic performance negatively because he/she is Asian American. This can be accomplished by having the client identify successful Asian American athletes and list their accomplishments. It may also be worth it for the client to look for explicit evidence (e.g., verbal comments, etc.) that other people are more likely to judge his/her athletic performance in a negative manner than they are to others. Both of these tasks will systematically test the client's developed and distorted beliefs and cognitions of himself/herself and of others. Furthermore, these tasks are likely to provide the client with systematically-derived evidence that is contrary to his/her distorted beliefs and cognitions, which may help facilitate cognitive restructuring efforts in therapy. It is also of importance that the client does not develop an extrernely positive but still inaccurate and distorted perception of society, because this may also contribute to maladaptive behaviors (e.g., believing that racism and other forms of oppression no longer exist).

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Instead, the goal is to help the client develop an accurate and realistic understanding of society, consisting both of positive and negative attributes. Developing a more accurate and realistic view of his/her self (e.g., "I am not bad at sports just because I am Asian American."), racial group (e.g., "Not al Asians or Asian Americans are bad at sports, actually, there are many very successful Asian or Asian American athletes in the world."), and of other people (e.g., "Not all and only a few people hold the stereotypical belief that all Asians are bad at sports" or "Most people are not more likely to judge me negatively just because I am Asian American.") may consequently reduce the client's experienced anxiety while participating in athletic events. Summary and Conclusions

According to Steir, Lasota, and Christensen 's (2007) national survey of Masters- and Doctoral-level psychologists, very few clinicians utilize ESTs in their work despite the strong emphases given by the American Psychological Association (APA) to research and training efforts surrounding ESTs. This finding led the authors to conclude that ESTs"... are not yet fully embraced by the psychological community. Although therapy such as Cognitive Behavioral Therapy... work(s), the data to date suggests that many therapists...do not utilize these approaches." (pp. 63-64). Furthermore, they found that only about 23% of therapists have had formal training in ESTs, supporting their speculation that one main reason for the low levels of EST utilization is the lack of training on the part of the therapists. In addition to many current psychologists not having training in ESTs, it is also very likely that many current and future psychologists do not have training in culturally appropriate applications of ESTs. Thus, I have presented some suggestions for how a very popular EST (i.e., CBT) may be applied in a sociopolitically and culturally

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appropriate manner to conceptualize and address an important client characteristic (i.e., internalized oppression) that may influence psychopathology development and treatment outcome. Furthermore, I have presented some basic information about the historical and contemporary experiences of various historically oppressed groups, which are intended to further supplement clinicians' toolboxes when providing services to members of such groups. It is recommended, however, that clinicians conceptualize internalized oppression as an individual differences variable and to not assume that all members of historically oppressed groups have internalized the oppression they have experienced or regard oppression as a primary stressor in their lives. It is important to note that the goal in therapy is not to help clients develop an extremely positive but still distorted and inaccurate perception of society (e.g., believing that oppression is not present) because this may invalidate clients' experiences of oppression and may lead clients to blame themselves for feeling unjustly treated. Clinicians should keep in mind that the essential goal of CBT as applied to internalized oppression, or of CBT in general, is to help clients develop a realistic and accurate perception of themselves, of others, and of the world they live in. Given that a realistic perception of society will likely involve the identification that oppression is still present in today's world, an accompanying goal for the client may be to develop a more adaptive perception of reality (i.e., they must learn that although oppression is real and powerful, it is not an insurmountable obstacle), and clinicians may work with their clients to develop strategies to cope with the oppression they experience (e.g., the client learns how to directly confront microaggressions in a way that feels empowering, the client learns about legal options if they experience work discrimination, etc.). Again, the experiences of oppression and the construct of internalized oppression may vary among individuals, and the goals and techniques of

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interventions should be personalized and tailored to the individual needs of each client. Nevertheless, clinicians who keep an eye for internalized oppression as potentially contributing to their minority clients' concerns may demonstrate to their clients that the therapist is genuinely attempting to understand clients' historical and contemporary sociopolitical experiences. Thus, in addition to potentially identifying a major etiological variable for clients' psychopathology, paying attention to internalized oppression may also improve rapport between client and therapist. Such an improved rapport, which may begin to eradicate cultural mistrust on the part of the client, and a more complete understanding of clients' experiences, may lead to improved intervention strategies and better therapeutic outcomes. Finally, eradication of cultural mistrust and improved therapeutic outcomes, in turn, may lead toward reducing the disparities in help-seeking among racial, cultural, and ethnic minority groups.

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