Gender and Race and stereotyping

Sometimes an older piece of writing can provide new inspiration. In a recent discussion with my daughter, who is working on her doctoral thesis in public health, she mentioned a course she will be teaching to undergraduates on the determinants of personal health. At the time, she was reading about some related research described by Claude M. Steele in piece in The Atlantic that was published several years ago. I was intrigued – the studies that Steele and his colleagues conducted1 were about the effects of stigma on black college students’ performance, but the findings sounded very relevant to my current work in mental health.

In the article Thin Ice: Stereotype Threat and Black College Students, Steele describes how negative stereotypes don’t just threaten how you view yourself, but can mess with your performance in real life. For example, negative stereotypes about women or people with different racial backgrounds have been related to lower entrance exam scores, poorer college performance, and higher dropout rates among women and people from visible minorities. When tests or other measures of performance are framed in a way that draws attention to these stereotypes, such as when a woman is told that men tend to perform better on a math test, or African American students are required to identify their race as part of an entrance exam, they perform worse than their male or white peers, respectively. Steele and his colleagues have also found that eliminating references to a person’s gender or race in these circumstances reduces the stereotype effect, and this improves performance. It also turns out that offering reassurance that things are okay is not in itself enough for people who have grown up under the influence of negative stereotypes. In part, this is because they are usually too mistrustful of the “system” and assume that they are being told “it’s just all in your head”. As a result of this mistrust they are less likely to change their attitude, beliefs, or behaviour.

Furthermore, Steele and his colleagues found that stereotype effects are strongest for the strongest students.

This is because the smartest students are usually the most motivated, and in order to overcome their belief that they are at a disadvantage they are prone to over analyzing test material, wasting time re-checking their results, and focusing too much on self-guided practice rather than working in groups. In other words, African American students may try too hard rather than not hard enough. This can make them spend too much effort and time on standardized tests that are set up, as Steele puts it, “so that thinking long often means thinking wrong…”

Steele links this effect with “John Henryism”, a term inspired by the American folk legend about an African American “steel driving man” racing to outperform a new steam driven drill, only to die of exhaustion after winning the contest.

Simply treating students “nice” by offering praise and reassurance wasn’t enough to reduce their tendency to try too hard. It turns out that students see positive criticism as biased, and are less likely to take it at face value. Consequently, even helpful advice is more likely to be ignored, and efforts tend to get wasted on weak strategies.

Stereotype Effects Can Be Beaten

Really good researchers know that it is not enough to simply study people and argue for one theory over another. They understand that what really matters is people’s behavior in the real world. If you can’t show how your research is important to somehow making the world a better place, it really isn’t of much use. To test the practical use of his ideas, Steele et al. came up with a program for new undergraduates that had three important pieces:

Provide “challenge workshops” that focused not on overcoming stereotyped weaknesses but instead reinforced academic work.

In part, the program encouraged group work over individual study, as this had been shown to result in better performance. This is similar to what I see in my own work with clients who have different kinds of mental health issues. Being identified as mentally unwell or vulnerable can be highly stigmatizing, and the negative beliefs that the average person holds about mental illness are similar to those that accompany gender or race in their impacts. Anyone who feels these effects will set about to try and hide how they are different and “blend in”. This often means we become isolated from the usual healing and supportive social world around us – one that would otherwise teach us better coping skills including many that rely on group effort. I experienced this effect myself once as a therapist who encountered a life crisis. Though I preached the merits of treatment to my clients, when it came to my own situation I stubbornly maintained a D.I.Y. approach until my symptoms made it impossible not to get help.

In fact, more than half of the people who experience mental health problems every year in North America, which amounts to over 50 million people, will decide not to get help and try to solve their problems on their own.

The power of a person’s ego and our need to be liked and respected by others can be the biggest barrier to getting help. Or as I am frequently heard saying to my clients in our sessions, “our greatest strengths are where we will find our most profound weaknesses”.

Provide outlets through peer sessions for discussing the personal side of college life.

These sessions involved a mix of African American and Caucasian students talking together about their everyday successes and failures as they began their first year of college. The conversations that resulted helped students relate to one another in a meaningful way and understand that “we’re all in this together. What is important here is that these sessions included people who held prejudices along with others who were usually targeted by prejudice. Instead of being gripe sessions in which members “preach to the converted” and insult each other, this format tends to break down stereotypes by making everyone more aware of the beliefs and experiences that they have in common.

The tendency of people to fall into groups that are alike and that hold the same firm beliefs is called the “silo” effect. The silo effect will often feel very comfortable if you are in a group that shares the same values and interests. It can also limit the sharing of new information and encourage bad habits and out of date, ineffective ways of doing things. Our society will often encourage silos by selecting people who have similar strengths or characteristics to work together. It happens a lot in primary care medical settings like the one’s that I have worked in. Often, doctors work in very “collegial” groups of other doctors, but they don’t have a lot of personal contact with other health care providers, who all tend to work in their own groups of like-minded people. On the patient or client side of things, there are plenty of opportunities for people to learn or receive treatment in groups, but they almost always carefully select only those people with the same or similar problems, like obesity, cardiac disease, or various mental health issues. In my clinic, I spent years going through elaborate and time-consuming rituals to identify and recruit “chronic pain and somatoform patients” or people with moderate to severe depression, to cite just a couple of examples, and then set about trying to teach them what they were doing wrong and how healthy people cope. In the meantime, my physician colleagues were doing the same thing with groups targeting type II diabetics or patients with hypertension. While these types of groups have their advantages, they overlook the fact that we are all not that different when it comes to the basic qualities that makes us human and help us cope.

Affirm student’s abilities rather than focusing on their weaknesses.

The final part of the program is similar to what we now refer to as a strength model of coping. Strength models help you build on your strong points instead of trying to simply eliminate your shortcomings. However, focusing on someone’s strengths will not be effective if the person who is trying to help is simply following new policies but still holds their usual prejudices and stereotypes. Equal opportunity will only be truly effective if the leaders in an organization or business believe in their students or employees. To accomplish this campus leaders emphasized that the college really wanted them and valued them as part of their student body. Rather than challenging students to improve because everyone assumed they were given an unfair advantage by the rules and will otherwise fail, a consistent message was given that emphasized how students were chosen for their strengths and were capable of great things. Teachers offered constructive criticism that encouraged students to rise to their potential and tap into their strengths, not overcome stereotyped weaknesses like being lazy or unmotivated.

The program worked well, and the results were surprisingly consistent with recent experience I have had trying to make changes to my approach within the primary care medical clinic where I work. One example is a workshop series addressing common mental health challenges such as newly diagnosed depression or anxiety, and another has targeted the challenging issue of weight loss for high-risk groups such as people with pain and other chronic diseases.

Myndplan Workshops

For anyone who has just been diagnosed with depression or anxiety, the experience is seldom positive. Usually a crisis of sorts is unfolding, and symptoms are creating a sense of desperation. Yet in a typical doctor’s office, the steps involved in getting a diagnosis and starting treatment can occur at a dizzying pace. Within a single session you may not only learn that your symptoms have something to do with a mood or anxiety disorder, but will probably also be presented with a prescription for medication or a referral to counseling. In either case, it is very likely that you have gained little or no idea about the mechanics of what is wrong, never mind how the treatment is supposed to work. Essentially, as the “patient” in this process you’ll have suddenly joined all the other people struggling with the stigma of mental illness, and be subject to the effects of all the stereotypes that go with this.

As with issues like gender and race, trust that you are going to be looked after and that everyone has your best interests at heart is not going to be enough to get you through, and may only strengthen qualities of the situation that are holding you back from reaching your full potential.

Part of the design of the Myndplan workshops was to overcome the stigma that goes with mental illness and the many problems associated with it. The workshops offer learning opportunities that focus on people’s curiosity about mental health and interest in self-improvement, instead of targeting specific mental illness “populations”. We recruit participants from the community at large, which means that the groups are diverse in their membership, and include not just people with newly diagnosed mental illness, but anyone who is curious about how to harness the workings of the brain in order to feel and perform better in life.

The brief workshop format is focused on a skill model that emphasizes how to recognize and build upon individual strengths rather than control genetic or personality based weaknesses. It is tries to be “client-centred”, which means that participants are given the tools they need to figure things out for themselves, including diagnosing their symptoms, picking the best treatment approach, and getting started in making changes happen. This is very different from the more traditional helping model where a professional talks down to you and tells you what is wrong and what to do about it. In the Myndplan group we even go so far as to show people how to carry out their own detailed personality assessment and review the evidence for all types of treatments (not just the one’s that are favorites among professionals). The groups have proved to be popular and more importantly, people who attend report that they leave feeling more hopeful and motivated to make changes.

Exercise for People Who Hate Exercise

There are several crucial populations in any primary care medical clinic that tend to demand a much greater amount of time and resources than is usually the case. For example, people with chronic diseases such as various pain conditions, diabetes, or heart disease often experience a spiral of increasing “morbidity”, meaning that they become more and more unwell over time. Chronic mental illness is another of this type of problem where morbidity often increases over time instead of improving. This means that a relatively small subgroup of people require increasingly large amounts of health care resources. As but one example, people with medically unexplained symptoms make up only 5% of the population, but account for more than 20% of a doctor’s office time and make up as much as 50% of the patient load for some specialists. In an effort to tap into this very broad group of patients, we trialed a group called “exercise for people who hate to exercise”.

As with the Myndplan workshops, this was an open group welcoming anyone who wanted to join. No effort was made to recruit a specific type of person. No “pre-group” interviews were held. No mention was even made about weight loss. Instead, we chose to focus on a simple fact – people who hate to exercise come in all types, but share some similar problems. They are usually out of shape, spend a lot more time sitting down, are prone to experiencing all sorts of unpleasant medical problems, and miss out on a lot of activities that we usually rely on to feel better. They are also just like anyone else – they want to do things, are as smart as the next person, and have gathered lots of experience from life. When given tools to learn about their own personality, the various things that can cause and maintain health problems, and the sorts of treatments that have proven effects, they are as likely as any “healthy” person to try and do the right thing. I’m cautious about interpreting the results of this new effort, but the initial trial has provided some pleasant surprises. First off, the group was even more diverse in its membership than we anticipated and included problems like chronic pain, obesity, and mental illness. The mix of problems meant that group discussion was much broader than is typically the case, as participants learned about their different life trajectories and discovered the common features.

By using a neuroscience model of cognitive therapy that I have dubbed neurodynamic feedback, a discovery process was set in motion that participants enjoyed because it reframed the challenge of weight loss and fitness not as an issue of diet, overeating, or laziness, but in terms of the need for understanding how the mind works and how to harness its strengths to bring about behavior change.

Essential to the group’s success was the fact that as the leader I was not trying to sell lifestyle change as a cure for everything, but truly believe that the only way for anyone to really get ahead in life is to understand how the mind works. Everything else is just a side effect of this effort – for better or for worse.

Overall, as the workshop facilitator I focused on creating a sense of mutual understanding in the group. In some cases, this meant that I might talk about my own problems and how I overcame them. This is very different from the usual group process, in which the leader is an expert who gives lots of advice, and everyone else is a “patient” in need of that advice. I like to think of my own role as that of a guide – someone who can show you the way not because they are somehow smarter, but because they have travelled the same route in their own life and have learned how to get to the destination safely and effectively.

Despite the unusual mix of people attending the sessions, the results proved to be surprising. Unlike most groups targeting “difficult to treat” problem areas, the EPHE sessions did not experience any drop-outs, group members each discovered strengths they had overlooked in themselves, and by the end everyone was proudly maintaining a light-weight exercise program. For the first time in my career, all the participants kept in contact even weeks after the end of the sessions to discuss tweaks to their programs and share new insights and experiences that had stumbled upon as a result of their change in direction.

In the beginning, I was focused on issues like building working model of client centred care and truly de-stigmatizing mental illness when I developed both the Myndplan Workshops and Exercise for People Who Hate Exercise group. Yet somehow I ended up with much more than that. Like Steele and his colleagues, I have discovered that when you mix people influenced by a particular stereotype with those who usually promote those stereotypes, and focus on something completely different, such as how to tap into your assets to cope in this wonderful world that we live in, the results exceed everyone’s expectations.