February 2017
Serving Families of Color
This month we take a special look at the experience of families of color and specifically how therapists, especially white therapists, can better serve these clients. We are pleased to have an essay from Diana Mena about how to be an anti-racist healer. We provide a synopsis of a newly published chapter about how to increase treatment engagement among women of color who are depressed and socio-economically disadvantaged. There's a great list of web resources for therapists who work with families of color. Our Parent Corner article highlights what you as a person of color need to know when seeking a therapist. And we summarize research about racial/ethnic disparities in postpartum depression specifically among low-income women.

We have chosen this as the topic for African American History month, and we want to make three important points. First, we know that while there is overlap in the experiences of African American women and other women of color, we also know that these are distinct groups of people, and we do not want to erase the lived experience of being a black woman. Second, we do not make assumptions that women of color are also always low income. We have two articles this month that mention both groups of people, but we know that these groups are not one and the same. Finally, we at Perinatal Support Washington want to make sure our sensitivity to families of color is more than just a once-a-year newsletter topic. We understand that facing racism is something that needs to be woven throughout our own work and the work of our therapists. We strive to do this with support groups for women of color and regular training for providers to better serve women and families of color. And we know we have more work to do to make sure that our families of color who experience perinatal mental illness feel heard, safe, and understood. 

As always, we appreciate your feedback about our newsletters.
In This Issue
Parent Corner
Race, Color, and Culture in the Therapy Room
Racism and systemic oppression affect one's mental health. We need to talk about it in therapy. Your therapy session should be the place where you can let your guard down and be honest without fear. In short, it needs to be a safe space. We know how beneficial and important it can be. For this reason many people of color prefer to work with someone who looks like them and/or knows about their culture. However, while there are a lot of well-meaning (and some not) white therapists, there are few therapists of color available (see above about racism and systemic oppression). That number gets even smaller if you are looking for someone who specializes in perinatal issues. Maybe you found someone, but there is a long wait list. And then there is insurance to think about. Sometimes we don't have many choices for who we're going to see for therapy.
For some people this is not an issue and they are able to open up freely to their therapist. For many, especially in the current climate both nationally and internationally, it is important to have someone who will understand their background and not have underlying racism or prejudice sneaking into therapy sessions. They don't want to have to teach their therapist about race and culture. If you fall in this group of people, you may want to first focus on finding a therapist of color. Ask friends, and call some organizations that align with your culture. Three online resources you can use are Washington Counselors of Color Network or African American provider list and Postpartum Progress Black Mental Health Providers List.
But what do you do if you can't find a therapist of color near you or one covered by your insurance?
When searching for a therapist who is not your race or from your culture, you can look for one that specializes in multicultural counseling or has recent training as part of her education (refer to the list of reputable trainings that therapists may attend at the end of this newsletter to get an idea of what is available). Then after you've narrowed it down, you might need to call the therapists and ask them about their training and experience. Be honest and tell them what you are looking for, if you are nervous about seeing a white therapist and why, and listen to your gut and how their answers make you feel. If the therapist has been trained well and is self-aware, she will gladly talk to you about her training and how you might or might not be a good fit together. She may even have some referrals for other therapists that might be a better fit.  
Even after you make the appointment and see the therapist, you can decide whether or not you are comfortable. While we do have to be mindful of insurance restrictions, sometimes it takes that first in-person session (or more!) to get a feel for whether or not it's going to work. This is true of any therapeutic relationship.  And sometimes even if you find a therapist of color who seems right, you might get to the session and realize you don't feel as comfortable as you thought you would or it's just not the right fit. Being the same race or having similar culture does not guarantee you will click with your therapist. Talk to your therapist about what you are feeling. If she is defensive, then she's probably not the right person for you. But if she is willing to address the issues brought up, you may be able to work it out. Whatever you do, don't let it deter you from getting needed help. 
Addressing Racism in Mental Health: An Anti-Racist Healer Approach
Diana Mena, MSW, LICSW, EMMHS, Esperanza Counseling & Consulting, LLC

Diana Mena
Here  in the Pacific Northwest, race relations and power structures are as complex as those 
nationa lly. Since this area was first settled, it has served as a haven for White supremacist groups, and this legacy continues to influence race relations today. Though in some ways we are at the front of organizing and mobilizing against bigotry, much of our community continues to practice racism, just in a different way. Liberal racism is different and often more traumatizing than overt racism. The daily onslaught of micro-aggressions, colorblind politics, White silence, and White liberal identities can be as harmful and deadly as overt racism.
Both covert and overt racism leave People of Color (POC) with deep psychological wounds. The DSM states that Post-Traumatic Stress Disorder is a normal response to an abnormal event; but racism is not abnormal. It is a reality in our social consciousness. Racism directly impacts the mental, emotional, and physical wellbeing of the people directly affected by it. Hence it is understandable that we would see such high rates of depression, anxiety, and post-traumatic stress in POC communities. Additionally, many POC come from communal societies. As such, when a person is assaulted, beaten and/or murdered, it is felt emotionally, psychologically, and physically by those connected to them, and this violence remains imprinted in their collective memory.
This intergenerational legacy of trauma, grief, and loss impacts POC in every aspect of their lives, including reproductive health. We as healers are aware of the negative consequences of racism and oppression on Women of Color during pre- and postpartum periods. WOC have increased vulnerability for high maternal and infant mortality. These poor birth outcomes should be of utmost concern to our healers.
While the field of psychology, our education, and our training have failed People of Color, they have ALSO failed White therapists. As structures and institutions, they have supported and maintained White supremacy and kept White folks intentionally ignorant of its doings and subsequently complicit in its impact. As a result, many therapists, 90% of whom are White, graduate without an adequate racial analysis or understanding and lack the appropriate tools to serve and care for their POC clients. They enter the field embodying White supremacy in both unconscious and conscious ways, causing grave harm along the way.
While White clinicians represent a microcosm of the rest of society, as healers, they have a double duty to engage in harm-reductive behaviors. It is therefore of utmost urgency that White folks who are working as therapists begin engaging in deep reflection and self-analysis around race, racism (both individual and structural), and White identity so that we can offer safe therapeutic spaces where POC can process and heal from their lived experiences within an oppressive society.
Some small, tangible steps:
  • White therapists must name Whiteness. White clinicians have been socialized and trained to think that naming racism is racist. But as any true trauma therapist knows, if we are not able to name it, we are not able to heal from it.
  • Reflect on the collusion of your ancestors and your complicity in maintaining White supremacy.
  • Start processing your emotions, especially guilt, shame, and grief, with other White people (not with POC or in cross-cultural spaces since this often leads to re-traumatization and the centering of Whiteness).
  • Practice distress-tolerance skills to cope with racist realities; pause, breathe, and ground yourself before reacting or engaging.
  • Make an effort to intentionally dialogue about race and racism.
  • Start acknowledging the very real, although different, lived experiences of POC.
  • Build a support network and community of White folks willing to dialogue about race, process emotions, and together develop strategies for dismantling White supremacy.
Know that being a true anti-racist healer is about being uncomfortable for the rest of your life. The work is a continuum, one that cannot be checked off or wrapped with a pretty bow; and as a White healer you have to be okay with that .

Diana Mena, MSW, LICSW, EMMHS, is a first-generation Nicaraguan American. Diana has a Bachelors Degree in Sociology from Seattle University and a Masters in Social Work from the University of Washington. Diana has over 7 years of experience working with nonprofit agencies and community mental health clinics providing case management and therapy for low income, marginalized populations, and communities of color. She is the proud owner of Esperanza Counseling & Consulting where she focuses on interpersonal violence and trauma, cross-cultural issues of identity, and the psychological consequences of oppression. She provides consultation on issues of race and social justice with the hope of leaving a better world for the next seven generations. 
See information about her training, How to Be an Anti-Racist Healer, in the Resources for Therapists section below. 
Engaging Women of Color Who Are Depressed and 
Socio-Economically Disadvantaged in Mental Health Treatment

This is a synopsis from Grote, Nancy K., Swartz, Holly A. & Zuckoff, Allan (2016).  Depression Treatment for Disadvantaged Women of Color.  In  Valerie Carr Copeland (Ed.), People of Color in the United States Contemporary Issues in Education, Work, Communities, Health, and Immigration Vol. 3, Health and Wellness (pp. 78 - 85).  Santa Barbara, California: Greenwood.

Depression among women of color who are socio-economically disadvantaged is prevalent, and more common than in the rest of the U.S. population. Importantly, there is a peak in depression onset in the childbearing and childrearing years. But this group of women is also less likely to seek or remain in treatment than the population at large.

Why is there this barrier to engagement with mental health treatment for this group? The authors describe three factors:
  1. Practical: Issues like cost, insufficient insurance, lack of time, unpaid time off, transportation, and childcare logistics make it more difficult to seek and attend treatment.
  2. Psychological: Women in this group may have a perceived stigma about depression, especially that the woman herself has caused or is responsible for this condition. They may have also had previous bad experiences with the mental health providers, either personally or as a social group, which leads to suspicion and mistrust of the mental health system. There are real worries about CPS removing their children. And women in poverty in general have more chronic stressors than the general population (e.g., discrimination, unstable employment, crowded living situations, etc.) that make it harder to stay in treatment.
  3. Cultural:  Providers may be insensitive to or ignorant about cultural differences. Clinicians from a different background may not understand women's culturally endorsed symptoms of distress (like somatic complaints), and may fail to appreciate the adaptive ways the clients have coped in the past (e.g., spirituality and religion).
The authors have developed a strategy to address this barrier to engagement. They call it the Engagement Interview--a pre-therapy intervention. It's guided by the ideas of EI (ethnographic interviewing) and MI (motivational interviewing). This approach relies on open-ended questions, reflective listening, recognizing and affirming a woman's strengths, and working with ambivalence (about depression itself, therapy, or both).
The steps, in brief, are:
  1. Elicit the story. Understand the woman's symptoms in her socio-cultural context. Listen also to the adverse impact of chronic stressors, like poverty, discrimination, etc., and how they exacerbate the depression. Summarize the story to make sure the woman feels understood.
  2. Treatment history/hopes for treatment. The goal here is to understand the history of depression and what supports (including therapy) have worked for the woman before. It's also important to understand any negative experiences with social agencies in general. End this section by asking the woman what she would want at the end of therapy and what she wants in a therapist.
  3. Feedback and psycho-education. In this section, the therapist gives feedback about depressive symptoms and psycho-education about depression. Importantly, the provider should use the term "depression" only if that's what the woman uses. If, for example, she calls this experience "feeling stressed," the clinician accommodates her preference. One of the best ways to combat stigma is by using the MI technique of elicit-provide-elicit. (Elicit woman's perceptions about depression and ask permission to give more information; provide scientific information about depression as an illness and role of stressors and treatment options; then elicit her views about these treatment options).
  4. Address barriers to treatment seeking. At this point, problem-solve possible barriers to coming to treatment with the woman, using the elicit-provide-elicit technique. Emphasize personal choice and control.
  5. Elicit commitment. Finally, shift to eliciting commitment to treatment. Summarize the woman's story, review any ambivalence, and highlight her desire for change. Ask "What would you like to do now?" or "How does that sound to you?" and then transition to treatment. If the woman remains ambivalent, leave the door open to future treatment while agreeing that the choice is hers.
Studies have shown that this Engagement Interview is an effective way to improve engagement and retention in this group of individuals.
Disparities in Postpartum Mental Health Care in Low-Income Women
A retrospective cohort study led by Dr. Katy Backes Kozhimannil from the University of Minnesota revealed substantial racial/ethnic differences in the use of mental health services for post-partum depression.  Researchers examined data from 29,000 mothers who filed Medicaid claims in New Jersey. More than 13,000 of the women were black; 13,000 + were white; and roughly 3,000 were Latina.
The study found that 9% of the white women sought out postpartum mental health care, compared with 4% of black women and 5% of Latina women.As well, among those who initiated treatment, black and Latina women were less likely than white women to receive follow-up treatment.

The study also found differences in type of care (antidepressant medication versus outpatient visits) among those initiating treatment. Black women were more likely to initiate outpatient mental health care, but blacks and Latinas who initiated antidepressant use had lower chances than white women of refilling a prescription.

The study concludes:  

"The differences in initiation and continuation of care uncovered in this study imply that a disproportionate number of black women and Latinas who suffer from postpartum depression do not receive needed services. These differences represent stark racial-ethnic disparities potentially related to outreach, detection, service provision, quality, and processes of postpartum mental health care. Although suboptimal detection and treatment rates are not uncommon for this condition or in this population, these results emphasize that postpartum depression remains an underrecognized and undertreated condition for all low-income women, especially for those from racial and ethnic minority groups."
Resources for Therapists Who Work with Families of Color
APA Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists
NASW Standards and Indicators for Cultural Competence in Social Work
Competencies for Counseling the Multiracial Population Multi-Racial/Ethnic Counseling Concerns (MRECC) Interest Network of the American Counseling Association Taskforce
Online Resources
National Center for Cultural Competence
The mission of the NCCC is to increase the capacity of health care and mental health care programs to design, implement, and evaluate culturally and linguistically competent service delivery systems to address growing diversity, persistent disparities, and to promote health and mental health equity.
Racial Equity Resource Guide  
The resource guide was prepared as a shared tool for building a community of connected, informed, and engaged practitioners. With the ability to generate a Resource Guide tailored to their own goals, these materials are practical resources that will assist organizations working within the racial healing and racial equity field.
Clinical Strategies to Enhance Your Practice with African American Clients
Cultural Competence and Diversity
Think Cultural Health: The Context of Culturally and Linguistically Appropriate Services in Mental Health
The Cross Cultural Health Care Program
The Cross Cultural Health Care Program (CCHCP) is a nonprofit training and consulting organization founded in 1992. Their mission is to serve as a bridge between communities and health care institutions, in order to advance access to quality health care that is culturally and linguistically appropriate.
Cultures Connecting
Cultures Connecting provides consulting, professional development workshops, coaching, one-on-one diversity leadership support, and keynotes to assist organizations in entering into conversations about race, culture, and social justice. Through their programming, clients learn new skills they can apply in the workplace and beyond. They tailor presentations to meet the specific needs of your organization.
The People's Institute for Survival and Beyond Northwest
The People ' s Institute Undoing Racism Workshop is an intensive workshop designed to educate, challenge, and empower people to " undo " the racist structures that hinder effective social change.
Community Connection Consulting
Community Connection Consulting provides professional development, keynotes, and consulting services to assist organizations and individuals to engage in authentic outcomes-based dialogue about race, equal justice, equity, social/economic opportunity, and the development of "Life Mastery"  skills. Their training sessions inform how to create, adopt, and cultivate successful sustainable strategies that promote diversity, equity, and inclusion in personal, professional, and community environments.
Stirfry Seminars
This program provides an online intensive level communication and facilitation training to those wishing to develop their cultural intelligence, as well as individual and group process skills from a Mindful Facilitation and multicultural perspective. The program also provides participants with the necessary skills and knowledge to effectively work with educational and social institutions, professional environments, and diverse communities on diversity issues and cross-cultural needs and concerns.
How to Be an Anti-Racist Healer
An intimate gathering to begin exploring topics of Race, Racism, Whiteness and White Privilege in order to promote collective healing specifically for those who identify as healers, including therapists, counselors, and social workers. It is a workshop intended for White folks who would like to begin the process of self-exploration and allyship.
Welcoming Black and Native Families to Your Practice. 
Explore the perinatal needs of Black and Native families to benefit your clients and your practice in a one-day interactive workshop
Articles and Blogs
After the Violence and Videos, Therapists Learn to Treat Racial Trauma
From specialized clinics for African Americans to social media events that take the shame out of sharing, there's a movement to heal the psychological scars of racism.
The Race to Good Health
A tour of minority mental health and behavioral pediatrics
How Therapists Drive Away Minority Clients
Many therapists unknowingly perpetuate racism against their own clients.
African Americans and Psychotherapy: Why Race Is Important

Birth Professionals Networking Event. Thursday, 2/16, 1-3pm, Northgate Library. Ever wonder what happens on a Warm Line call? Wondering if our support groups are right for your clients? Not sure how to where to find a referral for a mental health professional if a client needs one? Please join us for an informal networking event and learn about Perinatal Support Washington's programs and services and to best serve your clients experiencing unexpected emotional challenges. You will have the opportunity to meet the parents who answer the Warm Line calls and the professionals who facilitate our support groups. Additionally you can tell us about your practice and how you are supporting new families. Please indicate on the Facebook Event if you can join us.

Understanding Infant Sleep for Professionals, Monday, 2/27, 5:30 - 8pm. Join Macall Gordon, certified gentle sleep coach, for a presentation on infant sleep--what's normal and what might need intervention. This event is geared toward those who work with new parents--therapists, midwives, OBs, pediatricians, doulas, lactation consultants, home visitors, and case managers. For more information and to register, click here.
Giving to Perinatal Support Washington
Employee Giving
Are you a Microsoft or King County Employee or spouse of one?  
Please consider supporting us through your respective workplace giving programs. For King County employees, our code is 9187. Our tax ID is 91-1448669. If you are looking for us, be sure to check our old and new name if you don't see us--we are there.

Warm Line: 1-888-404-7763 (PPMD)

Support Education, Referral
(formerly Postpartum Support International of Washington)