Psychologists are teaching health care teams to identify and address microaggressions

As public awareness of systemic racism has intensified since the murder of George Floyd in 2020, psychologists are seeing increased openness in clinical care teams to learn about microaggressions—subtle statements, actions, or incidents that are unintentional or intentional forms of discrimination against members of a marginalized group.

Microaggressions are common in health care and can cause team members to feel less valuable and less inclined to share clinical input. Many do not feel comfortable expressing concerns about slights related to race, sexual orientation, socioeconomic status, or gender. That, in turn, can harm patient care. “Important clinical information can be lost when team members feel degraded and uncomfortable interacting with colleagues and patients,” said Veronica Shead, PhD, a clinical psychologist in the VA St. Louis Healthcare System who conducts team trainings on microaggressions.

By leading discussions about different types of microaggressions, the impact on patients and team members, and how to address the incidents, psychologists are pioneering culture change in health care systems. “Microaggression education is not focused on dismantling systems but improving them,” Shead said. “And providers want to feel equipped to deliver the best care possible.”

While taking time for microaggression training may seem difficult in a hospital’s fast-paced environment, research suggests that delaying these discussions can have significant effects on patients and providers. According to one review paper, studies conducted from 2007 to 2020 showed that microaggressions in the United States and Canada were associated with anxiety, depressive symptoms, low self-esteem, and suicidal ideation (Spanierman, L. B., et al., Perspectives on Psychological Science, Vol. 16, No. 5, 2021opens in new window). “If patients are coming to treatment for an ailment and they experience a subtle microaggression, this could compound the presenting problem,” said Lisa Spanierman, PhD, a professor of counseling and counseling psychology at Arizona State University who studies microaggressions. In the studies, microaggressions were also linked to back pain, hypertension, insomnia, and stomachaches among targets of the discrimination.

For health care providers, studies suggest that workplace mistreatment such as discrimination increases the risk of burnout and suicidality (Ehie, O., et al., Current Opinion in Anesthesiology, Vol. 34, No. 2, 2021opens in new window). One study of more than 7,000 surgery residents showed that roughly one-third reported discrimination based on their self-identified gender and 16% reported racial discrimination (Hu, Y., et al., The New England Journal of Medicine, Vol. 381, No. 18, 2019opens in new window). Factors such as depression, job dissatisfaction, and physician burnout have been associated with suboptimal care practices, including medical errors.

While much of the literature on microaggression intervention focuses on helping the target respond, this sends a message that the target is solely responsible for addressing harmful behavior, said Roxanne Upah-Crenshaw, PhD, a clinical psychologist in the VA Greater Los Angeles Healthcare System who provides training related to microaggressions throughout the Veterans Affairs (VA) system.

“This can create heaviness and stress for targets, which can lead to burnout,” she said. “This ultimately affects productivity and staffing turnover.” By teaching a team about microaggressions, colleagues who witness the incidents learn to support patients or team members who are targets. Discussions about these subtle forms of discrimination are often eye-opening for team members, and the benefits have a positive ripple effect on the work environment, patient satisfaction, and the quality of care.

An important message to relay to health care teams is that nobody is immune to these biases, said Derald Wing Sue, PhD, a professor of psychology and education at Columbia University’s Teachers College and a pioneer in microaggression research. “These beliefs are so deeply embedded that they are usually outside of our conscious awareness,” he said. “It’s valuable for individuals to explore the biases that they harbor.” In his new Microintervention Toolkit (PDF, 233KB)opens in new window, Sue outlines a strategy called making the “invisible” visible—bringing the microaggression to the forefront of the person’s awareness. This allows the targets or bystanders to verbalize what is happening in a nonthreatening manner. Tactics include asking for clarification of a statement, such as “What exactly do you mean?” or “Did I hear you correctly?” or reminding the perpetrator of the rules, such as “We don’t tolerate or condone those types of behaviors here.”

[Related: Tactics to disarm and neutralize microaggressions]

Upah-Crenshaw started increasing awareness about microaggressions at the VA in 2020. She partnered with Shead to present a national webinar to geriatric mental health providers who often worked in interprofessional teams in geriatric units. After the first training, other departments and specialties from VA health care facilities around the country started inviting them to speak. “We were getting traction, which suggested that this was a hot-button topic that had not been formally addressed in academic or DEI [diversity, equity, and inclusion] employment training,” she said.

Patient to provider discrimination is a frequent pathway for microaggression behavior in health care. Over time, these interactions can affect the physical, mental, and emotional well-being of providers. “If the comments happen once or twice, it is not a problem, but cumulatively it can be harmful,” said Odi Ehie, MD, vice chair of DEI for the University of California, San Francisco’s Department of Anesthesia. She has experienced microaggressions such as patients asking where she is from or where she trained. Others have commented on how young she looks and asked when and where she finished residency. Some of Ehie’s responses include asking the patient to explain more about what they want to know. “This gets them to think about what they are saying,” she said.

Incorrect name pronunciation is another common microaggression experienced by ethnically diverse team members. These providers will sometimes encounter requests from patients to use the first letter of their last name rather than the full name. Upah-Crenshaw has experienced this personally, and she addresses it by helping the patient learn to pronounce her name with tips such as “Upah” is like the state Utah with a “p.” Another type of slight that happens in health care is the assumption that two different providers of the same race or ethnicity are the same person. “I might gently point out that they are thinking of somebody else, and then suggest that they have more interactions with those team members to become familiar with them,” she said.

Judgments about providers who speak with accents are also somewhat frequent. When Shead hears a patient make negative comments about a colleague’s accent, she addresses the implications of the comments. “I may explain that the statement sounds like the patient is questioning the physician’s skill set,” she said. “I share that my colleague is a highly regarded provider on our team.”

At the University of California, San Francisco Benioff Children’s Hospitals, psychologist Marsha Treadwell, PhD, recently helped launch a coaching program for managers about issues related to DEI, including microaggressions. The managers learned to create “Brave Spaces,” or regular conversations with their teams about how implicit biases could impact the sense of belonging for team members. Each unit or team was given autonomy to decide on meeting frequency and how to address the problem, and one neonatal intensive care unit created a poster displaying nurses holding signs based on microaggressions they had experienced. The signs included phrases such as “I don’t have to be born here to be an American”; “Don’t ask me ‘what are you?’ I’m a ‘who,’ not a ‘what’”; “I am Chinese but I did not start the coronavirus. It is not called the Chinese virus.”

For Treadwell, the active interest in the Brave Spaces program has been encouraging. “We are creating an environment where everyone on the team owns the issue and individuals do not have to feel isolated,” she said.

Patients may also be the victims of microaggressions from providers, and learning to call out these insults tactfully can build trust within a team and with patients. Shead noticed a microaggression during a meeting when one of the providers warned the team that a patient and his family were being difficult, with loud vocalizations and resistance to the treatment plan. Although the provider’s intention was to prepare the team for the case, Shead, a Black woman, sensed implicit bias against the Black patient and his family. She spoke up and reminded the team that African Americans historically had been treated poorly in health care settings in St. Louis. The family’s distrust was understandable, and she encouraged her colleagues to gain the family’s confidence.

Shead has also worked alongside colleagues who do not use the correct pronouns for patients who have indicated that they are LGBTQ+. When she noticed this behavior in a physician, she reminded everyone during a team meeting that the pronouns for the transgender veteran on the unit were “she/her.” “When a leader on a team intentionally disregards a patient’s preferences, this can set a tone that discriminatory behavior is acceptable,” she said.

While providers may be the target of microaggressions from patients or vice versa, subtle biases among team members can also affect interactions. Team members may inadvertently assign patients to colleagues from a similar marginalized group without considering a match of patient concern and expertise. For example, a nurse or psychologist who is LGBTQ+ may be paired with an LGBTQ+ patient even though the patient did not make the request.

Hierarchy may also influence willingness to report microaggressions, said Shead. People lower in the pecking order, such as certified nursing assistants, technicians, or other support staff, tend to be less comfortable speaking up when they experience discrimination. Shead works to combat these inherent hierarchical biases by elevating these team members, asking them directly for their professional input on various issues within their responsibilities.

While it may feel jarring when a team member points out a microaggression, apologizing after an incident can improve a professional relationship. In a study of patients who had experienced microaggressions from their therapists, the working alliance was stronger after the therapist discussed the microaggression compared with those who did not. These repaired alliances were as strong as those in which no perceived microaggression occurred (Owen, J., et al., Professional Psychology: Research and Practice, Vol. 45, No. 4, 2014opens in new window).

When apologizing, it is critical to focus on the impact of the comment rather than the intent, said Upah-Crenshaw. “When someone tries to explain the intent, the conversation shifts to how the perpetrator is feeling rather than the hurt that was caused,” she said. “Instead, acknowledge the impact the comments or behaviors had on others.” People who receive nondefensive apologies are more likely to trust the person again, which creates a sense of psychological safety and helps teams function more effectively.

For psychologists at the forefront of the effort to increase awareness about microaggressions, the possibility of this type of healing in relationships is motivation to continue educating people on how to instigate change. “It is very difficult to escape the socialization that led to my implicit biases, but if I inadvertently commit a microaggression, there is hope that taking responsibility will create an even stronger relationship,” said Spanierman.

To help teams become comfortable talking about vulnerable topics like microaggressions, consider incorporating discussions about equality, diversity, and inclusion into weekly meetings, said Upah-Crenshaw. “This gives the team a chance to learn the terminology and practice their skills regularly,” she said.

Psychologists can not only lead the way in training teams, but also pioneer research on the prevalence and effects of microaggressions in interprofessional settings. Most research is focused on individuals in health care, not teams, said Shead. “I would love to see psychologists conduct studies in these integrated settings, because we are well equipped to understand how identity affects work,” she said. “We are uniquely prepared to ask how microaggressions are impacting outcomes and patient care.”