Intentional Call to Action: Mindfully Discussing Race in Group Psychotherapy

Acts and experiences of racism, whether brought into the therapy room as a narrative or enacted in the group, activate emotions. As therapists, our nervous system speeds up; our cortisol levels rise; and our fight, flight, or freeze responses can easily be aroused (2). The stress that can accompany race-related topics can make it challenging for therapists to understand what is happening in ourselves and in our therapy group members (3). Despite the stress that can occur, talking about race and power is essential in today’s world and in our groups. Thus, having tools to manage this stress is also essential.

This article proposes that the exploration of race within therapy groups is integral to group process and introduces how mindfulness can be used to ground these race-based conversations that otherwise can become difficult to traverse. Specifically, this article describes a contemplative tool called RAINN (recognize, allow, investigate, nonidentification, and nurture) and how it can be used to facilitate reflection and understanding in examining race within therapy groups (4, 5). The use of RAINN can assist group leaders in effectively facilitating psychotherapy groups through challenges related to pervasive sociopolitical and sociocultural issues. To this end, this article discusses how mindfulness strategies can be used in group psychotherapy when facilitating conversations about race.

Racial-Ethnic Disparities in Mental Health

According to U.S. Census Bureau estimates from 2019, non-Hispanic/Latinx White people comprise approximately 60.1% of the population, and 19% of these individuals reported having a mental illness within the past year (6, 7). Comparative data (6) show inequities among racial-ethnic groups in terms of rates of mental illness: Latinx individuals comprise 18.5% of the population, and 15.3% report having a mental illness; Blacks/African Americans comprise 13.4% of the population, and 16.8% report having a mental illness; Asian Americans comprise 5.9%, and 13.4% report having a mental illness; and American Indian, Alaskan Native, Native Hawaiian, and Pacific Islanders comprise 1.5% of the population, and 22.7% report having a mental illness. Data also show a disparate ratio in mental health providers along racial-ethnic lines, with a majority of providers being White. Specifically, approximately 88% of U.S. psychologists identify as White, and only 10% identify as psychologists of color (4% Hispanic, 3% Black/African American, and 3% Asian American) (8). Similarly, new research (9) has found that only 10.4% of practicing psychiatrists are Black/African American, Latinx, or Native American, although these racial-ethnic groups account for 32.6% of the U.S. population. Two particular health disparities that may limit how much race-ethnicity is brought up in therapy groups include lack of diversity among providers and lack of culturally competent providers (6). According to U.S. Census projections (10), non-White racial-ethnic populations will comprise more than half of the U.S. population by 2044. More attention needs to be paid not only to supporting a racially and ethnically diverse field of service providers in psychiatry and psychology but also to an enhanced focus on providing culturally sensitive and appropriate mental health care that will match the growing population of marginalized people seeking services (6, 11).

Race and Privilege

There is increasing discussion in the United States and across the globe about race, racism, and identity (12). For many therapists, this heightened awareness of the impact of racism requires us to recognize implicit and explicit issues in our psychotherapy groups that relate to race, racism, and social identity. As therapists, gaining this faculty of awareness means starting to examine ourselves with attention to these very issues. In exploring how our identities have formed and how we have been socialized, we need to use not only psychology but also sociological paradigms to help us recognize the impact of the dominant culture, its systemic racism, and its normative influences on all of us in the context of race (13, 14).

Discussion of race and racism leads us to the importance of privilege, defined in Webster’s Collegiate Dictionary as “a special right, advantage, or immunity granted or available only to a particular person or group” (15). Systemic racism is the system that privileges one racial group over another. In the United States, Whites comprise the more privileged group, which leads to less privilege for people of other groups (Black/African American, Indigenous, people of color) (2, 13, 16). In the United States, people who are White, cisgender male, able bodied, Christian, and heterosexual usually have the most advantage, privilege, and power (14). Introduced by Pierce (17) in 1970, the term “microaggression” is used to describe enaction of a behavior by a person with a privileged identity that insults or denigrates the value of a person with a less privileged identity. This concept was later researched further by Sue and colleagues (18). Microaggressions are everyday verbal, nonverbal, and environmental slights and insults, either unintentional or intentional, that communicate hostility or derogatory or harmful messages to an individual or group on the basis of membership in a marginalized group (19). Thus, in therapy groups, it becomes important to examine who holds power, who is privileged, and who is marginalized and to notice how interlocking systems of marginalization and privilege (related to social identities such as race) are explored in the group sphere. How do group leaders create a space to explore these issues among clients with social anxiety, depression, and other mental health issues? Leaders need practice examining their own racial and other social identities so they can understand how to facilitate this process for their clients (2).

Racial Identity Theory

Racial identity theory has been around since the early 1970s, but it has not been regularly integrated into the group literature because of the relative lack of focus, until recently, on diversity issues within group psychotherapy (13, 20). Racial identity theory is a model that can assist group leaders in understanding the socialization process that occurs over time and is reinforced by environmental influences. Regardless of an individual’s race, all racial identity theories start with looking at how a person is absorbed within a White or dominant culture and/or within a “colorblind” or “all-are-equal” culture (21, 22). The models diverge from there, depending on a person’s racial identity, and individual responses often include an initial awakening period where differences of treatment based on race can be noticed; feelings of guilt or anger, depending on one’s racial identity; and immersion into one’s own racial group and separation from other groups. These phases are followed by a period of reconnecting with others who are more sensitive to issues of race and bias and, finally, a commitment to others within and outside of one’s racial group to fight for more equity and inclusion (21, 22). Helms (23), who established White racial identity theory, describes a model of interactions between individuals that has specific relevance for therapy groups and can contribute heavily to group dynamics (23, 24). This interaction model entails three types of dynamics: parallel dynamics, which occur when the leader and members share similar racial identity statuses; progressive dynamics, which occur when one individual of higher social power, usually the group leader, exhibits a more advanced understanding of racial identity development than the group members; and regressive dynamics, which occur when the group leader’s racial identity status is less mature than that of some or all of the members. With parallel dynamics, interactions can result in a more harmonious race-based communication pattern, in which the group leader and clients will either address (more mature racial identity statuses) or avoid (less mature racial identity statuses) racial and cultural discussions. With progressive dynamics, when race is addressed in the group, leaders can facilitate healthy dialogue around identity development for the members of the group, regardless of the members’ awareness of these issues. Finally, with the regressive dynamics, the group leader may tend to treat issues of race or a member’s problem with racial identity as unimportant or irrelevant. This lack of attention or understanding can leave room for microaggressions to occur. Further losses related to this dynamic are missed opportunities for the group as a whole to examine sociocultural issues of race and other identities and their parallels within the group sphere (12, 14).

These models describe dynamics that can occur at all phases of the group process. However, race may or may not be discussed in group therapy unless the leader takes an active role in creating a norm to do so. Because preparation for group therapy is so vital to the group’s success, the pregroup meeting is the most natural place for conversations regarding norms, race, and safety to begin.

Mindful Discussion of Race in Group Therapy

Pregroup Preparation and Contract

The pregroup meeting is often an essential component of group therapy and serves several primary functions (25). These functions include assessing the severity of symptoms that have brought the clients or patients to group therapy, the group members’ diagnoses, and the appropriateness of each person’s membership to the group (inclusion or exclusion criteria). Other specifics to assess include the potential members’ attachment styles, concerns about family of origin, capacity for mentalization and insight, and how each person relates to others. As part of this interpersonal assessment, group leaders can begin to also assess the potential members’ racial identities, how the clients relate to others from the same or different racial groups, and how open or closed they are to these explorations. Questions that group leaders could benefit from considering include the following: When and how are race, culture, and other social identities (e.g., gender, sexual orientation, religion) discussed in group (26, 27)? What information do members have of each other regarding social identities, and what is the role of the therapist in bringing these issues into the group?

Group therapy begins at the pregroup meeting (28). There are several ways a group therapist can address the salience of members’ racial identity status and other social identity statuses as part of the group orientation. For example, a group therapist could use a racial identity scale or model to assess the current identity status of clients (21, 22, 29). Another option is to ask general questions of the potential group members: How does your race influence your life, if it does at all? What other social identities, if any, are important or salient for you? How might race and/or other identities intersect with some of your goals for group or areas you may want to discuss in group? We are all affected by what is happening in our society, and sometimes people in groups want to talk about cultural issues related to their experience of racism and discrimination. How would that be for you (27)?

By using the orientation meeting to set the stage for such discussions, race and social identity can be legitimized as normal and pertinent to mental well-being and to the work of the group. Whether the clients see their race as interfacing with their mental health is less pertinent than creating a space in the orientation meeting to acknowledge and discuss race, just as a therapist gives time and attention to goals and guidelines for group therapy (27).

Microaggression

Leaders facilitate groups in a variety of settings, including universities, hospitals, private practice, community mental health centers, and rehabilitation centers. As a result, the amount that race is discussed within the group can vary by setting (e.g., university versus inpatient hospital) as well as by the types of issues or disorders the clients are managing (e.g., interpersonal issues versus schizophrenia). As such, college students, private practice clients, and members of diversity training groups may be more primed to encounter issues regarding racism than are clients with more severe and debilitating disorders. Regardless of the type of setting or clients, the group leader should remain aware of issues regarding race and racism but should naturally make informed and decisions based on the unique characteristics of the populations being served. The group contract opens the door for the therapist to explain the varied levels of discussion based on differences in client populations (i.e., it provides the opportunity for group therapists to explain the extent to which racial identity can be discussed in group).

Discussing microaggressions (when clinically appropriate) as part of the group contract during the first group session is a valuable norm to practice. By letting clients know that recognizing race and other social identities and the connection of these identities to mental well-being is a part of the group, the leader begins to legitimize the group as a place to explore these topics. Discussion may be related to a group member or to something that has happened generally in society (e.g., recent epithets written on a wall at a university during Yom Kippur can have an impact on a group member who identifies as Jewish). The leader can ask the clients whether they have heard the term microaggression, and if they have, to explain in their own words what it means. The group leader can then summarize and note the often unintentional nature of microaggressions and the intent versus the impact that often occurs. The leader may also ask if anyone has an example to share with the group to aid in the group’s understanding. The group therapist can acknowledge that if or when microaggressions happen in the group, it is the group’s work to make the experience visible and to discuss its impact. As the group therapy unfolds, microaggressions will inevitably occur. The ability of the group leader to help the group navigate rupture and repair will be an opportunity and a challenge.

In addressing microaggressions, it is also important to note the leader’s need to maintain cultural humility when inviting group members to process how the microaggression may have been experienced (26). In most situations, an apology by the leader or whomever committed the microaggression can be useful. It is important, however, to ensure that the leader or member does not overapologize to the point that the targeted person or other group members feel the need to take care of the person who committed the microaggression. It can be helpful for the leader and group members to listen with care and understanding and to validate the experiences that marginalized members express having, because marginalized people’s experiences are often discounted (26, 30, 31). In summary, for most groups, discussing microaggressions as part of the group contract at the first group meeting gives leaders a way to openly orient and process issues of race, and other social identities, that could negatively affect the group if not discussed.

White Fragility

DiAngelo (32) coined the term “White fragility” as a state in which even a minimum amount of racial stress becomes intolerable. This racial stress can then activate a range of defensive moves, including outward displays of emotions, such as anger, fear, and guilt, and behaviors, such as argumentation, silence, and leaving the stress-induced situation to try and reinstate White racial equilibrium (32). Logan (33) highlights the importance of compassion and holding a space for members not perceiving the racial dynamics playing out in the group, so that all group members can lean into the discomfort of racial stress with curiosity rather than with automatic judgments. For example, a therapist recognizing White flight behaviors could comment mindfully and with compassion: “Talking about race, gender, power, and oppression may elicit a variety of responses, including shutting down, getting defensive, and possibly interrupting others in the group. I want us to recognize when that might happen with each other or in ourselves so we can slow down our talking and reground ourselves. I want us to stay engaged in the process of dialogue and understanding.” When a therapist can name race-based social processes in group, there is a greater possibility for a client who experiences marginalization to feel that the group space could offer a more productive dialogic experience than they have experienced outside the group.

Safety

Does everyone experience safety equally? How does a member’s race (and other social identities) influence safety? Safety is the foundational necessity for vulnerable interchange to occur and to deepen the potential for understanding, growth, and change. Safety, however, is not felt equally by all within a group (34). Race can implicitly influence how members of a group feel, respond, and act, depending on the group members’ racial composition. Feeling unsafe around discussions related to race can also impede growth for some White members. Boostrom (35) has alluded to bravery as an often needed condition of growth, because “learning necessarily involves not merely risk, but the pain of giving up a former condition in favor of a new way of seeing things.” Thus, for more privileged members of the group, finding the bravery to challenge long-held perspectives may be a useful practice.

Mosley et al. (36) has delineated how racial trauma can easily be activated by sociocultural experiences and then brought into the group. She noted that her study participants who identified as Black experienced psychological and social processes related to racial trauma as a result of vicarious experiences of bearing witness to anti-Black racism (36). The psychological processes of these participants included awareness of the chronic cognitive and emotional burden of overt and covert forms of anti-Black racism, which were internalized and experienced as feelings of anxiety, shame, anger, exhaustion, and disempowerment. The effect on their social processes included lacking safety, experiencing isolation, and having relationships weakened or severed. Participants often described feeling sad as a result of the isolation and articulated their need for social support. Group members identifying as Black may have had experiences of racism and trauma that are quite different from those of White members and other people of color. Being able to acknowledge this difference may be vital to the safety felt by group members from racial and ethnic minority groups.

An example of this process occurred in a general interpersonal therapy group, which included one Black woman (Sonja), two multiracial group members (one Latina and White woman [Ariel], and one Indigenous and White man [Andrew]), two White women, and one White man (all names have been changed). The Black woman described how alone she felt at her predominantly White university and in her struggle with an eating disorder. She shared that she was the only Black person in her residence hall and that the only person who talked to her there was her resident advisor. She described having a sense of pride in being Black prior to coming to college because she lived with her mother and grandmother, who reinforced a sense of unity and strength in her. Andrew (who came to the group because of social anxiety) nodded and expressed that although he could not relate to being Black, his mother, who is White, had rejected his father’s family, who are Indigenous. Andrew shared how valuable it had been for him to visit his grandparents at their reservation and to connect to the Indigenous part of his culture. Sonja sighed and said, “I feel you see me. Few people here have. Thanks for sharing a little part of your connection to family with us.” Andrew in a shaky tone stated, “Thank you for talking about your culture and family, as I haven’t stopped to think about how much I want to connect to my Native family until hearing about how you miss your grandma.”

Therapeutic factors—in particular, group cohesion, interpersonal learning, universality, and catharsis—are processes that occur in group therapy that can combat the exact symptoms and traumas that can erupt as a result of racism (37). The same is true for White accountability, in that when some White group members can own their lack of experience in talking about race, other White members can sense that they are not alone and may be more apt to engage in conversations that deepen their understanding of Whiteness. Routinely, or when relevant to the group, therapists can thus open a group by acknowledging the effect of these factors: “Although our goal is to create a sense of safety, there are members who, because of racism and other marginalized identities, may feel this group is less safe for them. How can we create a group where all members can feel safe while not impeding growth?”

Mindfulness as a Tool

There are numerous ways that mindfulness has been adapted to the fields of Western psychology and medicine (4, 38, 39). Mindfulness does not just shift our attention, it deepens it. Kabat-Zinn (40) defines mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment.” Research suggests that mindfulness enables individuals to regulate their emotions in a more positive manner, leading toward approach versus withdrawal behavior (41, 42). Functional and structural neuroimaging studies of the left anterior side of the brain have shown that even during emotion-provoking stimuli tests, a pause or a reduction in activation occurs when an individual practices mindfulness. This pause or lessening of activation could create space for an individual to reflect and to approach situations with others in a more thoughtful and relational way (3, 41). The capacity to approach situations rather than withdraw is particularly useful when examining issues of race in the interpersonal context of group therapy, where such topics can be uncomfortable to discuss, particularly for White people (32). Neuroscience research (41, 43, 44) has also documented changes in particular parts of the brain brought on by the practice of mindfulness, including in the prefrontal cortex, which is where executive functioning (including planning, organizing, and decision making) occurs; the anterior cingulate cortex, which is associated with self-regulation and the ability to flexibly switch strategies; and the hippocampus, which is associated with memory and emotion. The use of mindfulness strategies holds promise for enabling clinicians and group members to stay engaged in learning about issues such as racial, ethnic, and cultural diversity that are deeply charged and associated with difficult narratives in people’s lives. Mindfulness can assist group leaders and members to make slower, thoughtful, intentional decisions and to stay more open to hearing about how one’s comments may affect others, despite one’s intent. This flexibility and ability to self-regulate are valuable skills that mindfulness can offer when people discuss issues of race (2, 45). RAINN (4, 5) is a specific framework that uses multiple underpinnings of mindfulness and can be incorporated into any group therapy process, particularly in interpersonal process groups.

Therapy groups are not immune to the world outside of groups, because they occur within the context of society. Group therapy is a social microcosm of the larger society (46). There are multiple layers of systems that impede the group, including sociopolitical, sociocultural, institutional, administrative, group as a whole, subgroup, interpersonal (dyad), and intrapsychic (individual) (47). Because of these multiple, interwoven layers, therapists have an ethical responsibility to address microaggressions and to invite critical consciousness of privilege and marginalization into the practice of our psychotherapy groups (48). To hold a space for rupture and repair requires a mindful approach. The example below (all names have been changed) and the meditation framework, RAINN, that follows will elucidate how mindfulness can be used as a tool for engaging in conversations about race-based experiences.

In this example, the group had two facilitators, one White cisgender woman (Monica) and one White cisgender man (John). In the room were six clients starting their third week of an interpersonal process group. The members included three cisgender men (Luis, who identifies as Mexican; Wang, who identifies as Chinese and is an international student; and David, who identifies as White); three cisgender women (Dinah and Autumn, who identify as White, and Sophia, who identifies as African American). The goals for the group were to build stronger relationships, communicate more effectively, and connect in meaningful ways. Members were asked by the leader to share thoughts or reflections from last week’s group or anything they were sitting with in the group that day that they wanted to share. Sophia led by stating that all the news about Black people had caused her to feel more anxious and during a recent interview for an internship: she had wondered whether the White interviewer was judging her negatively because of her anxiety and because of being Black. The group initially sat silent until Dinah nodded her head and, in what came across as a light-hearted tone, shared that she could empathize with Sophia’s fears but wanted Sophia to know that she does not automatically assume negative things about Black people just because of the news, so she would not want Sophia to feel that every White person was judging her. Sophia looked at Dinah and then looked down silently. After a long pause, Sophia said, “Since I’ve moved to Oregon from Los Angeles, I feel my race is much more apparent, especially in this predominantly White town.” The group became silent again. After a few moments, Wang spoke up and shared that he had been feeling lonelier since attending classes online rather than in person. David interjected, “I can relate to Wang, as I have been also feeling lonely since coming back and needing to isolate because of COVID.”

Use of RAINN

Mindfulness and compassion-based approaches can be very useful in processing race and other social identities in general process groups because, as in the example above, negating statements can be made so quickly (3, 33). Emotions immediately follow, and leaders and group members may not know how to move forward with a slower pace and curious demeanor. Experiences involving race can be fueled by complex narratives. In the group example above, one of the members, Dinah, responded to Sophia in a way that seems to have invalidated her experience, as is typical of microaggressions. The members’ silence after Dinah’s response could have indicated that they did not notice the microaggression, they felt anxious about how to respond to what they heard, and/or they colluded (showed acceptance) through silence. Mindfulness can become a valued tool at this juncture. Because several things seem to happen at once in the group, leaders can take a breath to slow down the processing and their own reactions. By slowing down, the group leader can invite members to also take a breath and access what might be going on in their bodies at that moment (2, 39).

The first step of RAINN, “recognize,” is to slow down the nervous system. Recognizing is about acknowledging what one is experiencing in the moment and being fully in one’s experience. In the example, Dinah has invalidated Sophia’s comments and feelings of anxiety related to potentially being judged by her race. Then Wang, without mentioning anything about Sophia’s comments or the interaction, likely unintentionally, speaks to his sense of isolation. David then attempts to connect to Wang’s experience, but his experience as a U.S. citizen may differ from Wang’s as an international student. In the beginning stages of a group, such expressed commonality may be useful to help build cohesion. In a later stage of group development, however, it may be experienced as a microaggression, because the members’ current experiences in society may vastly differ: Wang, as an Asian, might experience negativity toward his country and people related to COVID-19, and David, as a White man in the current U.S. climate, might have an entirely different experience. Additionally, the first microaggression with Sophia and Dinah now has gone unattended for several minutes. By applying the skill of recognizing, the therapist could elucidate the following:

This pause would allow space for Dinah and Sophia to share their feelings and thoughts. Another comment that could enable members to “recognize” might be, “I’d like members of the whole group to recognize what feelings came up for you as you listened to Sophia express how her race became more salient when she moved from Los Angeles to a predominantly White town?” Any statements or questions that lead members to recognize what was happening in the moment of a rupture or that elicit comments around racial experiences could create an opening for deeper understanding of members’ experiences.

The second step of RAINN is to “allow” one to be present with whatever emotions surface in the moment. The group therapist could say,

As people begin to share, the therapist can invite members to be curious:

The third step of RAINN is to “investigate.” What is causing a leader or a member to have the emotion they are feeling? In this example, the therapist could inquire about the interaction between David and Wang. “How does hearing about Wang’s experience of loneliness sit in your body? What about David’s experience? How do their experiences of loneliness and your experience with it feel in your body? The therapist could ask, “What would happen to each of us, and our group as a whole, if our emotions of sadness (or fear, anger, confusion, or another emotion) were allowed to be here without resisting?” The group therapist could share their own experience:

The fourth step of RAINN is “nonidentification”—seeing the truth of our emotions as they truly are, as a mix of bodily sensations and thoughts coming and going (49). The therapist might ask,

As people share, the therapist can invite members to stay with their sensations as an observer rather than reacting to them in the moment: “What happens next to the sensations, how do they change, if they do? How do you understand the potential for changing emotions in here with each other?”

The final step of RAINN is to “nurture.” The therapist nurtures the group members through compassion and loving-kindness, so they can do the same for each other. This step is about asking, “How can we be kind to ourselves and to each other in the midst of all of this confusion, fear, anger, or whatever emotion might be coming up for us as individuals or for the group as a whole?” The therapist may say something like, “Given what is happening in our society, all of us are affected by racism in one way or another. How do we nurture ourselves and each other through these pains that are experienced at varying degrees depending on our racial background and families?”

These are just a few examples of how to use the mindfulness framework of RAINN when discussing emotionally charged issues of race and racism in the group sphere. As group therapists work with RAINN within themselves and their groups, everyone is invited to acknowledge and process any activated reactions or responses to create more space for understanding and compassion.

Conclusions

Group therapists have the responsibility of addressing social identities, specifically race, in the group psychotherapy context. Prior to integrating discussions of race and other identities into the group, group therapists need to first examine the intersectionality of their own privileged and marginalized identities to better prepare for their clients’ examination of their identities and the processes that occur within the group. When race and other social identities go unexamined, the therapist, whether consciously or unconsciously, may cause or allow undue harm in the group in the form of microaggressions. Because examining and processing issues related to race within sociocultural and political issues present in today’s society can elicit strong emotions, the mindfulness practice of RAINN can be introduced to help ground the therapist and the group members in order to keep them engaged in dialogue rather than engaging in fight, flight, or freeze behaviors. This grounding becomes a strong base for creating and advancing relationships to self and others, working through ruptures and/or microaggressions as they arise, and, ultimately, creating more space for authentic connections and healing.