Welcome back to the Healing Pain Podcast with Lisa VanHoose, PT, PhD, MPH, FAAPT, FAPTA
Racism shows up in every aspect of our lives, and white body supremacy always finds a way to ingrain itself into our entire biology. Racial issues act as a persistent stressor that causes psychosocial distress, chronic pain, and even emotional trauma. Dr. Joe Tatta sits down with Lisa VanHoose, PT, PhD, MPH, FAAPT, FAPTA to discuss how racial embodiment impacts the vast healthcare system. She explains the best way to bring a social justice lens to physical therapy care in pain management and learn not to invalidate other people’s challenges with health disparities. Lisa also shares their work of decreasing implicit bias and advancing Black health and wellness through their organization, Ujima Institute.
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Racial Embodiment And White Body Supremacy In Pain Management With Lisa VanHoose, PT, PhD, MPH, FAAPT, FAPTA
In this episode, we’re discussing the embodied experience of racism and how it impacts healthcare. Many countries have a history of racial discrimination and racist policies. Racism shows up in our homes. It shows up in our schools. It even shows up in our government. It also exists in our healthcare institutions and our healthcare policies.
We know that when individuals or groups are subjected to the racism that it can actually change their biology. Racism is most definitely a persistent stressor that causes psychosocial distress. When I say distress, what I really mean are conditions such as anxiety, depression, panic disorders, and post-traumatic stress disorder. Neuroscience tells us that racism activates the hypothalamic pituitary adrenal axis in our brain. This chemical pathway then releases a wave of stress hormones, such as cortisol and adrenaline, that circulate throughout the entire body, and persistently high levels of stress hormones are associated with conditions such as chronic pain, anxiety, and diabetes and even affect learning and memory circuits in the brain.
Racism even has the ability to impact one’s genetic code and DNA. A persistent stressor like racism changes one’s DNA, making it a social determinant of chronic health conditions. This altered DNA can be passed down from one generation to the next and the next, maintaining poor health. In this way, the lived experience of racial discrimination can actually get under the skin or become what is known as embodied.
My guest is Dr. Lisa VanHoose. She describes herself as an intercultural guide that can help you make uncomfortable situations and topics such as racism comfortable and potentially even exciting. She’s a clinical professor at Baylor University in the Physical Therapy Department. She is also the Founder and Chief Scientific Officer of The Ujima Center. The center’s mission is to improve Black health outcomes and patient satisfaction. She has investigated workforce diversification and racial health disparity since 1995.
I’m always excited when I have an opportunity to hear her speak because each and every time, I learn something new. Her forward-thinking perspectives and the great work she’s doing for all people impact healthcare, pain care, and physical therapy. With that further ado, let’s begin and let’s meet Dr. Lisa VanHoose and learn about the embodied experience of racism.
Lisa, thanks for joining me.
Thank you so much for having me. I’m excited about this conversation.
I am too. We had a whole conversation before this, which lots of people would have liked to know and had access to, but I’m excited to speak with you. We did write a chapter in our book called Integrative and Lifestyle Medicine in Physical Therapy about oncology, which is one of your specialties. We want to thank you for that and point people toward that, but now we are talking about White Body Supremacy.
I reached out to you about that topic and other topics that relate to diversity, equity, and inclusion in physical therapy and healthcare in general and how it relates to pain management. If it’s okay with you, I want to read a definition of White body supremacy for people before we begin to help us inform this episode.
White body supremacy can be defined as individual and institutional attitudes, practices, and policies that elevate the White body as a standard against which all person’s worth is measured. White body supremacy is a form of embodied trauma. It’s a response that results from the intergenerational transmission of oppressed, race, bias, and fear that is held within the body.
This construct is grounded in the belief that racism is sustained in the body. Although cognitive processes are helpful, they are alone inadequate to address racism somatically within the body. I reached out to you about that because it’s talking about addressing racism somatically in the body, and we, as physical therapists, play a strong role in treating the body.
I agree with that. As physical therapists and physiotherapists, for us to be able to elevate our practice, we need to understand that concept and understand how our interactions with humans that we are privileged to serve can either can be healing, traumatizing, or even re-traumatizing based on our knowledge and our understanding of how the body does always keep score. I’m excited about this conversation.
When people hear White supremacy, they start thinking to themselves, “What is that, and where is that showing up?” We are talking about this as professionals PT to PT or healthcare professional to healthcare professional. Does this show up in some way in our professional education as physical therapists?
Most definitely. We would be foolish to think that it doesn’t. Often when people hear White supremacy, the knee-jerk is to be defensive because of the connotations around that. We all, including those of us who don’t identify as White, have to understand that we live particularly if you are growing up in the United States, in a culture that has woven this throughout the fabric of our society.
If you think about like the things that you see on TV, the messaging, the way in which if something happens and a person who is non-White as involved, at that point, we give race or ethnicity. The denominator is always whiteness. We are all being planted in a garden that is constantly telling you that the definer of everything is white.We are being planted in a garden constantly telling us that we are the definer of everything that is white. Click To Tweet
Because of that, you can’t be shocked about this concept of White supremacy. If you study Project Implicit’s research, even those of us that identify as Black, Asian, or Pacific Islander, we often have the same biases towards whiteness as White people have, and it’s all because we are all getting the same messaging. If you think it’s not happening in the physiotherapy world, I’m going to need you to sit and reflect on that and have some moments of introspection.
By it being baked into our education, that would mean that it is in some way brought over into our clinical practice.
Most definitely. Medicine has been talking about this for a while. As physiotherapists, we have to remember that our roots are in medicine. The curriculums we use, the curricular resources, and all of those have White supremacy woven into them. How you learn is how you are going to practice.
I have a good friend Carla Sabus, who published some research a while back that said that even if your PT program goes above and beyond, and maybe they have got this very social reconstructionism and social justice lens to their curriculum, or maybe it’s evidence-based practice in a particular content area, that within six months, you will practice like the people that you are with. That is how powerful the environment is. We have to be thinking about how we are training people in school and also how we are retraining older therapists like you and me.
The concept of embodiment is popular in the world of trauma. They talk about trauma being an embodied experience. When we hear that racism is embodied, it’s a little bit harder for maybe a professional who hasn’t spent time in this to understand what that means and how that could possibly happen. Are we treating trauma or racism more specifically or an aspect of the fallout from racism in our patients?
It’s almost like racism-induced trauma. Most of us are comfortable saying now that pain and trauma have a subjective component to it that doesn’t devalue it. It just reminds us of how individual and how unique everyone’s perception of their experiences is. To me, the conversation and the science around pain should help us be able to better understand racism because that’s what it is. It’s a pain invoked on marginalized people by society, and society has validated that pain and structuralized it. It’s fascinating to me, as someone who identifies as Black as my race and my ethnicity being African-American, that we are leaning into this conversation about pain, but it almost feels like we are leaning away from this conversation about racism, and I often wonder why.Racism is a pain invoked on the marginalized by society. It is even validated and actually structuralized. Click To Tweet
As we look at pain as biopsychosocial phenomena, it seems like, as a profession, we have worked our way through the bio and psycho pretty well at this point. What you are saying in some way is that racism is a social construct. It’s something that’s happening in our environment, and it’s worked its way into every aspect of our social environment. The outcome of that is it shows up in our body in various ways, but pain could be one way.
I think pain is one way. Some of the myths that were out there, particularly persons who identify as Black as having thicker skin or maybe differences in the sensitivity of their nerve endings, I often wonder if the inaccuracy in that myth wasn’t because of the methodology but because we were naming the wrong thing. Maybe some of the difference in the presentation and severity of pain isn’t biological per se, but it is how that person is integrating all of this hurt which also causes inflammation. Maybe as science improves and after we are all or most of us are willing to acknowledge that racism is a trauma that is shortening people’s lives and also their quality of life, we can put more science behind this.
That makes me think about ways we can then engage with the community. If we are going to treat people in a one-on-one environment for their chronic pain, that’s going to take a long time.
It’s going to take a long time for us to have grade-A evidence, but there are things that we can do to impact lives right now. In preparing for this discussion with you, I was reading an article from Knobel. It’s a 2021 article. In this article, they were referencing a formula that talked about phenotypes and how you present is your genotype, which is your genes plus environment, which we all knew that but then they added in triggers, and then they also added in chance.
I was thinking about that and how any of the isms, be it racism, sexism, and homophobia, increase your risk for triggers. They increase your risk for higher chances of trauma and how all of that impacts your phenotype. It decreases your odds of being well. I was like, “Could we have this conversation around isms from that light? Would people be more open to that?” instead of when we start talking about isms, they poo-poo, “Is that your feelings?”
Everything the body responds to is about feelings. If it’s too cold outside, that’s a sensory response. That’s a feeling component to that as well, but it’s fascinating to me how some things are okay and aligns with someone’s reasons and other things that they are like, “No. That can’t be possible.” To me, that’s where people have to be willing to do their work and challenge their biases. As healthcare providers, if I’m not willing to recognize someone’s perceptions, I’m not willing to provide individualized care.
It’s not person-centered care at that point. Not recognizing your own biases and not recognizing that person’s experience or lived experience, then, in some ways, you are discounting a potential vulnerability that they may have been exposed to in their life, which is informing their current pain experience.
Yes. That, to me, is the definition of supremacy, the fact that I have decided that my understanding of your condition and what you need is better than yours, even though they are your experience. If that is not supremacy and colonizing someone’s lived experience, I don’t know what is.
That takes a lot of inquiry from the side of the healthcare professional, and I also think it takes a lot of self-inquiry. Before we started this episode, you asked me about me and my life, and we spent some time chatting and learning about each other to inform what we are going to do here. I’ve questioned and maybe have some information about this. Either in school or in continual education, are we helping professionals work their way through their lived experience to see how it’s impacted their health and then to see how their thoughts and beliefs have an impact on the therapeutic exchange or the therapeutic alliance?
I agree. I have had the pleasure of working with faculty at Regis University. Part of what they do is each learner does an intercultural assessment with an actual reliable and validated tool. The majority of the learners who identify as White, when you ask them about their culture and their understanding of why they do the things they do, most say, “I don’t have a culture.”
You have to walk them through the dimensions of the diversity wheel. You have to say, “Tell me about your family. Tell me about your favorite holiday. What are your holiday traditions? Who do you hang out with?” I do agree with you that a large population of American society has not done that work.
They’re sitting down and going, “Who am I?” There’s that part of it, but then I say that people, in general, because we are so caught up in being busy that we don’t practice the pause. We don’t value the silence of sitting with ourselves and the power that comes from sitting and going, “Who am I? Why am I doing what I’m doing? Where am I headed? What do I value?” Those are the things that define your mental models, and your mental models will define your behaviors. As we were initially talking about that PTs or physios, we don’t understand that we might be the most important intervention. Yes, manual therapy, physical agents, and all the things we have in our toolbox are great. In my mind, you may potentially be the biggest predictor of someone’s success in their PT clinic.
It’s the human intervention. You can have the best skills possible, but if you do not understand the power of the human intervention, your treatment may have a temporary benefit but not a long-lasting benefit, or you might potentially be causing that patient harm. Regarding some of the health disparities data that we see, we are not yet at the place where we can tease out some of that negativity in outcomes because of the providers.
The psychology world has provided us with a lot of data in that area because they have CBT and AC Act. They have all these psychological interventions, but there’s a whole lot of research that shows that interventions are wonderful, but what they are doing in some way is they are optimizing the therapeutic relationship. The intervention itself doesn’t necessarily have a whole lot of power on its own in certain contexts.
Coming from that psychology body of literature, they have shown us also that there’s power in having concordance of some affinity with the people that you serve or doing the work to have a shared value set so that you can make that connection, and how those health outcomes are associated with the connection. I know the hot topic right now is PT private practices decreasing no-shows. There are a few well-published articles that say to make a connection. If you make a connection, that will substantially decrease your no-shows.
I’m tracking with you here. In the pain world, especially in PT, we have spent a lot of time, which I’m a part of this, a lot of focus on psychologically informed pain care or psychologically informed physical therapy, but the narrative you are building is we need to have socially informed pain care or socially informed physical therapy.
I love that. I might use that. I’m going to borrow that and give you credit for it. There has been pushback to culturally responsive care and culturally responsible care, which culture is social. It all comes down to social. When you think about your families and friends, those are your interpersonal connections, which are social connections and then how you navigate society. It’s all social. I love that socially-informed care, which then might make people more open to having conversations about ZIP code-related care because we know that that’s also a strong predictor of health outcomes.
Tell me a little bit about ZIP code-related care. You and I spoke earlier that I have worked in New York City in what I would consider extremely wealthy neighborhoods. I have also worked in neighborhoods where there’s poverty. I have noticed that the bodies that come in and the outcomes are different.
It’s very different. Your ZIP code is going to dictate both access and quality to most of the things that are key to life, like education. The quality and access to education are based on the ZIP code. Health is all about which ZIP code you are in. Are you going to have access to good nutrition? Are you going to have access to physical activity resources? You are going to have access to providers.
What’s going to be your burden of care? All of that is related to ZIP code. I was looking at an article and was about to fall out of my seat when I read it. Granted that this article is probably about several years old, but I’m curious to replicate it. I’m like, “Do I have the bandwidth?” It was talking about 80% of Black patients, their care was provided by this small subset of physicians.
I started thinking about this when I first read it, and I was like, “That can’t be true,” but we know that there’s a small subset of providers that are willing to do care in Black and underserved communities. Even when I think about your practice as a physical therapist, there are very few therapists that are going to be willing to go and provide care for marginalized communities.
This article was talking about the burden associated with that. When you have decided as a provider that you are going to do this socially informed care, know full well that you are fighting mountains. We try to make it sound like for pain or any impairment, body structure and function issues that are individual factors if we address what’s going on with the individual, but no. You are fighting societal influences on health, and you, as a provider, know that you will be held responsible for that. Sometimes your pay is even going to be docked based on how some of these quality measures are put together. It’s interesting how the system has been set up in such a way to discourage people from taking care of some of the people that deserve equitable care.
It leads us to the idea of feelings of injustice that people experience with the healthcare system and with healthcare providers. Physical therapy, in many ways, sits in a broader field of pain care. Let’s talk about physical therapy first because most people reading this will be PTs. How do we start to bring a social justice lens to physical therapy care in pain management?
We have to figure out ways to structuralize it. I used to believe we could teach people to do the right thing. That was very Pollyannish of me. It has to be built into the structure. If clinics want to provide or if educational systems want to push socially informed care, then it has to be built into our performance of ours. It has to be built into the patient satisfaction surveys.
There’s a tool called the CARE tool which asks the patient, client, or individual, depending upon the terms you use, how compassionate or empathetic their therapist was, and taking that tool and there being some teeth behind it that this is something that we value and we are going to determine your livelihood. It’s shifting the power dynamics. When we are talking about isms, power has to shift.
Right there, it makes people very uncomfortable. They are very uncomfortable with a lot of things that you said because it forces them to look at themselves and say, “How do my beliefs about this particular person and who they are in their life experience impact the outcomes that I’m receiving? Now you are saying that my livelihood may be dependent on that.” I hear people saying, “If you are Black or gay, why is that my problem? Why is that my concern?”
It’s because we are all connected. If you have decided that it is okay for me to have an increased risk of disease, that then is going to decrease my ability to maintain employment. Sooner or later, you will pay. The part we forget is that there is connectivity, both known and unknown, and I talk about reparations. Someone has to pay the debts that we allow society to develop. You can either pay the debt now and deliver socially informed care, or you can pay the debt later with we will have to cover this somehow. The last valuation I saw was that health disparities cost us about $80 trillion. When PTs want to talk about reimbursement and why we are getting this small amount and these regular cuts, I’m like, “Provide some equitable care, which would then be health savings.”
The care is substandard, basically.
It’s sub-standard and expensive. If we could understand that social justice is going to benefit us because we are addressing the root because of their health issues, there would be more money in the system, and then you might get paid more.Social justice is beneficial to everyone. If people were healthier since they knew how to address the root cause of their health issues, there would be more money in the system. Click To Tweet
As a society, we look at education and healthcare as these two topics. In your neighborhood where you live, when you pay taxes, whether you have children or not, that money goes toward improving the school, and we are all on board with that because well-educated children in our community lead to safer or more productive communities.
We have not reached the place yet where we see healthcare as a social justice movement where when we invest in healthcare. Your neighbors’ health impacts your health and your well-being as well. I appreciate you bringing that topic to light. I also want to make sure we mention your work at the Ujima Institute. Tell us what your mission is there and some of the things that you have planned there.
I will say out loud that the Ujima Institute has been a blessing and has probably saved my life. We have now grown to the Ujima Center. We have a physical location here in Monroe, Louisiana, which I did not plan on being in Monroe, Louisiana. It is the seventh poorest congressional district in the United States, but it has been a blessing for me to be able to be here.
At the center, we now have five entities. The Ujima Institute, which was our initial body, still exists, but it primarily does continuing education, consulting work, and training of healthcare providers with the goal of decreasing implicit bias and the impacts of implicit bias. The literature’s pretty strong that your bias doesn’t change. It’s your response to the bias we are trying to get you to be aware of. We also have The Ujima Success Academy. Thank you for the great segue. The focus there is on the education of how we improve the academic and social development of children, predominantly Black children, so that they can enter the workforce and so that they can achieve whatever their definition of success is.
We provide services from six weeks old all the way to eighteen years old, either childcare services, after-school or even mentoring programs. We also have The Ujima Wellness and Rehab, where we address all dimensions of wellness either with our internal services or by partnering with local communities. If you or someone in Monroe, West Monroe, or surrounding cities, you can show up at the center. We have an intake form where we ask you, “What is it that you need?” and then we walk that journey with you and follow up.
What I’m excited about is that we received a grant, that we are going to be employing fifteen teenagers and training them to be community health workers. Each teenager will monitor and do surveillance on five families, reaching out to them monthly and finding out what it is they need, and then navigating them to services.
The other entity at the center is our foundation, which is what our fundraising is to support the efforts here at the center. We also have our collective, which the collective is our policymaking arm. As I told you before, I was a little Pollyannish at first, but policies are needed so that when people pass on or when the interest is no longer there because right now, everybody’s hyped on social justice, but several years from now when this is no longer a sexy woke topic, we are going to need some policies in place to make sure that we are accountable to the things that we said we valued.
That is what the focus of the collective is. Our mission here is to advance Black health and wellness through our programming and with socially conscious partners, and we do that from birth all the way to the end of life. We have got some amazing partners, like Greater Realness Cathedral, our faith-based partner. It’s been a fun and great journey.
This is why I wanted to have you on because you are leading this area for not only PTs but many health professionals in this area. If people want to reach out to you and read all the resources you have mentioned, can you let people know how they can learn more about you, your website links, and other ways?
You can go to www.TheUjimaCenter.org. I’m also on Twitter, @LisaVanHoosePT or @TheUjimaCenter. You can find us on Instagram and TikTok under that same @TheUjimaCenter. We are learning the power of branding as well. We are watching your show, Joe. If anyone, we are always open to these conversations about implicit bias and trauma-informed care. I love this socially-informed care and even racism-related traumas.
As you so beautifully stated, psychology research has been looking at this for decades. Even in my own search, finding out that in the 1950s, the government had started looking at the influences on racism and health because they were interested in the health of soldiers, but that literature never got to the public space. We are behind on many of the things that the government has known for a long time.
I appreciate your work. As you mentioned, we are growing together in this area because a lot of the work that you are doing is impactful on pain management, and we have to bring a social justice lens into pain management because treating it in the clinic is important. People are coming to us with a whole life experience, and sometimes, it’s generations of experience that are impacting the people.
Every people talk about the nervous system, and I’m like, “No, it’s every system of the body. It’s not the nervous system.” You are more than a nervous system. You are a whole complete human, and a lot of what’s happened in your past is informing how you presently feel now. I want to thank Dr. Lisa VanHoose for joining us on the show. You can reach out to her directly at The Ujima Center. That’s TheUjimaCenter.org. Make sure to check out Lisa on her social media as well.
You made me think of something. For those of you who know me, you know that I have these moments where I’m like, “There’s a study.” In 2019, the University of Delaware and New York University researchers looked at pain perception and what they identified. It was a sample of about 90 people, but we are more likely to perceive the early signs of pain in White faces than we are in non-White faces. As I was listening to you talk about the intergenerational experiences of pain, it is our role as a provider to be perceptive and pick up on that, but the literature states that we have a strong bias that we are only willing to perceive it. Accurately perceive it and perceive it early in certain groups.
The challenge to us is how we could be better tools in the healthcare ecosystem. As I was listening to you talk about that, it made me think of that study. I’m going to stop perseverating, but I want people to know that there’s so much rich data out there, and we are not just talking about feelings. There is science behind this if we would be willing to be the evidence-based and evidence-informed practitioners we say we are.
Thank you for your work. As you bring up the idea of perception, it makes me think about our ability to a perspective take on someone else’s experience. What you are saying is can you, as a professional, take a different perspective of a different human being and see how physical or emotional pain is showing up for them? Some of it is implicit, and some of it is a skill we hopefully can teach people.
Yes, if they are willing to be aware. Just as much time as we spend on our hands, we have to spend that much time on our eyes, brains, ears, and even our mouths on the things we say to people that may trigger pain for them. Thank you so much for letting me share time and space with you, and I hope we can do it again. I learned just as much from you in our conversation. Thank you so much.
Thank you. We will do it again. Make sure to check out Dr. Lisa VanHoose’s work. You can find her awesome chapter that she co-wrote in the textbook, Integrative and Lifestyle Medicine in Physical Therapy. That’s on oncology, which is her other specialty, but make sure with regard to this conversation, to check her out at TheUjimaCenter.org. Make sure to share this episode with your friends and family on Facebook, LinkedIn, and Twitter. You can tag me on Instagram. I’m always there. I’m happy to converse with you on this topic and the importance of it. I will see you in the next episode.
- The Ujima Center
- Integrative and Lifestyle Medicine in Physical Therapy
- Ujima Success Academy
- Ujima Wellness and Rehab
- @LisaVanHoosePT – Twitter
- @TheUjimaCenter – Twitter
- Instagram – The Ujima Center
- @TheUjimaCenter – TikTok
- Instagram – Dr. Joe Tatta
About Lisa VanHoose
Dr. Lisa VanHoose describes herself as your intercultural guide. She can help you make uncomfortable situations and topics comfortable and exciting. She is a Clinical Professor at Baylor University in the Physical Therapy Department. Dr. VanHoose is the Founder and Chief Scientific Officer of the Ujima Center. The mission of the organization is to improve Black health outcomes and patient/client satisfaction through workforce upskilling focused on intercultural development and interactions. Dr. VanHoose has investigated workforce diversification and health disparities since 1995. She is always excited to learn with and from all humans.