The Microaggressions Triangle Model: A Humanistic Approach to Navigating Microaggressions in Health Professions Schools

Abstract

Microaggressions are types of interactions that create a cognitive load that can impede a health professions student’s ability to perform well in their program. This paper discusses the Microaggressions Triangle Model, which is a framework for understanding microaggressions from a human interaction standpoint. At each point in the model, the authors provide approaches designed to help recipients, sources, and bystanders construct responses that may allow for rebuilding. From a restorative justice standpoint, rebuilding gives all people involved the opportunity to restore their reputations and repair relationships. Rebuilding is about individuals and communities acknowledging and learning from the interaction as a way to promote a climate of inclusion in their organization.

The term microaggression was coined in 1970 by the late Harvard psychiatrist Chester Pierce.¹ Microaggressions describe interactions, whether intentional or not, that convey, in subtle but powerful ways, negative messages about specific groups of people.^2,3 Microaggressions are subtle in the sense that the person who is the source of the microaggression or even bystanders may not understand the impact of the microaggression, particularly if they do not share the identity that has been targeted. For the recipient, however, it can be very painful. In fact, Salvatore and Shelton suggested that although Black people may be better prepared to deal with overt racism than White people are, they are particularly impacted by ambiguous or subtle racism, such as racial microaggressions.⁴ Sue described a continuum of microaggressions, including microassaults, microinsults, and microinvalidations² (see Table 1). Although some people use the term macroaggression to emphasize the impact that a microaggression has on the recipient, this term was used by Chester Pierce to describe physical violence, such as lynching. As microaggression theory has developed, the term macroaggression has been used to refer to institutional and structural racism.^3,5 This paper focuses on the kinds of individual microaggressions that tend to be unconscious and unintentional.

Table 1: Forms of Microaggressions

Why Microaggressions Are a Problem

Microaggressions have been shown to have a dose–response relationship with depression and anxiety.^2,3,6,7 In other words, the more often an individual experiences stressful interactions, such as microaggressions, the higher the likelihood they will develop symptoms of depression and anxiety. Meyer introduced the concept of minority stress to describe the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often minority, position.⁸ It is also known that chronic stress, such as that caused by the daily experiences of discrimination, microaggressions, and racial battle fatigue, increases allostatic load, which is associated with physical health outcomes, such as cardiovascular disease, obesity, and diabetes.^9,10

In addition to mental and physical outcomes, microaggressions can create a “cognitive load,” which refers to the workload imposed upon intellectual functions, particularly during learning.¹¹ Upon receiving a microaggression, the recipient must deal with the psychological impact of what was said or done, determine the intent and meaning of the statement or action, and then decide how to respond.² This cognitive load, cumulatively and over time, wears down mental function, impairs productivity, and erodes relationships—all of which can contribute to diminished academic performance.² Cognitive load can impede a health professions student’s ability to perform well, advance, or even graduate. The effects of cognitive load are contrary to goals of increasing retention rates and meeting our values of equity, diversity, and inclusion.

A natural and reasonable response to microaggressions or threats to one’s identity is to avoid the situation. This reaction becomes evident in health professions schools when students do not respond to emails, stop coming to class, or withdraw from school. We also see this as students divest in classroom discussions and essentially put their heads down to survive our programs. One underrepresented minority student described their response to frequent microaggressions in nursing school by saying, “I remind myself to keep my head down and keep my mouth shut—not draw any attention to myself.”⁶

Introduction to the Model

We created the Microaggressions Triangle Model (see Figure 1) as a framework for understanding and addressing microaggressions from a human interaction standpoint. This framework was the natural outgrowth of the research done by Ackerman-Barger and colleagues on microaggressions⁶ and the desire expressed by many to have the skills necessary to coherently respond to microaggressions. The Microaggressions Triangle Model encourages people to view microaggressions from all 3 perspectives (recipient, source, and bystander) and humanizes individuals by encouraging participants to step into the shoes of others. Although it may be easier to recall a time when you have been the recipient of a microaggression rather than the source of a microaggression, the reality is that we have all been involved in microaggressions as the recipient, the source, and the bystander at some point.

Figure 1: The Microaggressions Triangle

During a microaggression, there are threats to the reputations of all involved. The recipient may be seen as oversensitive, the source as racist, and the bystander(s) as cowardly. From a restorative justice standpoint, rebuilding gives all involved the opportunity to restore their reputations and repair relationships. Rebuilding is about individuals and communities acknowledging and learning from hurtful interactions. Involvement at any of the 3 points of a microaggression does not have to be a defining moment—it can be a learning moment. It is important to note that the Microaggressions Triangle Model provides a way of thinking and decision making that may help individuals at any point on the triangle to make a decision about how to promote inclusion. It may also be the framework for deciding that the source intended harm or that this is not a microaggression but overt racism or discrimination. In such a case, it would be unwise to engage with the source in the moment; instead, it should be addressed through other channels. Either way, it is important to make informed and well-thought-out decisions. In the following discussions, we will explore ways to engage if you have decided the situation is a microaggression and might be a teachable moment or an opportunity to promote inclusion.

How the Model Works

Using the following scenario, let us address, separately and in turn, the experiences of the individuals in the triangle, focusing on how each person can respond in a way that rebuilds and restores reputations and repairs relationships. Please note that this scenario focuses on a peer interaction; there can be additional complexities to navigate when this model is applied to patients or when there is a power dynamic involved. We have provided additional scenarios in Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B14 that address these situations. An African American male nursing student, Rick, described an interaction with peers after an exam:

Classmates were asking, okay, what did you get on the exam? People responded: “I got an A, a B, or I have to retake it”—things like that. And I didn’t even want to mention it, but I was specifically asked what I had gotten, so I said, “I got a 100 percent on this exam.” And people did not believe it for some reason. Even though other people had a similar grade, everyone was kind of surprised that I got such a high score and didn’t take me seriously. I don’t know if it’s because of me being Black or if it’s because of other things.

The recipient

When an individual perceives a microaggression, a very difficult dilemma arises. First, the recipient needs to figure out what was meant; then, they must figure out how to respond. Of course, every situation has context, such as the power dynamics of those involved and what exactly is at stake. A recipient who decides against addressing the microaggression often feels guilt for passively allowing the microaggression to perpetuate stereotypes and devalue their identity group. A recipient who does address the microaggression might be accused of being too sensitive or even risk their standing in either the relationship or the organization.

The recipient’s response is ACTION

Recipients can use the ACTION model, created by Cheung and colleagues,¹² to guide their response when they have received a microaggression. It is important to understand that, when you receive a microaggression, you are in a compromising situation and many factors must be considered. First, recognize that, upon receiving a microaggression, your mind and body sense a threat and the primal functions of your brain can easily take control of your frontal lobe or rational brain. This is when you are likely to respond in a way that makes the situation worse or even makes you seem like the aggressor. Consider, for example, a situation in which a student has been on the receiving end of a disturbing racial microaggression from her preceptor in a clinical setting. When she seeks assistance and guidance from her school’s program directors, they downplay her experience and question her professionalism. In frustration, the student bangs her hand on the table. She is then formally disciplined by the institution and placed on academic probation. Although deeply unfair, this is a common scenario and it is in the best interest of the recipient to avoid this.

As a recipient of a microaggression, you must consider whether you are safe both physically and in terms of your status. For example, a student who objects to a microaggression that a faculty member initiated risks the faculty member responding in a way that could jeopardize the student’s progression in the program. Choosing to address the issue at a later time does not equate to ignoring it. For example, if you are a student and you received a microaggression from a faculty member, it may be appropriate to delay addressing it, choosing instead to seek the wise council of a trusted mentor or friend who can help you make an informed plan about how to respond.

Addressing it in the moment is also an option. When you choose to do this, consider what your motivation is for engaging with the source. If your motivation is based in emotion, the situation is likely to escalate. If your motivation is to uphold inclusion principles and to take advantage of a teachable moment, you may have more success. Cheung and colleagues suggest the ACTION approach to frame a response, as described below.¹²

Ask a clarifying question.

For example: “You seem surprised that I received a high grade. Are you surprised?”

Come from curiosity, not judgment.

For example: “I want to better understand your surprise, can you explain it to me?

Tell what you observed in a factual manner.

For example: “I noticed that when you asked some of the other students about their grade you did not express the same level of surprise.”

Impact exploration.

Discuss the impact of the statement. For example: “Ouch. Your surprise makes me feel like people doubt my ability and intellect.”

Own your thoughts and feelings about the subject.

For example: “It’s difficult being the only Black student in our cohort. People often think I am here only to fulfill a diversity goal. That’s hard because I have always done well in school.” (If the source has been able to hear what you have shared, consider the following, which may help rebuild the relationship.)

Next steps.

For example: “Hey, let’s go to class now, but if you want to talk about this later, I would be happy to grab some coffee with you.”

Please note that these steps are simply ideas for how to respond. Each person must make the decision for themselves, given the circumstances, whether they want to engage and how.

The source

A powerful way to address microaggressions is to decrease the amount of times you are the source of them. Because microaggressions tend to be the output of unconscious bias, the source of the microaggression may not be aware of the impact of what they have said or done. Remember that one’s unconscious bias may be in opposition to one’s values. So, a well-intended source who realizes that they were responsible for a microaggression can feel humiliation, causing cognitive dissonance, anger, and defensiveness. When individuals are the source of a microaggression, they are often deeply concerned about their self-image and harm to their reputation. By reflecting upon one’s own experiences having been the source of a microaggression, it becomes possible to develop perspective when you are the recipient or bystander trying to make a decision regarding if, how, and/or when to respond to the source of a microaggression.

The source’s response is ASSIST

We created the ASSIST model to guide the responses of individuals when they become aware that they may have been the source of a microaggression. The steps of the ASSIST model are described below.

Acknowledge your bias.

A way to avoid becoming the source of microaggressions is by familiarizing ourselves with and mitigating our unconscious bias. The most direct route to doing this is to seek out others who are different from you and to have authentic genuine interactions and relationships with them. If you lack opportunity to directly engage with folks different from you, seek out the literature, music, art, or other reflections of the cultural heritage of different groups as a first step to more deeply understanding the experiences of others. In the scenario above, the source should consider that bias may have played a role and comment accordingly.

Seek feedback.

It takes courage to respond to a person who, intentionally or not, was the source of a microaggression; therefore, if you are the source, listen. Further, if you are confused by an interaction and have any doubt about whether you were the source of a microaggression, seek honest feedback from the recipient, or from a trusted friend or colleague who is more invested in you learning or growing than in helping you build a case that you are right. For example, “I noticed when we were talking about exam grades, you became quiet. How was that interaction for you?”

Say you are sorry.

Realizing that you have been the source of a microaggression can cause guilt (regret for your action) and/or shame (a sense that you are a horrible person), both of which are painful. Apologies can be difficult, because we often think of them as an admission of wrongdoing. An apology should be about recognizing someone else’s pain. See below for an example.

Impact, not intent.

Whether your intention was to hurt another person or not, this is a great opportunity for you to learn about someone else’s experience. When a person feels accused, a tendency is to protect oneself by defending one’s actions and trying to establish who is right or wrong. However, defensiveness can further harm the recipient and making this about right and wrong misses an important opportunity to learn about another person’s perception. It is important to realize that whatever the intention may have been, there was an impact. In the above scenario, you could say: “Although it was not my intention to harm you, I see now how my questioning your score affected you and I am sorry.”

Say thank you.

For example, “Thank you for the feedback. I appreciate you taking the time to help me grow as a person.” As the source, when you view the scenario through a lens of humility, you realize the courage and emotional intelligence the recipient (or bystander) exercised to respond to you in a way that can help you grow. This is a gift, and the only appropriate response is an expression of gratitude. This is an opportunity to make a commitment to yourself to change your behavior. This also would be an appropriate time to make a verbal commitment to the individual to change your behavior and to do better in the future.

The bystander

Microaggressions affect not only the recipient and the source but also bystanders and the community. A bystander is an individual who witnesses the event. “Active” bystanders are individuals who intervene in the situation. People are often wary of being active bystanders because of the inherent risk in becoming involved. People worry: “Will I become a target, too? Will I make the situation worse? How should I respond?” Other individuals may be passive bystanders—those who do nothing. Coloroso stated, “Standing idly by or turning away have their own costs.”¹³ Bystanders should intervene for many reasons. Inclusive climates depend on each of us having the strength and courage to hold ourselves and others accountable. Many bystanders know what it feels like to be the person receiving a microaggression, understand the cost of remaining silent, and would appreciate support if the situation were reversed.

The bystander’s response is ARISE

We created the ARISE model to guide the response of a bystander when they observe a microaggression.

Awareness.

Mindfulness skills can help the bystander to be aware of what is happening in the moment and have been shown to be effective in mitigating bias.¹⁴ Perspective taking, a skill that can be used to imagine how the comment could be taken by the recipient, also has been shown to decrease bias.¹⁵ In the above scenario, a bystander could have raised awareness of the situation by saying, “Your surprise about Rick’s score suggests a biased assumption.”

Respond with empathy and avoidance of judgment.

While it may be tempting to respond with the negative emotions that have been engendered by the interaction, approaching with empathy is critical because the goal is to rebuild community. The source of the microaggression likely does not intend to be rude, and empathy may allow those in the situation to learn something they can use to work together. In responding, it is also important to avoid judgment. Remember that everyone has implicit bias, and all of us have been the source of microaggressions. Judgment halts any opportunity for learning and engagement. Avoiding judgment means allowing others the grace to make mistakes, and to learn from their mistakes.

Inquiry.

Approach the situation with curiosity and make inquiries. Bystanders can ask questions of the source of the microaggression to understand the reasons behind their statement, such as: “Can you explain your comment to me?” or “What did you mean by that?”

Statements that start with I.

“I” statements can be used to express what the bystander noticed about what was said and about how others reacted. A bystander also can use “I” statements to talk about how the comment made them feel. For example: “I noticed that Rick seemed offended when you made that comment about his score, and so was I.”

Educate and engage.

Educating the source can be done by developing discrepancy. Borrowing from the philosophy of “motivational interviewing,” developing discrepancy can be described as the process of differentiating between the speaker’s intent and the outcome of their behavior.¹⁶ When bystanders create a discrepancy between the speaker’s intention and the impact of their comment, they are poised to assess the motivation of the source which can help guide the bystander about how to respond. Engaging toward a common goal is the second part of this step. Research has shown that implicit bias can be mitigated through focusing on egalitarian goals.¹⁷ Bystanders can talk with the source of the microaggression about how they can create consistency between their behaviors and their values. A response to the scenario could be: “I know you didn’t intend to stereotype anyone, but as your friend, I want to let you know that what you said could be interpreted that way.”

Conclusion

Health professions schools must do more than merely increase the diversity of the health professions student body and work force; they also must practice inclusion excellence and focus on creating equitable spaces in which all students and faculty members can thrive. The alarming prevalence and impact of microaggressions in health professions education behoove students, educators, and administrators to train themselves and others on how to best respond to these interactions. Although the Microaggressions Triangle Model focuses on what individuals can do to promote inclusion, it can also be nested within mentoring and training programs to promote systemic inclusion within health professions schools. We are currently developing a toolkit, Addressing Microaggressions in Academic Health: A Workshop for Inclusive Excellence, which will provide a package of case scenarios that trainers can use to teach individuals to apply the Microaggression Triangle in their institution. This paper provides the framework for thinking that would support such training efforts.