A Case Report on Lower Self-Esteem Issues Among Black American Men in Relation to their Dark Skin Color and Homosexuality

which is based on how one different and of one’s [2]. High self-esteem is viewed as promoting healthy functioning in different areas of life such as achievement ABSTRACT Objectives This case report describes the intersectionality between low self-esteem, dark skin color, homosexuality, and mental health while working with BAGM. The client’s symptomology was specified as moderate depression with recurrent episodes 296.32 (F 33.1) (DSM-5, 2013). The treatment was focused on treating client’s underlying issues related to low self-esteem, his dark skin color, and same sex-orientation, which were found to be directly related with client’s depressive symptoms. The treatment methodology was a combination of existential therapy, Gestalt therapy, and cognitive behavior therapy (CBT) with its emphasis on treating the whole person. In addition, psychoeducation was offered on various psychological issues. Client-centered approach and multicultural approach was used throughout the entire counseling relationship. Results: The client indicated improved depressive symptoms with an integrated approach of existential therapy, Gestalt therapy, and CBT. Conclusion: After 6 months of weekly counseling sessions, client indicated improvement in his self-esteem related to his overall personality and more specifically related to his dark skin color along with his improved comfort level in sharing his preferred sexual orientation as evidenced by his verbal and non-verbal cues. In addition, pre- and post-assessment with the help of Beck Depression Inventory showed improvement in his depressive symptoms.

, job-satisfaction [3], improved resilience. In contrast, low selfesteem can be a contributing factor in developing various mental health issues including substance abuse, violence, depression [4], depressed mood (Patterson and Capaldi, 1992) eatingdisorders, suicidal tendencies and attempted suicide, and other high-risk behaviors [5]. Moreover, Wilhelm, et al. [6] found that low self-esteem in early adulthood is one of the major predictors of depression in later life. Homosexuality is referred to a physical attraction toward the same sex (Dworkin & Gutierez, 1992). There are several stages a person has to pass after realizing one's sexual attraction toward member of the same sex. Cass [7] theorized six stages from identity confusion to acceptance and pride.
Black-Americans (BAs) were also found to move through different developmental stages during attaining their racial selfconcept [8], which varies from unawareness of their cultural identity and shame over their ethnic heritage to acceptance, pride, and commitment to their ethnic community. It was also found that Black-American gay men (BAGM) often seek acceptance and validation within the BA community as well as in the gay community [9], which they struggle with due to homophobia in the BA community and racism in the gay community. The self-esteem issues may arise due to lack of validation and acceptance. Crisp, et al. [10] conducted interviews with four BAGM who were from lower-middle to middleclass families and had attended college. All of them showed some common themes including sense of isolation from organized religion within the BA community, fear of creating conflicts with their parents because of disclosing their sexual orientation, difficulty maintaining romantic relationships, feeling ignored or misrepresented by media that led to negative selfimage [10]. Skin color in BAs refers to various shades of skin and indicates different levels of symbolisms including both positive and negative. For instance, coal black, skillet blonde, tar baby, and blueblack are identified with the dark skin color; and red-bone, light bright, red, and high yellow are attributed to light skin color. Some dark-skinned BAs view their dark skin as a sign of oppression [11], whereas some light-skinned BAs feel disparaged due to them being seen as not black enough [12].
Racial Identity of Black Americans were found to be evolved and consisted of five sequential stages including preencounter, encounter, immersion-emersion, internalization, and internalization commitment [13]. According to the study conducted by Coard, et al. [14], acceptance of one's skin color may not necessarily be equivalent to one's satisfaction with acceptance, and thus lowers self-esteem. For instance, dark skinner BAs may indicate acceptance of their darker skin rather than satisfaction of it. Moreover, they may have intellectual satisfaction and still have underlying emotional conflicts regarding their skin color.
Individuals may feel satisfied with their dark skin color but continue to feel that their skin color is not acceptable by others leading to their negative overall sense of self. It was also found that men who scored high on satisfaction with their skin color showed low self-esteem. Thus, considering self-esteem issues among BAGM as a strong contributor factor for various mental health issues and suicidal tendencies, it is crucial to focus on improving their selfesteem for their overall wellbeing and mental health promotion.

Case History
The client for this report will be referred to as the client or under the pseudonym, Andre. Andre is a 21-years old, Christian, BA, homosexual cis-male; and was pursuing his major in pharmacy when he started receiving counseling service. Andre preferred to work with a female counselor in his screening questionnaire.
His medical history indicated that he was diabetics, and he was recommended by his physician to take shots before each of his meal on daily basis. Nothing was reported about his legal history and counseling history. In the first session, he did not make proper eye-contact with the CMHC and his voice was very slow. Andre presented with low self-esteem due to his dark skin color and homosexuality, which led to loneliness, relationship-issues, schoolrelated stress, and procrastination. Andre realized that he was gay at the age of 14 but he had been hiding that since then, which was very stressful for him. His parents were divorced, and his father was living with his newly married wife at that time. He was not comfortable talking to his father about his sexual orientation, but he recently opened up with his mother and brother about it. He reported that his brother was fine with that, but his mother could not take it and cried a lot. Andre shared with a few of his friends on campus that he was bisexual, which was a lie. However, he told some of his close friends that he was gay. Andre stated that he was feeling guilty because of his sexual orientation as it is not accepted in his religion. He also reported low self-esteem because of his dark skin color, guilt due to not being active during high school, feeling of loneliness, and not being in a relationship.

Skin color
Andre mentioned that he had been struggling for years because of his dark skin color. He stated that his father was BA and had a dark skin color like him, but his mother and brother had lighter skin color than him because his grandfather from his mother's side was a white man. According to Andre, his brother had a bigger friend circle than him due to his light skin color, which made him envious towards his brother. Andre also mentioned that he never had any black friend in his friend-circle and he still avoid it, because another black person in the group would receive more attention than him.
Andre reported that he had thoughts of bleaching his skin many times, but he never tried that.

Guilt
Andre said that he never participated in games or organizations during his high school which lowered his self-esteem. He mentioned that if he had been more active during high school, he would have more friends and higher self-esteem than now. He reported that there was a large population of BA students in his high school, and mostly white students were at higher educational levels.

Loneliness
Andre reported that he got his own room as he was working on campus and he did not often meet with his friends who live off campus. He said that he had cut off communication with people and were feeling lonely most of the time, which he did not like.

Relationship Issue
Andre reported that he had never been in a relationship, as he had a specific type of people he was attracted toward. It was interpreted that Andre had a fear of being single forever as he has specific type which he thought was difficult to find. Andre also reported that he had doubts if the person whom he likes would like him back or not. He mentioned that he started doing excessive workout in order to have stronger physique that might help him overcome his low self-esteem.

Stress Related to His Study/Work and Time Management
Andre reported that he started working on-campus, because he wanted to get noticed and recognized by other people. He further reported that his increased workload and procrastination had affected his studies negatively, which increased his stress level.

Risk Assessment
Andre reported that he had thoughts of suicide a year ago but he never planned or attempted suicide. He said that he was living on 16th floor at that time and thought multiple times to jump out of the window. He also reported that he had fantasies of cutting his wrist and had thoughts that how long it will take someone to find him. Andre mentioned that he has talked about his suicidal ideations to one of his best friends only and no one else. Based on the diagnostic assessment of the symptoms and identified criteria, Andre was diagnosed with moderate depression, recurrent and recurrent suicidal ideations without a specific plan. However, his depressive symptoms were found to be directly related with his underlying issues related to low self-esteem, his dark skin color, and same sex-orientation.

Treatment Plan
The clinical mental health counselor (CMHC) used an integrated therapy as a combination of existential theory, Gestalt theory, and cognitive behavior theory (CBT) to help Andre integrate his cultural aspects into his whole self. In addition, psychoeducation was provided on the importance of learning one's individuality as well as becoming aware of one's ethnicity and cultural identity to find a healthy balance between them for thriving in society. It was identified that Andre was in the pre-encounter stage of his development, which is the first stage of racial identity development.
This stage is described as having Eurocentric or anti-Black attitude and characterized as a dependency on White society for their approval [13,14]. This interpretation was based on Andre's selfreport that he did not know much about his culture and his negative talks about BA culture, for example "I think black people are only famous among their own people, not among white people", "I don't even like their music, because it is too aggressive." When asked about any of his favorite BM celebrity, he said that "I can't think of anyone." The CMHC gave him homework to find something good about BA culture on internet such as a success story BA person or something on BA celebrity(ies) he finds inspiring. He was also encouraged to explore history of his culture by reading books or articles on the Internet, watching movies, or talking to someone from his community. Client was also encouraged to join on-campus or off-campus BA associations to increase his awareness of his own culture. Being an immigrant Asian-American counselor, CMHC chose to do some self-exposure about her own ethnicity and cultural identity, which was taken as positively by Andre as evidenced by his verbal and non-verbal cues.
The purpose of CMHC's self-exposure was to help Andre see a different worldview on integrating cultural identity in the overall self-identity without feeling the need of changing or ignoring it.
Andre was also suggested to attend on-campus or off-campus workshops on homosexuality for educating himself and feeling accepted. Gestalt therapy was used to help Andre to improve his ability to live fully in the present moment, resolve his unfinished past issues, and increase his self-awareness and self-acceptance.
It was interpreted that Andre's high school experience with other BM was traumatic, which was evidenced by his self-report that he was bullied by other BM students and he had guilt related to not  [15], it leads to prominent existential concerns. Andre in his early adulthood was observed to be going through this stage of identify formation. Therefore, existential therapy was used to help him develop self-respect, selfunderstanding, and self-concept all of which are directly related to high self-esteem. Another purpose of using this approach is the correlation of suicidal risk with negative self-concept, hopelessness, and isolation [16], which were all present in Andre's case. Our aim was to help Andre with his occasional suicidal fantasies by educating him learn to make better choices and have some experiences in which he feels integrated and connected with the world. He responded well towards this approach as evidenced by his self-report of no current suicidal ideations. CMHC also used existential approach to work with Andre develop his individuality on a broader or humanistic level, which is based on the foundation that although we belong to a certain group or culture, we all are human beings and can shape our individuality freely without any Black men without feeling threatened by them, and his report of feeling better about his skin color and his sexuality, and reaching out to men of his interest more easily than before. He also showed improved depressive symptoms on the Beck Depressive Inventory after 6 months of therapy.

Discussion
Literature indicates that there is a strong relationship between low self-esteem, dark skin color, and homosexuality among BAM that adversely affected different areas of their life. A study conducted by Coardz, et al. [14] indicated that Dark-skinned BAM were satisfied with their skin color, however showed low self-esteem due to their unresolved underlying issues and concluded that satisfaction with their dark skin color may not be same as that of acceptance of it. In the present study, CMHC assisted the client in resolving his issues during his high school such as getting bullied by other BA students that might have adversely affected his sense of identity. Another study showed that BAGM viewed their ethnicity as most important aspect of their identity followed by their sexual orientation, however faced difficulties in various areas of their life for getting acceptance for their homosexuality such as from their church and own community as well as from the dominating ethnic group [10].
This leads to a lack of social and religious support, which causes a sense of isolation within their own community. In our literature review, we also found a strong relationship between dark skin color among BAM, mental health issues, and suicidal tendencies.
Previous studies indicated causal role of self-esteem, for instance, low self-esteem during early adulthood is an important predictor factor of depression in later life [6,17,18].
According to Baumeister [19], in severe cases, when individuals are not able to live up to their personal standards, they tend to have low self-esteem which further leads to depression. For the treatment purpose, it is crucial to promote positive self-esteem which is considered as a leading factor for both mental and physical wellness (Mann et al., 2004). Our choice of existential theory for Andre's treatment was based on the correlation between existential despair and suicidality [20] and the multidimensional construct of manhood that includes "the self, a man's relationship and responsibility to family, and a worldview or existential philosophy" (p. 473). According to Heisel, et al. [21], increased purpose and satisfaction in life is found to be a high predictor of improved mental health issues and reduced suicidal tendencies. Moreover, 26888 by acceptance, self-knowledge, awareness, and engagement [22].
The meaning of the term Gestalt is 'whole' [23]. Gestalt therapy is experiential in nature [24] and perceived as an existentialist humanistic psychotherapy [25] that enhances awareness and focuses on the client's immediate experience [26].
One of the most efficient technique of Gestalt therapy is an enactment methodology known as EC technique that facilitates in resolving unfinished past businesses by identifying them in relation to one's present life [27]. The EC is an enactment methodology [22] that facilitates emotional processing of unresolved issues by recognizing them in relation to current life [27]. The EC technique help clients in focusing on the organized entity (Andre's younger self) in the 'here and now', embracing their present-self and the organized entity [22], empowering them to perceive their thought process and belief system in relation to their whole-self [24]. This technique helped Andre resolve his past unfinished businesses during his high school and integrate his past segmented experiences in his current reality to promote seeing himself as a whole self. CBT approach was integrated in the treatment process to help Andre identify his unhealthy and irrational beliefs that might have led to his low self-esteem, procrastination, poor time-management, lack of social skills, guilt about his identity and sexual-orientation.

Future Recommendations
In case of working with clients of different racial and ethnic background than CMHCs, it is crucial to convey a positive and unconditional regard to their clients. It is recommended for CMHCs to become aware of their sources of discomfort with differences that exist between themselves and clients in terms of race, ethnicity opportunity to talk about this topic could put them in a vulnerable situation, but a competent professional clinician with the help of unconditional positive regard and acceptance can create a safe space for their clients. For suicidal intervention, we strongly recommend applying three basic principles of existential therapy discussed by Lybbert, et al. [15], which includes follow the client, respect the client via using a strength-based approach, and finding meaning in suffering when the suicide risk is found to be low. However, for the assessment indicating high risk, we recommend a combination of existential therapy and the traditional crisis intervention model.

Conclusion
This case report describes an integrated approach of existential therapy, Gestalt therapy, and CBT to treat the whole person and improve depressive symptoms among BA gay man related to his low self-esteem, dark skin color, and same sex-orientation.
Intersectionality between low self-esteem, dark skin color, homosexuality, and mental health was also highlighted in terms of its relation to depressive symptoms. In conclusion, based on our literature review and case study, we strongly emphasize identifying intersectionality between these variables while working with BAGM, and utilizing that information to treat the whole person002E.