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Racial Trauma Assessment, Diagnosis, and Treatment adaptation for BIPOC
I have compiled a long-format list of relevant research and resources for clinicians who want to become more competent when dealing with racial trauma. I have not written an exhaustive article detailing how to work with racial trauma because the adaptations, assessments, and treatment methodologies require competent engagement which requires the clinician to interact with the research and understand the specific ways to integrate these treatments into their processes.
In other words, if I were to condense the instructive research articles here, they would lose some of their integrity and may cause incompetent use of the adaptations described. What I did in this post is to provide you with the resources you need to educate yourself. Like a self-lead masterclass. It is a lot of reading, but we are good at that in the mental health world, right?
One note, this research can apply to BIPOC LGBTQ+, however, there are particular traumatic experiences that the BIPOC LGBTQ+ experience that needs to be addressed. I am currently trying to find more research geared towards this population, in particular, to include in this post and I am finding that there is not a large amount of research here. As soon as I can, this will be added to what I was able to find. If you have a resource for that population to help us better work with this group of clients, please let me know so that I can share it.
These are the articles specifically addressing this population that I have found so far:
(Hailey, Burton, & Arscott, 2020)
(Ching, Lee, Chen, So, & Williams, 2019)
Precedent and Prevalence
The interesting thing that I found after reading the research is that African Americans have a prevalence rate for PTSD at 9.1% compared to 6.8% for European Americans (Williams, et al., 2014)
For a more detailed breakdown, read the article found here
What was also interesting is that the presentation of the traumatic disorder for BIPOC can vary. For example, among African American and Black doctoral students in one study, those who were seemingly asymptomatic showed a greater impact on academic performance as reflected in their GPA, however, students who were symptomatic and carried a PTSD diagnosis had higher GPAs. The study asserted that help-seeking behaviors provided the diagnosed students with greater resources. (Truong & Museus, 2012)
Additionally, other studies have found unexpected results with Blacks being less likely to develop psychopathology at all in response to trauma. In these studies, specifically McLaughlin, et al. (2018), I have noticed that racial trauma is not explicitly considered in the research and this is something to take notice of as it affects the interpretation of trauma for BIPOC and the subsequent diagnosis of traumatic symptomology. When reading research, pay close attention to the way in which trauma is interpreted in relation to providing diagnoses and generalizable results. This is discussed more in the diagnosis section of this post.
Couple those two points of interest with the often stated and statistically relevant fact that African Americans and Blacks are less likely to have access to or seek help from mental health professionals and a pattern begins to emerge. This vulnerable population is able to benefit from treatment for racial trauma IF they are able to access the help and have a clinician who is competent in racial trauma to provide this help rather than dismissing it or helping them to further identify with their trauma (internalized racism).
For more information on this correlation, read this article.
If you would like to read about the prevalence of the complications of racial trauma and the comorbidity of alcoholism the following article is relevant:
(Desalu, Goodhines, & Park, 2019)
(McLaughlin, et al., 2018)
Another complication of this correlation and the effects of untreated, compounded trauma is the development of comorbid diagnosis and severe mental illness. (Williams, Holloway, & Ross, 2019)
Another article that helps to understand the correlation between treatment-seeking and severity of symptoms is (Ghafoori, Barragan, Tohidian, & Palinkas, 2012).
Changing perspective and world view
“Historical trauma refers to a complex and collective trauma experienced over time and across generations by a group of people who share an identity, affiliation, or circumstance.” (as cited in Mohatt, et al., 2014). This term, historical trauma, is a concise descriptor for racial trauma in the US. This is especially applicable as medical science has found indicators that generational trauma can alter biological processes as well. This is especially applicable as medical science has found indicators that generational trauma can alter biological processes as well. Read Mohatt, et al. for a greater understanding of the impact of considering historical trauma on the public narrative.
The encompassing nature of systemic racism makes the assessing, diagnosing, and treatment of racial trauma overwhelming when viewed at the macro level. As clinicians, we need to be able to stand in the gap for clients who are overwhelmed by the immense nature of racism and what it means about their past, current, and future experiences. The most foundational way to do this is to update our perspective and worldview to reflect the reality of the world in which we live.
In addition to popular memoirs and sociological explorations such as White Fragility by Robin Diangelo and The Fire Next Time by James Baldwin, please see the below resources for maintaining an accurate worldview when working with all clients:
(Greene & Bilitz, 2012)
(Dixon, Ahles, & Marques, 2016)
(Mohatt, Thompson, Thai, & Tebes, 2014)
(Hemmings & Evans, 2018)
Considerations impacting diagnosis of BIPOC
The current PTSD diagnosis outlined in the DSM-5 was changed to acknowledge the need for greater flexibility in the definition of experienced traumas. While this is a great boon for the client population experiencing trauma, the definition is still found lacking for the recognition of racial traumas such as microaggression, systemic experiences, and perceived traumas. The inability to qualify for this diagnosis means that the resources and treatments reserved for the population experiencing this diagnosis are unavailable to those who are experiencing PTSD as a result of racial trauma. This creates another racial disparity in access to resources and healing. (Williams, Metzger, DeLap, & Leins, 2018)
This also means that research on PTSD and other traumatic disorders will not include racial trauma within its diagnostic parameters. This will affect treatment research on PTSD in BIPOC populations. You can imagine that these consequences ripple throughout the mental health industry and into other industries as BIPOC find that their daily living activities and productivity are more greatly impacted by the trauma-induced symptoms. (Williams, et al., 2014)
Recommended assessments and adaptations for BIPOC
The following is a round-up of the adapted and created measures for the assessment of racial trauma. Please note that I have not summarized these findings as these articles are instructive and require thorough reading for competent implementation in practice. For more information on how standard trauma exposure assessments perform in African American populations when racial trauma is not considered, please read (Malcoun, Williams, & Nouri, 2015) and the book from which this article was excerpted Guide to Psychological Assessment with African Americans.
Additionally, an important part of racial trauma lies in the racial identity of an individual. Understanding that African American and Black cultures do not mean the same thing (see the vocabulary section) and that the amount of identity assimilation varies as the BIPOC culture, in general, is not homogenous is essential. Additionally, identity for BIPOC is also greatly affected by internalized racism. Identity must be assessed in order to fully address racial trauma and its role in trauma-exposure-related diagnoses.
The UCONN Racial/Ethnic Stress and Trauma Survey (This article also presents a model of racial trauma on page 248 which is incredibly helpful.) (Williams, Metzger, DeLap, & Leins, 2018)
A primer on PTSD symptom presentation in veteran populations (Koo, Hebenstreit, Madden, & Maguen, 2016)
Refugee Health Screener- 15 (Bosson, et al., 2017)
Use of the Impact of Event Scale-Revised (IES-R) with Latinx populations (Tiemensma, et al., 2018)
Trauma Symptoms of Discrimination Scale (Also explores the use of other racial trauma scales within the article which establishes validity for the population tested. Note, the population tested was recruited from a student population which limits the generalizability of the results as the scale is self-report in format.) (Williams, Printz, & DeLapp, Assessing Racial Trauma with the Trauma Symptoms of Discrimination Scale, 2018)
Cultural Adaptations for the Posttraumatic Diagnostic Scale, the Standardized Trauma Interview, and racial identity assessment (Williams, et al., 2014)
Understanding the Differential Vulnerability Hypothesis and how it can affect assessment and treatment (Aruguete & Edman, 2019)
A more comprehensive exploration of race-based traumatic stress (Carter, 2007)
Considerations for the effect of police violence for assessment (Bryant-Davis, Adams, Alejandre, & Gray, 2017)
Recommended treatment modalities and adaptations for BIPOC
Prolonged Exposure therapy has been cited as incredibly beneficial in the articles below as a treatment for racial trauma. I do, however, want to caution the clinicians reading this recommendation – if you have not engaged in intense work towards competency in the area of racial trauma, you will do more harm than good in the treatment of racial trauma. This is called practicing outside of your level of competency.
“For instance, if those who experience a racist incident are told that if they work hard, dress a certain way, and get along well with others, they will not experience racism again. When these rules are followed, and racism still occurs, powerlessness, hyperarousal, and other symptoms associated with PTSD may set in or worsen.” (As cited in Malcoun, Williams, & Nouri, 2015).
Cultural Adaptations of Prolonged Exposure Therapy (An incredibly thorough article about how to use PE safely with this population) (Williams, et al., 2014)
Visual Thinking Strategies for the clinician and educator (Gardner, 2017)
Resources for Adolescent BIPOC
General overview (Hardy, 2013)
Prevalence and the MMRI used for racial identity assessment (Sellers, Yip, & Seaton, 2009)
Treatment using TF-CBT (Phipps & Thorne, 2019)
A model of the impact of racial trauma on youth of color (Saleem, Anderson, & Williams, 2020)
A manual for treating African American Youth (highly recommend) (Singh, Al-Mateen, & Breland-Noble, 2016)
Additional resources to explore can be found here:
http://www.monnicawilliams.com/racial-trauma-readings.php
http://www.monnicawilliams.com/publications.php
Eliminating Race-Based Mental Health Disparities: Promoting Equity and Culturally Responsive Care across Settings
Vocabulary
Racial Trauma: “a traumatic response to race-related experiences that are collectively characterized as racism, including acts of prejudice, discrimination, or violence against a subordinate race group based on attitudes of superiority held by the dominant group” (as cited in Williams, Holloway, & Ross, 2019).
African American: “…reflects the ethnic experience associated with darker-skinned Americans of African descent.” (Williams, et al., 2014)
Black: “…the ethnic group of darker-skinned individuals with ancestral origins in Africa who may or may not have been born in the U.S.” (Williams, et al., 2014)
References (Please forgive the imperfect formatting as I am limited by my publishing medium)
Aruguete, M. S., & Edman, J. L. (2019). Trauma Exposure and Academic Performance in African American College Students. North American Journal of Psychology, 573-582. Retrieved from https://www.questia.com/library/journal/1G1-603152523/trauma-exposure-and-academic-performance-in-african
Bosson, R. S., Williams, M. T., Schlaudt, V. A., Corrico, R. M., Pena, A., Kotey, S., . . . Kanter, J. (2017). Evaluating Mental Health in Cuban Refugees: The Role of the Refugee Health Screener-15. ULJR&GH, 15-23. Retrieved from https://ir.library.louisville.edu/cgi/viewcontent.cgi?article=1006&context=rgh
Bryant-Davis, T., Adams, T., Alejandre, A., & Gray, A. A. (2017). The Trauma Lens of Police Violence against Racial and Ethnic Minorities. Journal of Social Issues, 852-871. Retrieved from https://spssi.onlinelibrary.wiley.com/doi/full/10.1111/josi.12251
Carter, R. T. (2007). Racism and Psychological and Emotional Injury: Recognizing and Assessing Race-Based Traumatic Stress. The Counseling Psychologist, 13-105. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0011000006292033?journalCode=tcpa
Ching, T. H., Lee, S. Y., Chen, J., So, R. P., & Williams, M. T. (2019). A Model of Intersectional Stress and Trauma in Asian American Sexual and Gender Minorities. Psychology of Violence, 1-12. Retrieved from https://psycnet.apa.org/record/2018-40440-001
Desalu, J. M., Goodhines, P. A., & Park, A. (2019). Racial discrimination and alcohol use and negative drinking consequences among Black Americans: a meta-analytical review. Society for the Study of Addiction, 957-967. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30714661/
Dixon, L. E., Ahles, E., & Marques, L. (2016). Treating Posttraumatic Stress Disorder in Diverse Settings: Recent Advances and Challenges for the Future. Current Psychiatry, 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533577/
Gardner, R. P. (2017). Discussing Racial Trauma Using Visual Thinking Strategies. Language Arts, 338-345. Retrieved from https://secure.ncte.org/library/NCTEFiles/Resources/Journals/LA/0945-may2017/LA0945Lessons.pdf
Ghafoori, B., Barragan, B., Tohidian, N., & Palinkas, L. (2012). Racial and Ethnic Difference in Symptom Severity of PTSD, GAD, and Depression in Trauma-Exposed, Urban, Treatment-Seeking Adults. Journal of Traumatic Stress, 106-110. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599779/
Greene, M. P., & Bilitz, L. V. (2012). The Elephant is Not Pink: Talking About White, Black, and Brown to Achieve Excellence in Clinical Practice. Clincial Social Work, 203-212. Retrieved from https://link.springer.com/article/10.1007/s10615-011-0357-y
Hailey, J., Burton, W., & Arscott, J. (2020). We are Family: Chosen and Created Families as a Protective Factor Against Racialized Trauma and Anti-LGBTQ Oppression Among African American Sexual and Gender Minority Youth. Journal of GLBT Family Studies. Retrieved from https://www.tandfonline.com/doi/full/10.1080/1550428X.2020.1724133
Hardy, K. V. (2013). Healing the HIdden Wounds of Racial Trauma. Reclaiming Journal, 24-28.
Hemmings, C., & Evans, A. M. (2018). Identifying and Treating Race-Based Trauma in Counseling. Multicultural Counseling and Development, 20-39. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1002/jmcd.12090
Koo, K. H., Hebenstreit, C. L., Madden, E., & Maguen, S. (2016). PTSD detectino and symptom presentation: Racial/ethnic differences by gender among veterans with PTSD returning from Iraq and Afganistan. Journal of Affective Disorders, 10-16. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26402342/
Malcoun, E., Williams, M. T., & Nouri, L. B. (2015). Assessment of Posttraumatic Stress Disorder with African Americans. Guide to Psychological Assessment with African Americans, 163-182. Retrieved from https://psycnet.apa.org/record/2014-54243-011
McLaughlin, K. A., Alvarez, K., Fillbrunn, M., Green, J. F., Jackson, J. S., Kessler, R. C., . . . Alegria, M. (2018). Racial/ethinic variation in trauma-related psychopathology in the United States: a population-based study. Psychological Medicine, 2215-2226. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30378513/
Mohatt, N. V., Thompson, A. B., Thai, N. D., & Tebes, J. K. (2014). Historical trauma as a public narrative: A conceptual review of how history impacts present-day health. Social Science & Medicine, 128-136. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4001826/
Phipps, R., & Thorne, S. (2019). Utlizing Trauma-Focused Cognitive Behavioral Therapy as a Framework for Addressing Cultural Trauma in African American Children and Adolescents: A Proposal. The Professional Counselor, 35-50. Retrieved from https://files.eric.ed.gov/fulltext/EJ1215487.pdf
Saleem, F. T., Anderson, R. E., & Williams, M. (2020). Addressing the "Myth" of Racial Trauma: Developmental and Ecological Considerations for Youth of Color. Clinical Child and Family Psychology Review, 1-14. Retrieved from https://link.springer.com/article/10.1007/s10567-019-00304-1
Sellers, R. M., Yip, T., & Seaton, E. K. (2009). A Longitudinal Examination of Racial Identity and Racial Discrimination Among African American Adolescents. Child Development, 406-417. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791402/
Singh, N. N., Al-Mateen, C. S., & Breland-Noble, A. M. (Eds.). (2016). Handbook of Mental Health in African American Youth. New York: Springer.
Tiemensma, J., Depaoli, S., Winter , S. D., Felt, J. M., Rus, H. M., & Arroyo, A. C. (2018). The performance of the IES-R for Lations and non-Latinos: Assessming measurement invariance. PLoS ONE, 1-14. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195229
Truong , K. A., & Museus, S. D. (2012). Responding to Racism and Racial Trauma in Doctoral Study: An Inventory for Coping and Mediating Relationships. Harvard Educational Review, 226-326. Retrieved from https://scholar.harvard.edu/truong/publications/responding-racism-and-racial-trauma-doctoral-study-inventory-coping-and
Williams, J. C., Holloway, T. D., & Ross, D. A. (2019). Witnessing Modern America: Violence and Racial Trauma. Biological Psychiatry, e41-e42. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31668222/
Williams, M. T., Malcoun, E., Sawyer, B. A., Davis, D. M., Nouri, L. B., & Bruce, S. L. (2014). Cultural Adaptations of Prolonged Exposure Therapy for Treatment and Prevention of POsttraumatice Stress Disorder in African Americans. Behavioral Sciences, 102-124. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219246/
Williams, M. T., Metzger, I. W., DeLap, C., & Leins, C. (2018). Assessing Racial Trauma Within a DSM-5 Framework: The UConn Racial/Ethinic Stress and Trauma Survey. Practice Innovations, 242-260. Retrieved from https://psycnet.apa.org/record/2018-37737-001
Williams, M. T., Printz, D. M., & DeLapp, R. C. (2018). Assessing Racial Trauma with the Trauma Symptoms of Discrimination Scale. Psychology of Violence, 1-12. Retrieved from https://psycnet.apa.org/record/2018-48184-001