Treating Race-Based Traumatic Stress

Treating Race-Based Traumatic Stress

Race-based traumatic stress (RBTS) is a significant source of psychological distress for those who are Black, Indigenous, or people of color (BIPOC). Yet, many individuals from BIPOC communities are reluctant to seek professional help for this distress. The reasons for this reluctance are numerous and include an overall lack of cultural sensitivity in mental health services provided to the BIPOC community, as well as low numbers of mental health professionals who are also people of color. However, with culturally sensitive attention to the various aspects of clinical practice that influence treatment outcomes among this population, research suggests that therapies such as cognitive behavioral therapy can be effective for people who experience RBTS. In fact, when therapy is approached in ways that center the experiences of those on the receiving end of racism, individuals with RBTS are able to develop tools that not only enhance coping but also support empowered action. Read on to learn more about how RBTS is treated and how individuals who experience RBTS can benefit from this treatment.

Diagnostic Considerations

Currently, RBTS is not acknowledged in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This means that there is no formal diagnosis for this type of trauma. Nonetheless, research shows that RBTS results in symptoms that are similar to other trauma disorders such as PTSD. These symptoms include primary trauma reactions, such as are intrusion, avoidance, and arousal/reactivity symptoms. For example, individuals who have been victims of hate crimes or racial profiling may have flashbacks of the event and may avoid people, situations, or other reminders of the incident. These individuals may also find themselves being constantly “on guard” or alert for similar threats of harm, which over time, may lead to difficulties with concentration, irritability, or panic. Other symptoms that can develop in response to RBTS include dissociation, anxiety, depression, sexual problems, sleep disturbance, low self-esteem, substance misuse, and anger.

Despite the similar symptomatology between RBTS reactions and PTSD, diagnostic criteria in the DSM-5 states that a PTSD diagnosis requires exposure to actual or threatened death, serious injury, or sexual violence. Some race-based events including racially motivated threats of violence, physical assaults or threats from law enforcement, community violence, medical mistreatment, assault while in prison, and deportation can meet criteria for PTSD under the definition offered in the DSM-5. However, many other race-related experiences, such as repeated microaggressions, discrimination, being denied services, verbal assaults, being ignored or stereotyped, and being racially profiled, do not meet the DSM-5 definition of a traumatic stressor. Accordingly, responses to experiences with racism may not always be recognized by the treating clinician, which, unfortunately, may limit access to potentially helpful mental health care for many BIPOC individuals experiencing RBTS. Individuals who seek therapy for RBTS, therefore, should attempt to work with providers who have an adequate understanding of how to account for the unique experience and pervasive impact of racism in the development of trauma and trauma disorders. 

Assessment

Assessment of RBTS typically begins during the initial evaluation session. At this time, the clinician may use a semi-structured interview protocol to develop a broad understanding of the ways in which race and other cultural aspects influence how individuals view and cope with their problems. Some clinicians may also utilize interview protocols that more specifically explore distress and trauma caused by racism. The University of Connecticut Racial Ethnic Stress and Trauma Survey (UnRESTS), for example, is an interview that explores an individual’s experience with various types of racism, including overt racism, racism by loved ones, vicarious racism, and covert racism. This interview protocol also includes questions to assess the extent to which these symptoms meet DSM-5 criteria for PTSD, and a measure of ethnoracial identity.

In order to obtain a baseline assessment and measure progress over time, quantitative measures such as the may be used in the assessment of RBTS. This short and easy to administer scale was developed in consideration of DSM–5 PTSD criteria, the literature on racial stress and trauma, and developers’ clinical knowledge of symptoms. It includes three subscales: (1) Lack of Safety, (3) Negative Cognitions, and (3) Difficulty Coping. Examples of items of the RTS include “thinking the world is unsafe,” “feeling like I am not as good as others,” and “having nightmares about discrimination.”

Addressing RBTS

After an initial assessment of RBTS, the clinician and the client will work together to develop a treatment plan to address the client’s specific symptoms. Typically, treatment plans in cognitive behavioral therapy focus on helping clients reduce their symptoms by teaching them to examine their thinking and develop alternative explanations for distressing situations. However, when listening to a client’s experience with racism, it is important that the therapist believes the client’s interpretation of events as well as the pain these events cause. Research shows that when therapists miss these opportunities, clients experience negative treatment outcomes, such as a worsening of mood, a breakdown of the therapeutic alliance, or even premature termination of services. Therefore, cognitive behavioral therapists who work with RBTS should focus on validating experiences with racism, while challenging any maladaptive self-appraisals or behaviors that develop in response to the trauma rather than the client’s view of the situation itself. The goal of this approach is to help clients experience a reduction of symptoms, develop more positive and active ways of coping, and increase their sense of empowerment.

Finally, given the sensitive nature of racism and the amount of vulnerability required to discuss this topic, therapists who treat RBTS should also emphasize building rapport with clients and establishing safety in the therapeutic relationship. Seeking therapy and acknowledging the pain and hurt that result from experiences with racism can be difficult. The reasons for this vary and include cultural stigma around receipt of mental health services, mistrust of the health system, and the belief that individuals should be strong enough to handle problems on their own. Therefore, clients who seek treatment for RBTS should expect a therapeutic relationship characterized by warmth, empathy, and affirmation of one’s live experience with racism. 

Resources

Survivors of RBTS do not have to deal with their experiences alone. If you are dealing with the psychological wounds of racism, therapy, (particularly, cognitive behavioral therapy), can teach you strategies to settle your body, reduce unhelpful thinking patterns that limit your ability to cope, and intervene in systems that impinge on your mental health and wellness. You can also obtain support from the following resources:

ICRace Lab toolkit resource:
https://icrace.files.wordpress.com/2017/09/icrace-toolkit-for-poc.pdf

NPR article on psychological toll of racism:
https://www.npr.org/sections/codeswitch/2015/07/02/419462959/coping-while-black-a-season-of-traumatic-news-takes-a-psychological-toll

Audre Lorde’s article on turning silence into action:
https://caps.sfsu.edu/sites/default/files/documents/Audre%20Lorde%20-%20Silence%20Into%20Action.pdf

Monnica Williams’ Racial Trauma Scale can be found in the appendix to the article:
https://psycnet.apa.org/record/2022-81213-001?doi=1

contributed by Janeé M. Steele, PhD, LPC

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