Williams, PhD, M. T., Haeny, PhD, A. M., & Holmes, PhD, S. C. (2021). Posttraumatic Stress Disorder and Racial Trauma. PTSD Research Quarterly, 32(1), 1–9. https://www.ptsd.va.gov/publications/rq_docs/V32N1.pdf
Definition/Description
Butts (2002) was the first to draw attention to what we now call racial trauma, or race-based trauma, in the mental health literature. Racial trauma can be defined as the cumulative traumatizing impact of racism on a racialized individual, which can include individual acts of racial discrimination combined with systemic racism, and typically includes historical, cultural, and community trauma as well. Helms et al., (2012) argue that acts of racial and ethnic hostility can trigger trauma reactions due to a person’s own past experiences or historical events, even when there is no recent or direct evidence of threat to one’s life. Carter (2007) compiled a comprehensive overview of the psychological impact of racism and events that can result in race-based stress and trauma. Racial trauma appears to be relatively common among treatment-seeking people of color. Hemmings and Evans (2018) conducted a survey of counselors and found that the majority of professionals had encountered race-based trauma in their clinical work (71%), but few had received training in the assessment or treatment of those afflicted.
Liu et al., (2019) detail the process of acculturation that many people of color experience when navigating dominant culture. White supremacist ideology, the belief in White biological or cultural superiority that serves to maintain the status quo of racial inequality, is deeply integrated in dominant culture values (Liu et al., 2019). Through chronic exposure to racism, people of color learn their positionality and how to become racially innocuous Continued on page 2 as part of acculturating to White culture. As a result, some people of color may change their presentation and behavior and accommodate the cultural preferences of White people to avoid triggering responses that might further their own racial trauma. As part of acculturating to White culture, some people of color actively maintain their intersecting identities, whereas others may internalize racism by embracing stereotypes about their racial group. Given how inextricably linked White supremacist ideology is within dominant cultural values, Liu et al., (2019) encourage researchers and clinicians to consider how they may have internalized standards of practice consistent with White supremacist ideology.
Evidence of Harms
Racism has been linked to a host of negative mental health conditions, but the connection between racial discrimination and PTSD symptoms appears to be the most robust. Racial and ethnic discrimination was postulated to have a causal role in PTSD symptoms and alcohol problems in a longitudinal study of Hispanic college students (Cheng & Mallinckrodt, 2015). Sibrava et al. (2019) found the same in a longitudinal study of Latino and African American adults, where frequency of experiences with discrimination significantly predicted PTSD diagnosis but did not predict any other anxiety or mood disorder, indicating a potentially unique relationship between discrimination and PTSD. Examining data from a large health maintenance organization in Northern California, mediational analyses indicated that adolescents who experienced more discrimination reported worse PTSD symptoms, which was related to more alcohol and drug use, fights, and sexual partners (Flores et al., 2010). Having multiple stigmatized identities may have compounding effects on traumatization. Dale and Safren (2019) found that gendered racial microaggressions (subtle acts of prejudice) predicted PTSD symptoms and posttraumatic cognitions among Black women with HIV, to a degree greater than discrimination based on either race or HIV-status alone.
Traumatization may occur at a community level as well. In a population-based, quasi-experimental study, Bor et al., (2018) found that highly publicized police killings of unarmed Black people had spillover effects on the mental health of Black people in the region where the killing happened. The impact was felt for months afterwards, whereas no ill effects were found for White people in those same localities. It is thought that the cultural legacy of state-inflicted oppression is a contributing factor leading to poor community health through vicarious retraumatization. Gone et al., (2019) have explicated the community impact of historical trauma on health outcomes for indigenous populations in the USA and Canada, and likewise, Nagata et al., (2019) have shown how the Japanese American wartime internment experience has caused lasting traumatizing effects on those interned and their descendants.
Mechanisms
Different forms of racism may contribute to race-related stress or trauma responses, which may be salient in terms of mechanisms for traumatization. Similarly, an understanding of the various ways in which trauma may present is informative for treatment development. The accumulation of race-related stressors including intergenerational racial trauma, racial microaggressions, racial discrimination, and overt racism that many people of color experience can result in developing PTSD (Williams et al., 2018). Kira (2010) offers a broad conceptualization of trauma that encompasses cumulative and collective identity trauma. Cumulative traumas may involve core traumas, which sensitize and provoke responses to subsequent stressors, and triggering traumas, which ultimately set off the trauma response (Kira, 2010). Ability to differentiate between these different types of traumas is important for case conceptualization and treatment. Kira (2010) highlights the importance of interventions that focus on empowering victims of oppression and increasing their perceived control. These interventions can help reduce traumatization through enhancing perceived self-control and executive functioning through encouraging and supporting the victim in seeking retributive justice. The focus on empowerment and increasing self-control is consistent with other race-related stress and trauma interventions (Carlson et al., 2018).
Several studies have investigated mechanisms associated with race-related stress and trauma among people of color. Torres et al., (2015) found that symptoms of traumatic stress (hypervigilance, arousal, avoidance) mediated the association between ethnic microaggressions and depression with a stronger association found among Latinx adults with low levels of ethnic identity and self-efficacy. Among women of color, lower self-esteem partially mediated the relationship between racism and trauma symptoms and high ethnic identity buffered the effect between racism and trauma symptoms (Watson et al., 2016). In a sample of Chinese international students, racial discrimination was associated with PTSD symptoms above and beyond general stress, and high ethnic social connectedness buffered this effect (Wei et al., 2012). Thus, the literature suggests race-related stressors can cause trauma symptoms through lowering self-esteem which can contribute to poor mental health outcomes. In addition, high ethnic identity and self-efficacy can serve as protective against the negative impact of race-related stressors on mental health.
It has also been suggested that people of color may experience shock after a race-related stressor (Williams et al., 2018), which may result in shame for not defending themselves in the moment and contribute to lowering self-esteem and maladaptive coping (Williams et al., 2018). Further, the potential social costs associated with discussing racist events may contribute to avoidance in discussing these experiences with others (Carlson et al., 2018). In addition to lowering self-esteem, the experience of shame and avoidance after a race-related stressor may also contribute to the development of PTSD symptoms and maladaptive coping.
Assessment
Racial trauma can stem from a variety of causes, many of which are not represented in typical measures designed to assess PTSD. When considering PTSD, clinicians often consider sexual abuse, combat, and life-threatening assaults. Williams et al., (2018) explicate the many additional sources of traumatization people of color may experience as a result of racialization, such as police violence, racial threats, immigration difficulties, and workplace harassment.
Loo and colleagues (2001) were among the first to develop and validate a measure of racial traumatization, the Race-Related Stressor Scale (RRSS) for Asian American Vietnam Veterans. The RRSS measures exposure to racism, and among Veterans assessed, exposure to race-related stressors accounted for an additional 20% of the variance in PTSD symptoms over and above combat exposure and military rank (Loo et al., 2001). Carter and colleagues (2013) developed the landmark Race-Based Traumatic Stress Symptom Scale (RBTSSS), the first tool to evaluate racial trauma in a clinical setting. Limitations of the measure include its length, a complicated scoring process, and its inability to render a diagnosis. Williams at al., (2018) developed the Trauma Symptoms of Discrimination Scale (TSDS), which covers anxiety-related PTSD symptoms. The measure includes trauma symptoms from any source of discrimination but has thus far only been validated in African American and multiracial individuals and, similar to the RBTSSS, does not render a diagnosis. Furthermore, it can be helpful for clinicians to discuss racially charged materials directly with patients in an interview style-format. To address this need, Williams et al., (2018) developed the UConn Racial/Ethnic Stress & Trauma Survey, which is a clinician-administered interview that can also help in rendering a PTSD diagnosis due to discrimination, based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.
Treatment
The literature is sparse on empirically supported approaches for treating PTSD and racial trauma among people of color. The few treatments available range from cultural adaptations of evidence-based PTSD treatments (Williams et al., 2014) to interventions explicitly targeting racial stress and trauma (Bryant-Davis & Ocampo, 2006; Carlson et al., 2018; Saleem et al., 2020). When working with victims of oppression, Kira (2010) suggests that helping victims to forgive collaborators in an oppressive system is associated with positive mental and physical health outcomes and contributes to reconciliation, whereas supporting anger against the oppressor and helping the victim seek retributive justice is associated with healing and positive mental health outcomes related to regaining self-control and executive functions.
A group race-based stress and trauma intervention (RBST) (Carlson et al., 2018) was developed for Veterans of color to discuss experiences of racism that led to stress or trauma symptoms. Group discussion themes include psychoeducation on different forms of racism, identity development, power, White privilege, and stress and trauma reactions, race-based stressors in mental and physical health and military experiences, challenges with discussing race-based stressors with mental health providers, and resilience and empowerment. Psychoeducation on the sociohistorical context of racism, cognitive restructuring to reshape beliefs that people of color are not to blame for racist incidents, and hearing experiences of racism from others may help reduce shame and alleviate internalization of racism. Veterans reported that participating in the RBST intervention provided them with a new way to think about their experiences with racism, empowered them to address racism in a way that felt authentic, and provided skills for coping with regular experiences of racism. The authors provide suggestions for implementation of the RBST intervention across service areas. As of this writing, RBST groups are operating at over a dozen US Department of Veterans Affairs (VA) facilities.
The Developmental and Ecological Model of Youth and Racial Trauma was developed for addressing race-based stress and trauma for youth and adolescents of color (Saleem et al., 2020). This is a critical area of study because young children may be affected by experiences of racism yet lack the verbal skills to process these experiences. This article proposes a model of how race-related stress and trauma may develop and present in youth and adolescents with a focus on the impact of family and community systems. Case examples are provided for elementary, middle, and high school-age youth. The authors also provide recommendations for future research to develop prevention and intervention programs based on this model potentially incorporating approaches for enhancing racial socialization in families.
Multisystemic, multimodal, multicomponent therapies typically include the individual, family, and the community in the healing process and are considered more ecologically valid and culturally competent approaches for treating race-related stress and trauma (Kira, 2010). These therapies are flexible which allows them to be adapted for different cultures and different types of traumas. In addition, multisystemic, multimodal, multicomponent therapies tend to be more comprehensive by addressing both clinical and non-clinical needs. Further, a strengths-based approach is often used
in these therapies by identifying strengths of the individual, family, and community that can be leveraged in treatment.
Future Directions
There is still much work to be done to address the reality of racial trauma. Ample empirical evidence attests to the nature and impact of racial trauma on victims. The next critical steps include raising awareness of racial trauma among clinicians, which includes incorporating the assessment and treatment of racial trauma into clinical training programs and adding some discussion of racial trauma into important diagnostic manuals, such as the DSM-5. Holmes et al., (2016) provide a compelling argument for expanding Criterion A for PTSD based on the deleterious impact of oppression. Many others have called for racial trauma to be included in the DSM-5, noting the broad and cumulative impact of racism on people of color (Loo et al., 2001; Williams et al., 2018).
Oppression may have the greatest impact on those with multiple stigmatized identities (Dale & Safren, 2019). Ching et al., (2018) presented a model of intersectional stress and trauma in Asian American sexual and gender minorities. More work is needed to understand how marginalization surrounding these intersecting identities may differentially and collectively result in traumatization.
In order to accomplish the needed work, people of color must be better represented in clinical trials for PTSD, and new studies are needed to examine treatment outcomes for protocols specifically focused on racial trauma. In a novel examination of Methylenedioxymethamphetamine- (MDMA-) assisted therapy for PTSD in people of color, Williams et al., (2020) detail culturally informed methodology to access and retain those suffering from racial trauma in clinical trials. This methodology could be a guide for other researchers who aim to study these vulnerable populations for the purpose of developing effective interventions.