Therapy

Intersection of Racism and PTSD: Assessment and Treatment of Racial Stress and Trauma Monnica T. Williams, Ph.D. 1, * Muna Osman, Ph.D.-Sophia Gran-Ruaz, B.S.1 Joel Lopez, B.A.? Address *School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON K1N 6N5, Canada Email: Monnica. [email protected] Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA Published online: 29 August 2021 © The Author (s), under exclusive licence to Springer Nature Switzerland AG 2021

article is part of the Topical Collection on PTSD Keywords Racial trauma • Posttraumatic stress disorder • Racism • Ethnicity • Psychotherapy : Assessment • Cultural competency Abstract Purpose of Review Racial trauma is a severe psychological response to the cumulative traumatic effect of racism. This review synthesizes emerging theoretical and empirical evidence of racial trauma, outlines the mechanisms, and lists available assessment and treatment options for racial trauma. Recent Findings Emerging evidence illustrates that these cumulative experiences can result in the cognitive, behavioral, and affective presentations of PTSD in people of color. Asta result, the evidence to inform the assessment, treatment, and implications of racial trauma has grown exponentially. There are several validated interview and self-report instruments for clinicians to better understand client's experiences of racism, discrimination, and traumatic stress. There are several emerging treatment options for people of color experiencing racial trauma. However, given the scarcity of literature, we need more studies to establish the validity and efficacy of available assessment and treatment options.

Summary Emerging and promising advancements can extend our knowledge on racial trauma, including incorporating the cumulative and lasting negative impacts of racism on people of color in how we define PTSD. Additionally, strengthening clinical training and continued education programs for professionals to hone their capacity to discuss the impact of racism effectively administer appropriate assessment tools and implement interventions specific to racial trauma. Introduction Sharon is a 22-year-old First Nations woman, currently completing her law degree. She travels back to her northern rural town in Canada in the summers to work at the local pharmacy and help finance her studies. She loves spending time with her friends and family; however, the prejudice and discrimination she experiences have been increasingly difficult. A few weeks into her return, while at work, a White customer mistook her for another customer and closely followed her around the pharmacy. When Sharon confronted the customer, the woman admitted she was following Sharon to deter her from stealing. This caused a heated argument about prejudice and racial profiling. Sharon's supervisor was not supportive and SEP 25 tv neighboring township. This news caused her to think a lot about the countless other missing and murdered Indigenous women and girls who suffered similar injustices [1]. As a result, Sharon dreads leaving for work and risking a possible confrontation with the locals or police. She notices that her anxiety mounts during the drive from home to work, and her heart is pounding by the time she reaches the parking lot. As a result, she opts to stay in the protection of her home, as opposed to going out with family and friends, when she is not working. She also finds herself feeling anx-ious, questioning her abilities, and becoming more socially withdrawn. Moreover, she is jumpy, irritable, and experiencing intrusive thoughts that perhaps she

asked Sharon to keep her opinions to herself. She has experienced similar incidents at work, the local grocery store, and around her town. She has recurring intrusive thoughts about these incidents for weeks after they happen. Driving to and from work has also resulted in Sharon being pulled over by police four times for "routine" checks. When Sharon asks her local White friends if they have had similar experiences, not one had been pulled over in the past 6 months. Sharon was also deeply saddened to read in the town's paper of a violent attack on some First Nations women in the *g Options - All comments - Get help y is to blame for her experiences of racism. Sharon is suffering from racial trauma. In this article, we examine the intersection between racism and posttrau-matic stress disorder (PTSD) - a response many individuals have to a traumatic experience. We review the emerging theoretical and empirical evidence of racial trauma, outline the antecedents, protective mecha-nisms, and consequences of racial trauma as well as list the available assessment and treatment options for racial trauma. Understanding racial trauma Although formally associated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with discrete events such as surviving a natural disaster, being in a war or combat, or being subject to a sexual assault, emerging research suggests experiences of racism can have similarly debilitating psychological effects on people of color (POC [2-4]) as PTSD. As such, racial trauma can be defined as the severe mental and emotional injury caused by

the cumulative traumatic effect of racism experienced throughout one's life. Racism scaffolds the prejudice, discrimination, and violence targeted at a subordinate racial group by a dominant group and justified by false notions of superiority [5]. Using the DSM-5 criteria for PTSD as a framework, Williams and colleagues proposed a model of racial trauma that reconceptualizes the race-based traumatic stress injury model and explicitly outlines how traumatic experiences of racism can result in the cognitive, behavioral, and affective presentations of PTSD [6, 7•°]. Their model of racial trauma conceptually maps the cumulative effect of racial strese and trauma across one's life, including cultural trauma, overt and covert racism, racially traumatic events, and invalidation, as well as institutional racism and barriers to treatment [7••]. This model posits that historical and cultural trauma predispose individuals to heightened levels of stress, and perpetual experiences of overt and covert racism further aggravate this predisposition. Together, these experiences form the initial vulnerabilities for racial trauma. At this point, an unexpected and uncontrollable racially traumatic event, which threatens one's safety or humanity, can result in a strong emotional response, including fear, anger, shock, and humiliation. This is further exacerbated when others invalidate and dismiss these experiences, especially health professionals, and limited access to supportive opportunities to process this triggering event. As these experiences accumulate, individuals will exhibit symptoms of PTSD over an extended period of

Options - All comments ~ Get help Clinically, racial trauma may be captured by four symptom clusters, including reexperiencing the event, avoiding trauma reminders, worsening cognitions and mood, and heightened arousal and hypervigilance resulting in psychological distress and impaired functioning not attributable to another cause (7•*]. Reexperiencing the racially traumatic event can include distressing memories and reminders of the trauma, intrusive thoughts, and even flashbacks or nightmares. As in the aforementioned case, Sharon has recurring intrusive thoughts regarding her experiences of discrimination, for weeks following the events themselves. Symptoms of avoidance consist of eluding reminders of the trauma, not thinking about the event, keeping away from groups associated with the traumatic event, such as White people or law enforcement, or self-isolation. With Sharon, we see this in her avoidance to go out with friends/family and risk a confrontation. Negative cognitions and mood are seen in symptoms of depression, anxiety, cognitions that the world is unsafe, self-blame, and self-doubt, as well as emotions and cognitions of guilt and anger. haron has started to wonder if there is something she is doing to attract negative attention, or if perhaps she is being overly sensitive. Lastly, physiological arousal includes patterns of hypervigilance, being easily startled, and poor quality sleep and limited concentration. Following her experiences of discrimination, Sharon reports feelings of anxiety, heart palpitations, and being more easily startled. Of note, these four symptom clusters map easily onto criteria B-E PTSD diagnosis.

Antecedents, protective mechanisms, and consequences of racial stress and trauma Racial stress and trauma can be deeply distressing. As outlined in the model of racial trauma, some individuals who experience one or more race-based traumatic events will develop PTSD. The likelihood of a diagnosis depends on a complex interplay between initial vulnerabilities, antecedents that promote a likely onset of PTSD, and protective mechanisms that reduce this likelihood. Yet, emerging data suggests racial trauma among POC is quite common. Spe-cifically, Hemmings and Evans surveyed 106 American counselors and found 71% of those interviewed had encountered racial trauma in one or more of their clients [8]. Alarmingly, the same study found that 67% of counselors lacked any formal training on the diagnosis of racial trauma, and 81% were absent the knowledge on how to appropriately treat it. This section outlines the antecedents, protective mechanisms, and consequences of racial trauma.

Antecedents of racial stress and trauma Experiences of racial trauma can originate as any combination of events that are overt or covert; singular or serial; personal or vicarious; tangible or per-ceived; individual or systemic; and from one's present, past, or from sometime in their cultural history. Moreover, racism permeates all life domains. It is no understatement that POC live, work, and raise their families in a society that is prone to traumatizing them [9]. When we think of traumatic experiences due to racism, explicit acts of aggression and violence often come to mind. However, experiences of indirect and/or covert racism, including preju-dice, bias, and discrimination, can also be a spurce of race-based stress and trauma. Additionally, immigrants and refugees may have experienced ethnic cleansing or persecution, living in a warzone, or experiencing or witnessing torture. Research suggests that POC experience a heightened fear of persecution on a regular basis compared to their White counterparts. Specifically, it is well-supported that POC are more likely to be pulled over in a traffic stop compared to White members within the same communities [10, 11]. This fact coupled with a higher likelihood of police either using excessive force or killing POC during these traffic stops contributes to the anxiety surrounding interactions with law enforcement and the possibility that such an interaction could lead to more trauma [12, 13]. Thus, studies show that Black Americans worry about police violence five times as much as Whites (14]. Additionally, POC are vulnerable to experiences of racism in their work-places, as racism includes interpersonal, social, and cultural structures that leverage disproportionate access to, and control of, resources via a perceived sense of authority [15]. This strongly applies in the workplace; the social structure which places the financial security and general well-being of an employee in the hands of a manager oftentimes results in the workplace discrimination. A recent study examining rates of workplace discrimination Intersection of Racism and PTSD Williams

within a culturally diverse sample of workers over 47 years of age found that compared to White workers, Black workers reported 60% higher rates of discrimination [16]. These findings indicate that the workplace may be considered as an especially stressful environment for already traumatized individuals who are additionally subject to being vulnerable within the power hierarchy. Indirect effects of racism can include vicarious trauma, which includes experiences of violence towards family members, witnessing police brutality in the media, or witnessing the implications of structural racism. One study found Black adults were more likely to report "not good" mental health days shortly following the police killings of unarmed Black individuals [17]. Sharing racist experiences at home can influence other family members, including children [18]. Additionally, Hispanic and Black students in diverse communities with high rates of police violence show significant decreases in cumulative GPA and the most negative impact on GPA arising from isolated instances of police killing unarmed POC [19]. Finally, Borosits that not only do police killings of unarmed Black adults contribute to widespread negative mental health outcomes on communities of color, but also that this frequent, often highly publicized behavior ratifies larger, structural systems of racism which result in POC living with anxiety caused by the fragility of their well-being and the uncertainty of their safety [17].

Although racism often results in lasting effects on POC, it is not the case that all people who encounter racism in its cumulative forms are trauma-tized. There are several factors which serve as buffers of the negative effects of racial trauma, including social connectedness and familial support [20, 21]. Finally, strength of ethnic identity was found to be a buffering factor for the severity of anxiety and depressive symptoms in African Americans, but not in European Americans [22]. Additionally, this buffering role of ethnic identity was explored in a 2016 study that examined self-esteem and ethnic identity among women of color who reported experiencing racism, among other oppressive experiences [23]. It was found that while low self-esteem was positively correlated with increased severity of trauma symptoms, high level of ethnic identity served as a buffer for the severity of these symptoms among these women 23] Consider these buffering factors in the comtext of our case example, Sha- ron. Suppose Sharon, who is experiencing trauma symptoms as a result of the hostility towards First Nations people in her community, goes home at the end of the day to her family who comforts her and provides a sense of validation for her intense emotional response. If not her family, possibly other members of her Nation or community Elders are able to provide this support. Perhaps, as with many, Sharon's spiritual or religious beliefs and practices, like attending sweat lodge ceremonies, prove grounding and allow her to interpret and cope with traumatic events in a healthier way [24, 25]. Finally, consider the reassurance that Sharon is afforded from these support

woman is something to celebrate instead of resent. While these inherent sup. port systems may not be enough to extinguish the symptoms that Sharon is feeling, the research shows that she will likely be better off as a result of them. Consequences of racial trauma Experiences of discrimination, race-related stressors, and traumatic events have been found to significantly predict a PTSD diagnosis in Latino and African American adults 26]. A concerning and pervasive consequence of racial stress and trauma is problematic substance use. One large study found that high rates of racial discrimination among African American women served as a strong predictor of problematic substance use [27]. In another study, frequency of discrimination in Mexican Americans was associated with increased risky behavior, such as involvement in more physical fights and having more sexual partners 28]. While the impact of racial trauma bears resemblance to other sources of trauma, there are unique outcomes that arise from various institutions and systems in which POC are deeply embedded. In contrast to, for example, those who experience trauma while in war and subsequently struggle with reintegrating into a society that accepts them, POC suffering from the symptoms that have arisen as a result of their trauma often cope with their issues in an environment that further traumatizes them [29].

The assessment of racial trauma There are several validated interview and self-report instruments available to screen, diagnose, and measure any treatment and progress related to PTSD. However, when considering their use specifically with clients of color who may have racial trauma, many question their appropriateness [30, 31]. This section outlines both interview and self-report measures often used to assess PTSD and whether these measures are appropriate to assess racial trauma. Additionally, a range of self-report instruments are available to clinicians to better understand client's experiences of racism, discrimination, and traumatic stress. Early discussion and assessment of racial stress and trauma can (a) enhance the racial awareness of clinicians; (b) cultivate a deeper understanding of racism for both clients and clinicians; (c) inform the therapeutic pro-cess, even in cases, when clients do not meet all PTSD criteria; and (d) support the development of a racial trauma-informed treatment plan [32, 33°, 34]. Interview instruments The Clinician-Administered PTSD Scale (CAPS-5), for instance, while a gold standard in PTSD assessment, does not include trauma related items

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