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Monnica Williams, Ph.D. Director, Center for Mental health Disparities Department of psychological & Brain Sciences

University of Louisville

The Role of Racial Trauma in Psychotherapy

CEU Information • All attendees will receive an email after the webinar with

links and instructions on how to apply for the CEU through the NYU Silver School of Social Work.

• To get your 1 CEU credit for attending this webinar: – You will need to create a user account with the Silver School

first. – You will then be able to choose the CTAC webinar from the

listing and register. Note: There is a nominal $15 CEU processing through the School.

– You will need to complete a brief knowledge test – You will then receive your certificate within 10 business days

About Myself 4

Monnica Williams, Ph.D. • Director of the Center for

Mental Health Disparities • Associate Professor of

Psychological & Brain Sciences at the University of Louisville

• Clinical Director of Behavioral Wellness Counseling Clinic, LLC

• Licensed psychologist in KY and PA

Warning: This presentation may make you uncomfortable!

• There are many stereotypes about different ethnic and racial groups

• We are socialized not to talk about many racial issues

• Many people are afraid of being perceived as racist

• We will talk about all of this • I may try to make you laugh • Some of you will still be

uncomfortable – that’s ok!

Sensitive Topic Matter • Given that all audiences (public, undergraduates,

graduates, med students, and even professionals in psychology and medicine) have reported this topic matter to be difficult at times, I make some assumptions

• Assumption #1 – If you experience discomfort during this talk it is because you are one or more of the following groups: – Caring, empathetic, least likely to offend others, and wanting to

avoid harming others – Exposed to racism either personally or in your environment

• Assumption #2 – You are here because you care about your clients and want to do even better

Slides at http://www.mentalhealthdisparities.org/docs/RacialTrauma.pdf

Cultural Competence Ethnically Sensitive

Therapy • being aware of the

existence of cultural differences

• having knowledge of the client’s culture

• ability to distinguish culture from psychopathology

• taking culture into account for assessment and treatment

Multicultural Counseling Competence

• being aware of one’s own cultural heritage and biases while respecting other help-giving practices

• knowledge, such as understanding sociopolitical factors that affect ethnic minorities

• skills, such as sending and receiving culturally adequate verbal and nonverbal messages

CAN THE EXPERIENCE OF RACISM BE TRAUMATIC?

A) Yes B) No C) I’m not sure

Who experiences racism & discrimination? • African Americans (M=22.9) report significantly

more instances of discrimination than either Asian (M=18.7) or Hispanic Americans (M=19.6) (Chao, Asnaani, Hofmann, 2012) – Hispanic Americans who experienced racism were

significantly more likely to experience symptoms of MDD

– African Americans who experienced racism were significantly more likely to experience symptoms of PTSD

• The darker your skin, the more likely you are to experience racism (Klonoff & Landrine, 2000)

Some Types of Racism Racism: the routine, institutionalized mistreatment of a person based on his/her membership in a racial group on the downside of power.

o Dominative Racism o Symbolic/Modern Racism o Aversive Racism o Microaggressions

Examples of Racism • Being followed in stores

(“shopping while Black”) • Cashiers asking for extra

identification • Insensitive remarks by

coworkers and friends • Profiling by law

enforcement (“driving while Black”)

• Being feared and avoided • Racial slurs • Threats • Others? Can you think of examples from your own experience?

Microaggressions • Small racist acts

that are not clearly racially motivated

• Create uncertainty and anxiety in minorities

How might experiences like these impact mental health?

Race Based Traumatic Stress Injury (Carter, 2007)

Racism stress includes: 1. racial discrimination 2. racial harassment 3. discriminatory

harassment

Summary of Mental Health Consequences

• Perceived discrimination has been linked to – Stress (Clark et al., 1999) – PTSD symptoms (Carter, 2007; Pieterse et al.,

2012) – Serious psychological distress (Chae et al., 2011;

Chao, Mallinckrodt, & Wei, 2012) – Depression (Banks & Kohn-Wood, 2007; Torres et

al., 2010) – Binge drinking (Blume et al., 2012) – Binge eating (Harrington et al., 2010)

Effects May Be Cumulative (Carter, 2007)

• For most traumatic experiences, people show signs of re-experiencing (intrusion) the event(s). In the case of race-based traumatic stress, the encounters may be clustered or cumulative, and a “last straw” event may serve as the trigger for the trauma – e.g., one may be stressed, but the level of stress may not

reach threshold for being traumatic until the trigger or last straw. In such an instance, the trigger experience may be a major or minor event.

• Many minorities report their stress is not because of one event, but a series of emotional wounds and blows experienced

Ethnoviolence (Helms et al., 2012)

• Violence and intimidation directed at marginalized and stigmatized members of an ethnic group because their inability or unwillingness to assimilate – threatens the dominant group’s entitlement to

society or community resources • People in ethnic group treated as symbols of

undesirable cultural practices • It’s not about “race” but culture

How Racism Causes Trauma (Helms et al., 2012)

• Racist incidents are traumatic

• They affect survivors in ways that are analogous to the effect that rape and domestic violence have on their victims

• Act is a violation of an individual’s personhood

• The victim feels disempowered/powerless

• Event is unpredictable and uncontrollable

• May be challenged or ridiculed by others (Sue et al., 2007)

“I’ll bury your body so deep no one will ever find it.”

CULTURAL CASE STUDY

True Story: PTSD in Workplace (1) • 49 year old African American

female living with partner – Lives with her teenage daughter

and partner’s daughter • Has 2 master’s degrees: MBA

& Technology • Works as IT professional at

large firm: $85K • Does trainings in computer

security internationally

True Story: PTSD in Workplace (2) • Role model to other Black women at her

workplace • Conducts diversity trainings (not in her job

description) • Has stress at work due to being the only Black

female in her position, but no psych history • Has experienced many acts of racism over the

years, and has coped well

True Story: The Trauma • While on a business trip in Sydney was traumatized by a

coworker during dinner – Coworker also a senior-level person, and former soldier in military

operation • Boasted about people tortured and killed, made racist

statements, threatened patient’s life, and made sexual advances

• She felt more vulnerable foreign country and did not think anyone would come to her rescue

• Employer was slow to ensure patient’s safety on the job • Patient anxious and fearful at work

– Mistrustful of White co-workers – felt people were “out to get her”

– Wondered if trauma was attempt to punish her for superior performance

Ethnoviolence PTSD Model Racist event A negative, unexpected,

uncontrollable violation, assault to one’s personhood

Traumatic Reaction Shock, disbelief, fear, shame, humiliation, confusion

Re-experiencing

Distressing memories, Nightmares, Intrusive thoughts, Flashbacks, Distress over reminders of event

Avoidance

Trying not to think about it, Avoiding White people, Agoraphobia/Isolation

Negative Mood & Cognitions

Depression, Anxiety, Belief that world is unsafe, Self-blame, Self doubt, Guilt, Anger

Physiological Arousal

Hypervigilance, Increase startle, Poor sleep, Concentration problems

Symptom Clusters May be exacerbated by cumulative small assaults

True Story: The Aftermath

• Patient sought consultation at top university center • Diagnosed with severe PTSD; afraid to leave home

alone or go to workplace (panic attacks & agoraphobia) – Advised to seek worker’s comp for cost of treatment – Patient only willing to work with female Black therapist

What cultural issues might impact treatment?

True Story: Treatment Issues

• Symptoms were severe (PDS=38, GAF=37) • Patient received Prolonged Exposure – EST for PTSD • Therapist attended weekly group supervision for treatment

of patient • After completion of protocol, patient was no longer fearful

of the memory of the trauma • But was still terrified of returning to work!

Idiographic Case Formulation Needed • Several relevant cultural issues not

adequately addressed • European American psychologists

at expert treatment center unable to comprehend or advise anxiety connected to racism

• Consultation with board-certified African-Centered psychologist for additional treatment strategies

Side Note: Ethnic Matching? This can be helpful when possible

…assuming the therapist is at an advanced stage of his/her own racial identity development! (Helms, 1984)

• However, having a Black therapist does not

guarantee a culturally-competent approach • Why?

– Because we (clinicians, even the Black ones) are usually trained by White people (Eurocentric perspective) using Eurocentric methods (ESTs tested and validated on White people) (Parham, Ajamu & White, 2011)

African Centered/Black Psychology • Emphasizes:

– Balance and centering – Harmony and

interconnectedness – The capacity for self-

healing – Unique personal

experiences – Spirituality – Relationships, kinship

PTSD Treatment Issues • PTSD Cognitions Include

– Self-Blame – Negative thoughts about the World – Negative thoughts about Self

• African Americans tend to have more negative thoughts about the world (and less self-blame) than European Americans (Poulin & Silver, 2008; Williams, Jayawickreme, Sposato & Foa, 2012)

• Vicarious traumatization and ethnoviolence (Helms et al., 2011)

Treatment Issues • Refocused treatment on the patient’s:

– Expectations about the workplace – Experience of racism – Fear that there was no safe place for her

• Improved her self-concept and feelings of competence using Afrocentric principles

• Instilled more realistic expectations about co-workers

• Developed goals and made an “escape plan” for future career aspirations

Ongoing Ethnoviolence (1) • Patient referred to Board

Certified African Centered therapist for remainder of treatment

• Worker’s comp wanted to: – Have client evaluated by

their selected clinicians (Whites, males)

– Assess patient with Eurocentric measures (MMPI)

– Stop paying for treatment – Have patient return to work

prematurely

“…[patient] has described anxiety symptoms that she attributes to the comments made by a coworker at a dinner in [Sydney]. It is my opinion that the behavior of [the] coworker did not cause an experience necessary for the development of the condition of posttraumatic stress disorder, and [patient] was not subjected to an experience from [company] that would cause posttraumatic stress disorder.”

Ongoing Ethnoviolence (2) • Patient’s suffering met

with doubt and ridicule • Afrocentric psychologist

considered unsuitable – Despite referral from

previous therapist and expert treatment center

• Assessing clinician pressured to state that patient was recovered

• Re traumatization slowed her recovery

“…there is no indication for ongoing psychological treatment for [the patient] in relationship to the incident of October 1, 2010. It is my opinion that [patient] is at maximum medical improvement and she is capable of return to work without restrictions…” – White female, MD

INTEGRATING MULTICULTURAL ISSUES INTO THERAPY

Don’t treat Clients the way you want to be treated.

Treat them the way they want to be treated.

Expectations About Race and Racism

in a Helping Relationship • Most minorities have already

encountered discrimination in other contexts

• Acknowledge and validate mistrust • Ask clients about previous experiences

with mental health and medical professionals

• Raising these issues early in the relationship conveys cultural sensitivity and may address patients’ concerns about a racially different clinician (Neville, Tynes, & Utsey, 2009)

Does discussing race with clients make you feel uncomfortable?

A) Yes B) No C) Somewhat

1. Culturally Respectful Behavior

• Respect > Rapport for ethnic minorities • Variability in respectful behavior(s) cross-culturally

requires clinician sensitivity • Example: Repeated questioning during assessment

– Potential Adaptations: slow down questioning, silences, small talk, self-disclosure

2. Identify Cultural Strengths and Supports • Cultural strengths/supports = Resources for

Treatment • Types of Cultural strengths/supports

– Personal strengths (e.g., pride in culture, religious faith, language abilities)

– Interpersonal supports (e.g., extended family, traditional celebrations)

– Environmental supports (e.g., comfort foods, access to cultural activities)

3. Internal vs. External Influences • Internal = Cognitive factors • External =

Environmental/situational factors

“How did it feel to be carried by the White EMT who was speaking sharply to you at the scene of the accident?”

4. Addressing Environmentally-Based Problems

• Treatment goals should include making changes that: – Minimize stressors – Increase personal strengths/supports – Build skills for more effectively interacting with

environment

5. Validate Self-Reported Experiences of Oppression

• When client discloses perceived discrimination/oppression, avoid: – Automatically looking for alternative explanation (e.g.,

Could it be that he/she meant something else?) • What may be the result of challenging such

perceptions?

6. Emphasize Collaboration Over Confrontation

• What are the advantages of encouraging a collaborative relationship rather than confrontational relationship?

• Why might a collaborative approach be especially important when working with minority clients?

7. Cognitive Restructuring: Helpfulness over Validity of Thoughts/Beliefs • Validity of belief

– Questioning the rationality of a belief

– Risk: Appear uncaring or naïve

• Helpfulness of belief – Consider the utility or

advantages of the belief – Ex: “You are right to be angry,

but is this helping you?”

8. Do Not Challenge Core Cultural Beliefs

• Example: – Individualistic therapist challenging a collectivistic

client to separate themselves from their family, which is a primary source of stress for the client

• What are some potential issues with this therapeutic approach?

9. Creating a List of Helpful Cognitions

• Generating a list of personal strengths or external support can act as reminders: – Internal coping resources – Past successes – They are valued by others – Community and family – Support from a Higher

Power

10. Culturally Informed Homework Assignments

• Consider whether assignments fully capture the client’s cultural context – Making sure an inventory of enjoyable activities

includes culturally-relevant activities for the client to choose from

• Involve client to the creation of homework – “What is the smallest possible step you could take

that would feel like you are making progress?”

QUESTIONS?

Reflect on Your experiences with clients from a different race or ethnicity.

Personal Growth as a Therapist 1. What were your first experiences

with feeling different? 2. What were you told about others

who were ethnoracially different? 3. What were your earliest memories

of race or color? 4. What stereotypes do you hold of

pluralistic populations? 5. What are your experiences as a

person having or not having power in relation to race or class?

6. What steps can you take to learn more about your clients’ cultural backgrounds?

6. What are your preferred therapeutic methods that may not be culturally attuned or adequate?

7. How might you be inadvertently repeating negative or oppressive interactions representing the dominant culture with clients?

8. How can you make use of therapeutic “mistakes” or microaggressions in ways that increase therapeutic alliance?

9. What is difficult for you to address regarding race, culture, or other differences you have with your clients?

Thank You! • Center for Mental Health Disparities

– www.mentalhealthdisparities.org – Twitter: @UofLCMHD – Phone: 502-852-3017

• Monnica Williams, Ph.D., Director – Email: m.williams@louisville.edu – Phone: 502-852-2521, 502-608-7483 – Psychology Today Blog:

www.psychologytoday.com/blog/culturally-speaking

Recommended Reading • Carter, R. T. (2007). Racism and Psychological and Emotional Injury: Recognizing and Assessing

Race-Based Traumatic Stress. The Counseling Psychologist, 35(1), 13-105. • Helms, J.E., Nicholas, G., & Green, C. E. (2012). Racism and Ethnoviolence as Trauma: Enhancing

Professional and Research Training. Traumatology, 18, 65-74. • Parham, T. A. (2002). Counseling Models for African Americans. In: T.A. Parham (Ed.), Counseling

Persons of African Descent (pp. 100-118). Thousand Oaks, California: Sage. • Terwilliger, J. M., Bach, N., Bryan, C., & Williams, M. T. (2013). Multicultural versus Colorblind

Ideology: Implications for Mental Health and Counseling. In: Psychology of Counseling, A., Di Fabio, ed., Nova Science Publishers.

• Williams, M. T., Gooden, A. M., & Davis, D. (2012). African Americans, European Americans, and Pathological Stereotypes: An African-Centered Perspective. In: Psychology of Culture, G. R. Hayes & M. H. Bryant, eds., Nova Science Publishers. ISBN-13: 978-1-62257-274-8.

• Williams, M. T., Malcoun, E., Sawyer, B., Davis, D. M., Bahojb-Nouri, L. V., & Leavell Bruce, S. (2014). Cultural Adaptations of Prolonged Exposure Therapy for Treatment and Prevention of Posttraumatic Stress Disorder in African Americans. Journal of Behavioral Sciences, 4(2), 102-124. doi:10.3390/bs4020102.

Download these at www.mentalhealthdisparities.org/workshops.php

Resources • Racism’s Psychological Toll:

http://www.nytimes.com/2015/06/24/magazine/racisms-psychological-toll.html?_r=1

• Coping While Black: A Season of Traumatic News Takes A Psychological Toll: http://www.npr.org/sections/codeswitch/2015/07/02/419462959/coping-while-black-a-season-of-traumatic-news-takes-a-psychological-toll

• A Conversation on Racial Disparities in Mental Health Treatment: http://wfpl.org/conversation-racial-disparities-mental-health-treatment/

• Expectations About Race and Racism in a Helping Relationship (Handout available for download at www.ctacny.com)

• Race and Trauma: Race Based Traumatic Stress and Psychological Injury presented by Robert T. Carter (Webinar recording) http://www.ctacny.com/race--trauma-registration.html

CEU Information • All attendees will receive an email after the webinar with

links and instructions on how to apply for the CEU through the NYU Silver School of Social Work.

• To get your 1 CEU credit for attending this webinar: – You will need to create a user account with the Silver School

first. – You will then be able to choose the CTAC webinar from the

listing and register. Note: There is a nominal $15 CEU processing through the School.

– You will need to complete a brief knowledge test – You will then receive your certificate within 10 business days

Upcoming Events Person Centered Care/Recovery Centered Care

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