Curr Treat Options Psych _#####################_

DOI 10.1007/s40501-021-00250-2

PTSD (SK Creech and LM Sippel, Section Editors)

Intersection of Racism and PTSD:

Assessment and Treatment of Racial
Stress and Trauma
Monnica T. Williams, Ph.D.1,*
Muna Osman, Ph.D.1
Sophia Gran‑Ruaz, B.S.1
Joel Lopez, B.A.2

Address

*,1
School of Psychology, University of Ottawa, 136 Jean‑Jacques Lussier, Vanier Hall,
Ottawa, ON K1N 6N5, Canada
Email: Monnica.Williams@uOttawa.ca
2
Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021

This 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. As a
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 trau‑
matic 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.

Vol.:(0123456789)
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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, cur-
rently 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 cus-
tomer 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
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
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
is to blame for her experiences of racism. Sharon is
suffering from racial trauma. In this article, we exam-
ine the intersection between racism and posttrau-
matic stress disorder (PTSD) – a response many indi-
viduals 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, emerg-
ing 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
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Racial Oppression
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 col-
leagues 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 conceptu-
ally maps the cumulative effect of racial stress 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 expe-
riences 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 oppor-
tunities to process this triggering event. As these experiences accumulate,
individuals will exhibit symptoms of PTSD over an extended period of
time.
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 result-
ing 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, keep-
ing 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. Nega-
tive 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. Sharon 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 of a DSM-5
PTSD diagnosis.
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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 some-
time 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 experi-
ences 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 source 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 persecu-
tion 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
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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]. Shar-
ing racist experiences at home can influence other family members, including
children [18]. Additionally, Hispanic and Black students in diverse communi-
ties 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, Bor posits 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].

Protective mechanisms

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 context 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
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systems – all of whom assure Sharon that her heritage as a First Nations
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 Afri-
can 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, fre-
quency 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 trau-
matic stress.
Early discussion and assessment of racial stress and trauma can (a)
enhance the racial awareness of clinicians; (b) cultivate a deeper understand-
ing 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 racial trauma related items
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and has been demonstrated to yield differential item functioning for cer-
tain non-White ethnoracial groups compared to their White counterparts
[35, 36]. Similarly, the Structured Clinical Interview for DSM-5 (SCID-
5-CV) examines primarily discrete traumatic events, thus failing to recog-
nize the cumulative impact of several racist acts over the lifespan in the
development of PTSD [7••, 37]. Like the CAPS-5, the SCID-5-CV also fails
to consider acts of racism and discrimination as possible traumatic stress-
ors, focusing largely on an individual’s exposure to sexual assault, serious
injury, or actual/threatened death. Such gaps have sparked a move towards
the development of racial trauma-targeted assessment tools for use with
diverse clients.
The UConn Racial/Ethnic Stress & Trauma Survey (UnRESTS [7••]) is a
dedicated measure of racial trauma and is one of the only clinician-admin-
istered tools available. Intended to capture the cumulative impact of various
experiences of racism (e.g., overt personal experiences, vicarious experiences,
microaggressions), it includes questions on the client’s ethnoracial identity
development, several racism-related experiences, and a racial trauma symp-
tom checklist modeled from DSM-5 PTSD diagnostic criteria. The UnRESTS
is also formatted to provide clear differentiated instructions for evaluators
versus interviewing clinicians. However, the measure’s creators emphasize
the UnRESTS not be used as the sole determining factor in a PTSD diagno-
sis, since there may be other sources of trauma in addition to racism. The
UnRESTS has also been translated into Spanish, with a French version under
development [38, 39].
In support of the UnRESTS’ development, PTSD and diversity leaders were
consulted in the early stages, and the interview was tested in several settings
(e.g., clinician workshops, outpatient clinics, forensic setting, multisite PTSD
treatment program [7••]). Experts and users are positive about the accessibil-
ity of this clinical interview for clinicians. For one, many mental health pro-
viders are currently unaware of the potential impacts of racial discrimination
or may inappropriately attribute racial trauma symptoms with another cause,
with this measure shedding light on this issue [40, 41]. Further, the DSM-
related framework with which this measure employs may help to broaden
the dominant understanding of PTSD and validate the psychological distress
felt by POC as a result of racism.

Self‑report instruments

There are several validated instruments that are particularly valuable to assess
racial trauma and serve as supplementary tools for clinicians. Self-report
instruments are easy to use and less time consuming that a clinician-admin-
istered measure, and as such they are convenient for screening purposes.
These can be included in intake paperwork to gain an initial understanding
of client issues surrounding racialization. Also, self-report measures can be
used to track changes in symptoms over time, such as in the course of treat-
ment. We list a few useful measures below.
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Race‑Based Traumatic Stress Symptom Scale

The Race-Based Traumatic Stress Symptom Scale was created for use in ethnora-
cially heterogeneous groups (RBTSSS [42]). Clients record three of the most
memorable events of racism they have experienced, and respondents must
then choose their most memorable and indicate if this experience was sud-
den or unexpected, beyond their control, and/or emotionally painful. Next,
individuals consider a list of 52 emotional symptoms, which they appraise
using a 5-point Likert scale on (i) their reaction immediately following the
event; (ii) their current appraisal of the event; and (iii) if others in the test-
takers social circle noticed differences in their affect/behavior following the
memorable racist event. Sample symptom items include “as a consequence
of the memorable encounter I had with racism, I found myself getting upset
rather easily” or “as a consequence of my most memorable encounter with
racism, I am inclined to feel that I am a failure”. Higher scores are indicative
of potential race-based trauma. Further, an exploratory factor analysis yielded
seven subscales: avoidance, intrusion, depression, anger, hypervigilance, low self-
esteem, and physical symptoms. Additionally, a shorter and more efficient ver-
sion is now available (RBTSSS-SF [43]).
It is important to note that Carter and team created the RBTSSS using a
race-based traumatic stress model which they explicitly differentiate from
PTSD. The authors explain that as the DSM-5 criteria for PTSD relates trauma
to physical danger and pathology, it fails to recognize many aspects of rac-
ism and experiences of discrimination that can still deeply traumatize POC
[6]. Therefore, while there are several similarities between Carter’s model
and the DSM’s definition of PTSD, he suggests that for a racial experience to
be considered traumatic, it must be sudden and without control, as well as
negatively perceived, and result in symptoms of anxiety, anger, depression,
low self-esteem, intrusion, shame, guilt, arousal, and avoidance.
Carter and Muchow further established the factorial and theoretical valid-
ity of their measure of race-based traumatic stress using a confirmatory factor
analysis and a second-order structural equation modeling [44]. The first-order
factor structure represented the seven symptoms of race-based traumatic stress
model and a second-order factor of traumatic stress. Their findings found
measurement equivalence of this second-order factor model for both gender
and race (Black and POC). Furthermore, this assessment of race-based trau-
matic stress was related to key psychological outcomes, including anxiety,
depression, loss of control, positive affect, and emotional ties (as measured
by the Mental Health Inventory [45]).

Trauma Symptoms of Discrimination Scale

Following the release of the RBTSSS, Williams and colleagues developed a

shorter and simpler assessment tool for discrimination-based trauma symp-
toms that recognized the additive effect of several negative experiences over
the lifespan. In so doing, they created the Trauma Symptoms of Discrimination
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Scale (TSDS [34]), a 21-item, self-report questionnaire assessing discrimi-

natory distress, with a focus on anxiety-related symptoms (e.g., avoidance,
negative cognitions, social fears). These discriminatory experiences need not
strictly be tied to racism, but can also include negative experiences on the
basis of one’s gender, sexual orientation, social class, faith, age, and/or disa-
bility. In part 1 of the TSDS, test-takers are asked to consider all of the stressful
discriminatory experiences in their lifetimes and rate resultant distress from
1 (“never”) to 4 (“often”; e.g., “Due to past experiences of discrimination,
I feel the world is an unsafe place”.). In part 2, test-takers select any and all
types of discrimination experienced and attribute a corresponding percent-
age to represent how much of each type has been experienced (e.g., 40%
disability and 60% racial/ethnic). The higher the score obtained, the greater
the individual’s distress.
In a study of 123 monoracial and biracial African American undergradu-
ate students, a principal component analysis yielded a four-factor structure,
which included (i) uncontrollable distress and hyperarousal, (ii) feelings of
alienation, (iii) worries about bad things happening in the future, and (iv)
perceptions that others are dangerous. Further, the TSDS demonstrated high
internal consistency (Cronbach alpha of 0.94) as well as significant same-day
and 2- to 3-week test–retest reliability scores (0.91 and 0.78, respectively). The
TSDS was also found to be significantly and positively correlated with other
measures of psychopathology, including the Posttraumatic Diagnostic Scale
(PDS; moderate correlation of 0.49, p < 0.05), a measure of PTSD symptom
severity over the past month [34].

Racial Trauma Scale

The Racial Trauma Scale (RTS [46]) is another promising up-and-coming self-
assessment tool for quantifying distress symptoms due to racial trauma. The
measure asks test-takers to “think about all the times when you have heard
about, seen, or experienced racial discrimination” and endorse resultant
thoughts, behaviors, or symptoms on a 4-point Likert scale (where 1 is “not
at all” and 4 is “extremely”). There are a total of 30 resultant experiences
probed, for example, “feeling I cannot win” or “having nightmares about
discrimination”. These items fit within three domains: lack of safety, negative
cognitions, and difficulty coping. Internal consistency is high with a Cronbach
alpha of 0.97 for participants of color in a US national sample. A 9-item short
form is also available.

Other measures of interest

In addition to the measures described above, there are a handful of other

useful tools available within the racial trauma space. For instance, the Gen-
eral Ethnic Discrimination Scale (GEDS [47]) is an 18-item measure of the
frequency of ethnoracial discrimination within (i) the past year and (ii) over
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the test-taker’s lifetime. The GEDS also allows test-takers to quantify how
stressful such events are to them. Of note, there are several microaggression-
related measures, and for a list of these, readers are referred elsewhere [48].

The treatment of racial trauma

Before the authors can outline the appropriate steps for treating racial trauma
in POC, there are basic skills needed by treating clinicians. Note, these skills
are non-negotiable, and serve as the foundation for quality treatment of racial
trauma, while also preventing further harm to clients. First, clinicians must
feel comfortable bringing the topic of race and racism into the therapeutic
space. This may seem an obvious tenant, and yet research suggests many
therapists feel uneasy discussing race, especially White therapists and therapist
trainees [49–51]. Second, clinicians must do their homework in educating
themselves on the different overt and covert forms of oppression and dis-
crimination at play in the lives of POC (historic and current). This includes a
willingness to acknowledge biases within society, institutions, and the field of
psychology. Moreover, given that clinicians are human and products of their
biased contexts, this requires personally uncovering and confronting explicit
and implicit biases within oneself. This could involve anti-racism workshops,
courses in cultural competency, extensive reading, and community engage-
ment. This is no easy task, and therefore, it is recommended that clinicians
working with clients of color, especially in race-based trauma, seek expert
consultation as needed. Nevertheless, even the most ethnoracially attuned cli-
nician will at times commit microaggressions. For example, one study found
over a median number of four sessions, 53% of clients of color followed
perceived a microaggression from their therapist [52]. When such mistakes
happen in session, it is important clinicians be prepared to act in a humble
and non-defensive manner and do what is needed to regain client trust [48].

Cultural adaptations of PTSD treatment

Evidence-based and trauma-informed treatments available for PTSD include

cognitive behavioral therapy (CBT), specifically prolonged exposure (PE), and
cognitive processing therapy (CPT) among many others [53, 54]. Although
these treatments are well-established, few directly recognize and address the
nature of racial trauma among POC, in part due to the underrepresentation
of POC in clinical research [55•]. As a result, there is growing recognition of
the need for cultural adaptations of empirically supported PTSD treatments
to address the thoughts and feelings related to traumatic experiences of rac-
ism, racial discrimination, and race-related stress. For example, Williams and
colleagues provide examples of cultural adaptation of PE therapy for African
American clients that incorporate client’s experiences of race-related stress
and trauma [56]. The authors suggest PE is uniquely positioned to provide
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diverse clients with the opportunity to revisit, reprocess, and give meaning to
their racial trauma within the boundaries of that therapeutic protocol. These
cultural adaptations will need further empirical evidence to support their
utility and applicability to African Americans and other POC experiencing
race-based PTSD.
In general, culturally informed therapies include several main elements
not available in mainstream treatment options [57]: first, an explicit rec-
ognition of race and culture and how this impacts/informs an individuals’
experiences of race-based PTSD [57, 58]; second, the addition of culturally
relevant concepts, such as ethnoracial identity, spirituality, and systems of
oppression, as well as social and racial justice into clinical care and practice
[59, 60]; and finally, creating space within the therapeutic setting to process
and assess race-based trauma is key. This requires a willingness for therapists
to discuss openly experiences of racism and race-related traumatic experi-
ences. Experiences of racism need to be validated by therapists and healing
from racial trauma incorporated into therapy [56].

Racial‑trauma‑specific treatment

Despite the mounting evidence in support of expanding the common under-

standing of PTSD to include racial trauma, and the development of several
dedicated racial-trauma assessment tools, much of the present treatment
offering remains tied to the typical PTSD presentation (i.e., what is offered
to those with trauma from sexual assault or combat). There is a dearth of
research on empirical approaches that treat POC with race-based trauma
specifically. Below are examples of the select few racial-trauma-specific inter-
ventions in existence; however, readers should know: this is an area of much-
needed research, and that even the few racial treatments that are mentioned
are in their infancy.

Race‑based stress and trauma intervention in veterans of color

Carlson and colleagues developed a group intervention for the treatment

of veterans of color suffering from race-based stress and trauma that was
implemented across four sites. The interventions typically include a mini-
mum of 8 sessions, each 60–90 min in length on a weekly basis with 6–12
veterans per group [61•]. It is informed heavily by CBT, dialectical behavioral
therapy (DBT), and acceptance and commitment therapy (ACT). Over the
course of treatment, trained program facilitators guide clients on content
that maps onto 8 overarching themes: (1) introduction and establishing a
safe space; (2) interpersonal, intrapersonal, and systemic racism; (3) physical
and psychological toll of chronic exposure to race-based stressors; race-based
stressors and (4) mental health, (5) physical health, (6) military experiences;
(7) challenges to addressing the emotional impact of racism with provid-
ers; and (8) resilience and empowerment. Together, these themes focus on
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psychoeducation of one’s own racial identity development, as well as the

deleterious impacts of various forms of racism within and outside military
contexts. Overall, program participants found the intervention left them feel-
ing empowered and able to address past, present, and future racism in an
“authentic” way. However, there is not yet published quantitative data on the
efficacy of the program.

The developmental and ecological model of youth and racial trauma

In 2020, Saleem and colleagues proposed the Developmental and Ecological

Model of Youth Racial Trauma (DEMYth-RT [33•]). Contextualized within
three developmental periods (i.e., childhood, age 3–11; early to middle ado-
lescence, 12–14; and high school-aged youth, 15–18), the model explains how
family and community systems are essential to a young person’s understand-
ing and coping of race-related stress [33•]. While a specific intervention has
yet to emerge from this model, Saleem highlights the centrality of family and
community systems in prevention and intervention processes. How youth
interpret and manage racial trauma directly reflects the ecological systems
of their environment. This model informs ways clinicians can conceptualize
racial trauma among diverse youth and enhancing treatments to interrupt
experiences of racial trauma.

Therapeutic approach to treatment

The appropriate treatment of racial trauma among diverse racial and ethnic
groups can be informed by guidelines for cultural competence for therapists.
Bryant-Davis and Ocampo proposed a thematic overview of key considerations
in the assessment and treatment of racial trauma [32]. These themes can be
organized more broadly as validation themes, emotional response, and resistance
and empowerment, which are consistent with other recommendations to build
the capacity of therapists to provide a safe therapeutic environment for diverse
clients. Specifically, the themes to guide therapy include acknowledging, sharing,
safety and self-care, grieving/mourning the losses, shame and self-blame/internal-
ized racism, anger, coping strategies, and resistance strategies [32].
Hays provides excellent CBT guidelines for working with POC who come
from culturally and ethnically diverse backgrounds, with a particular sensi-
tivity towards the underlying dynamic between clients and clinicians from
different cultures [62]. The crux of these guidelines is that clinicians admin-
istering CBT exercise genuine and mindful consideration for the nuanced
culture and beliefs of the clients they serve. This begins by understanding the
client’s cultural background from their own perspective, focusing on their
needs and identifying relevant strengths and supports. During this period, it
is essential to acknowledge the culture’s display of respect and to learn the cli-
ent’s cultural attitudes, traditions, interpersonal supports, and environmental
supports. Directing attention towards cultural influences, while identifying
Curr Treat Options Psych _#####################_ Page 13 of 19 _####_

cognitive and environmental problems as treatment begins, is paramount,

as well as validating the client’s experiences of oppression. Client reports of
racism and discrimination should not be challenged but rather validated.
Hays encourages clinicians to exercise patience and self-restraint when deal-
ing with cultural differences between the therapist and client and suggests
emphasizing efforts to collaborate on cultural differences rather than argue.
Lastly, culturally responsive CBT suggests that the clinician continues treat-
ment from a culturally conscious lens. By honoring and incorporating mean-
ingful experiences and beliefs of the client into their treatment plan, clinicians
can increase effectiveness of their psychotherapy in diverse populations [62].
These guidelines can be applied in the context of other evidence-based psycho-
therapeutic treatments for PTSD, such as PE and CPT. From a culturally respon-
sive lens, treatment plans should be prepared and enacted with consideration for
experiences and beliefs that the client feels are important. At no time should the
clinician attempt to challenge the core cultural beliefs of their client, as any effort
to do so could greatly harm the rapport built between clinician and client. People
who come from diverse cultural backgrounds already exist in a society which
imposes widely held cultural attitudes upon them, and experiencing this cultural
imperialism while undergoing treatment for PTSD could potentially traumatize
the client further. In order to have effective treatment through any therapeutic
framework, the clinician should show the client respect and patience for all of
their beliefs, and the same goes for beliefs surrounding the client’s background.
This research is also in line with the recognition of the need for ecologically
valid and culturally aware approaches to address race-based stress and trauma.
Specifically, this includes therapies that are multisystemic, multimodal, and
multicomponent as well as that incorporate individual, family, and commu-
nity wellness in the healing process [33•, 62]. The flexibility of multisystemic,
multimodal, and multicomponent therapies facilitates their adaptation to dif-
ferent traumas and cultures. Using a strength-based approach, these therapies
comprehensively address the diverse needs of racially diverse youth, including
both clinical and non-clinical dimensions of their care. Overall, clinicians need
to be aware of these key considerations to ensure they provide equitable and
appropriate therapeutic care for POC experiencing racial trauma.
Researchers have also emphasized the centrality of an intersectional
approach to therapy and clinical science in general [3, 58, 59, 63]. The Ameri-
can Psychological Association (APA) Multicultural Guidelines consider how
social context and multiple intersecting identities can impact clinical research
and care, independent of the evidence-based treatments used, but clinicians
must recognize the multidimensional nature of diverse individuals and the
ways multiple identities are associated with multifaceted forms of oppres-
sion [3, 64]. For example, Dale and Safren found the intersection between
multiple identities uniquely explained PTSD symptoms and cognitions above
and beyond the individual contribution of traumatic stress from each iden-
tity separately [65]. Specifically in their study of Black women living with
HIV, gendered racial microaggressions were more problematic for stress and
trauma than either race-related or HIV-related discrimination alone.
APA Multicultural Guidelines inform professional practice on how
to engage fully with diversity in research, training, and professional judg-
ment [3]. As guidelines, individual psychologists and professional are not
_####_ Page 14 of 19 Curr Treat Options Psych _#####################_

mandated to adhere to or work to advance the implementation of these

guidelines. Although psychologists are encouraged to endorse and imple-
ment these guidelines, it is unclear whether these guidelines have informed
updates to training and licensing requirements.
In line with using an intersectional approach, Ching and colleagues
propose a model of intersectional stress and trauma for those with multi-
ple intersecting identities based on race, sexuality, and gender [63]. Their
model explicates the interconnectedness of structural and cultural factors,
interpersonal discrimination, internalized oppression, and deleterious cop-
ing strategies to impact the mental and sexual health outcomes of diverse
individuals. Furthermore, Ching and colleagues rely on an extensive review
of the literature to identify clinical implications of using an intersectional
approach and, additionally, outline the appropriateness of existing treatment
approaches and the importance of cultural adaptations with therapy [63].
Thus, as outlined extensively by others, validating and acknowledging the
identities, experiences of racial trauma by clients are essential to culturally
responsive and respectful care [32, 59, 63].

Promising future directions

One promising treatment for racial trauma is psychedelic-assisted ther-

apy. 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy
is among the most exciting developments in psychedelic treatments, showing
that three administrations in the treatment of PTSD are substantially more
effective than traditional pharmacologic treatment methods such as long-term
prescription of SSRI medication [66, 67]. As such, MDMA-assisted therapy
was designated a “breakthrough therapy” by the FDA in 2017 [68]. Examining
psychedelics in race-based trauma specifically, Williams and colleagues found
significant reductions in depression, anxiety, and stress symptoms following
naturalistic use of psilocybin, lysergic acid diethylamide (LSD), or MDMA
[69]. These results are consistent with the increasingly supported notion that
psychedelic substances offer solace to those suffering from various mental
disorders [70, 71]. To examine the benefits of ketamine-assisted therapy spe-
cifically, Halstead and colleagues provided intensive outpatient treatment for
a client with treatment-resistant PTSD due to racism and child abuse [72].
During the 13-day therapeutic intervention, clinicians administered ketamine
on four occasions, integrated with mindfulness-based cognitive therapy and
functional analytic psychotherapy. This case study intervention, with treat-
ment-resistant PTSD, found significant reductions in symptoms posttreatment
and sustained benefits 4 months after [72]. That being said, we do not yet
have data as to which if any psychedelic medicine is better than another for
addressing racial trauma.
In addition to the benefits of psychedelics, these studies highlight the
importance of focusing on interventions specifically for POC, a group that has
historically been excluded from psychedelic research [73]. While psychedelic-
assisted treatment modalities are promising for the future, barriers to access-
ing and adhering to treatment exist (e.g., cost of treatment, practitioners who
Curr Treat Options Psych _#####################_ Page 15 of 19 _####_

exhibit cultural competency, practitioners of diverse identities), and these

barriers disproportionately prevent underserved racial and ethnic groups,
from receiving effective treatment despite clear and demonstrated need [74].

Conclusion
There have been great strides in the last two decades to characterize and
validate the traumatic discriminatory experiences of POC, but there is much
work yet to be done. First, experts call for a formal expansion of the defi-
nition of PTSD, to acknowledge the real, cumulative, and lasting negative
impacts of racism on POC. This includes modification of key tools, like the
DSM, and the incorporation of evidence-informed assessment and treatment
approaches for racial trauma within PTSD clinical treatment guidelines. Sec-
ond, future studies can use validated assessment tools to map the preva-
lence, symptoms, course, and consequential outcomes of racial trauma across
community and clinical settings. And finally, clinical training and continued
education on how to discuss the impact of racism safely and competently as
well as effectively administer racial trauma-targeting assessment tools and
interventions are essential. This training must encourage clinicians to reflect
on their explicit and implicit biases that may interfere in providing POC with
the trauma treatment they deserve. Overall, these research directions call for
the systematic consideration of culture, race, and experiences of racism in
clinical training, teaching, learning, and research as essential to the advance-
ment and equity of clinical science [58, 59].

Funding
This research was undertaken, in part, thanks to support from the Canada Research Chairs Program, Cana-
dian Institutes of Health Research (CIHR) grant number 950–232127.

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