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CEU Information Thank you for joining us! Many of you may be
viewing the webinar in a group but for those of you who wish to receive Continuing Education Units for viewing this webinar, you must sign into the webinar yourself.
You can do so here: http://www.mentalhealthnys.org/login/login.cfm?EventSID=457
You can also copy and paste the link from the chat box.
We will begin shortly!
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: [email protected] – 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
in a Managed Care Environment. Are You Ready? Part 1 of 3: Person and Family-Centered Planning and Leadership: Implementing Recovery-Oriented Planning at the Organizational Level • Date/Time: Wednesday, July 29, 2015, 12pm-1pm • Presenters: Edye Schwartz, DSW., LCSW-R & Ruth Colón-Wagner, LMSW • Register: http://www.mentalhealthnys.org/login/login.cfm?EventSID=471
Self-care in the Present Moment: Mindfulness for the Helping Professional
• Date: August 19, 2015; 12:00pm- 1:00pm • Presenter: Reka Prasad from Global Spiritual Life • Register: http://www.mentalhealthnys.org/login/login.cfm?EventSID=431
Visit www.ctacny.com to view all of our offerings!