Super Bowl Slurs
Amy was a 21-year-old, Japanese American college student at a large, public university in New England. She decided to seek out therapy after an emotionally charged conflict with her White boyfriend’s twin brother, Tom – something she described as “the straw that broke the camel’s back.”
The incident happened during a Super Bowl party, and racial tensions in the room were high. While drinking, Tom made increasingly racist comments about Black football players. “These Black players are only in here because they needed them to make up numbers,” he snarled. Tom used the n-word repeatedly and hurled other derogatory racial epithets at players as they appeared on the television screen.
Amy told Tom several times that she was hurt and angered by his behavior, only to have the vicious verbal responses turned on her. “Shut up, you stupid b***!” he said. “What the f*** do you know about football, you slant-eyed b****? Your people don’t even f***ing play football!” Amy felt flushed and angry but didn’t know what to do. She looked around the room for support, but neither her boyfriend nor his parents stood up for her against the barrage of racist insults. She finally left the house in tears, feeling threatened and powerless. A week later, her boyfriend broke up with her, and this exacerbated her sense of betrayal and abandonment.
After these events, Amy became increasingly depressed. She was anxious and had trouble falling asleep. Despite being an achievement-oriented student, she lost her motivation to excel academically and her self-esteem fell. She began having nightmares about the incident and actively avoided her ex-boyfriend and his brother on campus. Reminders of the incident, such as seeing her younger sister wearing her ex-boyfriend’s sweatshirt (which he had left at their home), triggered strong emotional reactions, including what she described as panic attacks. After a careful assessment, it was determined that Amy was experiencing symptoms of posttraumatic stress disorder (PTSD) as a result of racial trauma (Williams, Printz, Ching, & Wetterneck, 2018).
What Is Racial Trauma?
People of color experience higher rates of PTSD compared to White Americans, and one explanation for this difference is the experience of racism, which can itself be traumatic. When traumatization is due to experiences of racism it is sometimes called racial trauma. Racial trauma can result from major experiences of racism such as workplace discrimination or hate crimes, or it can be the result of an accumulation of many small occurrences, such as everyday discrimination and microaggressions. Due to the current political climate, there has been a recent rise in overt racism and hate crimes on college campuses.
Racial trauma may merit a DSM-5 diagnosis of PTSD when there is an identifiable index trauma (Criterion A), re-experiencing of the trauma (Criterion B), avoiding trauma reminders (Criterion C), negative mood and thoughts (Criterion D), and hyperarousal (Criterion E). However, all symptoms of PTSD may be present due to racial trauma, even if a Criterion A event cannot be identified. The DSM-5 limits what is defined as a traumatic experience to direct exposure to physical and sexual violence, repeated exposure to traumatic information in a work setting, and indirect exposure by way of receiving news of a traumatic event involving a close friend or loved one. This may preclude a PTSD diagnosis, even if all symptoms are present. However, if the nature of the trauma does not meet DSM-5 criteria, PTSD may still be diagnosed based on the ICD-10 criteria (International Classification of Diseases), because it does not explicitly restrict the types of traumas that may result in a diagnosis of PTSD.
Why Diagnosing Racial Trauma Can Be Difficult
Sometimes bonafide Criterion A events are missed by mental health service providers because they are unaware of the impact of discrimination, fail to recognize experiences of racism as traumatic, or fail to inquire about experiences of racism at all. For example, being bullied at school for “looking different,” racial profiling by police, and workplace racial harassment can all be DSM-5 Criterion A events, but are these rarely included in conventional checklists and batteries for trauma (Malcoun, Williams, & Bahojb-Nouri, 2015).
Examples of Race-Related Traumas That May Meet DSM-5 Criteria for PTSD
Below are some common racial trauma, followed by examples of Criterion A events that could merit a DSM-5 Diagnosis of PTSD (Williams, Printz, Ching, & Wetterneck, 2018):
- Overt racial slurs and threats made by anyone: Perpetrator threatens the victim with assault or death using a racial/ethnic epithet.
- Police harassment, body searches, and assaults: Law enforcement officers assault the victim of color physically, issue threats, or search the victim’s body for evidence of a crime (e.g., weapons, drugs).
- Workplace discrimination: Coworkers express racially motivated threats or carry out physical assaults against the targeted individual in the workplace.
- Community violence: Victim witnessed gang violence or was afraid for his/her life/personal safety or that of family members.
- Distressing medical experiences: Victim of color has persistent fear for life of self/loved ones due to medical mistreatment.
- Incarceration: Victim of color was physically or sexually assaulted while in prison.
- Immigration difficulties: Victim of color experienced physical/sexual assault or robbery or feared for life of self/loved ones during the immigration process.
- Deportation: Children of undocumented immigrants witness violent confrontation, abduction of, and separation from parents by law enforcement.
Further, assessing race-related distress in clients of color during a clinical encounter may be uncomfortable for therapists who have not had practice discussing racial issues (Sue, Rivera, Capodilupo, Lin, & Torino, 2010). Many White people are socialized to demonstrate non-racist values by taking a colorblind position and not talking about race (Underhill, 2018). However, this approach leaves such clinicians ill-equipped to have conversations about race with their clients of color, making it even less likely they will be able engage in productive conversations surrounding traumatic experiences of racism.
UConn Racial/Ethnic Stress & Trauma Survey
One solution to this problem is the UConn Racial/Ethnic Stress & Trauma Survey (UnRESTS; Williams, Metzger, Leins, & DeLapp, 2018), recently unveiled in the APA journal, Practice Innovations. The UnRESTS is a clinician-administered, semi-structured interview designed for use with clients who are members of stigmatized racial and ethnic groups.
In terms of the structure of the UnRESTS, the introduction section provides information regarding the scope of the interview and asks clients what racial and ethnic group they identify with. In order to understand the context in which people of color experience racism, it is important to understand something about their racial and ethnic identity. As such, the Racial and Ethnic Identity Development section focuses on the client’s socialization to race/ethnicity and how the person feels about their racial/ethnic group to better inform the clinician about the context of the person’s distress.
The interview then guides the clinician in asking about experiences surrounding explicit and obvious racism, racism experienced by loved ones, being vicariously impacted by racist experiences that interviewees learned about, and experiences with subtle forms of racism or microaggressions. The end of the UnRESTS is a checklist designed to determine if symptoms are present in each of the critical areas delineated by the DSM-5 as indicative of PTSD.
After the UnRESTS was initially drafted, all questions were reviewed and tested by numerous diverse clinicians with various levels of experience, and then refined to arrive at the final interview. This process included soliciting input from PTSD and diversity experts in the early stages of development, followed by piloting the interview and eliciting feedback from clinical psychology doctoral students and clinicians at clinical diversity workshops. The refined UnRESTS was then tested at several additional sites, including varied clinician workshops, a student counseling clinic, outpatient clinics, a multisite PTSD treatment program, and forensic settings. A shortened version that queries about stigma more broadly is in use as part of an international PTSD research study.
The UnRESTS is useful to clinicians as an aid to uncovering racial trauma, developing a culturally-informed case conceptualization, and including experiences of racism into the diagnosis of PTSD when warranted. Three case examples are provided in the article that describe the impact of racial stress and trauma and the role of the UnRESTS in understanding the experiences of those impacted by racism. The UnRESTS has also been translated into Spanish, with input from bilingual clinicians speaking several different dialects of Spanish (Williams, Pena, & Mier-Chairez, 2017).
Treating Racial Trauma
Amy was administered the UnRESTS and found to have PTSD symptoms as a result of these experiences. There are not yet any empirically validated treatments for racial trauma, but there are several approaches that are recommended by experienced clinicians with expertise in these issues (i.e., Carlson, Endsley, Motley, Shawahin, & Williams, 2018; Comas-Diaz, 2016; Williams et al., 2014).
Amy responded well to strong initial affirmation of her ethnoracial identity, as well as values she identified with that were part of her cultural heritage. This was facilitated by racial similarity with her therapist, who was Chinese Singaporean, and a sense of closeness and relatability to him, which was enabled through the use of Functional Analytic Psychotherapy (FAP). Amy’s subsequent treatment plan included self-care and academic organizational skills training, as well as empathic support in processing the racist incident and the emotional betrayal by her ex-boyfriend. Over time, this allowed her to experience substantial symptom improvement and regain her academic motivation and self-confidence, in line with her personal values.
Carlson, M. D., Endsley, M., Motley, D., Shawahin, L. N., & Williams, M. T. (2018). Addressing the impact of racism on veterans of color: A race-based stress and trauma group. Psychology of Violence, 8(6), 748-762. doi: 10.1037/vio0000221
Comas-Díaz, L. (2016). Racial trauma recovery: a race-informed therapeutic approach to racial wounds In A. N. Alvarez, C. T. H. Liang & H. A. Neville (Eds), Cultural, Racial, and Ethnic Psychology Book Series. The Cost of Racism for People of Color: Contextualizing Experiences of Discrimination (pp. 249-272). Washington, DC: American Psychological Association.
Malcoun, E., Williams, M. T., & Bahojb-Nouri, L. V. (2015). Assessment of Posttraumatic Stress Disorder in African Americans. In L. T. Benuto & B. D. Leany (Eds.), Guide to Psychological Assessment with African Americans (pp. 163-182). New York, NY: Springer. ISBN: 978-1-4939-1003-8.
Sue, D. W., Rivera, D. P., Capodilupo, C. M., Lin, A. I., & Torino, G. C. (2010). Racial dialogues and White trainee fears: Implications for education and training. Cultural Diversity and Ethnic Minority Psychology, 16(2), 206-214. doi: 10.1037/a0016112
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. Behavioral Sciences, 4(2), 102-124. doi:10.3390/bs4020102
Williams, M. T., Metzger, I., Leins, C., & DeLapp, C. (2018). Assessing racial trauma within a DSM-5 framework: The UConn Racial/Ethnic Stress & Trauma Survey. Practice Innovations, 3(4), 242-260. doi: 10.1037/pri0000076
Williams, M. T., Pena, A., & Mier-Chairez, J. (2017). Tools for assessing racism-related stress and trauma among Latinos. In L. T. Benuto (Ed.), Toolkit for Counseling Spanish-Speaking Clients. Springer. ISBN: 978-3-319-64880-4. doi: 10.1007/978-3-319-64880-4_4
Williams, M. T., Printz, D., Ching, T. & Wetterneck, C. T. (2018). Assessing PTSD in ethnic and racial minorities: Trauma and racial trauma. Directions in Psychiatry, 38(3), 179-196.
Underhill, M. R. (2018). Parenting during Ferguson: making sense of white parents’ silence. Ethnic & Racial Studies, 41(11), 1934–1951. doi: 10.1080/01419870.2017.1375132