Posttraumatic Stress Disorder and Racial Trauma

Authors’ Addresses: Monnica T. Williams, Ph.D., is afﬁliated with the University of Ottawa, School of Psychology, 136 Jean-

Jacques Lussier, Vanier Hall, Ottawa, Ontario, K1N 6N5, Canada. Angela M. Haeny, PhD., is afﬁliated with Yale School of

Medicine, Department of Psychiatry, 300 George St #901, New Haven, CT 06511. Samantha C. Holmes, PhD., is afﬁliated

with Yale School of Medicine, Department of Psychiatry, 300 George St #901, New Haven, CT 06511 and with City University

of New York, College of Staten Island, Department of Psychology, 2800 Victory Blvd, Staten Island, NY 10314. Email

Addresses: [email protected]; [email protected], and [email protected].

Deﬁnition/Description

Butts (2002) was the ﬁrst to draw attention to what

we now call racial trauma, or race-based trauma, in

the mental health literature. Racial trauma can be

deﬁned as the cumulative traumatizing impact of

racism on a racialized individual, which can include

individual acts of racial discrimination combined

with systemic racism, and typically includes

historical, cultural, and community trauma as well.

Helms et al., (2012) argue that acts of racial and

ethnic hostility can trigger trauma reactions due to

a person’s own past experiences or historical

events, even when there is no recent or direct

evidence of threat to one’s life. Carter (2007)

compiled a comprehensive overview of the

psychological impact of racism and events that can

result in race-based stress and trauma. Racial

trauma appears to be relatively common among

treatment-seeking people of color. Hemmings and

Evans (2018) conducted a survey of counselors and

found that the majority of professionals had

encountered race-based trauma in their clinical

work (71%), but few had received training in the

assessment or treatment of those afﬂicted.

Liu et al., (2019) detail the process of acculturation

that many people of color experience when

navigating dominant culture. White supremacist

ideology, the belief in White biological or cultural

superiority that serves to maintain the status quo of

racial inequality, is deeply integrated in dominant

culture values (Liu et al., 2019). Through chronic

exposure to racism, people of color learn their

positionality and how to become racially innocuous

Continued on page 2

as part of acculturating to White culture. As a

result, some people of color may change their

presentation and behavior and accommodate the

cultural preferences of White people to avoid

triggering responses that might further their own

racial trauma. As part of acculturating to White

culture, some people of color actively maintain their

intersecting identities, whereas others may

internalize racism by embracing stereotypes about

their racial group. Given how inextricably linked

White supremacist ideology is within dominant

cultural values, Liu et al., (2019) encourage

researchers and clinicians to consider how they

may have internalized standards of practice

consistent with White supremacist ideology.

Evidence of Harms

Racism has been linked to a host of negative mental

health conditions, but the connection between racial

discrimination and PTSD symptoms appears to be

the most robust. Racial and ethnic discrimination

was postulated to have a causal role in PTSD

symptoms and alcohol problems in a longitudinal

study of Hispanic college students (Cheng &

Mallinckrodt, 2015). Sibrava et al. (2019) found the

same in a longitudinal study of Latino and African

American adults, where frequency of experiences

with discrimination signiﬁcantly predicted PTSD

diagnosis but did not predict any other anxiety or

mood disorder, indicating a potentially unique

relationship between discrimination and PTSD.

Examining data from a large health maintenance

organization in Northern California, mediational

analyses indicated that adolescents who

Monnica T. Williams, PhD

University of Ottawa, School of Psychology,

Ottawa, ON

Angela M. Haeny, PhD

Yale School of Medicine, Department of Psychiatry,

New Haven, CT

Samantha C. Holmes, PhD

Yale School of Medicine, Department of Psychiatry,

New Haven, CT

City University of New York, College of Staten Island,

Department of Psychology, Staten Island, NY

Posttraumatic

Stress Disorder

and Racial Trauma

advancing science and promoting understanding of traumatic stress

Research Quarterly

Published by:

National Center for PTSD

VA Medical Center (116D)

215 North Main Street

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(802) 296-5132

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Email: [email protected]

All issues of the PTSD Research

Quarterly are available online at:

www.ptsd.va.gov

Editorial Members:

Editorial Director

Matthew J. Friedman, MD, PhD

Bibliographic Editor

David Kruidenier, MLS

Managing Editor

Heather Smith, BA Ed

National Center Divisions:

Executive

White River Jct VT

Behavioral Science

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Dissemination and Training

Menlo Park CA

Clinical Neurosciences

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Evaluation

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Women’s Health Sciences

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VOLUME 32/NO. 1 • ISSN: 1050-1835 • 2021

PAGE 2 PTSD RESEARCH QUARTERLY

Continued from cover

PTSD symptoms above and beyond general stress, and high ethnic

social connectedness buffered this effect (Wei et al., 2012). Thus, the

literature suggests race-related stressors can cause trauma

symptoms through lowering self-esteem which can contribute to

poor mental health outcomes. In addition, high ethnic identity and

self-efﬁcacy can serve as protective against the negative impact of

race-related stressors on mental health.

It has also been suggested that people of color may experience

shock after a race-related stressor (Williams et al., 2018), which

may result in shame for not defending themselves in the moment

and contribute to lowering self-esteem and maladaptive coping

(Williams et al., 2018). Further, the potential social costs associated

with discussing racist events may contribute to avoidance in

discussing these experiences with others (Carlson et al., 2018). In

addition to lowering self-esteem, the experience of shame and

avoidance after a race-related stressor may also contribute to the

development of PTSD symptoms and maladaptive coping.

Assessment

Racial trauma can stem from a variety of causes, many of which

are not represented in typical measures designed to assess

PTSD. When considering PTSD, clinicians often consider sexual

abuse, combat, and life-threatening assaults. Williams et al.,

(2018) explicate the many additional sources of traumatization

people of color may experience as a result of racialization, such

as police violence, racial threats, immigration difﬁculties, and

workplace harassment.

Loo and colleagues (2001) were among the ﬁrst to develop and

validate a measure of racial traumatization, the Race-Related

Stressor Scale (RRSS) for Asian American Vietnam Veterans. The

RRSS measures exposure to racism, and among Veterans

assessed, exposure to race-related stressors accounted for an

additional 20% of the variance in PTSD symptoms over and above

combat exposure and military rank (Loo et al., 2001). Carter and

colleagues (2013) developed the landmark Race-Based Traumatic

Stress Symptom Scale (RBTSSS), the ﬁrst tool to evaluate racial

trauma in a clinical setting. Limitations of the measure include its

length, a complicated scoring process, and its inability to render a

diagnosis. Williams at al., (2018) developed the Trauma Symptoms

of Discrimination Scale (TSDS), which covers anxiety-related PTSD

symptoms. The measure includes trauma symptoms from any

source of discrimination but has thus far only been validated in

African American and multiracial individuals and, similar to the

RBTSSS, does not render a diagnosis. Furthermore, it can be

helpful for clinicians to discuss racially charged materials directly

with patients in an interview style-format. To address this need,

Williams et al., (2018) developed the UConn Racial/Ethnic Stress &

Trauma Survey, which is a clinician-administered interview that can

also help in rendering a PTSD diagnosis due to discrimination,

based on the ﬁfth edition of the Diagnostic and Statistical Manual

of Mental Disorders (DSM-5) criteria.

Treatment

The literature is sparse on empirically supported approaches for

treating PTSD and racial trauma among people of color. The few

treatments available range from cultural adaptations of evidence-

based PTSD treatments (Williams et al., 2014) to interventions

experienced more discrimination reported worse PTSD symptoms,

which was related to more alcohol and drug use, ﬁghts, and sexual

partners (Flores et al., 2010). Having multiple stigmatized identities

may have compounding effects on traumatization. Dale and Safren

(2019) found that gendered racial microaggressions (subtle acts of

prejudice) predicted PTSD symptoms and posttraumatic cognitions

among Black women with HIV, to a degree greater than

discrimination based on either race or HIV-status alone.

Traumatization may occur at a community level as well. In a

population-based, quasi-experimental study, Bor et al., (2018) found

that highly publicized police killings of unarmed Black people had

spillover effects on the mental health of Black people in the region

where the killing happened. The impact was felt for months

afterwards, whereas no ill effects were found for White people in

those same localities. It is thought that the cultural legacy of

state-inﬂicted oppression is a contributing factor leading to poor

community health through vicarious retraumatization. Gone et al.,

(2019) have explicated the community impact of historical trauma on

health outcomes for indigenous populations in the USA and Canada,

and likewise, Nagata et al., (2019) have shown how the Japanese

American wartime internment experience has caused lasting

traumatizing effects on those interned and their descendants.

Mechanisms

Different forms of racism may contribute to race-related stress or

trauma responses, which may be salient in terms of mechanisms

for traumatization. Similarly, an understanding of the various ways

in which trauma may present is informative for treatment

development. The accumulation of race-related stressors including

intergenerational racial trauma, racial microaggressions, racial

discrimination, and overt racism that many people of color

experience can result in developing PTSD (Williams et al., 2018).

Kira (2010) offers a broad conceptualization of trauma that

encompasses cumulative and collective identity trauma.

Cumulative traumas may involve core traumas, which sensitize and

provoke responses to subsequent stressors, and triggering

traumas, which ultimately set off the trauma response (Kira, 2010).

Ability to differentiate between these different types of traumas is

important for case conceptualization and treatment. Kira (2010)

highlights the importance of interventions that focus on

empowering victims of oppression and increasing their perceived

control. These interventions can help reduce traumatization through

enhancing perceived self-control and executive functioning through

encouraging and supporting the victim in seeking retributive

justice. The focus on empowerment and increasing self-control is

consistent with other race-related stress and trauma interventions

(Carlson et al., 2018).

Several studies have investigated mechanisms associated with

race-related stress and trauma among people of color. Torres et al.,

(2015) found that symptoms of traumatic stress (hypervigilance,

arousal, avoidance) mediated the association between ethnic

microaggressions and depression with a stronger association found

among Latinx adults with low levels of ethnic identity and self-

efﬁcacy. Among women of color, lower self-esteem partially

mediated the relationship between racism and trauma symptoms

and high ethnic identity buffered the effect between racism and

trauma symptoms (Watson et al., 2016). In a sample of Chinese

international students, racial discrimination was associated with

VOLUME 32/ NO. 1 • 2021 PAGE 3

explicitly targeting racial stress and trauma (Bryant-Davis & Ocampo,

2006; Carlson et al., 2018; Saleem et al., 2020). When working with

victims of oppression, Kira (2010) suggests that helping victims to

forgive collaborators in an oppressive system is associated with

positive mental and physical health outcomes and contributes to

reconciliation, whereas supporting anger against the oppressor and

helping the victim seek retributive justice is associated with healing

and positive mental health outcomes related to regaining self-control

and executive functions.

A group race-based stress and trauma intervention (RBST) (Carlson

et al., 2018) was developed for Veterans of color to discuss

experiences of racism that led to stress or trauma symptoms. Group

discussion themes include psychoeducation on different forms of

racism, identity development, power, White privilege, and stress and

trauma reactions, race-based stressors in mental and physical health

and military experiences, challenges with discussing race-based

stressors with mental health providers, and resilience and

empowerment. Psychoeducation on the sociohistorical context of

racism, cognitive restructuring to reshape beliefs that people of color

are not to blame for racist incidents, and hearing experiences of

racism from others may help reduce shame and alleviate

internalization of racism. Veterans reported that participating in the

RBST intervention provided them with a new way to think about their

experiences with racism, empowered them to address racism in a

way that felt authentic, and provided skills for coping with regular

experiences of racism. The authors provide suggestions for

implementation of the RBST intervention across service areas. As of

this writing, RBST groups are operating at over a dozen US

Department of Veterans Affairs (VA) facilities.

The Developmental and Ecological Model of Youth and Racial

Trauma was developed for addressing race-based stress and trauma

for youth and adolescents of color (Saleem et al., 2020). This is a

critical area of study because young children may be affected by

experiences of racism yet lack the verbal skills to process these

experiences. This article proposes a model of how race-related

stress and trauma may develop and present in youth and

adolescents with a focus on the impact of family and community

systems. Case examples are provided for elementary, middle, and

high school age youth. The authors also provide recommendations

for future research to develop prevention and intervention programs

based on this model potentially incorporating approaches for

enhancing racial socialization in families.

Multisystemic, multimodal, multicomponent therapies typically

include the individual, family, and the community in the healing

process and are considered more ecologically valid and culturally

competent approaches for treating race-related stress and trauma

(Kira, 2010). These therapies are ﬂexible which allows them to be

adapted for different cultures and different types of traumas. In

addition, multisystemic, multimodal, multicomponent therapies tend

to be more comprehensive by addressing both clinical and

nonclinical needs. Further, a strengths-based approach is often used

in these therapies by identifying strengths of the individual, family,

and community that can be leveraged in treatment.

Future Directions

There is still much work to be done to address the reality of racial

trauma. Ample empirical evidence attests to the nature and impact

of racial trauma on victims. The next critical steps include raising

awareness of racial trauma among clinicians, which includes

incorporating the assessment and treatment of racial trauma into

clinical training programs and adding some discussion of racial

trauma into important diagnostic manuals, such as the DSM-5.

Holmes et al., (2016) provide a compelling argument for expanding

Criterion A for PTSD based on the deleterious impact of oppression.

Many others have called for racial trauma to be included in the

DSM-5, noting the broad and cumulative impact of racism on people

of color (Loo et al., 2001; Williams et al., 2018).

Oppression may have the greatest impact on those with multiple

stigmatized identities (Dale & Safren, 2019). Ching et al., (2018)

presented a model of intersectional stress and trauma in Asian

American sexual and gender minorities. More work is needed to

understand how marginalization surrounding these intersecting

identities may differentially and collectively result in traumatization.

In order to accomplish the needed work, people of color must be

better represented in clinical trials for PTSD, and new studies are

needed to examine treatment outcomes for protocols speciﬁcally

focused on racial trauma. In a novel examination of Methyl enedioxy

methamphetamine- (MDMA-) assisted therapy for PTSD in people of

color, Williams et al., (2020) detail culturally informed methodology to

access and retain those suffering from racial trauma in clinical trials.

This methodology could be a guide for other researchers who aim to

study these vulnerable populations for the purpose of developing

effective interventions.

FEATURED ARTICLES continued

VOLUME 32/ NO. 1 • 2021 PAGE 5

Holmes, S. C., Facemire, V. C., & DaFonseca, A. M. (2016).

Expanding Criterion A for posttraumatic stress disorder:

Considering the deleterious impact of oppression.

Traumatology, 22(4), 314–321. doi:10.1037/trm0000104

The ﬁfth edition of the Diagnostic and Statistical Manual of Mental

Disorders includes edits to Criterion A for posttraumatic stress

disorder in an attempt to capture a wide variety of potentially

traumatic events. However, despite criticism by scholars in the

ﬁeld (e.g., Kira, 2001; Gilfus, 1999; Helms, Nicolas, & Green, 2012)

and overwhelming evidence documenting the negative impact of

oppression on the mental health of its targets (e.g., Carter, 2007),

the way in which Criterion A is written fails to include the insidious

trauma of oppression. There is a small but compelling literature

base that has demonstrated oppression to be a form of trauma by

examining the relationship among various forms of oppression

(e.g., racism, sexism, heterosexism) and trauma-related symptoms

(e.g., Alessi, Martin, Gyamerah, & Meyer, 2013; Berg, 2006;

Pieterse, Carter, Evans, & Walter, 2010). The authors make a case

for expanding the current deﬁnition of Criterion A to incorporate

the full range of oppressive forces by providing empirical support

demonstrating the relationship between experiences of

oppression and trauma-related outcomes and by arguing that this

change is appropriately political and consistent with social justice

values held by psychology.

Kira, I. A. (2010). Etiology and treatment of post-cumulative

traumatic stress disorders in different cultures. Traumatology,

16(4), 128–141. doi:10.1177/1534765610365914 Developments in

the theories of identity, culture, and traumatology enrich our

cross-cultural understanding of mental health dynamics, case

conceptualization, and developing effective intervention models to

help victims of complex and cumulative traumas especially in

different cultures and minority populations. Identity traumas, along

with pre-identity and non-identity traumas, contribute to forming

cultures. On the other hand, cultures may contribute to delivering

some types of culture- and social-made serious traumatic conditions

that can be transferred cross-generationally, such as poverty and

caste systems. Most current interventions are designed to help with

single trauma and ignore the cumulative trauma dynamics as well

the collective identity and culture-speciﬁc traumas. This

understanding entails revising our culturally limited and single-

trauma-based interventions to help clients who belong to different

cultures or to minority victims of culture- and social-made traumas

as well as those who are victims of cumulative traumas.

Multisystemic, multimodal, multicomponent ﬂexible and ﬁddle

therapy models emerged as potentially more effective in the

treatment of disorders resulting from cumulative and identity

traumas. They are more ecologically valid and culturally competent.

Speciﬁc models of multisystemic, multimodal therapies—the

wraparound psychosocial rehabilitation approach, for torture

survivors, and the summer day and after-school treatment, for child

victims of cumulative traumas—are discussed.

Liu, W. M., Liu, R. Z., Garrison, Y. L., Kim, J. Y. C., Chan, L., Ho, Y. C.

S., & Yeung, C. W. (2019). Racial trauma, microaggressions, and

becoming racially innocuous: The role of acculturation and

White supremacist ideology. American Psychologist, 74(1),

143–155. doi:10.1037/amp0000368 Acculturation theories often

describe how individuals in the US adopt and incorporate dominant

cultural values, beliefs, and behaviors such as individualism and

self-reliance. Theorists tend to perceive dominant cultural values as

“accessible to everyone,” even though some dominant cultural

values, such as preserving White racial status, are reserved for White

people. In this article, the authors posit that White supremacist

ideology is suffused within dominant cultural values, connecting the

array of cultural values into a coherent whole and bearing with it an

explicit status for White people and people of color. Consequently,

the authors frame acculturation as a continuing process wherein

some people of color learn explicitly via racism, microaggressions,

and racial trauma about their racial positionality; White racial space;

and how they are supposed to accommodate White people’s needs,

status, and emotions. The authors suggest that acculturation may

mean that the person of color learns to avoid racial discourse to

minimize eliciting White fragility and distress. Moreover, acculturation

allows the person of color to live in proximity to White people

because the person of color has become unthreatening and racially

innocuous. The authors provide recommendations for research and

clinical practice focused on understanding the connections between

ideology, racism, microaggressions and ways to create

psychological healing.

Loo, C. M., Fairbank, J. A., Scurﬁeld, R. M., Ruch, L. O., King, D.

W., Adams, L. J., & Chemtob, C. M. (2001). Measuring exposure

to racism: Development and validation of a Race-Related

Stressor Scale (RRSS) for Asian American Vietnam veterans.

Psychological Assessment, 13(4), 503–520. doi:10.1037/1040-

3590.13.4.503 This article describes the development and

validation of the RRSS, a questionnaire that assesses exposure to

race-related stressors in the military and war zone. Validated on a

sample of 300 Asian American Vietnam Veterans, the RRSS has

high internal consistency and adequate temporal stability.

Hierarchical regression analyses revealed that exposure to

race-related stressors accounted for a signiﬁcant proportion of the

variance in PTSD symptoms and general psychiatric symptoms,

over and above (by 20% and 19%, respectively) that accounted for

by combat exposure and military rank. The RRSS appears to be a

psychometrically sound measure of exposure to race-related

stressors for this population. Race-related stressors as measured

by the RRSS appear to contribute uniquely and substantially to

PTSD symptoms and generalized psychiatric distress.

Saleem, F. T., Anderson, R. E., & Williams, M. (2020). Addressing

the "myth" of racial trauma: Developmental and ecological

considerations for youth of color. Clinical Child and Family

Psychology Review, 23(1), 1–14. doi:10.1007/s10567-019-00304-1

Trauma is prevalent among children and adolescents, with youth of

color generally reporting greater exposure compared to White youth.

One factor that may account for this difference is racial stress, which

can manifest into trauma symptoms. Although racial stress and

trauma (RST) signiﬁcantly impacts youth of color, most of the

research to date has focused on adult populations. In addition, little

attention has been given to the impact of the ecological context in

how youth encounter and cope with RST. As such, we propose the

Developmental and Ecological Model of Youth Racial Trauma

(DEMYth-RT), a conceptual model of how racial stressors manifest

to inﬂuence the trauma symptomatology of children and adolescents

FEATURED ARTICLES continued

PAGE 6 PTSD RESEARCH QUARTERLY

of color. Within developmental periods, we explore how individual,

family, and community processes inﬂuence youth’s symptoms and

coping. We also discuss challenges to identifying racial trauma in

young populations according to clinician limitations and the

post-traumatic stress disorder framework within DSM-5. The article

concludes with implications on applying DEMYth-RT in clinical and

research settings to address RST for youth of color.

Sibrava, N. J., Bjornsson, A. S., Pérez Benítez, A. C. I., Moitra, E.,

Weisberg, R. B., & Keller, M. B. (2019). Posttraumatic stress

disorder in African American and Latinx adults: Clinical

course and the role of racial and ethnic discrimination.

American Psychologist, 74(1), 101–116. doi:10.1037/amp0000339

Research has suggested that African American and Latinx adults

may develop PTSD at higher rates than White adults, and that the

clinical course of PTSD in these minority groups is poor. Factors

that may contribute to higher prevalence and poorer outcome in

these groups are sociocultural factors and racial stressors, such

as experiences with discrimination. To date, however, no research

has explored the relationship between experiences with

discrimination and risk for PTSD, and very little research has

examined the course of illness for PTSD in African American and

Latinx samples. The present study examined these variables in

the only longitudinal clinical sample of 139 Latinx and 152 African

American adults with anxiety disorders, the Harvard/Brown

Anxiety Research Project-Phase II. Over 5 years of follow-up,

remission rates for African Americans and Latinx adults with PTSD

in this sample were 0.35 and 0.15, respectively, and reported

frequency of experiences with discrimination signiﬁcantly

predicted PTSD diagnostic status in this sample but did not

predict any other anxiety or mood disorder. These ﬁndings

demonstrate the chronic course of PTSD in African American and

Latinx adults and highlight the important role that racial and ethnic

discrimination may play in the development of PTSD among these

populations. Implications for an increased focus on these

sociocultural stressors in the assessment and treatment of PTSD

in African American and Latinx individuals are discussed.

Torres, L., & Taknint, J. T. (2015). Ethnic microaggressions,

traumatic stress symptoms, and Latino depression: A

moderated mediational model. Journal of Counseling

Psychology, 62(3), 393–401. doi:10.1037/cou0000077 Although

ethnic microaggressions have received increased empirical

attention in recent years, there remains a paucity of research

regarding how these subtle covert forms of discrimination

contribute to Latino mental health. The present study examined

the role of traumatic stress symptoms underlying the relationship

between ethnic microaggressions and depression. Further, ethnic

identity and general self-efﬁcacy were tested as moderators

between the ethnic microaggressions and traumatic stress link.

Among a sample of 113 Latino adults, moderated mediational

analyses revealed statistically signiﬁcant conditional indirect

effects in which traumatic stress symptoms mediated the

relationship between ethnic microaggressions and depression

while ethnic identity and self-efﬁcacy functioned as moderators.

The major ﬁndings suggested that the indirect effects were the

most robust within low ethnic identity and low self-efﬁcacy. The

ﬁndings are discussed within a stress and coping framework that

highlight the internal resources and stress responses associated

with experiencing ethnic microaggressions.

Watson, L. B., DeBlaere, C., Langrehr, K. J., Zelaya, D. G., &

Flores, M. J. (2016). The inuence of multiple oppressions on

women of color's experiences with insidious trauma. Journal

of Counseling Psychology, 63(6), 656–667. doi:10.1037/

cou0000165 In this study, we examined the relations between

multiple forms of oppressive experiences (i.e., racism, sexism,

and sexual objectiﬁcation) and trauma symptoms among Women

of Color (WOC). In addition, self-esteem was explored as a partial

mediating variable in these links, and ethnic identity strength was

proposed to buffer the negative relationship between multiple

forms of oppression and self-esteem, and the positive relationship

between oppressive experiences and trauma symptoms. Results

suggested that self-esteem partially mediated the positive

relationship between racist experiences and trauma symptoms,

such that racism was related to lower self-esteem, which was

then related to more trauma symptoms. Sexism and sexual

objectiﬁcation were directly linked with trauma symptoms.

Moreover, average and high levels of ethnic identity strength

buffered the positive link between racism and trauma symptoms.

Consistent with an additive intersectionality framework, results

demonstrate the importance of attending to multiple forms of

oppression as they relate to trauma symptoms among WOC.

Wei, M., Wang, K. T., Heppner, P. P., & Du, Y. (2012). Ethnic and

mainstream social connectedness, perceived racial

discrimination, and posttraumatic stress symptoms. Journal of

Counseling Psychology, 59(3), 486–493. doi:10.1037/a0028000

Carter (2007) proposed the notion of race-based traumatic stress

and argued that experiences of racial discrimination can be viewed

as a type of trauma. In a sample of 383 Chinese international

students at 2 predominantly White midwestern universities, the

present results supported this notion and found that perceived

racial discrimination predicted posttraumatic stress symptoms over

and above perceived general stress. Furthermore, Berry (1997)

proposed an acculturation framework and recommended that

researchers advance the literature by examining the moderation

effects on the association between racial discrimination and

outcomes. The present results supported the moderation effect for

Ethnic SC (i.e., social connectedness in the ethnic community), but

not for Mainstream SC (i.e., social connectedness in mainstream

society). A simple effects analysis indicated that a high Ethnic SC

weakened the strength of the association between perceived racial

discrimination and posttraumatic stress symptoms more than a low

Ethnic SC. Moreover, although Mainstream SC failed to be a

moderator, Mainstream SC was signiﬁcantly associated with less

perceived general stress, less perceived racial discrimination, and

less posttraumatic stress symptoms.

Williams, M. T., Metzger, I. W., Leins, C., & DeLapp, C. (2018).

Assessing racial trauma within a DSM-5 framework: The

UConn Racial/Ethnic Stress and Trauma Survey. Practice

Innovations, 3(4), 242–260. doi:10.1037/pri0000076 Many ethnic

minority groups experience higher rates of PTSD compared to

their European American counterparts. One explanation for this is

the differential experience of racism, which can itself be traumatic.

FEATURED ARTICLES continued

VOLUME 32/ NO. 1 • 2021 PAGE 7

This article aims to provide a theoretical basis for the traumatizing

nature of various forms of racism within the DSM-5’s framework

for PTSD. PTSD caused by racism, or racial trauma, is likely to be

underrecognized due to a lack of awareness among clinicians,

discomfort surrounding conversations about race in therapeutic

settings, and a lack of validated measures for its assessment. We

review the literature and existing measures for the assessment of

racial trauma and introduce the UConn Racial/Ethnic Stress &

Trauma Survey (UnRESTS), a clinician-administered interview. The

UnRESTS is useful to clinicians as an aid to uncovering racial

trauma, developing a culturally informed case conceptualization,

and including experiences of racism in the diagnosis of PTSD

when warranted. Three case examples that describe the impact

of racial stress and trauma and the role of the UnRESTS in

understanding the experiences of those impacted by racism

are included.

Williams, M. T., Printz, D. M. B., & DeLapp, R. C. T. (2018).

Assessing racial trauma with the Trauma Symptoms of

Discrimination Scale. Psychology of Violence, 8(6), 735–747.

doi:10.1037/vio0000212 Objective: Racial discrimination can cause

symptoms of trauma, yet few tools for measurement exist. African

Americans have higher rates of posttraumatic stress disorder and

experience more racial discrimination than other groups. This study

is a preliminary assessment of the psychometric properties of the

TSDS, a new measure of discriminatory distress measuring anxiety-

related trauma symptoms. Method: African American monoracial

and biracial undergraduate students (n=123) completed

questionnaires, including the TSDS, the Multigroup Ethnic Identity

Measure, assessments of racial discrimination, and a range of

psychopathology measures. The TSDS factor structure was

determined with a principal components analysis and internal

consistency was assessed. Pearson’s correlations were conducted

between the TSDS and measures of discrimination and

psychopathology. Linear regression was used to predict the TSDS

from frequency of discrimination. Results: Item loadings suggested 4

components: a) uncontrollable hyperarousal, b) feelings of alienation,

c) worries about future negative events, and d) perceiving others as

dangerous. All measures of discrimination signiﬁcantly predicted

symptoms of trauma, even when accounting for prior traumatic

experiences. Conclusions: Preliminary evidence supports the validity

of the TSDS for the measurement of anxiety-related trauma

symptoms due to racial discrimination. All forms of discrimination

may contribute to traumatization in African Americans.

Williams, M. T., Reed, S., & Aggarwal, R. (2020). Culturally

informed research design issues in a study for MDMA-assisted

psychotherapy for posttraumatic stress disorder. Journal of

Psychedelic Studies, 4(1), 40–50. doi:10.1556/2054.2019.016

Recent research suggests that psychedelic drugs can be powerful

agents of change when utilized in conjunction with psychotherapy.

MDMA-assisted psychotherapy has been studied as a means of

helping people overcome posttraumatic stress disorder, believed to

work by reducing fear of traumatic memories and increasing

feelings of trust and compassion toward others, without inhibiting

access to difﬁcult emotions. However, research studies for

psychedelic psychotherapies have largely excluded people of color,

leaving important questions unaddressed for these populations. At

the University of Connecticut, we participated as a study site in an

MDMA-assisted psychotherapy for PTSD- (MAPS-) sponsored, US

Food and Drug Administration- (FDA-) reviewed Phase 2 open-label

multisite study, with a focus on providing culturally informed care to

people of color. We discuss the development of a study site

focused on the ethnic minority trauma experience, including

assessment of racial trauma, design of informed consent

documents to improve understanding and acceptability to people

of color, diversiﬁcation of the treatment team, ongoing training for

team members, validation of participant experiences of racial

oppression at a cultural and individual level, examination of the

setting and music used during sessions for cultural congruence,

training for the independent rater pool, community outreach, and

institutional resistance. We also discuss next steps in ensuring that

access to culturally informed care is prioritized as MDMA and other

psychedelics move into late phase trials, including the importance

of diverse sites and training focused on therapy providers of color.

Additional Citations

Awad, G. H., Kia-Keating, M., & Amer, M. M. (2019). A model of

cumulative racial–ethnic trauma among Americans of Middle

Eastern and North African (MENA) descent. American

Psychologist, 74(1), 76–87. doi:10.1037/amp0000344 The authors of

this paper present a conceptual model of cumulative racial-ethnic

trauma for Americans of Middle Eastern and North African (MENA)

descent. The model highlights adversities on both the macro level

(i.e., historical trauma, hostile national context, institutional

discrimination) and the micro level (i.e., interpersonal discrimination,

struggles with identity and recognition) that interact with each other

and contribute to a range of deleterious outcomes. Speciﬁcally,

racial-ethnic trauma may contribute to disparities in mental and

physical health, insecurity, helplessness, and alienation as well as

negatively impact MENA Americans with regard to their sense of

freedom versus restriction, belonging versus alienation, and

opportunity versus disadvantage.

Bierer, L. M., Bader, H. N., Daskalakis, N. P., Lehrner, A. L.,

Makotkine, I., Seckl, J. R., & Yehuda, R. (2014). Elevation of

11β-hydroxysteroid dehydrogenase type 2 activity in Holocaust

survivor offspring: Evidence for an intergenerational effect of

maternal trauma exposure. Psychoneuroendocrinology, 48, 1–10.

doi:10.1016/j.psyneuen.2014.06.001 In this study, authors examined

the glucocorticoid metabolism of adult offspring of Holocaust

survivors (n=85) in relation to comparison subjects (n=27). Holocaust

offspring demonstrated signiﬁcantly reduced cortisol excretion

(p=0.046) and elevated 11β-HSD-2 activity (p=0.008), particularly for

offspring whose mothers were children during the Holocaust. The

authors concluded that their results support a potential

intergenerational effect of maternal trauma exposure on a set-point

for 11β-HSD-2 activity, which may have implications for the mental

and physical health of offspring, even in adulthood.

Bryant-Davis, T., & Ocampo, C. (2006). A therapeutic approach

to the treatment of racist-incident-based trauma. Journal of

Emotional Abuse, 6(4), 1–22. doi:10.1300/J135v06n04_01 The

authors of this paper present a thematic approach to the

assessment and treatment of racial trauma, focusing on the

FEATURED ARTICLES continued

following themes: acknowledging, sharing, safety and self-care,

grieving/mourning the losses, shame and self-blame/internalized

racism, anger, coping strategies, and resistance strategies.

Additionally, the authors make speciﬁc recommendations for

therapist competence (e.g., exploration of one’s own racial

identity, awareness of the prevalence of racism, adoption of an

explicitly anti-racist position) and demonstrate their recommended

approach through a case study of a Native American client.

Butts, H. F. (2002). The black mask of humanity: Racial/ethnic

discrimination and post-traumatic stress disorder. The Journal of

the American Academy of Psychiatry and the Law, 30(3), 336–339.

The author of this paper critiques the DSM for its failure to account

for racial discrimination as a potentially traumatizing event and, thus,

its failure to capture the potential for racial discrimination to result in

PTSD. They suggest potential explanations for the exclusion of racial

trauma, including the tendency of White Americans to minimize and

deny the prevalence and deleterious impact of racism. Evidence

from the author’s clinical experience is provided to demonstrate the

range and intensity of emotional reactions of Black individuals who

have experienced racial trauma, including two case studies focused

on race-based housing discrimination.

Carter, R. T., Mazzula, S., Victoria, R., Vazquez, R., Hall, S., Smith,

S., Sant-Barket, S., Forsyth, J., Bazelais, K., & Williams, B. (2013).

Initial development of the Race-Based Traumatic Stress

Symptom Scale: Assessing the emotional impact of racism.

Psychological Trauma: Theory, Research, Practice, and Policy,

5(1), 1–9. doi:10.1037/a0025911 This paper describes the

development of the RBTSSS, a measure of emotional stress

reactions to racism. The initial items, both from published

instruments and the newly developed based on models of

traumatic stress and racial trauma, were administered to a racially

and ethnically diverse sample of adults (N=330). A series of

exploratory factor analyses resulted in a 52-item scale that

comprises 7 subscales: depression, anger, physical reactions,

avoidance, intrusion, hypervigilance, and low self-esteem.

Ching, T. H. W., Lee, S. Y., Chen, J., So, R. P., & Williams, M. T.

(2018). A model of intersectional stress and trauma in Asian

American sexual and gender minorities. Psychology of Violence,

8(6), 657–668. doi:10.1037/vio0000204 Based on their review of the

extant research, the authors of this paper propose a model that

delineates how intersectional stress and trauma impact lesbian,

gay, bisexual, or transgender (LGBTQ) Asian Americans.

Speciﬁcally, they describe how structural and cultural factors (i.e.,

structural oppression, cultural norms and stigma), interpersonal

discrimination (i.e., overt and subtle forms of racism, heterosexism,

and abuse), internalized oppression and stigma (i.e., internalized

racism, the “model minority” stereotype, homophobia, and

transphobia), and maladaptive coping and poor social support

interact to impact mental and sexual health outcomes. The authors

also discuss relevant clinical implications which include afﬁrming

clients’ intersecting identities, helping clients to externalize their

distress as coming from institutional sources, assessing the

potential applicability and appropriateness of existing empirically

supported treatments for trauma and PTSD, and considering

potential cultural adaptations to existing treatments.

Dale, S. K., & Safren, S. A. (2019). Gendered racial

microaggressions predict posttraumatic stress disorder

symptoms and cognitions among Black women living with HIV.

Psychological Trauma: Theory, Research, Practice, and Policy, 11(7),

685–694. doi:10.1037/tra0000467.supp This study examined the

associations between race-related discrimination, human

immunodeﬁciency virus- (HIV-) related discrimination, gendered

racial microaggressions and PTSD symptoms and posttraumatic

cognitions among a sample of Black women living with HIV

(N=100). In the ﬁnal hierarchical multiple linear regression models,

only gendered racial microaggressions were signiﬁcantly

associated with PTSD symptoms and posttraumatic cognitions,

above and beyond the other variables in the model. Further

examination revealed that, more speciﬁcally, the beauty and sexual

objectiﬁcation microaggressions as well as the strong Black women

microaggressions uniquely predicted trauma symptoms. Results

highlight the need for taking an intersectional approach to

understanding and addressing trauma and adversity.

Gone, J. P., Hartmann, W. E., Pomerville, A., Wendt, D. C., Klem, S.

H., & Burrage, R. L. (2019). The impact of historical trauma on

health outcomes for Indigenous populations in the USA and

Canada: A systematic review. American Psychologist, 74(1), 20–35.

doi:10.1037/amp0000338 A systematic review of historical trauma

was conducted among Indigenous populations in the US and

Canada given that racism impacts Indigenous people differently

relative to other racial and ethnic groups, and the politicization of

tribal nations is more relevant to this group given the atrocious

history of colonization. This review was organized by articles that

examined historical trauma assessed by 1) a speciﬁc historical loss

scale (e.g., loss of land, language, traditional ways, people) (k=19), 2)

whether a respondent’s ancestor attended a boarding school to

force assimilation among Indigenous children (k=11), or 3) other

measures of loss (k=3). Most studies reported statistically signiﬁcant

associations between historical loss and adverse health outcomes

and provided evidence that higher ethnic identity buffered against

negative health outcomes. The authors call for further reﬁnement of

the historical loss construct for future investigations.

Helms, J. E., Nicholas, G., & Green, C. E. (2012). Racism and

ethnoviolence as trauma: Enhancing professional and research

training. Traumatology, 18, 65–74. doi:10.1177/1534765610396728

The authors provide a cogent rationale for conceptualizing racism

and ethnoviolence as traumatic experiences, positing that direct

cataclysmic racial or cultural events, vicarious cataclysmic events,

and racial and cultural microaggressions are all capable of

producing PTSD. They critique existing PTSD assessments for their

inability to capture experiences of racism, ethnoviolence, and

accompanying stress reactions. Speciﬁc recommendations are

provided for both researchers and clinicians which include

developing more inclusive assessment instruments, creating a

supportive assessment environment in which the evaluator

understands factors relating to racial trauma and assesses broadly

for the individual’s full history of racial trauma and ethnoviolence,

culturally adapting existing cognitive behavioral trauma

interventions based on input from key stakeholders, and using

public and community mental health interventions rather than

relying exclusively on individual interventions.

PAGE 8 PTSD RESEARCH QUARTERLY

ADDITIONAL CITATIONS continued

Kirkinis, K., Pieterse, A. L., Martin, C., Agiliga, A., & Brownell, A. (in

press). Racism, racial discrimination, and trauma: A systematic

review of the social science literature. Ethnicity & Health. doi:10.

1080/13557858.2018.1514453 In a systematic review on the

association between racial discrimination and trauma symptoms,

70% of the 44 associations examined, across the 28 identiﬁed

studies, demonstrated that racial discrimination was signiﬁcantly

positively associated with trauma symptoms. The strength of the

signiﬁcant associations ranged from r=0.10 to r=0.68 and the

strongest associations were observed in Veteran populations

whereas the weakest associations were observed in student

populations. Based on their review, the authors make

recommendations for future research including controlling for other

types of trauma, assessing for intensity of racial discrimination

experiences in addition to frequency, and assessing for vicarious

and intergenerational experiences of racial discrimination in

addition to direct experiences.

Mosley, D. V., Hargons, C. N., Meiller, C., Angyal, B., Wheeler, P.,

Davis, C., & Stevens-Watkins, D. (2021). Critical consciousness of

anti-Black racism: A practical model to prevent and resist racial

trauma. Journal of Counseling Psychology, 68(1),1-16. doi:10.1037/

cou0000430 Given that critical consciousness is an intervention that

may help combat the well-documented impact of racial trauma, this

qualitative study explored the process of critical consciousness

development of anti-Black racism among 12 Black Lives Matter

activists. The results inform a model of Critical Consciousness of

Anti-Black Racism that includes three processes: witnessing

anti-Black racism, processing anti-Black racism which comprises

cognitive, intersectional, and behavioral growth, and acting critically

against anti-Black racism. Speciﬁc activism approaches include

storying survival, activism, physical resistance, organizing, teaching,

coalition-building, modeling/mentoring, scholar-activism, and

space-making.

Nagata, D. K., Kim, J. H. J., & Wu, K. (2019). The Japanese

American wartime incarceration: Examining the scope of racial

trauma. American Psychologist, 74(1), 36–48. doi:10.1037/

amp0000303 The authors describe how the wartime incarceration of

Japanese Americans and the post-war impacts resulted in individual,

race-based, historical, and cultural traumas. They detail speciﬁc

stressors experienced ﬁrsthand by incarcerees (e.g., loss of home

and possessions, severe conditions of the incarceration camps,

relocation and isolation upon release) as well as the intergenerational

impacts on subsequent generations (e.g., economic losses, poor

parental mental and physical health or premature death, parental

silence about the incarceration, loss of Japanese culture in an effort

to assimilate into mainstream American culture). The Japanese

Americans’ strategies for coping and healing (e.g., emphasizing

cultural values of collectivism, interdependence, ﬂexibility,

adaptation, perseverance, acceptance, and social harmony,

pilgrimages to former camp locations, Day of Remembrance

ceremonies, psychotherapy) as well as the positive impact of

governmental redress, albeit four decades later, are discussed.

Williams, M. T., Malcoun, E., Sawyer, B. A., Davis, D. M., Nouri, L.

B., & Bruce, S. L. (2014). Cultural adaptations of prolonged

exposure therapy for treatment and prevention of

posttraumatic stress disorder in African Americans. Behavioral

Sciences, 4, 102–124. doi:10.3390/bs4020102 This study highlights

the importance of culturally adapting trauma treatment as needed

for Black patients to encompass race-related trauma themes

speciﬁc to the Black experience. The authors provide steps for

culturally adapting Prolonged Exposure (PE) for Black patients that

includes adding sessions at the beginning of treatment to increase

opportunity to develop strong therapeutic rapport, directly

assessing race-related stress and trauma, and integrating race-

related experiences in treatment as needed. Two case examples are

provided demonstrating that the culturally adapted PE resulted in

decreased trauma symptoms.

Williams, M. T., Ching, T. H. W., Printz, D. M. B., & Wetterneck, C. T.

(2018). Assessing PTSD in ethnic and racial minorities: Trauma

and racial trauma. Directions in Psychiatry, 38(3), 179–196. The

authors deﬁne racial trauma and provide examples of race-related

traumas that may meet Criterion A including over racial threats,

assault and harassment by police, discrimination in the workplace,

violence in the community, medical mistreatment, incarceration,

immigration, and deportation. The only two validated self-report

measures of racial trauma include the Race-Based Traumatic Stress

Symptoms Scale and the Trauma Symptoms of Discrimination

Scale, and evidence of the efﬁcacy of empirically supported trauma

treatments among people of color is limited particularly for Asian

and Indigenous people with Prolonged Exposure and Cognitive

Behavioral Therapy showing similar outcomes and retention among

Black, Latinx, and White participants. Evidence is limited for the

efﬁcacy of Eye Movement Desensitization and Reprocessing

among people of color because very few are included in the

studies; evidence for Cognitive Processing Therapy was mixed with

some studies showing better treatment outcomes among White

participants than Black participants and some ﬁnding no

differences; the efﬁcacy of Narrative Exposure Therapy has been

found for treatment retention and outcomes up to 12 months

post-treatment particularly among refugee people of color.

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