Stress & Trauma Toolkit

for Treating African Americans in a Changing Political and Social Environment

Both overt and covert acts of racism influence the psyche of African Americans. Historical trauma occurs when there is a collective agreement that members of a certain group have been mistreated, and this understanding helps shape their identity. Throughout American history, African American people have suffered from physical, sexual, emotional, and psychological trauma during enslavement, the Jim Crow era, and the Civil Rights Movement. Recent cases of police brutality and divisiveness of the current sociopolitical climate are evidence of continued racial oppression and explicit and implicit biases against African Americans.

Acts of covert racism can take the form of microaggressions or slights that leave the recipient with a perceived sense that an act of prejudice occurred toward them during the interaction. Experiencing frequent microaggressions may cause chronic stress and/or adverse health behaviors, either of which can lead to mental and physical health consequences.

Clinical Vignette

Derek, 30 years old

Derek, a 30-year-old African-American man with a history of depression, has come in for a routine medication management follow-up appointment. While overall things have been "okay" since his last appointment, Derek notes that his girlfriend has been recently complaining about him being more irritable and "on edge." When asked to elaborate, Derek states, "I don't want to be that stereotypical angry black guy, but I can't help getting annoyed with people when I'm stressed out."

Upon further evaluation, Derek discloses an upsetting incident at his community college, which he attends part-time. He says that someone vandalized a bathroom with racial slurs targeted toward African Americans, who make up a small minority in the college. The patient did not see the slurs himself but heard about them. The college quickly painted over the slurs and sent out an email admonishing the behavior, but no further actions were taken. Derek experienced a great deal of anger about this situation. He believes that more of these types of incidents have been happening since the 2016 election but did not think that it would happen at his "liberal" school.

Additionally, Derek recently wore a "Black Lives Matter" t-shirt to a friend’s party after the incident and was accused by a white friend of being "divisive and overly political."

Finally, Derek notes increased anxiety when driving. Given the media stories of police officers shooting unarmed black men, he is extra cautious about obeying all traffic laws.

Factors that Put African Americans at Risk for Mental Health Problems

Racism, racial bias, and discrimination: These may contribute to poor physical and mental health among racial and ethnic minority populations.

Racial profiling: African-American males are disproportionately assumed to be criminals and are frequently stopped and searched based on the perceived notion of wrongdoing. Many individuals who have been profiled have developed symptoms of anxiety and post-traumatic stress disorder (PTSD).

Institutional racism and social determinants of mental health: Institutional racism is a critical social determinant of health. Other social determinants include quality education, safe housing, gainful employment, appropriate health care, and a clean environment. All can lead to adverse health outcomes.

  • Low socioeconomic status (SES): African Americans tend to have lower socioeconomic status than non-Hispanic Whites and Asian Americans, as determined by education, income, and occupation. Low SES has been significantly associated with a higher risk for mental illness. Even when adjusted by education level, the unemployment rate for African Americans is significantly higher than for their Caucasian counterparts. When employed, African-American workers are more likely to be in the lowest-paying economic sector.
  • Housing segregation: Despite the Civil Rights Act of 1968, which made housing discrimination illegal, housing segregation continues. This inadvertently affects access to quality education since constrained housing choices can impact health, education, and other life outcomes.
  • Mass incarceration: African Americans are disproportionately represented at every level of the justice system. They are more likely to be arrested, imprisoned, and sentenced to harsher terms than their white counterparts. Mass incarceration not only affects the individual who is imprisoned but also the family members who are left behind.

Trauma: Untreated traumatic stress has serious consequences for children, adults, and families.

  • Individual: African Americans disproportionately experience negative life events, including poverty, victimization, abuse, and trauma.
  • Complex trauma: African Americans often have complex trauma histories in their families, with multiple generations affected by adversity of an invasive, interpersonal nature such as poverty, physical abuse, sexual abuse, witnessing domestic and community violence, separation from family members and re-victimization by others, mental health issues, substance use, and negative contact with government agencies. Complex traumas usually begin in early childhood and can disrupt many aspects of development and the formation of one’s sense of self.
  • Collective Trauma: Refers to a trauma that happens to large groups of individuals and can be transmitted trans-generationally and across communities. War, genocide, slavery, terrorism, and natural disasters can cause collective trauma, which can be further defined as historical, ancestral, or cultural.
  • Historical Trauma: African Americans share public narratives of complex and collective traumas due to a long history of prejudice and unfavorable societal treatment of African Americans in the United States. These public narratives--which can be referred to as historical traumas--involve both shared historical experiences across generations such as lynching and slavery and present-day experiences such as police brutality and mass incarceration. These past and present-day experiences serve as reminders of the consistent dehumanization and devaluation of African Americans.
  • Cultural Trauma: Cultural trauma is often described as a collective traumatic event (e.g., slavery) that leaves permanent and enduring memories in the consciousness of an identified group. This may have long-lasting adverse effects on their future identity.

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Suggested Assessment and Treatment Recommendations

  • Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  • Incorporate individual strengths
    • Family support: Encourage support from immediate and extended family of patients.
    • Spirituality: Incorporate patients’ spiritual and/or religious values into treatment as appropriate. African Americans often view the church as a supportive family unit that remains important throughout the life cycle. Evidence suggests that spirituality often contributes to the resiliency of African Americans in navigating societally entrenched oppression and discrimination. According to the 2015 Religious Landscape Survey by the Pew Research Center, American millennials (those born between 1981 and 1996) are less religious than older Americans. Other studies have affirmed that, although African-American millennials are less likely to ascribe to traditional forms of religious observance than the previous generation, African-American millennials remain more spiritual and religious in comparison to millennials of other racial groups.
    • Community: Incorporate community involvement and engagement into treatment. African Americans are more likely to believe community involvement is important to their overall well-being, compared with other ethnicities.
  • Recognize provider bias: Be aware that provider biases exist and try to identify and address it appropriately.
  • Consider historical trauma: Explore how a patient's present experiences connect to historical trauma for a particular group or community.
  • Use validation and empowerment: Validate and empower; for example, normalize—instead of pathologizing— the feelings of stress and anxiety that Africans Americans experience due to continuous reports of police brutality and racial discrimination. Identify coping skills that may help patients deal with these feelings.
  • Consider narrative therapy: Using a narrative approach separates the problem from people and recognizes the skills, abilities, values, commitments, beliefs, and competencies that help patients to change their relationship to the the problems influencing their lives. This way of working with patients considers the broader context of people's lives, particularly the various dimensions of diversity such as socio-economic status, race, gender, sexual orientation, and ability.
  • Use talking or healing circles: Introducing talking or healing circles have been shown to be an effective and cost-effective technique through which individuals with similar life experiences can discuss their problems. Participants have noticed a statistically significant reduction in symptoms after engaging in talking circles.
  • Assess and address social determinants of health and community needs.
    • Assess community needs using a version of the Brief Risk Overview survey or other method.
    • Nurture trusted institutions within the community (e.g., Boys and Girls Clubs, schools, barbershops, and centers of faith).
    • Facilitate partnerships between and enhance roles of health care providers and community programs (e.g., YMCA) to increase probability of implementation success.
  • Encourage self-advocacy and increased healthcare engagement.
    • Consider using technology, peer navigators, and health coaches to reach members of the community.
    • Identify strengths, goals, and sustain well-being with the help of health coaches.

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Resources

APA Fact Sheet on Mental Health Disparities: African Americans. 2017. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-African-Americans.pdf

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. 2013.

Best Practice Highlights for Treating Diverse Patient Populations: Working with African American Patients. 2016. https://www.psychiatry.org/psychiatrists/cultural-competency/treating-diverse-patient-populations/working-with-african-american-patients/best-practice-highlights-for-working-with-african-american-patients

Lewis-Fernández R, Aggarwal NK, Hinton L, et al.: DSM-5 Handbook on the Cultural Formulation Interview. Arlington, VA, American Psychiatric Publishing. 2016.

Griffith, Ezra EH, Billy E. Jones, and Altha J. Stewart, eds. Black Mental Health: Patients, Providers, and Systems. American Psychiatric Pub, 2018.

Umbreit M. Talking Circles. Center for Restorative Justice & Peacemaking, August 2003. https://www.nacc.org/docs/conference/2014/M4%20-%20Talking%20Circles.pdf

References

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Authors

  • Jean-Marie Alves-Bradford, M.D.
  • Rahn Bailey, M.D.
  • Michelle P. Durham, M.D.
  • Latoya Comer Frolov, M.D.
  • Kimberly Gordon-Achebe, M.D.
  • Patrice Malone, M.D.
  • Carine Nzodom, M.D.
  • Amanda Wallace, M.D.
  • Walter Wilson, M.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.