Treatment strategies for race-based traumatic stress

July 2023

Black Americans often face increased risk of health and mental health conditions because of systemic and structural racism. For example, they are more likely to face discrimination in employment, schooling, housing and health care or to be exposed to and die from preventable or manageable illnesses (such as the COVID-19 virus) because of medical neglect. Exposure to life stressors exacerbated by oppression and chronic socioeconomic disparities leads to higher rates of illness and death. In fact, across most health metrics, Black Americans have increased chances of physical deterioration and early death.

These physical experiences compound Black Americans’ risk for emotional and mental health challenges because they all contribute to the suffering and complications of trauma. In addition, these experiences with discrimination and oppression can result in race-based traumatic stress, a term used to describe the stress Black Americans experience because of cultural, individual and institutional encounters with racism.

Although Black Americans experience mental illness at rates similar to or higher than other populations, research shows that they face multiple barriers to effective mental health treatment. For instance, Black Americans are more likely to terminate counseling prematurely when they do initiate counseling services because of prohibitive cost, limited health insurance, limited numbers of facilities in stressed neighborhoods and transportation issues, among many others. Often, inadequate care is associated with mental health providers’ lack of cultural competence, which exacerbates these mental health inequities.

As the ACA Code of Ethics stipulates, counselors have the ethical obligation to develop the awareness, knowledge and skills related to cultural competence to eliminate barriers effectively for Black Americans. For mental health professionals, that means understanding how to treat Black American clients who are affected by racial trauma. Counselors have a role to play in dismantling racism and its complicated, corrosive effects within our society.

Creating a safe environment

To address race-based traumatic stress, counselors first need to prepare to broach issues of race in session. When counselors are comfortable discussing racial issues in counseling, they reduce the likelihood that Black American clients will water down their racialized experiences to make them palatable to the counselor. It is also important for counselors to emphasize to clients that the responsibility for inclusive counseling rests solely on the counselor. A counselor could approach this by saying, “I know that it’s not your job to educate me about race and racism, and I want you to know that I’m doing my part to keep learning and growing in this area.”

Counselors can acknowledge the difficult issues that are present due to systemic racism and broach the topic in session by saying, for example, “Do I have your permission to point out and talk about what seems to be a racially based survival strategy in the discussion we are having right now?” or “I’m wondering if you are feeling like I get it when you are sharing your experiences with microaggressions at work.”

Black American clients have developed several strategies to deal with racial trauma and stress, including double consciousness and code-switching. Double consciousness, a term coined by W.E.B. Du Bois, describes how Black Americans face pressure to embrace their Black American identity to distance themselves from the presumption that Black people are culturally inferior, while also being aware of the need to internalize a Eurocentric identity and value system to gain respectability. Thus, Black Americans constantly scan and make decisions about whether their Black American identity can be acceptable in white spaces. Living with this double consciousness results in increased stress and hypervigilance.

Code-switching, or alternating between two or more languages or varieties of language in conversation, is a protective strategy that Black Americans use when responding to environmental stress associated with being Black in white spaces. In therapy, a Black American client might change their vernacular when expressing themselves to a non-Black clinician. For example, a client might not use the phrase “do you feel me,” which is a phrase commonly used in the Black community to establish relatability and check for cognitive and emotional connection and understanding, with a racially different counselor. Instead, they may say, “Do you understand what I mean?” to ensure that the clinician understands them. But this change in phrasing causes the counselor to lose the richness of the client’s desire for connection and relatability.

Code-switching also applies to appearance. A Black American client, for example, might feel pressure to conform to white norms of beauty or dress rather than embracing an Afrocentric aesthetic in how they style their hair or what clothes they wear. This constant switching is mentally and emotionally exhausting and prevents Black American clients from fully engaging in therapy as their authentic selves.

It is the counselor’s responsibility to unburden the Black American client from having to code-switch for the counselor’s benefit. Clinicians should develop awareness and address the pressure their clients feel to code-switch by saying, for example, “I wanted to let you know that I’m familiar with the phenomenon of code-switching and why it may have been necessary. In this space, I would like to support you in feeling safe to be fully yourself without fear of encountering microaggressions or being stereotyped.”

Treating race-based traumatic stress

Individuals with race-based traumatic stress can experience psychological and physiological symptoms similar to posttraumatic stress disorder, including avoidance, hypervigilance, flashbacks, nightmares and physical pains. They may also experience grief, loss, anger, shame and self-blame. Counselors who do not understand race-based trauma symptomatology, however, may overlook signs of this type of trauma, which further limits Black Americans’ ability to receive adequate treatment. (For more on assessing racial trauma, read the online exclusive “ Conceptualizing and assessing race-based traumatic stress.”)

After assessing for race-based traumatic stress, counselors can use the following treatment approaches to ensure they are addressing the underlying mental health issues related to racial stress.

Disenfranchised grief. Effective trauma treatment universally requires acknowledging and addressing losses that have occurred as a result of the trauma. The treatment considerations are similar when the trauma is caused by racism. Living as a Black American means dealing with pervasive impacts of systemic and structural racism stemming from slavery. It is no wonder then that Black Americans suffer from a profound sense of grief that often manifests as a loss of trust and safety on every level in both social and personal life. Furthermore, this type of grief is disenfranchised, meaning that it is not openly acknowledged, mourned or publicly supported as being legitimate.

To address the profound grief of racial trauma, counselors must recognize that single-incident racist experiences are compounded by collective racial trauma. This larger narrative of disempowerment, which is part of a whole history of trauma inflicted on people of African descent, needs to be recognized and validated as part of the process of healing.

When a Black client expresses grief related to their own racialized experience, or the cultural grief they carry, a counselor can ask the client to name the specific grief, and they may also need to situate the grief in the context of historical losses, such as the long-lasting impacts of slavery. It may be helpful to offer a validating comment such as “What you are experiencing is called disenfranchised grief because the grief that you feel is not always acknowledged or recognized by others.” In addition, the counselor can facilitate a grief ritual, or suggest that the client develop one that will have meaning and healing potential for them, such as sharing with other Black clients in group therapy.

Emotional processing and regulation. Clients who have survived racially charged incidents often present to counseling with complex emotions surrounding these experiences, which require processing in therapy. Several emotions that can be challenging for counselors to work through with Black American clients are anger, shame, humiliation, and internalization of stigma and racist attitudes that stereotype Black Americans as threatening, explosive, dangerous or impervious to pain.

Counselors need to acknowledge that Black people spend a lot of time managing their emotions in white spaces to protect against potential backlash resulting from stereotypes of aggression and violence. Part of this protection is to self-silence and push down emotional responses, such as anger. Dealing with anger and underlying hurt, however, is necessary for the recovery process. Therefore, counselors must work to elicit truthful expressions of anger that may be suppressed by the clients. For example, a counselor might broach this topic by saying, “I’m noticing that you seem agitated when we talk about this certain topic. I’m wondering how it feels to express your emotions in this space. I’d like you to know there is no need to self-silence here.” The counselor can also encourage the client to identify and deal with the underlying emotions, including hurt, injustice, and generational pain and oppression, and they can validate that these emotional expressions are justified considering the historical and ongoing racial issues.

When a counselor can sit with and hear the client’s anger, it creates a safe space for the expression of painful emotions. Thus, the ability to remain grounded when a Black American client expresses anger is an important skill for counselors to have when working with this population and requires an inner posture of non-defensiveness, particularly for white counselors who may experience their own discomfort with the interaction. Counselors need to practice being grounded before entering sessions with clients experiencing racial trauma. This may mean taking time to regulate their own breathing, thoughts or body tension; cultivating a curious and open mind; and seeking supervision with mentors to explore biases and process emotionally charged sessions.

Counselors can also support Black American clients in expressing anger in healthy ways, such as through journaling, music, dance, art and social justice activism.

Internalized racism. Trauma undermines the sense of self and the belief in one’s worthiness, so in racial trauma treatment, counselors must also directly address shame and self-blame. The humiliation that is associated with experiences of trauma often results in a sense of shame that leaves the person feeling intrinsically unworthy. These feelings are related to self-blame where a client might internalize a violator’s view of them and believe that aspects of themselves are responsible for the racial trauma they have experienced, rather than holding the violator alone responsible. Black American clients who internalize racism might speak derogatorily about themselves as a member of the Black American community.

Clinicians can address internalized racism with clients by using culturally adapted cognitive behavioral approaches that focus on restructuring the cognitive distortions that result from trauma and false beliefs. By holding those who violated them accountable, Black American clients can begin to heal and move toward healthy trauma integration.

Focusing on cultural strengths

Counselors must also challenge the notion that Black Americans live in communities that are riddled with problems that can only be solved by adopting Eurocentric solutions. That approach is based on deficit models, in which systemic and structural challenges due to oppression are assigned to Black people and their responses are pathologized. Instead of applying a Eurocentric lens to try to understand an Afrocentric culture, counselors should incorporate an Afrocentric worldview as an antiracist and culturally responsive approach to the treatment of Black American clients. Although largely ignored in counselor training, professional development and even scholarship, an Afrocentric worldview supports the development and maintenance of cultural pride, which research has found increases resilience as a buffer in the continued struggle against oppression. An Afrocentric worldview includes an awareness that Black Americans have retained elements of the ancestral wisdom of Africa, passed down generationally. This ancestral wisdom is reflected in many aspects of their cultural worldview, including:

• An understanding that spirituality is central to many Black American clients
• A focus on community connection, as opposed to individualism
• A holistic view of life experiences that includes natural rhythms and cycles
• A circular thought pattern that goes beyond a linear approach to include broader contexts
• An understanding of the importance of relational storytelling

Counselors can become knowledgeable about Black American culture through social justice initiatives such as Nikole Hannah-Jones’ The 1619 Project, which highlights the legacy of slavery in the United States. Counselors must be willing and able to listen to their clients’ stories and be mindful that storytelling may be fuller and more detailed and does not immediately “get to the point” in a way that they are used to. In addition, counselors must be comfortable exploring spirituality with clients and encourage them to use their cultural identity to care for themselves, their families and their communities as a part of healing.

Cultural beliefs and practices are protective for people who have experienced historical trauma. Counselors can use narrative counseling approaches to help Black clients facilitate a strong connection with Black American culture, which can help buffer them against racial harm, as noted in the literature. Viewing Black American culture as a rich source of strength and power can promote wellness by leveraging existing resources within the culture that have endured despite overwhelming and systemic oppression. Researchers have identified six primary cultural resources that operate as forms of wealth or capital for communities of color:

• Aspirational capital: the ability to pursue hopes and dreams even in the face of barriers
• Linguistic capital: the language and communication skills that a person has acquired throughout their life, including core expressive concepts such as virtuosity, originality, creativity and beauty, which are reflected in dance, music, poetry, theater and art
• Social capital: the ability to develop and maintain supportive relationships and networks
• Navigational capital: the ability to adaptively negotiate social institutions that are unwelcoming and exclusionary
• Familial capital: using kinship connection to build on generational knowledge and intuition
• Resistance capital: the endurance, perseverance and skill to stand firm in one’s cultural identity and engage in actions that protect and promote equality

Trauma recovery involves learning effective coping strategies. In counseling sessions, counselors can teach emotional regulation and stress tolerance skills, such as breathing techniques, somatic therapies and other trauma-responsive care, all with the understanding that these efforts are necessary to address the unique and ever-present racial stressors. Other coping strategies include inviting Black American clients to create a space for rest and restoration, exercise, movement and dance, self-expression and spiritual practice.

Counselors can also explore how Black American clients have coped in the past, including engaging with community support. Research shows the benefits that communal healing has for Black Americans, so group counseling can improve the well-being of survivors of racial trauma. Racial healing circles, for example, offer a supportive healing environment for processing racial wounds. Similarly, sister circles — a sacred space that Black women create to accompany one another as sisters on their healing journeys — is another example of communal healing that also draws from ancient African wisdom. Counselors can facilitate similar types of support through traditional group counseling that is modeled after healing circles or by referring clients to locally run racial healing circles within their community.

Another mental health strategy is to empower and support Black American clients’ need to self-advocate for social justice. Research shows that Black American clients benefit from resistance strategies that encompass activism, such as non-violent confrontation with racism, lobbying for anti-racist policies and other actions that support the client.

When counselors adopt an anti-racist stance and communicate it consistently, they join the client in actively challenging the status quo. In learning about culturally inclusive care and applying strategies for treating race-based traumatic stress, counselors can fulfill their ethical responsibility and make significant advances in addressing the existing mental health inequities for Black Americans.

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Learn how to access for race-based traumatic stress in the companion article “Conceptualizing and assessing race-based traumatic stress.”  

Portia Allie-Turco is an assistant professor, clinic director and program coordinator in the Counselor Education Department at the State University of New York at Plattsburgh. She is also a licensed mental health counselor who specializes in healing racial, generational and complex trauma. Contact her at p.allieturco@gmail.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.