An Evidence-Based Approach for Treating Stress and Trauma due to Racism

Abstract

Racism can be stressful or even traumatizing. Psychological unwellness emerges out of the confluence of historical, cultural, and individual experiences, and resulting syndromes may or may not fit into a DSM-5 PTSD diagnostic framework. Although racial stress and trauma are common presentations in therapy, few therapists have the resources or training to treat these issues. Based on the empirical evidence to date, this article describes the essential components of treatment for racial stress and trauma from a cognitive-behavioral perspective, called the Healing Racial Trauma protocol. Each technique is described with reference to the literature supporting its use for racial stress and trauma, along with guidance for how therapists might implement the method with clients. Also provided is information about sequencing techniques for optimal outcomes. Critical therapist prerequisites for engaging in this work are also discussed, with an emphasis on an anti-racist, empathy-centered approach throughout.

Racial trauma has been described as a psychological injury caused by hate or fear of a person due to their race, ethnicity, or skin color (Carter, 2007; Comas-Díaz, 2016). It is cumulative in nature and eventually overwhelms a person’s coping ability (Williams, Metzger, et al., 2018). It may manifest in a number of forms, including as a severe interpersonal stressor that threatens one’s well-being or even one’s life, or it may be an institutional stressor motivated by racism that causes severe ongoing distress (Reynolds, 2019). Racial trauma is linked with identity and can be experienced by people identifying as any race, people group, or ethnicity. Some experiences of racial trauma (e.g., physical assault in the context of a hate crime) would meet the DSM-5’s definition of a trauma (“exposure to an actual or threatened death, serious injury, or sexual violence”; APA, 2013, p. 271). However, other manifestations of racial trauma (e.g., chronic exposure to racial microaggressions, vicarious trauma through graphic media coverage of police brutality) may not match the aforementioned criterion, despite being experienced as traumatic (Holmes et al., 2016). We, nonetheless, retain such experiences in our definition of racial trauma given previous research demonstrating that the prevalence and severity of PTSD symptoms do not vary as a function of whether the event met Criterion A (e.g., Anders et al., 2011; Lansing et al., 2017; Roberts et al., 2012), and such experiences are associated with PTSD symptoms above and beyond Criterion A events (e.g., Loo et al., 2001).

Racial stress refers to the psychological response to experiencing racism that can develop into a pathology called racial trauma. Racial stress and traumatization can reflect the severity and symptomatology of post-traumatic stress disorder (PTSD). Although PTSD, as described in the DSM-5, is caused by discrete events such as combat, sexual assault, or accidents, research indicates that experiences of racism can have similarly debilitating psychological effects on People of Color. As such, racial trauma can be defined as the cumulative experiences of racism throughout one’s life that lead to severe mental and emotional injury (Williams, Osman, et al., 2021). Sufferers may display intrusion symptoms (e.g., recurrent nightmares, upsetting thoughts), avoidance behaviors, adverse changes in cognition and mood (e.g., distorted blame, embarrassment, isolation, dysphoria), as well as alterations in arousal and reactivity (e.g., self-destructive behaviors, hypervigilance, sleep issues; Williams, Metzger, et al., 2018). When untreated, racial stress may also lead to the development of other comorbid disorders, such as major depressive disorder, substance use disorders, social anxiety disorder, and even psychosis (Berger & Sarnyai, 2015; Gibbons et al., 2014; Williams, Printz, et al., 2018). It is estimated that 30% of People of Color may suffer from some degree of racial trauma, with many seeking help from mental health providers (Williams et al., in press). Research shows that racism is linked to a host of negative mental health conditions, but the connection between racial discrimination and PTSD symptoms appears to be the most robust (Williams, Haeny, & Holmes, 2021). Racial discrimination is the most common form of discrimination studied in relation to health outcomes, although all forms of discrimination can contribute to traumatization (e.g., Berger & Sarnyai, 2015; D. Williams et al., 2019). Racial stress and trauma are often compounded by community trauma, historical trauma, and cultural trauma.

To understand racial trauma, one must first have a clear understanding of racism. Racism can be defined as “a system of beliefs (racial prejudices), practices (racial discrimination), and policies (structural racism) based on race that operates to advantage those with historical power, White people in the United States of America (USA) and most other Western nations” (Haeny et al., 2021). Race, in the United States, is a social caste system that is constantly evolving, and is used to categorize people based on similar physical and social characteristics. Race is a social construct with no biological basis and is derived from White supremacy, an ideology that assumes the superiority of White people over People of Color (Haeny et al., 2021). This framework is based on the American racial paradigm. Still, it can be applied to other specific contexts where people are traumatized based on belonging to a specific people group (i.e., Serb-Croat, Tutsi-Hutu, Shiite-Suni conflicts). As such, although people with racial trauma are suffering psychologically, it is important to recognize that the source of the problem is not within the person, but rather is the product of a dysfunctional society.

White people can suffer from racial trauma as well. It should be noted, however, that because the impact of racial stress for White people is not augmented by their chronic and systemic racial oppression (as it is for People of Color), it may be less likely to be experienced as traumatic. Indeed, research shows that it is relatively rare for a White person to be traumatized due to persecution over their White identity (Carter et al., 2020), however, many White people can be subjected to racial stressors from other White people if they reject the rules of Whiteness as it exists in their societies (Malott et al., 2019). In racialized societies, the expectation is that White people will accept Whiteness as the unspoken standard to which all groups are compared, and this maintains the racial hierarchy whereby White people are treated as superior and People of Color are treated as inferior (Haeny et al., 2021). When White people in racialized societies attempt to stand up to racism, they are subject to persecution by other White people, which can result in traumatization. Although many of the techniques described herein can also be helpful for traumatized White allies, this paper will focus on using the Healing Racial Trauma protocol for People of Color.

Despite the fact that racial stress and trauma are relatively common, there are few evidence-based treatments available (Grau et al., 2021; Williams, Haeny, & Holmes, 2021; Williams, Osman, et al., 2021). Most counselors have seen clients with racial trauma, but few have received training in assessing or treating it (Hemmings & Evans, 2018). Although many experts in racial trauma have outlined what treatment might entail (e.g., Carlson et al., 2018; Chavez-Dueñas et al., 2019; Comas-Dias, 2016; Reynolds, 2019), there remains a need for a more detailed approach on how to help people suffering from racial stress and trauma. Further, no CBT treatments exist for racial stress and trauma that are grounded in the empirical literature.

Purpose of This Paper

The purpose of this paper is to provide guidelines for how therapists can help clients suffering from racial stress and trauma using a CBT framework. Notably, many interventions suggested in the literature focus on fostering resilience in People of Color. While we agree this is a worthwhile approach (and has been an essential conceptualization to combat notions of cultural deficiency), we argue that, in general, People of Color are already resilient enough. The issue is that no one can be continuously resilient in the face of ongoing abuse, and therefore treatment must also include components aimed at protecting the client from unnecessary racist acts and reducing racism in their lives. Despite that no manualized validated protocols are available, there is sufficient empirical support for multiple strategies to alleviate the stress or trauma associated with racist events, and as such it is our ethical obligation to offer this to clients who are suffering.

What follows is an intervention we have called the Healing Racial Trauma protocol to help clients who are struggling with racial stress and trauma. Accordingly, each section of this paper lists a technique within the intervention, provides research support surrounding the technique, and then offers guidance for therapists in making use of the technique. We also include a table of terms and definitions as Supplementary Materials to help orient readers to the terminology used here. However, anyone treating racial trauma should already be well-versed in current terminology, which is ever evolving.

Empirically Supported CBT Techniques for Racial Stress and Trauma

Assessment of Racial Stress and Trauma

Assessing a client’s racial stress and trauma is an essential part of the treatment process. When people who have endured racism are able to tell their story in a supportive environment, it is the first step in taking agency and power over the harmful event. Therapists should be familiar with common racial stressors; in addition to commonly recognized sources of trauma, People of Color are often subjected to traumatic police search and assaults, incarceration, workplace discrimination and harassment, and hate crimes; refugees and immigrants may have been victimized by ethnic cleansing and persecution, torture, and migratory hazards (Williams, Printz, et al., 2018). It is important to explicitly ask about these experiences because clients may not volunteer all of the information out of shame or because some of the experiences are so familiar, they do not think of them as “traumas.” Further, because so many People of Color are used to their experiences being dismissed or invalidated, they may fail to mention their racial stress and trauma entirely.

Scholars of color have developed multiple validated instruments to assist in the assessment of racial stress and trauma (for a comprehensive review, see Williams, Haeny, & Holmes, 2021). Some recommended instruments include the Racial Trauma Scale (RTS; Williams et al., in press) and the UConn Racial/Ethnic Stress & Trauma Survey (UnRESTS; Williams, Metzger, et al., 2018) clinical interview, designed to uncover various types of racism encountered by clients and assist in determining whether such experiences were collectively traumatizing. Clinicians may also make use of the cultural formulation interview (CFI; APA, 2013) to understand the client’s experience in the context of their cultural definition of the problem, perceptions of causes, cultural factors affecting self-coping and help seeking. The CFI does not inquire about racism or oppression but can help provide a broader picture of the client’s cultural context. The Race-Based Traumatic Stress Symptom Scale (RBTSSS) is available in self-report and interview formats and can help provide a good idea of key areas in need of intervention (Carter & Pieterse, 2020). Several of these measures are available in Spanish as well (Williams et al., 2017).

Besides using scales and specialized interviews to assess clients’ racial stress and trauma experiences, clinicians can further evaluate what clients believe the incidents and the aftermath tell them about themselves. Taking a complete trauma history is necessary when assessing racial stress and trauma, as all traumas are cumulative, even those unrelated to racism. Clinicians should ask clients about prior attempts at healing, psychological and treatment history, and their explanatory models about the trauma.

Validation of Experiences and Support From Therapist

When clients are suffering from racial stress and trauma, validating their experience is essential. As a rule, clinicians should accept that all experiences of racism shared by a client are real and not imagined or exaggerated. Racism by nature is a system of social collusion that undermines the credibility and authority of those who experience it. This socially punishing response can make victims question their reality and pressure them into remaining silent and helpless in the face of ongoing abuse. For this reason, Socratic questioning around the veracity of experiences of racism should be avoided, as it will only compound a client’s confusion and shame (e.g., Johnson et al., 2021). Indeed, the most important initial step on the journey of healing is ensuring that clients feel seen and heard.

Bryant-Davis and Ocampo (2006) note that survivors of racial trauma should acknowledge violations and identify them as a racist incidents. For some, this acknowledgment may be straightforward and easy; others, however, might need help working through denial, avoidance, and minimization. The therapist’s response to disclosures of racism is critical to the healing process. Laszloffy and Hardy (2000) remind us that therapists must be capable of validating the role that racism plays in the life of the client, even in circumstances where they may question this perspective. The fact that it is possible to validate a perspective without necessarily agreeing with it deserves mention. That being said, in our experience, clients are often ashamed of having been victims of racism, and as such are much more likely to understate the impact of racism than the reverse. As noted by Carter and Pieterse (2020), “Guilt and shame may arise due to self-blame and a sense of responsibility for the experience” (p. 36). Miller and colleagues (2018) underscore the importance of validation as a key general strategy for helping clients suffering the effects of racism. Validation includes a desire to acknowledge and explore racist experiences and racism-related stress, normalizing these experiences and reactions, recognizing a client’s strengths, and validating the resilience and survival strategies used to navigate racism.

In many cases, clients have internalized so many negative thoughts about themselves and their group that they manifest psychopathology surrounding their idenity, which is a result of being immersed in an extremely toxic racialized social environment. To counteract the damaging negativity coming from all directions, an intense detoxifying experience may be necessary, which may involve repeated affirming and positive affirmations about the client and their ethnic group (e.g., Koch et al., 2020; Roberts, 2021; Williams, 2020).

Therapists can start to validate their clients’ experiences of racism through body language that expresses empathy (e.g., being attentive, nodding thoughtfully, empathetic facial expressions). Support should be verbalized when the client discusses the reasons they sought treatment and the ways in which they have been harmed due to racism. Clinicians can provide responses such as, “I am so sorry you had to experience that” or “Nobody should ever have to put up with those behaviors.” Therapists can underscore that racism is not the fault of the client by making statements like, “That wasn’t right for them to make you feel responsible for their prejudice.” This may be particularly challenging for therapists when the client describes being mistreated by people from the same racial group as the therapist. Therapists must take care not to become defensive or assume the client is including the therapist in this description.

Psychoeducation About the Nature of Racism and Its Connection to Poor Mental Health

Understanding the source, history, and nature of racism and how it functions is a prerequisite for addressing racism-related stress, since it can be difficult to make sense out of an experience if the core nature of the problem is not understood. Clients may not even have the language to describe their experiences (Reynolds, 2019). Clients will be best equipped to cope with racism when they understand how racism works in our society, although this will differ some based on the specific marginalized identities of the client and their intersectionalities. Clients may have embraced falsehoods, such as the Myth of Meritocracy, which posits that success is predicated on hard work alone (Kwate & Meyer, 2010; Madeira et al., 2019). As such, they may see their race-related struggles as personal failures, and others’ dislike of them as being caused by personality flaws. Further, these experiences of racism have cumulative mental health sequelae that may reflect their reasons for coming to therapy.

Providing psychoeducation about a client’s psychopathology is not unlike Foa and colleagues’ (2007) empirically supported PTSD treatment protocol, Prolonged Exposure (PE), which dedicates time in an early session to reviewing common symptoms of traumatization that may be experienced by the client. In a review of the racial trauma literature, psychoeducation included educating clients that racism is a trauma and that clients may need treatment for PTSD symptoms due to racism, as well as education about the historical context of racism, the value of interracial connection, and antiracism strategies (Chapman-Hilliard & Adams-Bass, 2016; Miller et al., 2018).

Psychoeducation about racism early in the treatment process is important for building a strong foundation for healing. These concepts will be referenced and utilized repeatedly throughout the treatment process, and they give clients a language with which to describe and process their experiences (Reynolds, 2019). Psychoeducation should not be provided as a lecture, as therapists should try to make it as conversational as possible. A helpful start involves asking clients to share their understanding of racism and its impact. For example, the clinician might say, “Share with me the ways in which racism has impacted your life.” This will help the clinician have a sense of the client’s understanding of racism and its impact and identify gaps in knowledge they could share.

Furthermore, some time should be spent teaching clients that experiences of racism are a social problem that will make their lives more difficult in many ways and will bring about unmerited hate, even if they are doing everything “right.” One common misconception is: “If you do the ‘right thing’ you won’t be harmed by racism.” People who hold this belief might be more likely to internalize or blame themselves for not doing the “right thing” when they experienced racism. It is important to help clients understand the insidiousness of racism so that they properly externalize these experiences as opposed to internalizing them. The reality is that even when we do the “right thing” we can still suffer from the effects of racism. This shifts the focus to doing the “right thing” by engaging in behaviors that are consistent with the client’s values including after experiencing racism (this will be discussed further in the sections that follow).

Another approach for providing psychoeducation on racism to clients is to offer a reading list. If the client is interested in reading on racism, the therapist might select readings to do simultaneously outside of session and discuss them together in session. We recommend giving a weekly reading for homework, which should be tailored to the client’s reading level and time available to engage in reading tasks. Some clients like dense, academic materials, whereas others might prefer a short popular press article or a podcast. Some clients might be more visual learners and may prefer to learn about racism through videos. This could include brief videoclips in session or providing a list of movies or documentaries.

Assess and Strengthen Coping Strategies Being Employed for Racism

Therapists should assess whether clients are using unhealthy strategies to cope, which may include misuse of substances, parasuicidal self-harm, suicidal ideation, dysfunctional eating, or other risk-taking behaviors, which should be discouraged (Bryant-Davis & Ocampo, 2006; Saban et al., 2021). It is important to note these behaviors may serve a purpose (e.g., short-term emotion regulation), and more beneficial approaches may not be available or readily apparent to sufferers (Jacob et al., 2022). Problem-focused strategies may increase distress in the short term but result in greater well-being in the long term. Although ameliorating acute distress may have a more immediate impact on the client’s emotional state, behaviors that end ongoing racism rather than simply enduring it, constitute a more useful means of coping and contribute to reducing racism in the person’s life overall (Jacob et al., 2022).

Some strategies are ambiguous regarding whether they are helpful, as approaches that prove useful for some may serve to increase stress and reduce functioning for others. Hence, taking an inventory of coping strategies and evaluating their effectiveness should occur early in the treatment process and be a collaborative endeavor between the therapist and client (Malott & Schaefle, 2015). Coping strategies need not be labeled “good” or “bad” but rather examined in terms of whether they are adaptive for a client in their specific context, in both the short and long term. Some strategies will be determined maladaptive, and as such, the therapist can help identify replacement strategies for the client. For ambiguous strategies, that is strategies that may be adaptive in some contexts and maladaptive in others, the therapist can conduct an ongoing assessment of the effect of said strategy before, during, and after responding to racism, and then make a determination as to whether adjustments are needed (Malott & Schaefle, 2015).

One strategy, that is often overlooked but should be assessed, is termed “John Henryism” (Hill & Hoggard, 2018). This is a harmful coping mechanism that is often used by People of Color, famously named after the fable of a Black man who worked himself to death competing against a steam engine. This coping style is found to be prevalent in those who believe that enough hard work will eventually lead to them being appreciated as equal to their White counterparts. Some research has identified this strategy as positive in the short term as it can promote hard work and avoid conflict. However, in the long term, it can cause or accelerate physical ailments (Jacob et al., 2022).

To start the conversation around coping mechanisms, therapists can say to a Client of Color, “If you’re okay with it, I’d like to talk about how you respond when someone acts racist towards you or when you really feel the impact of being a Person of Color in society. What do you do after unpleasant things like this happen to you?” The clinician may want to give some examples to make it more tangible (crying, punching a wall, calling a friend, eating chocolate, etc.). The clinician can highlight that coping strategies range with regards to how adaptive or maladaptive they are. In the course of treatment, the therapist should encourage the use of coping strategies that they and the client collaboratively determine to be adaptive or “healthy” (next sections) with positive reinforcement while appreciating that change will be a process.

Self-Care

Self-care has been defined as activities performed by an individual for the purpose of promoting overall health and general well-being. It is also a skill that requires self-awareness of one’s emotional, cognitive, physical and spiritual state. Self-care is critical for recovery from all manner of physical and emotional insults, and is required for sustained well-being (Hansson et al., 2005). Self-care is a broad term, but here we are specifically referring to self-focused behaviors strictly for personal well-being. These include fitness, relaxation, enjoyable personal pursuits, taking a personal day off work, shopping, hobbies, massage, individual psychotherapy, aromatherapy, travel for fun, listening to music, turning off the phone, and unplugging from stressful social media. Wyatt and Ampadu (2021) make a distinction between regular self-care and racial self-care, described as a tool for social justice and survival for marginalized communities, as the goal is to promote self-determination, self-preservation, and self-restoration in an environment of ongoing oppression. Both types of self-care are useful.

An exhaustive review of the coping literature reveals that People of Color often neglect self-care, and almost no Black people make use of it when overtaken by the stress of racism (Jacob et al., 2022). It could be that People of Color feel they cannot relax or pursue pleasurable activities lest they be judged in accordance with negative stereotypes. Further, the ability to make time for self-care is a privilege, given that racism contributes to limited time resources, especially among working-class People of Color who may have to choose between taking time for self, working to make ends meet, or caring for a loved one. With this in mind, it is imperative that clinicians acknowledge these competing demands and be creative on how self-care might be incorporated in everyday life in this context.

In many European countries, people experiencing workplace burnout routinely take a few weeks off to recuperate at a relaxing Alpine mineral hot spring spa. Indeed, German researchers have found that those undergoing a traditional “Kur” (recuperation at an all-inclusive hot spring) found long-term positive effects (reduction in pain and increase in well-being) of at least 1-year duration after the Kur (Leuchtgens et al., 1999). Likewise, the aromatherapy Japanese art of shirin-yoku, or walking through a natural evergreen or cedar forest, has been found to decrease stressbiomarkers, increase natural killer cells, and enhance the expression of anticancer proteins. These positive effects have been found to be due in part to aerosol phytoncides released from trees (Antonelli et al., 2019; Timko Olson et al., 2020).

Self-care first requires accurately assessing one’s state of well-being, and those suffering from the trauma of racism should start building up a repertoire of self-care activities, such as resting, eating wholesome foods, exercising, engaging in spiritual practices, visiting nature, and pursuing fulfilling hobbies (Bryant-Davis & Ocampo, 2006). People from more collectivistic cultures may struggle with the idea of doing good things that appear to be just for themselves. Clients should be reminded that taking time for one’s own personal wants and needs is essential for good physical and mental health, because when one is debilitated by racism, it makes it difficult to meet family obligations or be of service to others. Further, unapologetic acts of self-care can be framed as an act of empowerment in the face of racist social attitudes that may label such behaviors as selfish or indulgent when enjoyed by People of Color (e.g., Cromer, 2021). Audre Lorde acknowledges the power inherent in self-care in the face of oppression and writes, “Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare” (Nayak, 2020, p. 405).

For clients who have chaotic lives and stressful jobs, time alone may be particularly important. Therapists might say, “You need to allow yourself time to recover. During this period, you may want to limit exposure to racism. This may mean avoiding going into places where you know, or suspect people will mistreat you. This is an important step in prioritizing your wellness. You will not avoid these places or people forever, but for now, it may be helpful to allow your heart and mind to have some peace while you are recovering and healing.” CBT strategies for helping clients to engage in self-care would include recognizing situations or people who might mistreat them, avoiding those situations when possible, and planfully preparing coping approaches for these situations when they are unavoidable. For clients with the means to do so, time away could be an excellent way to jump start self-care. For clients without means, as noted, even spending time in nature can facilitate healing.

Most clients we have seen with racial trauma are resistant to self-care, and carrying out these activities may require revisiting social notions of who is deserving of care and why. To help bring about change, therapists can work with clients to develop a self-care plan and even schedule days in the calendar when specific self-care activities will occur.

Self-Compassion

Self-compassion can be described as the ability to have compassion toward one’s self despite feelings of inadequacy, failure, or suffering. Self-compassion has been described as having three dimensions: “self-kindness versus self-judgment, mindfulness versus over-identification, and common humanity versus isolation” (Neff, 2003) (mindfulness to be discussed in a later section). Increasing self-compassion can decrease feelings of guilt and shame following experiences of racism by promoting feelings of love and kindness toward the self and recognizing that others suffer in the same way as well.

Social connection appears to play a critical role in the utility of self-compassion. Liu and colleagues (2020) conducted a study of Asian American college students, where they found that when participants had either high levels of social connection or high levels of self-compassion (i.e., self-kindness, mindfulness), their experiences of racism were associated with greater depression symptom severity. However, when participants had both high levels of social connection and high levels of self-compassion (i.e., self-kindness, mindfulness), their experiences of racism were not associated with depression symptoms. The results of this study highlight the importance of not only cultivating components of self-compassion (i.e., self-kindness, mindfulness) but also social connection as the combination is more likely to be protective against the deleterious impact of racial trauma.

Therapists should model and encourage self-kindness, which means being warm and loving rather than harsh or judgmental toward the self during times of difficulty. It is important to recognize that suffering and difficulties are part of a shared human experience rather than simply an isolated personal failure. Further, Litam (2020) recommends that clients with race-based trauma cultivate self-compassion by focusing on their immediate needs in the present without judgment. For example, a therapist might say, “I understand that you are frustrated with yourself for having to take a leave from work due to racial stress, but can you give yourself permission to feel unwell for a while? Everyone has times where they can’t do all the things they would like due to illness, stress, or unexpected life events. How would it be to accept that you need a break, and for now that is ok?”

External Social Support

One of the most successful and healthy coping mechanisms to combat the stress of racism is social support (e.g., Noh & Kaspar, 2003; Wright & Wachs, 2019). Family, friends, dating partners, coworkers, neighbors, and anyone who offers care and support for an individual are considered part of the social support network (Evans et al., 2016). Research has demonstrated that social support is protective against mental health concerns, generally (Turner & Brown, 2010), and posttraumatic stress, specifically (Bryant-Davis et al., 2011, 2015). Further, social support may be particularly important for People of Color. Due to a long and enduring history of institutional racism and medical racism, and the resulting cultural mistrust, People of Color may be less likely to utilize formal mental health care and may prefer relying on their own social support networks, which may also be consistent with collectivist values (Sue, Alsaidi, et al., 2019; Williams, Duque, et al., 2018). When people share their experiences of racism with those who have had similar experiences, they may feel a sense of kinship and understanding (Evans et al., 2016). Discussing experiences with trusted others also provides an opportunity for emotional processing and an opportunity for reexamining maladaptive cognitions (e.g., internalized racism, hopeless outlook).

Evans and colleagues (2016) suggest that in the case of racial trauma, therapists should first acknowledge the severity of the racism in the Western world, and then, help clients find social resources that address racial discrimination. In keeping with this, they suggest meeting with the client in a comfortable community-based setting, inviting supporting persons to the counseling session as needed, and promoting dialogue with the client’s cultural community. Likewise, Miller and colleagues (2018) advise therapists to help clients build meaningful ties within their family, racial and ethnic community, ethnic churches and religion, as well as to identify and connect with members of other racial groups, including White allies.

Another strategy to incorporate social support in the treatment of racial trauma is “within-group sanctuary” proposed by Watts-Jones (2002). That is because the shared experience of a within-group environment tends to limit the exacerbation of shame and reduces the possibility of defensiveness, both of which are more likely in the presence of those who have benefited from racism. In an environment comprising people from the same ethnoracial group, experiences such as racial microaggressions are less likely. However, even in spaces that provide within-group sanctuary with regards to race and ethnic group, there is potential for discrimination based on other marginalized identities (e.g., gender, sexual orientation, religion; Quaye et al., 2019), so this must also be considered.

For those with racial trauma, it is crucial to increase social support by purposefully connecting clients with members of their social network who are reliably supportive. For example, clients can reach out to someone important with whom they have lost touch (e.g., an old friend) or increase time with nurturing family members. Purposefully connecting with others within one’s own group can provide social support for survivors of racial trauma in the sense that the individual’s experiences with racism may be best validated by others who experience the same thing, rather than people who might not have a thorough understanding of these experiences (e.g., Carlson et al., 2018; Watts-Jones, 2002). Therapists can support clients in creating an interpersonal inventory for quick reference. Other options that can be cultivated include affinity groups like meetups, Equity, Diversity and Inclusion Committees at work or school, antiracism groups, healing circles, and/or friends and family members who understand racism (but not those who are overly critical).

Mindfulness to Connect With Emotions

The concept of mindfulness originated from Buddhist traditions, although all religions have some form of contemplative practice. In psychological contexts, mindfulness has been used to help clients learn to pay attention to the present moment by nonjudgmen-tally noting their surroundings, physical sensations, and thoughts without becoming involved in them. Specifically, mindfulness entails being aware of thoughts and feelings while refraining from ruminating about personal struggles (Sobczak & West, 2013). Sobczak and West observe that mindfulness allows clients to build a feeling of acceptance, which allows them to notice their interior sensations without ignoring, manipulating, or avoiding them. As such, clients who practice mindfulness and acceptance are less likely to participate in avoidance behaviors and more likely to engage in actions that help them to live a more meaningful, improved, and valued life. This is especially crucial for those who are experiencing racism, as emotionally distracting from experiences of racism is associated with greater depression severity (Noh & Kaspar, 2003).

Mindfulness can be a positive strategy because it presents a mechanism for accepting the negative emotions elicited by racist events, thereby reducing experiential avoidance (Graham et al., 2013; Zapolski et al., 2019). Many people struggling with racial trauma have difficulty acknowledging their feelings about these experiences and how they are impacted. But mindfulness can be potentially unhelpful if it results in acceptance of repetitive mistreatment that, in turn, facilitates continued victimization due to racism. As such, therapists must take care in their use of mindfulness with clients to ensure that it is being judiciously employed in the service of the client’s well-being. DeLapp and DeLapp (2021) provide a framework for addressing repressed emotions around experiences of racism. They suggest therapists explore this by saying things like, “I notice that when we start discussing events that cause racial stress, you say that the event ‘wasn’t a big deal.’ I wonder why you say this?” When the client responds, the therapist can follow up with, “What does it feel like when these things happen? What are you feeling in your body right now as we talk about the security guard following you in the store?” This approach acknowledges the behavioral patterns and invites the client’s awareness of these patterns while facilitating processing.

There are many ways in which mindfulness can be practiced, including through guided meditation (e.g., Hwang & Chan, 2019). Dr. Candace Nicole developed a Black Lives Matter guided meditation that includes mindfulness, affirmation, and loving-kindness (Hill, 2017). She developed two versions: (1) a Black Lives Matter Meditation for Healing from Racial Trauma, which is shown to be beneficial in reducing race-based stress reactions among Black people (Hargons et al., 2021), and (2) the Ally+ Accomplice Meditation for cultivating an anti-racist mindset. Both meditations are just under 20 minutes long and include affirmations specific for those seeking healing from racial trauma or cultivating an antiracist mindset. These meditations can be played in session or offered as an additional resource to clients outside of the therapy room as needed.

Psychoeducation Surrounding Colorism to Combat Internalized Racism: Not Born That Way

Every racialized society has a myth to justify the unjust treatment and discrimination endured by racialized groups. Psychological harm is caused when people believe these untruths, contributing to racial traumatization. Often these myths have been internalized in childhood and may be accepted by both racially dominant and minoritized individuals.

One of the more pernicious myths about race is that meaningful genetic or biological differences between races exist, and that visible inequality is a natural product of human biological variation (Donovan et al., 2019). The myth goes on to assert that there is a genetic colorist racial hierarchy in which darker-skinned people are less intelligent, moral, and/or valuable (Cerdeña et al., 2020; Evans, 2018; Hogarth, 2019). These racial fallacies are presented as facts and even legitimized in medical journals, which bolster society’s beliefs about biological White supremacy (Hogarth, 2019. Disparate healthcare profoundly affects life outcomes and success indicators for racialized people (Belak et al., 2018; Kwate & Meyer, 2010). The well-documented false belief by medical professionals that there are real (i.e., genetic) differences between races (e.g., Black people feel less pain than White people) leads to disparities in treatment, including the reduction in empathy from White clinicians to under-administration of pain medication to racialized patients (Cerdeña et al., 2020; Hoffman et al., 2016).

Examples of how this “innate inferiority” myth manifests can also be found in situations concerning education, promotion, and leadership when darker-skinned people are assumed to have lower “innate” ability or fewer higher-level skills. Microaggressions, such as tracking African American children into lower-level math classes, or saying “you are a credit to your race, so articulate,” also feed on the “biological races” myth. In this framing, saying to a Black physics professor or neurosurgeon, “Wow, I’ve never met anyone like you at this level,” can be an insult, not a compliment (Williams, 2020).

Research shows that people with darker skin experience more racism, and this has been termed by Landor and McNeil Smith (2019) as “skin-tone trauma.” For healing to occur, it is necessary to expose untruths about color (Donovan et al., 2019; Hogarth, 2019). Debunking these myths will also help answer questions People of Color may have about why POC seem to lag in societal success and health indicators. If true information is not provided to young POC, they will find the incorrect, societally imposed racist answer for themselves, assuming that the disparity is due to some biological or innate factor linked with skin shade (Márquez-Magaña et al., 2013). This myth also underlies the attitude by some that attempting to achieve racial equality is fruitless, because it assumes that disparities are innate and racial hierarchies are inevitable. They may think improving the situation will only be accomplished by handouts, since these disadvantaged groups are not capable of competing. As such, these biological myths may underpin a large swath of racist and supremacist thinking and saviorism.

According to a recent New York Times article, there is a growing sense that the avoidance of directly explaining how race is not a genetic category within high-school biology curricula is backfiring, because it leaves youth to rely on societal myths to explain social disparity (Harmon, 2019). More alarmingly, at least three randomized controlled trials (RCTs) show a cause–effect relationship between how race is taught in the U. S. biology curriculum and the development of racial biases (Donovan et al., 2019). Therefore, providing clients with evidence of race-based discrimination that specifically explains disparities in success indicators is critical (Cerdeña, et al., 2020; Donovan et al., 2019; Kwate & Meyer 2010; Lewis & Teasdell, 2021). Straightforward counterfactual examples can be provided—e.g., demonstrating tendency of darker-hued African and Caribbean children to overachieve in the U.S., or showing how increases in environmental pollution and lead poisoning disproportionately harm Black children (Griffith et al., 2011). Such facts can help clients process that the differences in success that they are witnessing are not because they were born that way (Schwarz et al., 2016).

The quality of the psychoeducation will be key for this intervention (Donovan et al., 2019; Márquez-Magaña et al., 2013). Americans are used to thinking about races of humans as they would breeds of dogs, as something tangible, familiar, and scientific, when it is in reality unscientific and bigoted (Norton et al., 2019). Part of the confusion around genes and race stems from the conflation of the understanding that genes define heritable traits such as height, blood type, and skin color, and then mashing this together with assumptions about how related individuals may be based on skin hue. This is as sensible as assuming, for example, that individuals must be biologically related because they are the same height or that skunks and pandas may be highly related because both have black and white fur.

Therapists can provide general scientific literature to clients, such as National Geographic’s special issue “There’s No Such Thing as Race—It’s a Made-up Category” (Kolbert, 2018), which can be helpful for certain clients. It can be important to explain to the client how the concept of “race” is inconsistent with population genetics and that humans cannot be categorized neatly into biologically distinct subcategories (Cerdeña et al., 2020). Some may have a hard time believing this as myth, as it is so firmly embedded in individuals at all educational levels up to and including university professors (Donovan et al., 2019). However, common sense can also be helpful as it may be easier to explain that in America it does not make much sense that a White mother and her Black child can be highly related, sharing 50% of their genes, but be called different “races” based on skin hue. People categorized as “Black” in America on average have 25% European ancestry but can have up to 90% European ancestry (Bryc et al., 2015). This illogical custom was originally implemented so that White slave owners could legally own and sell their darker-hued children (i.e., “one drop rule”; Lujan & DiCarlo, 2021).

Cognitive Restructuring and Defusion From Internalized Racism

One of the many ways racism may impact mental health is through internalized racial oppression (Banks et al., 2021). Internalized racism is described as a negative view of the self, based on the perceived inferiority of one’s own ethnic group or race, which can cause shame and self-blame in People of Color (Bryant-Davis & Ocampo, 2006). It is important that individuals suffering from internalized racism understand that their negative thoughts and feelings are a product of context (i.e., racism) and not an accurate description of the self. This is possible by helping clients to see internalized cognitions in the context of racism, defusing from these ideas, and using cognitive restructuring to critically question and edit these negative thoughts (Banks et al., 2021; Ching, 2021). Although it might be assumed that internalized racism is associated with low self-esteem and self-hate, it is important to note that given the insidiousness of racism, even People of Color with a strong racial/ethnic identity who might not experience self-hate or low self-esteem are subject to internalizing negative messages about their racial group, and it can be especially hard for these clients when they realize the ways in which they experience internalized racism and may unintentionally contribute to maintaining White dominance.

Banks and colleagues (2021) examined the effectiveness of an ACT-based intervention to help Black women heal from racial oppression. This included thinking about new ways of interacting with thoughts and feelings caused by internalized racial oppression. More specifically, the intervention included a focus on cognitive defusion, a strategy that helps clients recognize that their thought is not more than a thought; put more distance between themselves and the thought, and then, take value-based action regardless of the messages racism sends them about who they are or what they can do. As such, therapists must look for opportunities to address shame, self-blame, and internalized racism (Bryant-Davis & Ocampo, 2006). Clients may speak critically about themselves and/or their racial group, either with humor or with venom. Therapists must recognize such comments as self-defeating responses to trauma, even when delivered in a humorous manner.

Cognitive restructuring is a core component of one of the first-line treatments for PTSD, Cognitive Processing Therapy (CPT; Resick et al., 2016), where therapists work with clients to identify “stuck points,” evaluate the existing evidence for the stuck points, and generate more balanced and adaptive beliefs. To assist clients in their cognitive restructuring of internalized racism, therapists can help them make sense of their experiences by placing them in their appropriate sociohistorical context. It is critical that therapists do not reinforce clients’ cognitive distortions surrounding the incorrectly perceived low value of their ethnoracial group. Also, therapists should not remain silent in the face of a clients’ shame or self-blame. They should rather identify client comments that degrade their racial or ethnic group and discuss these in a nonshaming manner together with the client. The fundamental objective of CBT with clients who suffer from internalized racism is to help them become more aware of, confront, and alter their negative thoughts and beliefs about themselves and their ethnic group (Steele, 2020).

Modification of dysfunctional core beliefs can begin once clients have learned to recognize negative automatic thoughts and their accompanying emotional, behavioral, or physiological consequences. Clinicians can help clients externalize the impact of racial stressors by explaining discrimination-related events as the perpetrators’ own prejudice and biases, and thereby minimizing internalization of negative race-based messages (Guerin, 2005; Miller et al., 2018). Take, for example, a Black college student who has developed core beliefs reflecting White supremacist ideology and blames herself for not being smart or capable, because she keeps failing school tests. To deal with the client’s internalized racism, the therapist should help externalize the oppression by questioning the client’s beliefs and critically changing them—that is, helping the client to see that the problem is separate from themself. So, the first step would be increasing the client’s awareness about their automatic thoughts based on their internalized race-based core belief in different life situations (e.g., school, work)—for example, how the client thinks that she is not smart enough to finish school, because Black people are not as smart as White people. Next, the therapist can ask the client to keep a journal of their thoughts to help identify and challenge recurring patterns. After identifying the pattern of automatic thoughts, the therapist should work with the client to review the evidence to see if those thoughts/beliefs are supported, or if there are alternate explanations for the beliefs (e.g., failing tests because of test anxiety or stereotype threat, rather than not being smart). Helping clients discover new and more functional race-related beliefs would be the final stage in this approach (Steele, 2020).

Ethnic and Racial Identity Development/Identity Affirming Practices

Ethnic identity development is a multifaceted construct that describes how people develop a sense of belonging to their culture. Traditions, customs, and attitudes about one’s heritage are important facets of ethnic identity. Individuals progress through different stages as they learn to identify with their culture, whereby they come to understand their culture’s customs and values, and ultimately identify with their ethnic group (Roberts et al., 1999). This can be a challenging process for People of Color and White people alike, and it starts in early childhood. Having strong, positive feelings about one’s ethnoracial group is considered a protective factor against the stresses of racism for People of Color (Williams, Duque, et al., 2018). As such, strengthening clients’ ethnoracial identities is considered an important way to help combat negative cognitions about one’s group and self-worth.

Malott and Schaefle (2015) suggest that therapists view their clients’ identities as a rich source of positive attributes and strengths in the midst of the stresses caused by racism. Further, Metzger et al. (2021) have emphasized the importance of integrating racial socialization into trauma-focused CBT for African American youth. They explain that it is crucial to transmit culture, attitudes, and values to adolescents (i.e., racial socialization) in order to prepare them to cope with the oppression they will face as a racialized person in Western society.

As such, therapists need to thoughtfully implement strategies to strengthen ethnoracial identity in clients to help improve their overall psychological well-being (e.g., Umaña-Taylor & Douglass, 2017; Umaña-Taylor et al., 2018). CBT interventions might include discussions of what the client likes about their ethnic group, learning more about their history and the achievements of others from their group, explicit rejection of stereotypes, and increased involvement in traditional cultural activities to build a greater sense of ethnic and racial pride. To be an effective source of cultural support and healing for clients, therapists can set aside a few moments to think about each client of color individually. Reflect on what they have shared about their culture. Consider cultural sources of strength for them and identify admirable facets of their culture. Note several specific things that are applicable to the client and find opportunities to share these during sessions (Williams, 2020).

If therapists cannot think of anything clients have shared about their culture, find reasons to get curious and ask more about their heritage, family, and community during sessions. Ask clients to share with you what gives them pride in their ethnic group. Questions from the Cultural Formulation Interview (APA, 2013) might be used, including those assessing important aspects of their cultural identity. Identify role models and other sources of support who also identify as a member of their ethnic group. Ethnic identity measures such as the Multigroup Ethnic Identity Measure (MEIM-12; Roberts et al., 1999) might be used to assess the strength of ethnic identity. Items on which the client scores lower might be targets for strengthening. For example, if a client scores low on “I am active in organizations or social groups that include mostly members of my own ethnic group,” the goal might be to brainstorm ideas for getting involved in social groups of people from their ethnic identity. Finally, it is important that clinicians communicate they value their clients and the ways they are different.

Recounting Traumatic Racism-Related Experiences (Exposure to Trauma Memories)

Clients suffering from racial trauma may avoid thinking or talking about the experience because it feels emotionally overwhelming (Bryant-Davis & Ocampo, 2006). However, recounting memories of traumatic experiences has been shown to have beneficial effects on traumatic stress, as it leads to habituation (i.e., decrease in anxiety without the need of harmful safety and avoidance strategies), disconfirmatory learning (i.e., opportunities to find evidence against maladaptive trauma-related beliefs), and opportunities to process those experiences and find meaning (next sections).

Bryant-Davis and Ocampo (2006) highlight the importance of clients regaining control of the past by being able to recollect the trauma without feeling helpless. Recounting the trauma can be conceptualized as storytelling, and Chioneso and colleagues (2020) note that storytelling facilitates an understanding of human behavior and also functions as a tool for resisting oppression, and even promoting spiritual communion. Imaginal exposure is a type of storytelling that involves vivid revisiting of the traumatic event in the client’s imagination in the presence of the therapist (Foa et al., 2007). Williams and colleagues (2014) explain that a mechanism through which imaginal exposure helps clients to recover from racial trauma is in changing inaccurate cognitive patterns and anxieties related to trauma that are maintained through avoidance behaviors. Recounting traumatic racism-related experiences in a safe and supportive environment empowers clients by providing them with a greater sense of control over their response to trauma memories and ultimately a reduction in symptoms.

Prolonged exposure (PE) is one of the first-line treatments for PTSD, and therapists can use culturally relevant adaptations that include race-related trauma themes unique to the clients’ racial experience (Williams et al., 2014). These adaptations include asking explicitly about race-related issues throughout the treatments, and then bringing those distressing aspects to the center of treatment during imaginal exposures. In imaginal exposures, the therapist acts as a guide for the client’s recollection and recounting of the events. More specifically, the therapist asks the client to provide a comprehensive verbal description of their traumatic incident in the first-person present tense from beginning to conclusion, assessing their anxiety throughout. With repeated recounting, their subjective levels of distress can be expected to decrease over time.

Carlson and colleagues (2018) designed and implemented a group-based intervention to address racial trauma among veterans. The authors found that veterans sharing their traumatic encounters with each other allowed them to meaningfully recount uncomfortable memories that were previously avoided, which, in turn, led to new perspectives, less distress, and a healthier mental and emotional processing of those traumas. Not only did the veterans share their own experiences, they listened to others’ experiences and provided mutual support by sharing common struggles.

Writing can be used as an alternative way of recounting traumatic experiences (e.g., Gerger et al., 2021; Hirai et al., 2012; Tavakoli et al., 2009). Therapists should ask clients to write freely about their deepest thoughts and feelings concerning the traumatic race-related incident they encountered. It is recommended that clients continue writing about the same experience for at least 3 days. They should bring the written account to therapy and read it aloud to the therapist. The therapist and client should process what the client wrote (see next section) as research demonstrates expressive writing with therapist feedback is more effective in decreasing PTSD symptoms than independent expressive writing (Gerger et al., 2021). After discussing it, the therapist should take the written account and ask the client to prepare a new version of the story for homework, without referencing the previous version. The client should repeat this process until recounting the event no longer causes distress. Clients who have a great deal of distress may do better to start with writing facts only about their trauma and adding emotions to their stories later (Hirai et al., 2012).

Processing Racist Experiences

Processing experiences of racism is an important next step in resolving racial trauma and learning to cope with racial stressors (Comas-Díaz, 2016). Although revisiting the memories of upsetting events will help in reducing the distress caused by the recollections (previous section), processing is helpful for bringing new perspectives and insights into these events. Processing can take many forms, from formal discussion of different facets of the event with a therapist to creating art or music from the experience.

Williams et al. (2014) suggest that strong emotions connected with experiencing discrimination and racism can lead to skewed perceptions of society and the world in general. Thus, it would be critical to establish that the client’s experience should not be extended to all social circumstances. Accordingly, therapists should work through distorted cognitions by assisting the client in distinguishing between genuine social restrictions and distorted views created as a result of the trauma. In a similar vein, Mosley and colleagues (2021) argue that processing enables trauma survivors to understand racism on a systemic level, develop their intersectional awareness, and strengthen their capacity for coping with and confronting it (to be discussed in the following sections). Relatedly, Ching (2021) warns that failing to process the traumatic racist experience may lead to the misconception that the problem was not rooted in racism, but rather in personal inadequacies. Accordingly, assisting clients in discovering an external (instead of internal) attribution for their traumatic racist experience should help with processing by allowing them to learn to develop greater pride (instead of shame) in their racial identity.

Jernigan et al. (2015) suggest that it is vital that people suffering from racial trauma engage in activities that allow for processing emotions externally. Activities such as painting, sketching, singing, or dancing allow clients to express their emotions through body movement and expression. Drama therapy has been explored as a tool to help clients process their racist experience. In the form of applied performance research, Williams-Witherspoon (2020) developed a performance piece—From Safe to Brave—to address the trauma of racism on college campuses. The authors note that “giving voice” to the participants’ truth helped them process their emotions. Notably, the positive effects of movement-based creative expressions on mental health have been well-established (Stuckey & Nobel, 2010).

Another potentially helpful approach is called photovoice (Wang & Burris, 1997), where members of marginalized communities can use photographs of people, places, and events to construct narratives about experiences of adversity (e.g., racism; Williams, Byrd, et al., 2020). In addition to therapeutic effects inherent in sharing one’s story, photovoice is also focused on sharing narratives with others to facilitate critical consciousness-raising and impact policy, and thus could be a potentially important strategy in addressing racial trauma (e.g., Tessitore, 2021). See Williams, Byrd, et al. (2020) for details on how to use this technique in counseling to address experiences of racism.

Processing should occur after recounting the traumatic experience by the client to help clients understand their traumatic experience from a more functional vantage point. An important approach would be to inquire openly about their thoughts and feelings and how these fit into their racial identity in the context of their trauma. For example, by asking “Did you believe you were accused of stealing because you were Black?” the therapist may encourage the client to express themselves more openly about how they felt about their Blackness when they were confronted with the traumatic event. Next, to alleviate the suffering associated with memory, the therapist can broaden the context, allowing the client to have a more objective and helpful perspective on what happened. Socratic questioning can be used to point out cognitive distortions and false beliefs about the traumatic event, such as being inadequate. Williams and colleagues (2014) advise therapists to point out individual strengths during processing questions; for example, “It was very brave to press forth in a workplace where so much racism was present. What does this say about you?” (p. 113). Ching (2021) advises clinicians to help clients process their traumatic experience by communicating racism and its impact in a nonpaternalistic way, through open-ended questioning and compassionate, nonjudgmental listening, while maintaining a position of curiosity and humility.

Skills Building in Confronting Racism (Which Includes in-Vivo Exposure)

When confronted with racism, both targets and observers must decide whether to speak up or remain silent. This decision is influenced by many factors, including potential risks (e.g., losing a job), whether basic needs are met (e.g., too sick, tired, or hungry to effectively stand up at the moment), or emotional state (e.g., an initial response might be shock and paralysis). To decrease the impact of experiencing racism, clients will need to build skills in responding to these events. Strong personal agency can promote healing in the face of racism. People feel more empowered when they have greater control over how they respond to racist incidents.

Nonetheless, this critical aspect of healing and growth is glaringly absent from most clinical conversations on the issue of racism. It is not uncommon for racism to be considered an immutable and unchangeable reality, where perpetrators are given free rein to cause harm. Miller and colleagues (2018) found little to no representation of this topic in their content analysis of the counseling psychology literature on practice recommendations for addressing racism. It seems as if there is an unspoken expectation that People of Color may recover from the impact of racism only if they “stay in their place” and maintain the comfort of perpetrators. Unfortunately, some scholars advocate that People of Color should passively accept racism and give offenders “the benefit of the doubt” (Haidt, 2017). Yet, common sense tells us that the only way to overcome victimization is to resist being victimized. While this is not always possible, it often is. Nonetheless, traumatized clients will typically have lost their ability to confront racism effectively, even when it entails little or no personal risk. They will need to be taught (or retaught) how to do this and be encouraged to do so.

As such, treatment for racial trauma must include working with clients to make changes to things within their sphere of control (Laszloffy & Hardy, 2000). Clinicians should speak with clients about the different ways they might respond to racism. Clinicians can help clients process these experiences and situations, both in which they feel good about their response in the moment and situations in which they wish they responded differently. The first step in this process is to provide psychoeducation about small actions clients can take to counter microaggressions.

Imagery rescripting can be one good way to prepare clients for confronting racisms (e.g., Arntz et al., 2013). Rescripting allows clients to confront their distressing memories while simultaneously learning to think about such encounters in different ways. Rescripting provides alternate endings for upsetting experiences, and these can help clients imagine responding differently the next time they encounter a similar event. The next step would be to help clients develop courage and skill to confront racism through behavioral rehearsal using role-plays (e.g., Litam, 2020; Williams, 2020).

It is essential to respect a client’s fear or hesitancy to confront racism, especially when the therapist has a nonstigmatized identity. When clients have racial trauma, it will almost always feel unsafe to confront someone about their racism, even in small and safe ways. Usually, the traumatization will have resulted in some level of avoidance from feared people and situations, which can be counterproductive (Han et al., 2015). The client must learn to take calculated risks to increasingly venture outside of their comfort zone, whenever possible, and expose themselves to these situations. This process is similar to in vivo exposure, a core component of PE for PTSD (Foa et al., 2007). Strategies such as behavioral rehearsal can help People of Color start to build the skills required to confront racism in the moment. Litam (2020) borrows the phrase “microinterventions” from Sue and colleagues (2019) to explain various approaches that can be practiced. Educating the offender or calling out a racist joke as “not funny” are examples of microinterventions.

Further, some means of addressing racism in the moment will be better received by offenders than others. The client should understand that the goal is not to “stop people from being racist” or “educate other people,” although we can certainly hope for these outcomes. The more central goal is to facilitate clients being their authentic selves in the moment and tolerating any discomfort, which cannot occur unless they are empowered to use their voice in a manner that is fitting to their personality and values.

In a case study of an Asian American client who was distressed about ongoing microaggressions from his friends, Ching (2021) reports that speaking up against microaggressions was framed as value-driven, autonomous exposures that he could try, and for which he subsequently reported success. For example, he pointed out his roommates’ racially insensitive comments about peaceful Black Lives Matter protests in their town, which made them apologize. This sparked a deep conversation about racism in America, which ultimately brought them closer together.

Sue et al. (2019) provide an overview of how to address microaggressions through microinterventions, providing some insightful examples of the technique. However, these interventions are not appropriate for all people in all situations, and some interventions would only be safe for allies and not racialized people at all (e.g., elevator microintervention; Williams, 2020). There is some important nuance in choosing how to respond to everyday racism. The type of response should vary based on the relationship between the client and the perpetrator, which dictates the level of vulnerability appropriate for the situation (see Table 1; Williams, 2020).

Table 1.

Responding to Microaggressions

Perpetrator	Type of Response
Close friend or caring family member	The client should share how the racist act made them feel and why. They are appealing to the quality of the relationship to help bring about mutual understanding and positive change.
Coworker or acquaintance	Gently educate the person about stereotypes and racism. Although others may not show appreciation for being educated in the moment, over time and with repeated messaging, they may come to understand how they commit racist acts, and this awareness will allow them to more easily make nonviolent choices in the future. But more importantly, it empowers the client to take action against racism in a way that is positive, prosocial, and maintains personal integrity.
Stranger	Be assertive and correct the person; reject any controlling aspects of the encounter. Racism ultimately is a power-play, and clients should reclaim their agency and publicly resist.
Powerful person in a dangerous situation	Do not respond to the act of racism. Remove one’s self from the situation as quickly as possible and then make a report to the authorities. Clients should not expect their report to result in any particular outcome given that the structures in place are designed to protect and maintain racism, but the point is to practice being agentic. Even an anonymous report would be better than none at all in situations where it would be unsafe to reveal one’s identity.

Clients can keep a log or journal of their regular encounters with microaggressions and other forms of racism and discuss these during therapy. They should process with the therapist what worked, what did not, and what they might do differently next time. They should also be encouraged to lean on their social support system to process these experiences as they arise.

Posttraumatic Growth and Meaning Making

Meaning systems inform people’s understanding of themselves and their lives, direct their personal goals, and contribute to well-being and life satisfaction (Park & Kennedy, 2017). Posttraumatic growth refers to positive life changes individuals experience after a traumatic event and is one key objective in treating racial trauma (Comas-Diaz, 2016). This is accomplished through modifications to meaning systems that allow people to adapt their understanding of the world to accommodate their traumatic experience. Clinicians working to help clients recover from racial trauma will want to facilitate this meaning-making process (Comas-Diaz, 2016). As the client starts to feel less distress and more mastery in terms of managing racism, this is the time to introduce the concept of posttraumatic growth and engage in discussions around the meaning of their experiences (e.g., Hernández & Harris, 2022).

Of the strategies proposed by Evans and colleagues (2016) for fostering posttraumatic growth, one includes celebrating both racial and gender identity through meaning-making activities. This can include learning how others from the same racial/ethnic group made sense of the racism they endured and how they achieved, despite obstacles. Others might prefer to learn how those who came before them created change to make the path easier for those who came after them. Chioneso et al. (2020) further note that storytelling and resistance can help with meaning making by reducing disempowering thought patterns, combatting inertia, and raising awareness of systemic inequities that harm racialized communities. The solution to racial trauma is not to find ways to integrate oppressed groups into oppressive systems; rather, healing approaches should empower oppressed groups to transform oppressive systems.

Trauma can also injure a person’s sense of spirituality. With respect to meaning making after a trauma, Allen et al. (2017) note that “spiritual resources and interventions that are congruent with the clients’ beliefs should be utilized when this can help clients cope, heal, and grow.” Religious rituals can be used to enact destroying the traumatized life and nurture an experience of a renewed and more meaningful life in a way that symbolizes an inner transformation.

When clients are able to find meaning in stressful situations through creating more positive situational and global meanings, they generally have a better adjustment to stressful events (Park & Kennedy, 2017). The therapist should not hold specific expectations of meaning making for the client but rather anticipate that each client will heal at their own pace and in a myriad of different ways (Courtois, 2017). Clinicians can support posttraumatic growth through creating a climate of openness, promoting self-efficacy, and strengthening self-esteem. Clients will learn to appraise their posttraumatic stress as caused by the racism and normalize their reaction to the traumatic event, which will support the development of resiliency. Given that trauma silences the voices of anyone who speaks out against it, healing involves retelling the trauma story in a way that focuses on healing, growth, and empowerment. Comas-Diaz (2016) notes that storytelling is culturally congruent with many clients of color. It is an effective way to recall and honor people’s cultural memory and to facilitate identity reconstruction. As clients share their story of racial trauma with others, it promotes self-healing and group healing, collective empowerment, and racial solidarity.

In terms of meaning making, the therapist should introduce the idea that painful experiences are often quite terrible when we are going through them but can ultimately lead to growth and make us stronger and more empathetic toward others who suffer. Experiences of racism may similarly lead the client to acquiring useful and valuable knowledge. Reflecting on these experiences of racism may be an opportunity to promote healing by focusing on what was learned. Therapists might say, “What would you say you have learned from these difficult experiences of racism you’ve shared with me over the past eight weeks?” Even if no identifiable benefits emerged from the trauma experience, the survival and recovery of the client is a victory worth celebrating. The story has a happy ending because the client learned how to survive, heal, and thrive in a society where the odds were stacked against them. Meaningful works of art, music, or poetry that have emerged from the journey can be positive reminders of growth and triumph.

Social Action and Activism

Engaging critically against racism entails using racial justice strategies for activism (Mosley et al., 2021). Making a meaningful contribution to antiracist and projustice causes around issues of structural racism can be a healing act of agency and self-affirmation (e.g., Carlson et al., 2018; Hope et al., 2018). For example, Bryant-Davis and Ocampo (2006) advance resistance strategies as the final step in the treatment of racial trauma, which may include advocating for antiracist policies, distributing and/or signing petitions, voting, teaching people about racism, and, where necessary, bringing charges against perpetrators. They note that if the client has been subjected to an institutionalized racist occurrence, such as portrayals in the media or a prejudiced school curriculum, they may feel especially helpless to effect change. Therapists can help clients investigate what they might do to make an impact on a systemic level. Similarly, Comas-Díaz (2016) asserts that the final phase of race-informed treatment is social action. She notes that the goals of social action are collective agency, social change, and racial equality, which can be reached through various methods such as advocacy, activism, and solidarity. Chioneso and colleagues (2020) emphasize how public storytelling can lead to community healing and resistance and affect racism at personal, interpersonal, and organizational levels.

An important part of therapy is helping the client develop self-efficacy in engaging in antiracist efforts or social justice movements in ways that align with their values. Clinicians can help clients identify ways to respond to racism through social action, though it is important to emphasize that there is no single or “right” way to engage in efforts to create change. The clinician may ask the client whether there are ways in which they already engage in social action. If the client is not currently active but would like to engage, the clinician might ask what sorts of social actions are most appealing to them. Clinicians may also help the client find ways to be involved through discussing their strengths or resources. For example, maybe a client does not prefer to protest, but would be interested in creating advertisements for demonstrations. Perhaps a client does not have as many time resources but has money to donate to certain organizations. The clinician might also assess whether the client has an end goal and, if so, to specify that goal. For example, the client may share the desire to eliminate microaggressions in their place of work. With this in mind, the clinician can work with the client to develop SMART goals to help them identify reasonable action steps toward achieving this goal, where SMART goals are those that are specific, measurable, attainable, result-oriented, and time-bound (O’Neill, 2000).

The therapist must consider the various forms of activism and resistance that would be most beneficial and meaningful to the client. Community activism may address the root causes of racism, which can be therapeutic and satisfying, producing long-term benefits for both the individual and society as a whole (e.g., Carlson et al., 2018). Structural racism, which manifests itself in the form of discrimination in housing, work, and education, is a primary source of the community burden of racism and therefore proper targets for reform, as their resolution can lead to a wider alleviation of racism. Activities that directly address the community burden of racism can be therapeutic in ways that raise up both the individual and the community and thereby generate a positive feedback loop and make the community more resilient against racist threats. Additionally, community involvement that is thoughtful and well-targeted increases sources of social support. It is important to keep in mind that activism comes in many forms and may or may not involve formal protests or a Black Lives Matter event. Communal activities such as a community garden, after-school tutoring, elimination of neighborhood pollution, cataloging businesses owned by People of Color, classes on homeownership, or organizing a workshop addressing racism in schools are just a few examples of these types of pursuits (Jacob et al., 2022).

Some clients will be seeking treatment due to racial trauma that was precipitated by social activism. In these cases, it will be important to troubleshoot what specifically led to the traumatization, and what needs to change to enable them to resume these activities in a way that will not be traumatizing. It might simply be a matter of reducing the amount of time spent, or it could be that different types of activism are a better fit for the client’s temperament.

Discussion

Table 2 provides an overview of the phases of treatment using the techniques described herein, along with the goal and method. The treatment approach can be conceptualized as three phases: Part 1 for stabilization is called “Stop the Bleeding,” where the client is highly distressed with a focus on support; Part 2, “Healing,” focuses on cognitive restructuring, exposure, and reevaluation; and Part 3 is “Empowerment,” where the client starts to combat racism in their daily lives for sustained wellness. This model bears some similarities to the three-stage approach proposed by Herman (2015) (Safety; Remembrance-Mourning; Reconnection) and builds on the Racial Trauma Recovery approach by Comas-Diaz (2016) and Chavez-Dueñas et al. (2019). Approaches in the peer-reviewed literature tend to be relatively brief, and case examples can be helpful. We recommend additional reading for therapists who may be unfamiliar with any of the techniques described (see Ching, 2021; Halstead et al., 2021; Williams et al., 2014; Williams, 2020, for more case examples of techniques).

Table 2.

Healing Racial Trauma Treatment Protocol

Phase	Goal	Techniques
Assessment	Understand the scope of the client’s racial stress and trauma	Use of validated scales and clinical interview to assess racial stress/trauma
Part 1: Stabilization – “Stop the Bleeding”
1. Making Sense of Racism	Reduce shame by helping client understand racism is caused by society and is not the client’s fault	Provide psychoeducation about racism and resulting harms
2. Coping & Self-Care	Increase functional strategies and decrease dysfunctional ones	Assess coping and self-care strategies, and discuss these with client
3. Cultivating a Support Network	Reduce stress and provide resources for when racial stress occurs	Identify existing social supports and find ways to create more
Part 2: Healing
4. Dismantling Internalized Racism	Reduce shame, increase feelings of belongingness	Cognitive defusion and restructuring, cultural exploration/appreciation
5. Understanding Race & Whiteness	Increase feelings of control by better predicting racism in environment	Psychoeducation about race, including the invisibility of Whiteness
6. Exposure & Processing of Experiences of Racism (repeat as needed)	Habituation through exposure, new thinking about event, reducing distress, shame and guilt	Conversations about distressing events, expressive writing, Socratic questioning, artistic expression
7. Learning Strategies to Combat Racism	Skill building to respond to racism in various situations, increase confidence to act	Journaling racist events to discuss in session, review of possible responses, role play
Part 3: Empowerment
8. Practicing Combatting Racism in Everyday Life (repeat as needed)	Increase feelings of agency toward racism, reduce feelings of helplessness and victimization	Responding to racism in daily life, graduated exposure, make predictions and processing outcomes, skill building
9. Posttraumatic Growth and Meaning Making	Recognize and reinforce success	Consolidating events into a cohesive and meaningful narrative
10. Social Action, Activism, and Healing Outside Therapy	Ongoing meaning-making of prior trauma, promote change in one’s environment, feel agentic	Evaluation of values, exposure to challenging situations, attempting racial justice goals
11. Good-Byes – Moving On	Relapse prevention	Synthesize course of treatment and mastery of techniques

Although the techniques are listed in roughly the order they should be used, certain techniques will be utilized throughout and some may need repeating or periodic revisiting, depending on the client’s progress and life circumstances. Additionally, it is important to appreciate that the effects of oppression may have destabilized the client’s life across many domains, making regular meetings challenging (Bhambhani & Gallo, 2021), and, as such, therapists should be as flexible as possible (e.g., evening appointment times, phone/email support as needed, etc.).

Table 3 notes where each technique may be used in the intervention, along with the empirical support for readers who would like more information. The Expert Support items are all specifically about engaging with racism and/or racial trauma. In terms of empirical support for techniques, 9 studies are specifically about racial trauma (Anderson et al., 2018; Banks et al., 2021; Carlson et al., 2018; Conway-Phillips et al., 2020; Halstead et al., 2021; Hargons et al., 2021; Mosley et al., 2021; Saban et al, 2021; Williams et al., 2014), 6 studies are about racial stress or other racism-related pathologies (Ching, 2021; Heard-Garris et al., 2021; Hwang & Chan, 2019; Malott et al., 2010; Steele, 2020; Tavakoli et al., 2009), 1 study is focused on an intervention for refugee trauma (Tessitore, 2021), and 11 studies examine correlates of racism or oppression in general (Adkins-Jackson et al., 2019; Barclay & Skarlicki, 2009; Degife et al., 2021; Donovan et al., 2019; Graham et al., 2013; Koch et al., 2020; Márquez-Magaña et al., 2013; Noh & Kaspar, 2003; Umaña-Taylor et al., 2018; Williams, Kanter, Peña, Ching., & Oshin, 2020; Zapolski et al, 2019).

Table 3.

Support for Protocol Techniques as Applied to Racial Stress and Trauma

Racial Trauma Technique	Session	Expert Support	Empirical Support
Validation of Experiences/Support and Affirmation	1 (also 2–6)	Bryant-Davis & Ocampo, 2006; Miller et al., 2018; Roberts, 2021	Koch et al., 2020
Psychoeducation About the Nature of Racism and Connection to Mental Health	1, 5, 6	Miller et al., 2018; Reynolds, 2019	Carlson et al., 2018; Conway-Phillips et al., 2020; Williams, Kanter et al., 2020
Assess and Strengthen Coping Strategies	2	Bryant-Davis & Ocampo, 2006; Jacob et al., 2022; Malott & Schaefle, 2015	Anderson et al., 2018; Conway-Phillips et al., 2020; Saban et al, 2021
Self-Care	2	Bryant-Davis & Ocampo, 2006; Jacob et al., 2022; Nayak, 2020; Wyatt & Ampadu, 2021	Adkins-Jackson et al., 2019; Quaye et al., 2019
Self-Compassion	2	Litam, 2020; Watson-Singleton et al., 2021	Hwang & Chan, 2019; Liu et al., 2020
External Social Support	3	Evans et al., 2016; Miller et al., 2018; Watts-Jones, 2002	Liu et al., 2020; Noh & Kaspar, 2003; Saban et al., 2021
Mindfulness	2, 4, 8	Sobczak & West, 2013	Graham et al., 2013; Zapolski et al, 2019
Psychoeducation About Colorism for Internalized Racism	4	Landor & McNeil Smith, 2019	Degife et al., 2021; Donovan et al., 2019; Márquez-Magaña et al., 2013
Cognitive Restructuring and Defusion from Internalized Racism	4, 5 (also 1)	Bryant-Davis & Ocampo, 2006; Roberts, 2021; Williams, 2020	Banks et al., 2021; Hargons et al., 2021; Steele, 2020
Ethnic and Racial Identity Development and Affirmation	5	Chavez-Dueñas et al., 2019; Malott & Schaefle, 2015; Metzger et al., 2021	Malott et al., 2010; Umaña-Taylor et al., 2018
Recounting Racism-Related Traumatic Experiences	6, 7	Bryant-Davis & Ocampo, 2006; Comas-Díaz, 2016; Evans et al., 2016	Carlson et al., 2018; Halstead et al., 2021; Williams et al., 2014
Processing Racist Experiences	6 (also 3–5)	Ching, 2021; Comas-Díaz, 2016; Williams, Byrd, et al., 2020	Anderson et al., 2018; Barclay & Skarlicki, 2009; Williams et al., 2014
Skills Building in Confronting Racism	7, 8	Sue et al., 2019; Thurber & DiAngelo, 2018; Laszloffy & Hardy, 2000; Litam, 2020; Williams, 2020	Ching, 2021; Tavakoli et al., 2009
Posttraumatic Growth and Meaning Making	9	Chioneso et al., 2020; Comas-Díaz, 2016; Evans et al., 2016; Hernández & Harris, 2022; Williams, Byrd, et al., 2020	Tessitore, 2021
Social Action and Activism	10	Bryant-Davis & Ocampo, 2006; Chioneso et al., 2020; Comas-Díaz, 2016; Hope et al., 2018; Miller et al., 2018	Carlson et al., 2018; Heard-Garris et al., 2021; Mosley et al., 2021

Note. This table provides a list of each of the techniques discussed, along with supporting literature. The second column lists which session the technique will be used, based on the treatment protocol as outlined in Table 2. The third column provides sources that advocate the use of the method for treating racial stress and trauma in the scientific literature. The last column contains sources that provide empirical support for the technique, and these can be helpful in providing more details about how to implement the technique in clinical practice. In some cases, the technique was examined in isolation and in other cases it was part of a more comprehensive treatment approach. This is not an exhaustive list and there are many additional sources that speak to the merits of these techniques for trauma from other sorts of discrimination and in general.

Therapist Qualities

In this article, we have discussed the key techniques for treating racial stress and trauma that comprise the Healing Racial Trauma protocol, but this protocol alone is not enough to make one an effective therapist for traumatized clients (Carter & Pieterse, 2020; Spann, 2022). Treating racial stress and trauma requires a culturally humble and empathetic clinician, which is by no means assumed. Therapists enter the world with their own ethno-cultural lens and racial biases. If not specifically trained to do this work, there is the risk that they may further harm the client (e.g., Williams, 2020). In the U.S., 80% of therapists are White and many graduated before therapists were required to undergo multicultural training in their programs, and some are graduating without such training currently (Benuto et al., 2019). Therefore, before starting, the therapist should do their own work to ensure that their biases are assessed. Malott and Schaefle (2015) emphasize that any interventions for racial trauma must sit on a firm foundation of counselor multicultural and racial competencies, and conceptual frameworks must recognize racism’s role in the etiology of client issues.

Treating racial trauma should only be done by clinicians who have a good understanding of the traumatizing impact of racism. They should have the following competencies:

• A good understanding of microaggressions and racism (Williams, 2020)

• The ability to identify/diagnose racial trauma (Williams, Printz, et al., 2018)

• The ability to initiate a nondefensive repair of any microaggressions or cultural insensitivities committed in session (Williams, 2020)

• Have done their own personal antiracism and allyship work (e.g., Williams, Sharif, et al., 2021)

• Willingness to discuss racism and cultural issues, even when it evokes discomfort (Calloway & Creed, 2021; DeLapp & DeLapp, 2021; Malott & Schaefle, 2015)

• The ability to learn about a client’s culture from the client and other sources

• Appreciation of individualistic versus collectivistic cultural worldviews (Sue, Sue, et al., 2019)

• An understanding of their own cultural development (bias, blind spots, areas for growth) and how that can affect the therapeutic relationship (Miller et al., 2015)

• An understanding of models of racial identity development and how this might impact the therapeutic alliance (Graham-LoPresti et al., 2019)

Koch et al. (2020) examined affirming experiences reported by culturally diverse graduate students. Those who were deemed to be affirming were described as validating, nonjudgmental, interested, genuine, receptive, mindful, and self-aware, with an affirmative communication style. Such individuals were not afraid to acknowledge culture, were willing to grow and learn, and advocated for others who were marginalized. Therapists working with racialized clients should embody these qualities.

In addition, therapists must be able to do the things they are asking clients to do themselves. Much of the work clients will do, beyond processing their traumas, is learning a new way of approaching racism. For example, this includes calling out microaggressions when they occur. Therapists should ask themselves if they have ever done this themselves. If not, they need to make a concerted effort to increase not only their awareness, but also their courage (Williams et al., 2022).

Same Versus Mixed-Race Dyads

Given the benefits of working with someone from the same ethnic group, matching may seem like the best way to promote mutual understanding. Most clients feel more comfortable discussing their difficulties with someone of the same ethnic and racial background, and they may provide information about their symptoms more accurately when matched. They may feel their counseling experience is more effective when they are with someone who has a native understanding of their culture. Ethnic matching has been shown to strengthen the therapeutic alliance and improve retention (Cabral & Smith, 2011).

However, ethnic matching is not always possible, due partly to systemic barriers in higher education, which have resulted in relatively low numbers of non-White mental health clinicians (Stewart et al., 2017). Further, a client may prefer someone who is not a part of their own ethnic group for any number of reasons. For example, they may have struggles related to not adhering to their cultural group’s norms, and so may worry about judgment from someone from their same community. Additionally, unmatched dyads provide an opportunity to grow surrounding awareness, connection, and cross-cultural understanding in both the client and therapist (Miller et al., 2015).

Limitations and Future Directions

Although we have identified techniques for treating racial stress and trauma with evidence of empirical support, no RCT has been conducted to validate the approach as a whole. Future work in this area could investigate the efficacy of this combination of techniques by comparing this approach to treatment as usual (e.g., evidence-based trauma treatment not tailored to treat racial trauma). This would inform whether this new approach for treating racial trauma is associated with improved outcomes over existing trauma treatments. Further, although we emphasize the importance of engaging in antiracism training before a clinician can safely implement this treatment protocol for racial trauma, it is unclear specifically how much antiracism work is needed to deem a clinician ready to effectively implement this protocol, and so consultation is recommended (Calloway & Creed, 2021). Future research is needed to investigate specifically which components of antiracism training are essential competencies associated with the safe implementation of treatment for racial trauma (e.g., Curtis et al., 2019).

Conclusion

Racism is a widespread problem that continues to evolve and shift with the times. Although the ultimate goal must be to eliminate racism, the reality is that this will take time and people need support now managing the stress and trauma associated with racism. This is the first protocol for a racial trauma treatment utilizing a CBT framework, which fills an important gap in the literature. However, more work is needed to empirically test and disseminate this protocol widely. To effectively achieve these goals, substantial resources are needed. Specifically, resources are needed to: (1) fund clinical trials and studies aiming to understand the mechanisms of action to further refine the protocol; (2) develop protocol materials and make them easily accessible to clinicians; and (3) train clinicians to implement the protocol with high fidelity. Providing a racial trauma treatment protocol utilizing evidence-based cognitive-behavioral strategies is a necessary way to support healing while we continue the fight to end racism.