Many clinicians only recognize racism as trauma when an individual experiences a discrete racist event, such as a violent hate crime. This is limiting given that many ethnoracial minorities experience cumulative experiences of racism as traumatic, with perhaps a minor event acting as “the last straw” in triggering trauma reactions. Additionally, minority patients may not link current PTSD symptoms to cumulative experiences of discrimination if queried about a single event. Thus, the conceptualization of trauma as a discrete event may be inadequate for diverse populations. Our work in this area is focused on improved assessment of racial stress and trauma and culturally-informed treatment approaches.
The UConn therapist team for MDMA-assisted psychotherapy for PTSD/race-based trauma (from left): Sara J. Reed, M.S., MFT Associate (therapist); Michael D. Kisicki, M.D. (co-investigator; therapist); Monnica Williams, Ph.D. (lead investigator; therapist); Terence H. W. Ching, M.S. (therapist); Jamilah R. George, M.Div. (therapist).
The Multidisciplinary Association for Psychedelic Studies (MAPS) is a non-profit research and educational organization that is currently sponsoring Phase 3 clinical trials of 3,4-methylenedioxymethamphetamine (MDMA) as a tool to assist psychotherapy for treatment-resistant PTSD. Importantly, MDMA used in these trials is not the same as the street substances known as "ecstasy" or "molly," since these drugs frequently also contain unknown and/or dangerous adulterants. In laboratory studies, pure MDMA has been proven sufficiently safe for human consumption when taken a limited number of times in moderate doses. In fact, MDMA has been administered to over 750 human subjects in clinical studies with only one unrelated adverse event. In MDMA-assisted psychotherapy, MDMA is only administered a few times, unlike most medications for mental illnesses which are often taken daily for several years.
Preliminary studies have shown that MDMA can catalyze powerful psychotherapeutic work in helping people overcome PTSD by reducing fear of traumatic memories and increasing feelings of trust and compassion towards others without causing sensory distortions or inhibiting access to difficult emotions. As such, MDMA could increase the effectiveness of psychotherapy by strengthening the alliance between therapist and patient.
In our site at the University of Connecticut, we are preparing for clinical trials prior to estimated submission for FDA approval in 2021. We are focusing on the recruitment of ethnoracial minority participants who meet criteria for PTSD, with the experience of racism as component of their trauma. Specifically, we are looking to examine whether MDMA-assisted psychotherapy can work similarly for these members of underserved communities, taking into account the impact of cultural differences and the possible need to adapt MDMA-assisted psychotherapy to the needs and culturally specific traumatic experiences of ethnoracial minority individuals.
Williams, M. T., & Leins, C. (2016). Race-Based Trauma: The Challenge and Promise of MDMA-Assisted Psychotherapy. Multidisciplinary Association for Psychedelic Studies (MAPS) Bulletin, 26(1), 32-37.
Posttraumatic stress disorder (PTSD) is a highly disabling disorder, afflicting African Americans at disproportionately higher rates than the general population. Findings from the National Comorbidity Survey-Replication (NCS-R) and National Survey of American Life (NSAL) indicate that, while African Americans have a lower risk for many anxiety disorders, they have a 9.1% prevalence rate for PTSD, compared to 6.8% in European Americans. African Americans with PTSD also have significantly more impairment than traumatized European Americans in productivity and out of role domains, indicating greater difficulty carrying out daily activities.
When receiving treatment for PTSD, cultural mistrust and social factors may cause African Americans to feel differently towards a non-Black clinician. Furthermore, racism and discrimination experienced before or during the traumatic event may compound posttrauma reactions, impacting the severity of symptoms. Failure to adapt treatment approaches to encompass cultural differences and racism-related traumas may decrease treatment success for African American clients. Cognitive behavioral treatment approaches are highly effective, and Prolonged Exposure (PE) in particular has the most empirical support for the treatment of PTSD. We recently wrote an article discussing culturally-informed adaptations of PE that incorporates race-related trauma themes specific to the Black experience. These include techniques to better establish rapport, asking directly about race-related themes during the assessment process, and deliberately bringing to the forefront race-related experiences and discrimination during treatment when indicated. Guidelines for assessment and the development of appropriate exposures are provided. Case examples are presented demonstrating adaptation of PE for a survivor of race-related trauma and for a woman who developed internalized racism following a sexual assault. Both individuals experienced improvement in their posttrauma reactions using culturally-informed adaptations to PE.
Williams, M. T., Malcoun, E., Sawyer, B., Davis, D. M., Bahojb-Nouri, L. V., & Leavell Bruce, S. (2014). Cultural Adaptations of Prolonged Exposure Therapy for Treatment and Prevention of Posttraumatic Stress Disorder in African Americans. Behavioral Sciences — Special Issue: PTSD and Treatment Considerations, 4(2), 102-124. doi:10.3390/bs4020102
Malcoun, E., Williams, M. T., & Bahojb-Nouri, L. V. (2015). Assessment of Posttraumatic Stress Disorder in African Americans. In L. T. Benuto & B. D. Leany (Eds.), Guide to Psychological Assessment with African Americans, New York: Springer. ISBN: 978-1-4939-1003-8.
Sawyer, B., Williams, M.T., DeLapp, R. C. T., & Davis, D. M. (2016). Posttraumatic Stress Disorder. In A. Breland-Noble, C. S. Al-Mateen, & N. N. Singh (Eds.), Handbook of Mental Health in African American Youth. Springer. ISBN: 978-3-319-25501-9.
We have done a great deal of work toward the development of a mental health clinic for refuges in partnership with the Global Health Initiative in the UofL School of Medicine. In the initial phase, we identified the most appropriate measures to assess the mental health needs of our target population. These measures were made available in English, Spanish, and other languages as needed to facilitate use by bilingual clinicians and interpreters. Measures translated by the bilingual team into Spanish include the Hopkins Symptom Checklist, the Modified PTSD Symptom Scale, and the ADIS.
Designated psychology faculty trained and supervised clinical graduate psychology students to enable them to conduct culturally appropriate psychopathology assessments of refugees. Those with a diagnosis of PTSD were then offered empirically-supported treatment for their trauma by advanced graduate student clinicians. The clinical work conducted by the graduate students was facilitated via individual and group supervision and related graduate coursework. At the University of Louisville, Dr. Williams developed a series of courses to provide the necessary training for students participating in this project, including Culture & Diversity in Psychology, Treating Trauma in Diverse Populations, and Multicultural Counseling Skills.
We have also been conducting research on effective methods of assessing trauma in Hispanic (primarily Cuban), Middle Eastern (primarily Iraqi and Syrian), and African refugees. All patients receive the RHS-15, as well as gold-standard measures of trauma, culture, and psychopathology. Once we have collected data from an adequate numbers of patients, we will be able to conduct a psychometric investigation to determine how well the RHS-15 is able to identify trauma in each of the populations of interest.
Project Team: Monnica T. Williams, Adriana Pena, Victoria Schlaudt
Pena, A., Mier-Chairez, O., Bosson, R., Exposito, A., Ford, R., Diaz, Y., Carrico, R., & Williams, M. T. (2016, September). Validation of the Refugee Health Screener-15 (RHS-15) for Cuban Refugees/Entrants. Poster presented at the National Latino/a Psychology Association Conference, Orlando, FL.
Bosson, R., Williams, M. T., Lippman, S., Carrico, R., Kanter, J., Pena, A., Mier-Chairez, J., & Ramirez, J. (2017). Addressing refugee mental health needs: From concept to implementation. The Behavior Therapist, 40(3), 110-112.