Addressing Social Marginalization and Health Disparities in Trauma Psychology

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By: Bekh Bradley, PhD and Lesia M. Ruglass, PhD

Lesia Ruglass, PhD
Lesia Ruglass, PhD

A robust body of research demonstrates that social marginalization resultant from the intersection of multiple factors including race and ethnicity, gender, sexual orientation, gender expression, disability, immigration status, and socioeconomic status is associated with disproportionate risk of exposures to stress and trauma and increased vulnerability to its impact (Brown, 2008; Ford, 2008; Pole, Gone, & Kulkarni, 2008). For example, studies indicate women are twice as likely to develop PTSD compared to men, likely due to their greater exposure to high impact traumas (e.g., sexual violence) as well as gender-specific psychological and biological peri- and post-trauma reactions that confer greater risk for developing PTSD (Olff, Langeland, Draijer, & Gersons, 2007; Tolin & Foa, 2006). Likewise, studies indicate elevated post-traumatic stress reactions and risk for PTSD among sexual minority youths compared to their heterosexual counterparts, mediated by disparities in exposure to violence beginning early in childhood (Roberts, Rosario, Corliss, Koenen, & Austin, 2012). These findings highlight the urgent need for social, psychological, and legal interventions designed to ameliorate the detrimental effects of trauma among vulnerable populations.

Beth Bradley, PhD
Beth Bradley, PhD

These issues were central in a lawsuit recently filed against the Compton Unified School District (CUSD; Peter P. v. Compton Unified School District, 2015) in an attempt to require the school district to address the needs of students who have been impacted by trauma. The lawsuit notes that students in this school district are “routinely” exposed to high levels of trauma, the impact of which is exacerbated by poverty, racism, and oppression based on gender and gender expression. The absence of a systematic effort by the CUSD to take steps to mitigate the impact of pervasive trauma and stress–even though models for this type of intervention exist–is, in part, related to our current medical perspective on the impact of trauma, an understanding that is not well informed by sociopolitical factors and that does not include a social justice perspective.

What steps can be taken towards making improvement in this area? We might start with broadening our understanding of “trauma” in a way that takes social, cultural, and political factors into account. Consideration needs to be given to expanding the definition to include historical trauma and intergenerational trauma (Bowers & Yehuda, 2016; Evans-Campbell, 2008; Perdue et al., 2012). We also need to consider sociocultural risk and protective factors such as cultural values and beliefs, immigration status, acculturation, socioeconomic status, racism, and discrimination (Ford, 2008; Marsella, 2010). Furthermore, we must acknowledge the importance of psychosocial and political power in determining risk for exposure to trauma, its impact on health and the availability and utilization of appropriate interventions (CSDH, 2008). Taking these steps would help turn away from an ahistorical approach focused primarily at the level of the individual.

Our approach to the treatment of trauma related psychological problems needs to draw upon broader, cross-cultural understandings of health and approaches to healing. An example of this is the medical anthropology work examining Nepali beliefs about trauma (Kohrt & Hruschka, 2010) and work by Marsh and colleagues (Marsh, Coholic, Cote-Meek, & Najavits, 2015) in developing a model of treatment that blends traditional Aboriginal approaches to healing with Western approaches to support healing from intergenerational trauma and substance use disorders among aboriginal peoples. We need to take action in collaboration with communities impacted by trauma. This type of response to trauma is highlighted in the CUSD case, which identifies characteristics of a “trauma sensitive school” including training and coaching educators to recognize and address the effects of trauma among students, creating a safe, positive and predictable school environment, implementing resilience focused interventions, development of practices that support healthy relationships including methods for peaceful conflict resolutions, and using restorative justice and other non-punitive approaches to discipline. These types of approaches can be applied in a variety of settings (e.g. schools and prisons), as well as within neighborhoods.

It is important to address unmet need for treatment and barriers to access and utilization of treatment services across diverse populations. Strategies to reduce barriers may include increasing access to trauma-informed programs; additional training in multicultural competence among service providers; increasing multicultural programs and staff; and matching of clients and therapists if preferred and feasible (Brown, 2008; Carter, Mitchell, & Sbrocco, 2012; Ford, 2008; Marsella, 2010; Roysircar, 2009). Empowerment of disenfranchised and marginalized individuals and communities in both research and practice is also a key aspect in mitigating trauma’s impact (Cattaneo & Goodman, 2015). One way this can be done is by developing interventions implemented by community members. In addition, we need more research and interventions centered on the perspectives of marginalized individuals and giving voice to these perspectives. An example of this type of work is photovoice or participatory photography methods (Wang & Burris, 1994), which combine social activism and photography with the goal of giving voice to marginalized perspectives (Crabtree & Braun, 2015). A truly sociopolitical framework for understanding trauma and mitigating its impact will require a social justice perspective and it will be grounded in actions addressing the structural inequalities that contribute to health disparities.

Division 56 Activities

The Diversity and Multicultural Committee’s mission is to enhance awareness of the prevalence, consequences and treatment of trauma (traditional, indigenous, complementary, and alternative practices) among diverse populations (e.g., by Age, Sex/Gender; Race/ Ethnicity; Culture; Sexual Orientation; Disability; SES; International) utilizing a social justice framework. To this end, we have created seven workgroups tasked to create factsheets with the most up-to-date research on trauma exposure, risk and protective factors, PTSD and other trauma-related disorders, and treatment among diverse/multicultural populations. We hope these guides can serve as resources to communities, clinicians, and researchers. We plan to liaise with and help support the efforts of the greater APA body and international organizations on their work pertaining to diversity and multicultural issues. We also plan to develop international fieldwork placements in trauma psychology to help support efforts at the global level and provide much needed training opportunities for students/clinicians who wish to pursue this line of practice.

Members interested in getting involved in the Diversity and Multicultural Committee can do so in several ways: 1) join a workgroup and assist with the creation of resources for dissemination; 2) contribute an article to the diversity and multicultural issues column; 3) monitor our efforts and assist as you can. Contact us at rbradl2@emory.edu and ruglass.ccny@gmail.com for more information.

References

Bowers, M. E., & Yehuda, R. (2016). Intergenerational transmission of stress in humans. Neuropsychopharmacology, 41(1), 232–244.

Brown, L. S. (2008). Cultural competence in trauma therapy: Beyond the flashback. Washington, DC: American Psychological Association.

Carter, M. M., Mitchell, F. E., & Sbrocco, T. (2012). Treating ethnic minority adults with anxiety disorders: Current status and future recommendations. Journal of Anxiety Disorders, 26(4), 488–501. doi:10.1016/j.janxdis.2012.02.002

Cattaneo, L. B., & Goodman, L. A. (2015). What is empowerment anyway? A model for domestic violence practice, research, and evaluation. Psychology of Violence, 5(1), 84–94.

Crabtree, C., & Braun, K. (2015). PhotoVoice: A Community-Based Participatory Approach in Developing Disaster Reduction Strategies. Progress in Community Health Partnerships: Research, Education, and Action, 9(1), 31–40.

CSDH. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. The Lancet (Vol. 372). Geneva: Elsevier.

Evans-Campbell, T. (2008). Historical trauma in American Indian/Native Alaska communities: A multilevel framework for exploring impacts on individuals, families, and communities. Journal of Interpersonal Violence, 23(3), 316–338.

Ford, J. D. (2008). Trauma, posttraumatic stress disorder, and ethnoracial minorities: Toward diversity and cultural competence in principles and practices. Clinical Psychology: Science and Practice, 15(1), 62–67.

Kohrt, B. A., & Hruschka, D. J. (2010). Nepali concepts of psychological trauma: The role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Culture, Medicine, and Psychiatry, 34(2), 322–352.

Marsella, A. J. (2010). Ethnocultural aspects of PTSD: An overview of concepts, issues, and treatments. Traumatology, 16(4), 17–26.

Marsh, T. N., Coholic, D., Cote-Meek, S., & Najavits, L. M. (2015). Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduction Journal, 12(1), 14.

Olff, M., Langeland, W., Draijer, N., & Gersons, B. P. R. (2007). Gender differences in posttraumatic stress disorder. Psychological Bulletin, 133(2), 183.

Perdue, T. R., Williamson, C., Ventura, L. A., Hairston, T. R., La Tasha, C. O., Laux, J. M., … Lambert, E. G. (2012). Offenders who are mothers with and without experience in prostitution: differences in historical trauma, current stressors, and physical and mental health differences. Women’s Health Issues, 22(2), e195–e200.

Pole, N., Gone, J. P., & Kulkarni, M. (2008). Posttraumatic stress disorder among ethnoracial minorities in the United States. Clinical Psychology: Science and Practice, 15(1), 35–61.

Roberts, A. L., Rosario, M., Corliss, H. L., Koenen, K. C., & Austin, S. B. (2012). Elevated risk of posttraumatic stress in sexual minority youths: Mediation by childhood abuse and gender nonconformity. American Journal of Public Health, 102(8), 1587–1593.

Roysircar, G. (2009). Evidence-based practice and its implications for culturally sensitive treatment. Journal of Multicultural Counseling and Development, 37(2), 66–82.

Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959–992.

Wang, C., & Burris, M. A. (1994). Empowerment through photo novella: Portraits of participation. Health Education & Behavior, 21(2), 171–186.

Lesia M. Ruglass, Ph.D. is a Licensed Clinical Psychologist and Assistant Professor in the Department of Psychology at the City College of New York, CUNY, where she also directs the OASAS certified Credentialed Alcoholism and Substance Abuse Counselor (CASAC) program. Dr. Ruglass also maintains a private practice in NYC. Her research and clinical interests center on integrated treatments for trauma, PTSD, and substance use disorders (SUD), with a focus on understanding and reducing racial/ethnic disparities in mental health and PTSD/SUD outcomes. She currently serves as Member-at-Large and Co-Chair of the Diversity and Multicultural Committee.

Bekh Bradley, PhD received his BA in psychology from Wesleyan University in 1993 and his PhD in Clinical Community Psychology from the University of South Carolina in 2000. Dr. Bradley is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Emory University. Dr. Bradley has significant experience in clinically and empirically grounded research on PTSD and trauma.  Though his clinical work, research, teaching and leadership responsibilities, Dr. Bradley is dedicated to providing outstanding clinical care and to increasing knowledge of factors contributing to risk and resilience following trauma exposure.