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June 30, 2020

An Interview with Monnica Williams, PhD, ABPP on Collective Trauma

Type: Announcements Tags: Newsletter, Mental Health, Trauma Informed Care, Education, Primary Care, Resilience

This month's featured interview focuses on collective trauma and the role the primary care workforce plays in screening, training, and education. 

The NCIBH team spoke with Monnica T. Williams, PhD, ABPP,  associate professor at the University of Ottawa in the School of Psychology, where she is the Canada Research Chair for Mental Health Disparities and Director of the Laboratory for Culture and Mental Health Disparities. Dr. WIlliams is a board-certified, licensed clinical psychologist, specializing in cognitive-behavioral therapies. She is also the Clinical Director of the Behavioral Wellness Clinic, LLC in Tolland, Connecticut, and she has founded clinics in Kentucky, Virginia, and Pennsylvania. Prior to joining the faculty at the University of Ottawa, she was an assistant professor at the University of Pennsylvania School of Medicine in Philadelphia, director of the Center for Mental Health Disparities at the University of Louisville, and faculty at the University of Connecticut.

There are national calls for large scale changes to medical curricula to incorporate trauma and racism as social determinants of health. Given your work in cultural and racial trauma, can you provide guidance on how these topics should be included in primary care education?

A collective trauma is a traumatic psychological experience shared by a large group of people that can include an entire society. These collective traumas can afflict large cultural groups, and some examples of this include the trauma of slavery in the United States, the Nazi Holocaust, and genocide of Native Americans. Traumatization from these experiences is passed down as a cultural trauma, and this is slow to heal when aspects of the trauma are ongoing in the form of oppression and discrimination (Kira, 2010). It is important for all medical professionals to understand the potential of collective traumas to cause or exacerbate mental health problems in afflicted groups. This should be a required facet of mental health training, both in the classroom and clinic, and also a part of coursework in social determinants of health.

What barriers and challenges do you foresee when training and educating primary care providers on trauma-informed care?

When I was a clinical psychology graduate student, there were limited formal didactics to help us learn how to work with clients from different cultural groups. There were no courses offered in my department to train us, and students were actively discouraged from taking courses in the school of education -  the only place where one might find a graduate course focused on multicultural counseling. The clinical faculty thought they knew enough to adequately prepare us to become clinicians and researchers, but you cannot give what you never received. Faculty who were never trained in diversity issues could not give us the tools we needed to do this work effectively.In this case, faculty generally know something about trauma, but most never got any training on cultural issues or collective traumas, so they do not know how to teach it. Acquiring the necessary skills to teach this material may be more work than faculty feel they have time to commit.

The COVID-19 pandemic is a global health event that is resulting in both individual and collective mental health effects. How do we best prepare the primary care workforce to assess and care for increased behavioral health needs?

It is important to recognize that COVID-19 is a shared global experience, but it is impacting some cultural groups differently than others, leading to different collective traumas. In the US, people of color are suffering at much higher rates than their white American counterparts; Black Americans represent about 14% of the US population but 30% of those have contracted the virus (CDC, 2020; Garg et al., 2020). In the UK, Black people are over 4 times more likely to die with COVID-19 than white people, and British people of South Asian descent were perishing at 2-3 times the rate of white people. Recent reports from Norway indicate that immigrants from Somalia have infection rates over 10 times the national average (Masri, 2020). Consider that groups disproportionately bearing the burden of COVID-19 exposure and contraction also suffer a disproportionate mental health burden, which includes greater anxiety at the prospect of becoming infected, greater job stress and insecurity, and greater sorrow in having more friends and family become ill and die.

Individuals in public-facing and low-income professions appear to have a higher risk of contracting COVID-19; this includes bus drivers, grocery clerks, receptionists, firefighters, and personal-care aides. In the US there are 14.4 million workers in jobs where exposure to or infection with COVID-19 can occur with increased frequency, and these jobs are disproportionately held by people of color (Baker et al., 2020; Gamio, 2020). This situation is similar in Canada, as these same public-facing occupations are predominated by visible minorities, and these occupations pose a higher risk for exposure to viral infection and are not amenable to distancing measures. Primary care providers need to be aware of how groups may be impacted differently, and how this might manifest clinically.

What is the role that trauma informed (TIC) training and education can play in addressing collective trauma during this time of crisis?

Clinicians need to understand that trauma is more than just a single event. Most people do not get PTSD after a single trauma, rather trauma is cumulative. Therefore, most people with PTSD  have had multiple traumas. Well-trained clinicians will work to understand a person’s trauma history in concert with all of their traumas. Likewise, collective trauma overlays and is intertwined with individual trauma. 

For example, a person who experiences violence from a police officer may have trauma from the encounter itself, but there may be additional layers of trauma due to previous bad experiences with law enforcement, family members having been harassed by law enforcement, and historical trauma from the active participation of law enforcement in oppression. Thus, this collective trauma around police abuse of power heightens the fear and despair that may result from a single encounter. The Great Depression is another example of a collective trauma that still impacts people today. Someone who grew up during that time may have developed a pattern of saving too many things and might feel compelled to make sure food never goes to waste. That can be inflicted on children in the form of being forced to eat everything on their plate, which can in turn lead to eating disorders, or growing up with overvalued ideas about the importance of objects leading to a problem with hoarding. Clinicians must learn to look beyond what may be considered the immediate or apparent issue to see trauma in a broader context.

What are some successful strategies primary care providers and institutions can take to address mental health stigma in health care settings?

There is a general stigma around mental illness and mental health care, and this is even more pronounced in communities of color. Many people who need mental health care will not seek it out or may not know where to find it. The most efficient way to reduce stigma and increase access to care is to put the providers right where the people are.  Making mental health a part of primary care can streamline the process from when a family doctor recognizes a problem until the person is seen by a psychiatrist or therapist. If the mental health providers are in the same office, it can make a big difference and be much easier to initiate mental health care. Likewise, placing mental health professionals in churches, counseling centers, and schools can be another way to reduce stigma around help-seeking. Public education, specifically tailored to communities of interest, is also an important means of decreasing stigma.

Do you know of any resources specific to trauma informed education, curricula, or training for primary care providers? 

Here are a few papers about cultural traumas I recommend that could be included in a curriculum:

Anything additional you would like to share about this topic?

Collective trauma can arise from oppressive forces, such as racism. Unless a person is a victim of a blatant hate crime, clinicians are usually not looking for racial trauma when they assess patients. It is hard to be a person of color in America without experiencing some amount of racial stress and trauma, and so clinicians should not hesitate to assess for this.

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  • Interview References  
    • Baker, M. G., Peckham, T. K, & Seixas, N. S. (2020). Estimating the burden of United States workers exposed to infection or disease: A key factor in containing risk of COVID-19 infection. PLoS One, 15(4), e0232452. Advanced online publication. doi: 10.1371/journal.pone.0232452
    • Centers for Disease Control and Prevention. (2020). Coronavirus Disease 2019: Cases in the U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
    • Gamio, L. (2020, March 15). The workers who face the greatest coronavirus risk. New York Times. Retrieved from https://www.nytimes.com/interactive/2020/03/15/business/economy/coronavirus-worker-risk.html
    • Garg, S., Kim, L., Whitaker, M., O’Halloran, A., Cummings, C., ... Fry, A. (2020). Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. US Department of Health and Human Services/Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report, 69 (15), 458–464.  doi: 10.15585/mmwr.mm6915e3  Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e3.htm?s_cid=mm6915e3_w
    • Masri, L. (2020, April 24). COVID-19 takes unequal toll on immigrants in Nordic region. Reuters. Retrieved from https://www.reuters.com/article/us-health-coronavirus-norway-immigrants/covid-19-takes-unequal-toll-on-immigrants-in-nordic-region-idUSKCN2260XW

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