Decolonizing the Medical Model Approach to Trauma

Research on the negative impact racial trauma has on Black, Indigenous, and people of color (BIPOC) communities has substantially grown in recent years. Despite this increased attention, however, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) narrowly defines trauma in a way that excludes racial trauma.

In a new article, published in the International Journal of Social Work Values and Ethics, the authors explore how current, mainstream understandings of trauma, which are largely influenced by White, Western individuals, are reflective of colonialism in mental health care. They highlight how the posttraumatic stress disorder (PTSD) diagnosis does not capture the ongoing racial trauma experienced by people of color, and offer alternative understandings of trauma that are more inclusive. Additionally, the authors critique current Western approaches to treating trauma, and suggest that other pathways to recovery, particularly those that address the mind-body relationship, be adopted.

Critiquing the rise of Health Management Organizations (HMOs) in the 1990s, which “prioritized profit over care,” the authors, Debra K. Minsky-Kelley and Becki Hornung at Carthage College, write: “The mental health care ‘arm’ of the social work profession is increasingly adopting the view and subsequent practice that clients’ problems are pathologically located within their own individual inability to negotiate the world around them. Many social workers have bought into the distorted version of what is ‘normal’ as defined by a capitalist hegemonic system.”

The Social Work Code of Ethics emphasizes the role of social work in addressing social injustices. The authors argue that confronting injustices such as structural racism, including that within the mental health field, is key to the profession. They reference the work of West Indian political philosopher and psychiatrist Frantz Fanon, as well as more contemporary writers, to highlight the idea that Black children may experience thoughts, ideas, etc., that are not uncommon in the Black community, but are labeled as “abnormal” from the purview of the White-worldview grounded mental health field.

The authors write: “From a structural racism perspective, Fanon’s ideas speak to the emotional and psychological toll that this kind of constant code-switching can take on the mental wellbeing of BIPOC populations. Specifically, that there is a built-in form of oppression in our society that requires people who are not White to deny their Blackness, Brownness, Indigeneity to “adjust” to the White supremacist and dominant world view of ‘normal.’”

Additionally, Western understandings of trauma have been critiqued for not adequately getting at complex traumatic experiences, as the PTSD diagnosis is reserved for specific, past traumatic events, as opposed to traumatic experiences that are ongoing. Critics have offered alternatives, such as “developmental trauma disorder,” which includes a description of chronic trauma. Yet the proposal to include this diagnosis in the DSM was rejected. Some organizations, such as the Child Trauma Academy, have responded by no longer using DSM frameworks to study trauma; however, given that use of DSM diagnoses is required by insurers in the U.S. for reimbursement, many organizations have no way around them.

Attention is increasingly being paid to the negative effects racism and discrimination, including more covert forms of discrimination, such as racial microaggressions, have on the physical and mental health of people of color. In addition to the ever-present, chronic trauma of racism, the historical trauma of centuries of discrimination and abuse have been shown to continue to affect BIPOC communities today. Yet, despite a growing body of research, racial and historical traumas are still not included in the DSM.

Some providers have attempted to address this issue by screening for racial trauma, but this is not the norm. Others have suggested using the descriptor “continuous traumatic stress” (CTS) as a way to capture trauma that is ongoing, chronic, and significant. The descriptor was first developed by anti-apartheid mental health professionals in South Africa. It has been used to understand the traumas associated with war, refugee status, and community violence.

Minsky-Kelley and Hornung describe the major differences between PTSD and CTS, such as that CTS describes unavoidable and chronic trauma, accompanied with a lack of hope that circumstances will get better, whereas PTSD tends to refer to trauma that has occurred in the past. Further, while the symptoms of PTSD and CTS are the same, such as avoidance and negative mood, within the framework of CTS, these symptoms are understood as being adaptive and necessary, rather than something abnormal that requires professional intervention.

The authors advocate for approaches to recovery that are non-colonialist in nature. Rather than the mental health provider being seen as an “expert” who “fixes” the pathological client, the therapeutic relationship is instead a partnership, where the client is valued as holding important insights regarding how they have creatively adapted to a world that discriminates against and is harmful to them.

Mainstream, Western approaches to treating PTSD currently involve a combination of psychotherapy and medication. However, these treatment approaches fail to grasp the role that systemic injustice has on the mental health of marginalized groups, and instead, perpetuates the understanding that pathology is located within the individual, rather than within society itself.

A number of alternatives are offered, with emphasis placed on recovery pathways that address the mind-body relationship, which is critical to trauma recovery, such as yoga, tai-chi, mindfulness, movement, including song and dance, and massage or other body-based approaches. Additionally, the authors call attention to approaches that address underlying societal issues, such as access to healthcare, housing, and safety.

The authors conclude: “Helping clients to better understand the harmful social structures that contribute to their distress would be central to helping people create transformed narratives about where the pathology lies—within these social structures, not the individual. However, to do this, the social work profession will need to examine the structures in place that create a false binary of the macro-micro division as it relates to human behavior and how we can begin to blur that binary so that human behavior and coping are contextualized within racist social and economic structures towards a more liberatory paradigm of mental health.”

 

 

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Minsky-Kelly, D. K. & Hornung, B. (2022). Structural whiteness in mental health: Reexamination of the medical model through a lens of anti-racism and de-colonization. International Journal of Social Work Values and Ethics, 19(2), 153-173. https://doi.org/10.55521/10-019-210 (Full text)