Abstract
The coronavirus disease-19 (COVID-19) pandemic has disproportionately impacted Black, Indigenous, and People of Color (BIPOC) communities due to systemic health disparities based on race, ethnicity, and systemic inequities. Among extent literature on BIPOC mental health and COVID-19, there is a pressing need for culturally responsive, trauma-informed treatment approaches that go beyond the broader impacts of the pandemic or immediate pandemic-related concerns and address the persisting impacts of the COVID-19 on BIPOC mental health. To this end, our article aims to equip professional counselors with the necessary tools to serve BIPOC clients more effectively by (1) understanding the ethno-racial inequities of the COVID-19 pandemic, (2) assessing the intersectional dimensions of stress and trauma associated with COVID-19, and (3) employing therapeutic approaches to promote physical and mental well-being in BIPOC clients.
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The coronavirus disease-19 (COVID-19) pandemic has had an unprecedented global impact. Current investigations have revealed drastic increases in COVID-related mental health concerns among general populations (Dailey et al., 2022a), with a disproportionate impact on racially and ethnically minoritized and socioeconomically disadvantaged populations (Harrichand et al., 2021). Following the historical trends of public health crises, Black, Indigenous, and People of Color (BIPOC) communities are experiencing more severe and longer-lasting physical and psychosocial consequences due to pervasive health disparities based on race, ethnicity, and systemic inequities (Ho et al., 2020; Litam & Hipolito-Delgado, 2021). Increased risk and vulnerability for BIPOC communities can be directly attributed to health disparities that existed well before the COVID-19 pandemic (Berger & Miller, 2021). This encompasses higher rates of comorbid medical conditions, lower income and wealth levels, limited access to healthcare, and housing or employment conditions that make it difficult to adhere to social distancing recommendations (Hooper et al., 2020).
As such, professional counselors working with BIPOC clients should understand the multidimensional impact of the pandemic on mental health, considering factors such as systemic disparities, socioeconomic conditions, and racial and ethnic identities. Counselors must be able to assess how a client’s racial, cultural, and sociopolitical experiences associated with the pandemic influence mental health concerns and treatment, including the ways in which they experience distress and difficulty, as well as the ways in which they persist. While much literature has focused on the trauma and disparities during COVID-19, it is also crucial to acknowledge client resilience and post-traumatic growth (PTG) within BIPOC communities (Burt et al., 2022). By utilizing an intersectional trauma and resilience framework that addresses these layered individual and collective experiences, this article aims to acknowledge ethno-racial inequities and highlight the remarkable ability of BIPOC clients to emerge from adversity with increased strength and resilience (Cabrera Martinez et al., 2022). Our purpose is to help professional counselors better serve BIPOC clients by gaining a deeper understanding of (1) ethno-racial inequities of the COVID-19 pandemic, (2) ways to conceptualize and assess intersectional dimensions of stress and trauma, and (3) therapeutic approaches to promote well-being for BIPOC clients. We chose to use the term BIPOC based on our desire to identify an inclusive term that encompasses a shared experience across multiple minoritized groups. We acknowledge that some scholars view this term as problematic because it suggests homogeny among persons who do not identify as White or centralizes specific groups (i.e., Black and Indigenous; Halgunseth et al., 2022). Conversely, our intent is to elevate shared oppressive experiences within the context of the COVID-19 pandemic.
Systemic Health Disparities and COVID-19
Historical trends indicate systemic health disparities are associated with more severe and longer-lasting psychological outcomes following a public health crisis (Bai et al., 2004; Ho et al., 2020). Examinations of the emotional impact of quarantine during the severe acute respiratory syndrome (SARS) pandemic, the Ebola epidemic, and the Middle East respiratory syndrome (MERS) outbreak indicate adverse outcomes among the general population, including emotional distress, increased risk for depression and anxiety, and pronounced feelings of isolation (Bai et al., 2004; Lee et al., 2018). Specifically, loss of routine, diminished social connectedness, income loss, and resource instability are leading contributors of quarantine-related distress among nonclinical populations (Ali et al., 2020). A common factor across all these investigations is that BIPOC populations report more severe and longer-lasting physical and psychosocial consequences than their White counterparts (Ho et al., 2020). Current literature indicates COVID-19 is following a similar trajectory to prior public health crises.
In the first few months of the pandemic, COVID-19 positivity rates were nearly twice as high for non-Hispanic Black and Hispanic Americans as compared to their White counterparts (Rentsch et al., 2020). In comparison to White populations, BIPOC communities also experienced greater COVID-related disruptions in educational access and health and mental health care (Ho et al., 2020). In March 2020, the same month in which COVID-19 was declared a pandemic, 29 states and the District of Columbia reported statistically significant increases in unemployment, with higher disparities among low- or hourly-wage workers, women, and people of Color (Gemelas et al., 2021). While this gap has narrowed since 2020, COVID-related disparities persist for BIPOC communities in terms of infection rates, vaccination access, fatalities, and COVID-related unemployment (Gawthrop, 2022).
Immigrant BIPOC populations, who already face significant barriers accessing health care due to language barriers, immigration status, and income, experience considerable psychological stress related to higher levels of COVID-related unemployment and problems accessing COVID-19 assistance programs (Falicov et al., 2020; Solheim et al., 2022). The loss of elders to COVID-19 is a particularly painful source of grief, especially in cultures that strongly value generational hierarchies (Causadias et al., 2022). As the pandemic stretches into subsequent years, current research consistently demonstrates COVID-related stressors related to infection, death, loss of a loved one due to COVID-19, and pandemic-related unemployment concerns are higher within BIPOC communities (Jay et al., 2020). As such, assessing how the client’s multiple identities and oppressive systems (e.g., racism, sexism, ethnocentrism, or classism) intersect and produce multiple oppressive forces in clients’ lives is necessary to understand how some BIPOC clients may experience COVID-19 (Walby et al., 2012; Watson et al., 2020).
Intersectional Dimensions of Stress and Trauma During COVID-19
Crenshaw (1989) first introduced the concept of intersectionality to describe how the convergence of various dimensions of identity intersect and interact to shape individuals’ experiences of discrimination and privilege. Crenshaw’s seminal work has had a profound impact by highlighting the critical importance of recognizing and addressing the intersecting forms of discrimination faced by Black women, pioneering the concept of intersectionality in feminist and anti-racist discourse. Intersectionality recognizes that an individual’s experiences and social standing are not solely dictated by a single facet of their identity; rather, they are influenced by the complex interplay of multiple identity factors, including race, social class, gender, sexual identity, ability, religion, national origin, immigrant status, and other relevant aspects of identity or group membership (Walby et al., 2012).
Building upon Kimberlé Crenshaw’s foundational work, Collins and Bilge (2016) introduced a comprehensive framework consisting of six core tenets: power, complexity, social inequality, social context, social justice, and relationality. These principles facilitate the analysis of intersecting social identities in society, extending the understanding beyond race and gender to encompass issues of authority, multifaceted identities, systemic inequalities, societal influences, equity, and interconnected experiences. By considering these tenets, we gain valuable insights into how trauma operates within intersecting social identities (Kira et al., 2021). Intersectional trauma, as defined by Watson et al. (2020), encompasses the complex, multiple, and often ongoing (i.e., systemic) ways in which trauma is caused or exacerbated by social injustice and discrimination due to the convergence of identity dimensions.
Systemic traumas, coupled with COVID-related stressors, both endanger and further marginalize BIPOC communities (Ezell et al., 2021; Kira et al., 2021). Because trauma can be generated intergenerationally, from individual events or systemic factors, an intersectional approach can help counselors explore the convergence of client identities and the multiple ways systemic, institutional, and structural inequities impact individuals and communities with respect to access to power and privilege (Watson et al., 2020). A vital component of this work is understanding and addressing the pathways to resilience for individuals and the systems in which they are situated.
Resilience and Stress-Related Growth
Counter to Eurocentric views of trauma, resilience, not pathology, is the more common outcome following a severe stressor (Bonanno, 2005). Another common misperception is that resilience is a personal characteristic. Conversely, resilience is a dynamic, not static, phenomenon (Galatzer-Levy et al., 2018) that is built (or limited) based on access to personal, familial, social, and material resources (Hobfoll et al., 2015). As such, resilience must be understood from an intersectional perspective, as resilience is a process dependent on structural and systemic factors, such as access to resources or oppressive barriers (Hobfoll et al., 2015).
Despite centuries marked by colonialism, slavery, forced displacement, and discrimination, BIPOC communities have consistently demonstrated an extraordinary ability to persevere and adapt (Cabrera Martinez et al., 2022). Numerous studies emphasize the crucial role of resilience as a protective factor within BIPOC communities, illustrating that resilience is a dynamic process shaped by both individual and environmental factors (Hobfoll et al., 2015). While some might interpret these findings as suggesting that resilience is an outcome of systemic and generational oppression (Wong-Padoongpatt et al., 2022) or that individuals with multiple marginalized identities are “more resilient” due to their adeptness at navigating intersecting systems of oppression (Aguilera & Barrita, 2021), a closer examination of this literature underscores the significance of social support and coping strategies in fostering post-traumatic growth (PTG) and resilience among BIPOC clients (Hobfoll et al., 2015).
Research on stress-related growth within BIPOC populations during crises, like the COVID-19 pandemic, has countered deficit perspectives endemic to much academic research, with studies revealing how BIPOC individuals and communities harness adversity for personal and collective growth. These findings emphasize the role of resilience factors, including cultural strengths, community support networks, and shared historical narratives of overcoming systemic challenges, in facilitating growth, healing, and persistence despite adversity. For example, Dong et al. (2023) demonstrate how BIPOC communities have drawn upon their cultural heritage and traditions to cope with the emotional toll of the pandemic and cultivate resilience. Ortega-Williams et al. (2021) emphasize the importance of social cohesion and mutual aid within BIPOC communities, illustrating how collective efforts can lead to PTG. Oh et al. (2023) underscore the significance of acknowledging the intersectionality of identity factors and how they influence the experience of stress-related growth within Asian international students and workers. Overall, these findings highlight collective and culturally based forms of resilience within BIPOC communities. Taken together, it is unsurprising that resiliency research suggests that employing intersectional approaches when working with BIPOC clients enhances client resilience and leads to better and more enduring treatment outcomes (Parmenter et al., 2021).
Importantly, the exploration of stress/trauma and resilient or growth-oriented trauma responses must be situated in a broader understanding of the ways in which the mental well-being of BIPOC communities have been viewed. Specifically, well-being practices are endemic to BIPOC communities, but colonization and oppression attempt to erase, pathologize, and/or appropriate these practices within the counseling field and broader society (Milner et al., 2021). More recent counseling literature has challenged the field by pointing to the importance of understanding well-being practices, which are both culturally specific and overlapping across cultural groups. Specifically, intersectionally oriented literature has highlighted strengths and mental well-being practices within BIPOC communities including collective emotional expression for Latinx communities (Adames et al., 2021), holistic and interdependent wellness practices for Asian communities (Milner et al., 2021), cultural ceremonies for indigenous communities (Gone, 2013), and racial justice activism for Black communities (French et al., 2020). These exemplars are by no means an exhaustive list but shown as examples to underscore that counselors must understand BIPOC well-being not just in terms of overcoming or thriving in response to adversity, but also as a vital component of a lived cultural experience that exists regardless of experiences with adversity. There is a danger that in focusing on resilience and post-traumatic growth, even positive psychological outcomes for BIPOC individuals will be seen through the lens of damage, further pathologizing BIPOC communities.
Applying an Intersectional Trauma and Resilience Framework
While counselors have indeed made commendable progress in adopting culturally relevant, trauma-informed approaches, there remains a significant imperative to further integrate and implement these principles into practice; making counseling systems more resilience-promoting (Lenz & Lemberger-Truelove, 2023) and honoring the cultural wellness and healing practices (Milner et al., 2021). Creating a culturally sensitive and empowering therapeutic environment is pivotal for addressing the multifaceted challenges experienced by BIPOC clients during the COVID-19 pandemic while simultaneously nurturing growth and resilience. To employ an intersectional trauma and resilience framework, counselors must acknowledge historical trauma, systemic disparities, racial and ethnic identity, and oppression and validate the unique experiences of BIPOC clients (Watson et al., 2020). This approach encourages exploration of personal and community resilience, always considering the client’s cultural context, and facilitating discussions on areas of personal growth and empowerment that may have emerged during the pandemic. Additionally, it entails supporting clients in identifying opportunities for advocacy and collective healing within their communities. Trauma-informed care principles, recognizing the interconnectedness of personal experiences with socio-structural factors, should underpin the therapeutic process (Lenz & Lemberger‐Truelove, 2023).
Counselors should be acutely aware of how cultural norms, traumatic experiences, stigmatization, misdiagnosis, and cultural mistrust may impact BIPOC clients’ access to physical and mental health services. This awareness can be enhanced by understanding fundamental concepts related to multigenerational trauma, racial and ethnic identity, acculturation, and how to address client experiences of racism, discrimination, and cultural mistrust throughout the counseling process (Mukhtar, 2023). Moreover, counselors can strengthen their ability to conceptualize, assess, and treat these stressors by delving into critical concepts within the context of COVID-19. These include multigenerational trauma, racial and ethnic identity, acculturation, and the importance of attending to client experiences of racism, discrimination, and cultural mistrust. This is not a step-by-step analytical process, but the ability of the counselor to fully embrace all aspects of the client’s identity and systems which impact the client. By exploring the client’s multiple identities, group memberships, racial identity, and acculturation, counselors can also facilitate the recognition of racial and cultural strengths that clients can draw upon. This comprehensive understanding of essential domains and assessment strategies, along with the selection of appropriate treatment strategies, is central to the recommendations presented in this article, which aims to empower counselors and make counseling systems more resilience-promoting for BIPOC clients during and beyond the pandemic.
Recommendations for Case Conceptualization and Assessment
Professional counselors can improve their ability to conceptualize, assess, and treat these stressors by understanding and incorporating fundamental concepts related to multigenerational trauma, racial and ethnic identity, acculturation, and how to attend to clients’ related experiences of racism, discrimination, and cultural mistrust throughout the counseling process (Lenz & Lemberger-Truelove, 2023). Although counselor training supports an exploration of these concepts, the counseling and psychology literature base lacks the development of counseling strategies to combat multilayered systems of oppression (Ezell et al., 2021). We explore these fundamental concepts, particularly within the context of COVID-19, and provide recommendations for counselors to support case conceptualization and assessment.
Multigenerational Trauma
Having established a positive association between COVID-related traumatic stress and health disparities for BIPOC individuals (Kira et al., 2021), it is important to understand that adverse impact is not limited to individuals. Decades of research have established that executive functioning is largely genetic (Friedman et al., 2016; Hanson et al., 2012). Kira et al. (2021) found survival and cumulative traumas are directly associated with deficiencies in neurological functioning, specifically working memory and inhibition. Thus, the idea that neurological functioning is impacted by sociodemographic factors which contribute to traumatic stress demonstrates the deleterious impact of multigenerational trauma. It follows that multigenerational stressors and systemic oppression further challenge communities’ abilities to access protective resources that enhance resilience (Ezell et al., 2021; Kira et al., 2021). Lack of trust in government and social supports or harms perpetuated by institutions (e.g., genocide for American Indian/Native American communities, slavery and Jim Crow for African American communities) may exacerbate distress. Thus, ways in which a client may cope with and overcome current pandemic experiences are also driven by intergenerational experiences of resilience (Goodman, 2013).
To consider the impact of multigenerational trauma in the context of COVID-19, counselors should learn about the historical and current injustices that may have impacted their clients. Counselors should be particularly cognizant of how endemic cultural norms, experiences of trauma, stigmatization, misdiagnosis, and cultural mistrust may impact BIPOC clients’ access to physical and mental health services (Mukhtar, 2023). Testing the accuracy of this knowledge is required to avoid erroneous assumptions, but the responsibility of educating the clinician should not be placed on the client. Demonstrating a genuine commitment to acknowledging systemic disparities and working collaboratively with the client to address this in counseling can help ameliorate harm and (re)build trust violated by historical and ongoing intersectional trauma(s) and acculturative stress(ors) (Ezell et al., 2021).
Racial and Ethnic Identity
The concept of racial identity is related to the extent to which an individual identifies with the racial group to which they supposedly belong and the belief that commitment to one’s racial group is necessary for healthy psychological functioning (Helms & Cook, 1999). Ethnic identity refers to the extent people accept, identify with, and affirm a group’s cultural practices, norms, values, and beliefs (Umaña-Taylor et al., 2014). Both are seen as developmental processes that begin at an early age and are influenced by contextual factors (e.g., parental influences, peer group interactions, community support). High levels of ethnic and racial identity may assist BIPOC individuals in mitigating the negative effects of experiences of racism and discrimination (Lawrence et al., 2007). A high level of ethnic identity (i.e., positive feelings of one’s ethnic group membership, sense of belongingness) may also serve as a valuable resource for coping with stress related to acculturation (Cobb et al., 2016). Notably, racial and/or ethnic identity status may not serve as a protective factor for populations who experience unauthorized legal status or view their racial and/or ethnic group as unwanted, rejected, and/or criminalized by society (Carter et al., 2017).
When considering racial and ethnic identity in the context of COVID-19, counselors must attend to the ways in which existing health disparities have been exacerbated by the pandemic. Counselors should be aware of the complexity involved in clients’ racial and/or ethnic group membership(s) and provide culturally responsive support for feelings of loneliness, isolation, hopelessness, anger, and fear (e.g., experiences of hate crimes and police brutality). Counselors also must consider how the client’s racial or ethnic identity serves as a protective factor in supporting resilience (Oh et al., 2023) by encouraging exploration of personal and community resilience, considering the client’s cultural context, and promoting discussions on areas of personal growth and empowerment that may have emerged during the pandemic. Counselors seeking to utilize racial and/or ethnic identity measures, such as the Cross Ethnic-Racial Identity Scale—Adult (CERIS-A; Worrell et al., 2019), should consider whether they are focusing on racial and/or ethnic identity development or the meaning and significance of ethnicity and/or race, as these measures often fall within these broad categories (Yip, 2018). Another useful tool could be assessing BIPOC clients’ experiences with colorism (e.g., assessing skin tone variation preferences within racial and/or ethnic groups) since experiences with colorism have historically been linked to an individual’s self-concept, impression formation, upward mobility, and attractiveness/affiliations in African American populations (Harvey et al., 2017). Utilization of semi-structured interviews, such as the Cultural Formulation Interview (American Psychiatric Association, 2022), could also provide counselors with clients’ understanding of their lived experiences using a cultural lens.
Acculturation
Acculturation has been viewed as the phenomenon that occurs when an individual encounters more than one cultural system (Padilla, 1980). While it is most often associated with immigrants (Schwartz et al., 2010), acculturation has also been found to be relevant for non-immigrant BIPOC individuals (Johnson & Reynolds, 2018). We assert that acculturation is an important factor to consider for BIPOC clients who live or work in spaces that operate according to White Western European dominant cultural norms, which is common in the U.S. Acculturative stress, or dysphoria-related intercultural contact or cultural adaptation (Berry, 2006), is linked to personal and social concerns, including depression, anxiety, and identity confusion (Ellis & Chen, 2013). With respect to the acculturation process for immigrant populations, some research findings suggest that aside from the expected stress related to adapting to new cultural norms, undocumented immigrants may experience additional marginalization based on their fears of deportation and lack of access to physical and mental health services (Letiecq et al., 2022; Solheim et al., 2022), which could further account for deepening existing disparities. The notable disparate outcomes for immigrant communities related to COVID-19 suggest that addressing acculturative stress is a uniquely critical component of the counseling process. For example, parents who faced challenges navigating the educational system due to a lack of language support may have experienced additional stressors navigating online learning during the first year of the pandemic. Families also may have been unable to access technology due to prohibitive cost and systemic injustice that results in some immigrants being employed in low-wage work (Jay et al., 2020). Learning losses associated with these deficiencies remain unknown (Gemelas et al., 2021).
The acculturation process is an important aspect in counseling assessment since acculturative stress is associated with adjusting cultural values and beliefs to accommodate the norms and values of the dominant culture (Cobb et al., 2016). Accordingly, counselors should assess for stressors related to mental health impacts of acculturation and ways these intersect with COVID-19 stressors. Counselors can begin by identifying the barriers and stressors experienced by clients related to acculturation and provide support for the emotional distress related to acculturation barriers, including providing resources and opportunities for advocacy. Counselors should also assess family narratives of overcoming systemic oppression, such as cultural healing practices, ways of making meaning of events, and experiences with advocacy and social action. Counselors can seek to work in partnership with communities to understand how to build trust from the community’s perspective, rather than making assumptions. This is especially important for counselors working with communities different from their own in terms of culture, socioeconomic status, and other factors.
Counselors choosing to utilize formal assessment tools (e.g., Bidimensional Acculturation Scale for Hispanic; Marin & Gamba, 1996) to measure acculturation are advised to understand whether the assessment is focused on conditions, orientations, or outcomes related to acculturation. Within the context of ethno-racial oppression and discrimination, counselors should carefully consider measures that emphasize behavioral adjustments to the majority culture (e.g., accepting/understanding the local political system), as these may be counterproductive to supporting the client (Wallace et al., 2010).
Racism and Discrimination
The COVID-19 pandemic has amplified preexisting historical and ongoing racial stressors, disparities, and inequities (e.g., microaggressions, xenophobia, and lack of access to physical and mental health services) that continue to exist for BIPOC communities (Lou et al., 2022; Watson et al., 2020). Events like the killings of George Floyd and Breonna Taylor (among others) and hate crimes against Asian Americans have contributed to greater psychological distress for BIPOC communities (Lou et al., 2022). These racialized inequities underscore the critical need to understand and address race and discrimination as race-based trauma for BIPOC populations. Racism can manifest in various ways for BIPOC individuals, encompassing both individual acts (such as interpersonal discrimination fueled by personal racial biases) and structural or systemic racism. This systemic racism encompasses patterns deeply ingrained within systems, laws, written or unwritten policies, long-standing practices, and prevailing beliefs and attitudes. Such systemic racism results in the widespread endorsement, perpetuation, and endorsement of unjust treatment towards people of color (Braveman et al., 2022).
In addition to the different forms of racism, it is also important to address how racism manifests differently for BIPOC clients based on specific racial-ethnic identities as well as intersections of identity. For example, the pandemic exacerbates anti-Asian racism because of existing stereotypes of Asians and Asian Americans as “perpetual foreigners” and “disease carriers” (Hahm et al., 2021, p. 2). Stereotypes of Black individuals as threatening or dangerous intersected with COVID-19 health precautions of wearing a mask, as Black women and men feared being perceived as a robber or suspect if wearing a mask, with Black men having slightly higher perceived social identity threat (Kahn & Money, 2022). Indeed, both Asian and Black individuals worried about masking, reduced mask usage, and avoided police encounters based on these stereotypes, likely making them less able to get needed help and more vulnerable to illness (Kahn & Money, 2022).
Given this context, counselors are responsible for broaching the impact of injustice and including the intersection of racism-related trauma and COVID-19-specific discrimination in their assessment. Counselors failing to recognize and attend to a client’s experiences with racism and discrimination may not only serve as a barrier to treatment access, but also perpetuate oppressive health care practices (Williams, 2020). In the context of pandemic, access to health care that is attuned to the unique considerations for BIPOC individuals living in a racialized and racist society is a critical need. Counselors and health care providers that emphasize the critical need to mask for safety without acknowledging that wearing a mask may increase the perceived and real danger for some clients may not only fail to have a positive impact on their clients but may also further marginalize and exacerbate the distress already felt by the client. Counselors should give clients the autonomy and space to discuss their experiences with racism and discrimination and consider how the client’s current presenting problems, and associated goals, are related to their experiences – recognizing that each racial-ethnic group is not a monolith and racism may or may not be the primary presenting concern for BIPOC clients. This includes cognizant recognition of the impact of racial trauma and broaching differences and similarities in client/counselor ethno-cultural identities (Day-Vines et al., 2020), and ensuring any formal assessment tools used are appropriate and relevant to the client’s experiences and identities. Throughout this process, counselors must carefully assess and closely monitor their own reactions and motivations which impede the counseling process, including occurrences of transference, countertransference, implicit and explicit bias, and counselor privilege—which may occur both with clients and counselors that share similar identities and those that have different identities (Sue et al., 2019).
Microaggressions
Microaggressions, a form of racism and discrimination, are defined as “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults to the target person or group” (Sue et al., 2007, p. 271). Research suggests that repeated exposure to microaggressions (interpersonal and societal) can create toxic climates for those targeted, including impacting an individual’s and/or group’s sense of dignity, self-esteem, belongingness and feelings of safety in work, education, and health care settings (Freeman & Stewart, 2018; Sue et al., 2019). Microaggressions, particularly when experienced in health care systems, may be related to weak therapeutic working alliances, higher dropout rates in treatment, as well as mistrust toward health care systems (Owen et al., 2019; Williams, 2020). Although the pandemic has highlighted an even further exacerbation of the disparities in rates of mental illness between Whites and individuals from historically minoritized racial and ethnic groups (Thomeer et al., 2022), lack of trust in mental health services may explain lower access rates for BIPOC communities.
During the COVID-19 pandemic, the manifestation of racial microaggressions in counseling or therapy may be amplified. Increased stress and mental health needs, the transition to teletherapy with limited communication cues, heightened racial tensions, and disparities in the pandemic’s impact on racial and ethnic communities all contribute to this phenomenon (Owen et al., 2019). The reliance on technology, the potential for written communication microaggressions, and therapists’ own stress and isolation can further exacerbate the issue. Professional counselors should actively create a safe space for clients to address these microaggressions, all while reflecting on their own biases and behaviors. To effectively address biases and combat microaggressions in their work, counselors should engage in continuous self-reflection, consultation, and supervision to understand their own biases and assumptions. Adopting a stance of cultural humility, they should remain open to learning from their clients and actively educate themselves about various cultural backgrounds (Sue et al., 2007). Beyond educating themselves, counselors should understand classifications of microaggressions (see Sue et al., 2007; Williams et al., 2021) and scales, such as the Racial Microaggressions Scale (RMAS; Torres-Harding et al., 2012) and the Racial and Ethnic Microaggressions Scale (Nadal, 2011), to assess client perceptions and experiences with racial and ethnic microaggressions.
Cultural Mistrust
The term cultural mistrust was originally created to explain African Americans’ cynicism and mistrust of White people and White-controlled institutions due to historical events (e.g., race-based medical experiments) that were conducted at the expense of African Americans lives (Whaley, 2001). Cultural mistrust is a critical factor in understanding the underutilization of health services among African Americans and other minoritized populations. Cultural mistrust is about how an individual’s perception, understanding, and relationships with White populations and/or White-dominated systems may influence their use of, and interactions with, those systems (Whaley, 2001). This term has extended to include all minoritized populations that experience ongoing forms of racism, discrimination, and stigma from dominant and privileged populations. Consequently, the underutilization of mental health services and service satisfaction may be directly related to feelings of cultural mistrust (Alvarez et al., 2022).
Ezell et al. (2021) described the racialized nature of public health crises, such as Hurricane Katrina and the Flint Water Crisis, noting the ways in which disparate outcomes are linked to racism embedded within systems and structures promote cultural mistrust. They discuss the “psychosocial contract” (p. 78) that can either build or erode one’s trust in the government and public health. This contract is dependent upon one’s relational experiences, which cannot be separated from an individual’s racial and ethnic identities. During COVID-19, social distancing exacerbated adverse mental health outcomes for some vulnerable groups, creating even greater health disparities (Jay et al., 2020).
Recommended Treatment Approaches
Having reviewed critical concepts related to understanding and assessing intersectional trauma and resilience within the context of COVID-19 in BIPOC populations, we present therapeutic approaches counselors can use to address existing disparities and inequities as they move beyond the initial assessment approaches described above. While it is the ethical responsibility of all counselors to embrace the client’s social and cultural context throughout the counseling process, we present approaches which are uniquely positioned within the intersectionality and BIPOC literature. Specifically, Collins and Bilge (2016) six core tenets of intersectionality serve as guiding principles for our recommendations. These tenets remind us of the dynamic interplay between social identities, the unequal distribution of power, and the influence of broader social contexts in shaping individuals’ experiences (Collins & Bilge 2016). They emphasize the significance of recognizing not only the layers of oppression but also the strengths and resilience inherent in BIPOC communities, contributing to a holistic and culturally responsive approach to healing and empowerment. While other approaches, such as group counseling and Cognitive Behavioral Therapy (CBT), may share basic intersectional counseling tenets (Hays & Iwamasa, 2006), an individualistic, rather than ecosystemic, worldview is used. As such, when advocating for and promoting physical and mental well-being in BIPOC populations an intersectional lens is recommended (Wright & Chan, 2022).
Relational-Cultural Therapy
Relational-cultural therapy (RCT) was originally developed to focus on exploring relationships and feelings of belongingness in clients, rather than pathology, and to acknowledge and address how intersecting historical and ongoing systemic inequities could impact their relationships (Jordan, 2009; Trepal et al., 2012). RCT, based on the tenets of feminist, psychodynamic, and multicultural theories, puts power dynamics and social inequities at the core of understanding people’s experiences of isolation, shame, and disempowerment in their relationships (Haskins & Appling, 2017). RCT can be used to provide a supportive and safe space to work with clients on how to recognize, form, build, and maintain healthy relationships, while also acknowledging how external forces have impacted their relationships (Jordan, 2009).
Frey (2013) mentions four characteristics of growth-fostering relationships. First is mutual engagement and empathy that involve mutual involvement, commitment, and sensitivity in the relationship. The second is authenticity which involves the freedom and the ability to be open and honest about one’s feelings, experiences, and thoughts while knowing this authenticity may impact the other person. The third is empowerment that signifies becoming stronger and more confident because of the relationship. Lastly, the ability to express, receive, and process relationship differences in a way that fosters mutual empowerment and empathy.
RCT therapeutic strategies specifically aim to empower BIPOC clients by reconceptualizing relational disconnections from a systemic perspective; exploring clients’ cultural norms, expectations, and ideals in relational images; examining power and privilege within the social and relational context; promoting self-empathy; and building relational hope and resilience (Haskins & Appling, 2017; Jordan, 2009). Because individuals who have experienced interpersonal trauma may have limited exposure to functional relationships, an RCT strengths-based approach may be useful in reframing the self-blame (i.e., internalized racism) that often occurs in individuals who have experienced race-based trauma of an interpersonal nature and redirecting clients to focus on how external oppressive forces (e.g., hate crimes, gender role inequities) have influenced their relationships and feelings of self-worth.
Relationship building is particularly relevant in the context of COVID-19 because in addition to cultural mistrust, feelings of isolation and loneliness were more pronounced (Dailey et al., 2022a). RCT serves to establish higher levels of social connectedness, which has been identified as a vital protective factor in combating symptoms of depression and anxiety during COVID-19 (Dailey et al., 2022b). Professional counselors can use RCT to create supportive relationships among Asian American clients who, due to COVID-19, may have lost access to family/social connections. For example, when working with an Asian American student struggling with feelings of guilt, anxiety, and fear after being ridiculed by students in their dorm, counselors should provide a safe and mutually respective space by exploring the power and privilege in their relationships and associated social experiences. This can be done by asking the client to share their lived experiences and recent stressors, identifying the systemic and interpersonal forms of oppression related to their concerns (e.g., microaggressions they experience on campus, loss of supportive social connections, fear to leave their room, all which have increased during COVID-19), and ultimately helping them externalize the self-blame/guilt they feel and developing strategies to rebuild social connections on campus (e.g., exploring campus advocacy groups).
Psychology of Radical Healing
Like RCT, psychology of radical healing (PRH) is a form of radical affirmative therapy that focuses on creating a space for therapists and clients to actively work together to validate clients’ oppressive experiences (French et al., 2020). From a historical, systemic, social, and intersectional perspective, RCT takes a strength-based approach to promote internal resilience, hope, and healing strategies (Adames et al., 2023). Radical healing, rooted in the psychology of liberation, Black psychology, ethnopolitical psychology, collectivism, and intersectionality, was a framework originally created to move BIPOC communities dealing with racial traumas to new experiences of healing and liberation (French et al., 2020). PRH is considered radical because it requires BIPOC clients to actively resist their oppressive status and move towards freedom and wellness.
A radical approach moves beyond having clients develop coping skills to “survive” their oppressive status, which can lead to clients being defined only by their oppressive identities and experiences (Adames et al., 2023). Rather, radical healing is seen as a culturally responsive and strength-based approach to empower clients to thrive in an oppressive society by (1) revisiting and relearning the many positive contributions (historical and ongoing) oppressed populations have made in the world, (2) increasing clients’ awareness and understanding of systemic oppression, and (3) moving beyond oppression towards future possibilities and overall positive well-being (French et al., 2020).
Specifically, PRH therapeutic strategies consist of mental health practitioners creating a safe space for healing by increasing clients’ levels of critical consciousness, increasing clients’ awareness of cultural intersecting identities within both a realistic and positive framework (e.g., using media resources to explore populations’ historical and cultural contributions to society). Counselors also work with clients to develop strategies to fight oppression in their lives (i.e., identifying resources and allies) and work with the client to instill hope for positive future outcomes. This approach aims to assist counseling offer strength-based, culturally relevant, and racially responsive treatment whereby clients are viewed not only as oppressed people but also as human beings with strengths, agency, and future possibilities (Adames et al., 2021). Although some argue that having clients sit in both extremes (i.e., the despair of oppression and hope for freedom and future possibilities) can be detrimental to a client’s sense of well-being, theorists argue that increasing awareness of existing systems and historical contributions in an authentic, supportive, and safe space can result in positive future outcomes (Adames et al., 2021). Professional counselors can use a radical healing approach to supplement any theoretical counseling therapeutic approach by prioritizing the inclusion of internal and collectivistic strengths, external oppressive factors, and advocacy as part of a client’s evaluation and treatment process.
As counselors bring greater racial and cultural awareness into their work, they are also moving beyond Western forms of therapy and case conceptualization to incorporate a larger understanding of systemic inequities and their impact on people individually, collectively, structurally, and multigenerationally (DeAngelis, 2022). Other radical healing approaches consist of interventions such as healing circles, storytelling, dance, body positivity, spiritual practices, and connecting with faith leaders. These interventions allow individuals to rely on the cultural strengths of their respective communities to survive, thrive, and exist (DeAngelis, 2022). Counselors seeking to utilize these techniques do so with full understanding of the client’s connections to their community, value system, and cultural beliefs, as well as resources available to the client within their community.
Given that COVID-19 has blatantly exposed the ethno-racial inequities embedded in our health care systems, relational-cultural and radical healing therapeutic approaches can serve to empower, build resilience, and promote wellness in BIPOC communities who have faced intersectional and multigenerational trauma. Professional counselors, with the assistance of community leaders (e.g., church pastor, Black physicians), can create healing circles in African American communities (e.g., community centers, churches) that may be experiencing grief due to disproportionate rates of COVID-19 deaths in the African American community. This PRH intervention can assist community members with increasing their understanding of how systemic issues (e.g., cultural mistrust, lack of belief in or access to health systems) have contributed to these death rates while also remembering and sharing historical and current events (e.g., slavery, Black Lives Matter protests) where African Americans have rallied against oppressive systems. This collaborative sharing of historical and current strengths and successes as well as identifying available local community resources and allies could build community pride, trust, resilience, and care as well as promote positive future health outcomes for members of this community. Professional counselors can also work collaboratively with clients on the use of microintervention strategies to target those who perpetuate the use of microaggressions (Sue et al., 2019).
Microinterventions are viewed as “the everyday words or deeds, whether intentional or unintentional, that communicates to targets of microaggressions (a) validation of their experiential reality, (b) value as a person, (c) affirmation of their racial or group identity, (d) support and encouragement, and (e) reassurance that they are not alone” (p. 134). Strategies can include working with clients to acknowledge the harmful impact of the microaggressions they have experienced, disarming this impact by communicating its impact to perpetuators and educating perpetuators of the harm they have caused whether it was intentional or unintentional. For example, if an Asian American client express feeling hurt by comments their White roommates have made regarding Asian blame for COVID-19, using role plays to explore ways the client can respond to their peers regarding their blame and bias can be useful. Counselors should also work with clients to define safe spaces and places to do this work, discuss potential outcomes of using these strategies, and encourage clients to stay connected to support groups (e.g., buddy system, family support) to maintain healthy functioning while engaging in these active strategies.
Ecological Approaches
Ecological models of counseling, originating from Bronfenbrenner’s Ecological Systems Theory (1994), provide a framework for understanding the complexity of intersectional trauma and utilize systemic interventions to recognize oppressive experiences. Bronfenbrenner (1994) suggested that an individual’s environment is a nested arrangement of structures, each contained within the next. These systems include the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. At the macro-level, COVID-19 further highlighted issues of food insecurity, housing insecurity, income inequality, and health disparities that disproportionately affect BIPOC communities (Laurencin & McClinton, 2020). At the exosystemic level, informal networks of support, such as access to childcare, transportation, and school resources, were severely compromised (Fegert et al., 2020). Working from an intersectional trauma perspective, ecological models facilitate case conceptualization and development of meaningful treatment goals that are entrenched in understanding and responding to the client’s ecosystem (see Mayes & Byrd, 2022).
Suggested interventions to gather ecosystemic information are transgenerational trauma and resilience genograms (Goodman, 2013), cultural ecomaps (Yasui, 2015), and wrap-around counseling approaches (West-Olatunji et al., 2011). Like a traditional genogram, transgenerational trauma and resilience genograms utilized a strength-based framework which acknowledges generational patterns of trauma and related ecosystemic concerns (Goodman, 2013). While not specific to trauma, cultural ecomaps portray linkages between systems or persons within the client’s world and the nature of these entities within the client’s world (Yasui, 2015). When utilized in therapy, these visual depictions of interrelated client systems support discovery of various cultural and ecosystemic influences, such as a caregiver and a faith community, and barriers, such as a lack of family support and financial struggles. Wrap-around counseling approaches are especially well suited for schools or community-based mental health services in which the counselor has access to other service providers and support systems (Goodman, 2013).
Recommended ecological approaches for children, adolescents, and families include Lindblad-Goldberg’s Ecosystemic Structural Family Therapy (ESFT) which acknowledges the impact of cumulative traumas on family systems and supports the identification of interrelated patterns at the individual, systemic, and societal level (Lindblad-Goldberg & Northey, 2013). By intentionally focusing on the impact of trauma from a culturally aware, strength-based perspective, ESFT frames clinical issues as adaptive responses to hardship. Daniels (2022) recommends counselors working with BIPOC families combine ESFT with a family resilience framework.
Culture-as-Treatment
Another way of addressing the complex intersectional trauma experienced by BIPOC communities during COVID-19 is to center cultural practices. For clients who have experienced a legacy of colonization and oppression, there tends to be an erasure of history, culture and cultural practices, language, healing practices, and more. For example, Milner et al. (2021) discuss the erasure of a holistic view of mind and body that often present in Asian cultures due to colonization and ongoing oppression. Yet, counseling treatment commonly employs a Western European perspective which differentiates the mind and body. Erasure due to colonization also leads to othering and a pathologizing of many BIPOC communities; frequently, the dominant culture creates a view of the non-dominant culture as deficient, other, backwards, or stereotypical. The implications for counseling practice are significant, as the unconscious biases of clinicians can lead to misdiagnosis, pathologizing, and victim blaming.
As such, counseling approaches that seek to undo this erasure and pathologization can lead to healing for clients. Central to this work is for both counselor and client to develop an understanding of privilege and oppression and their own identities, or to develop critical consciousness (Comas-Díaz, 2016). Critical consciousness allows counselor and client to understand how systemic injustice operates to create harmful social conditions; greater awareness of the systemic sources of negative social outcomes can help prevent the continuation of pathologizing and the assumptions that problems—whether mental health, economic, or other—are the fault of individuals experiencing those problems.
Using a culture-as-treatment model can involve centering indigenous healing practices that may have been lost or pathologized due to oppression (Gone, 2013). Furthermore, this approach can involve engaging in cultural practices that might not appear to be therapeutic in nature, such as regaining language that was lost or wearing traditional dress. The culture-as-healing model (or culture-as-treatment) is potentially beneficial for BIPOC clients as it is a way of countering erasure and reclaiming of identity, leading to a sense of individual and collective identity, self-esteem, and community. For BIPOC clients during COVID-19, engaging in cultural practices with intentionality may have benefits for the entire family system. For instance, a counselor could support a Latina immigrant mother in cooking traditional meals with their child while the child is home from school. This intervention can help foster cultural pride and connectedness between parent and child, both of which can be healing and sustaining.
Future Directions for Counselor Research, Practice, Training, and Advocacy
Even as the COVID-19 pandemic transitions into a new phase with fewer restrictions and less severe COVID-related illnesses, certain factors persistently contribute to disproportionately high levels of mental health issues in BIPOC communities. These factors include systemic forms of oppression, limited access to care, and an unequal burden of stressors, notably the intense fear of future acts of racism (Lou et al., 2022). While the call for culturally responsive models of mental health service has been ongoing for decades, evidence-based therapy research, often led by White researchers with primarily White client populations, continues to dominate the field (Alvarez et al., 2022; Carter et al., 2017). Thus, there is a critical need for additional research, both quantitative and qualitative, focusing on BIPOC populations. Such research is essential to gather empirical evidence supporting more culturally inclusive assessment tools, therapy models, and preventative and resilience approaches. These culturally inclusive approaches may include evaluating the efficacy and outcomes of microintervention strategies, healing circles, and spiritual practices. This research is particularly crucial for assisting populations with intersecting oppressive identities, as these lived experiences can significantly impact physical and mental health outcomes, beyond the influence of socioeconomic circumstances.
We also suggest using a community-based participatory research (CBPR) framework since CBPR was originally developed to address health inequities by uniting researchers and community members as equal partners and collaborators in the co-creation of evidence based on culturally responsive services (Sánchez et al., 2021). Thus, working with BIPOC communities to gain a bottom-up understanding of their experiences related to intersecting trauma and mental health, while simultaneously assessing their understanding of, and trust in, mental health from a cultural perspective, can add new culturally relevant information grounded in the lived experiences of these communities (Rhodes & Langtiw, 2018).
Finally, counselor educators and clinical supervisors are responsible for ensuring that counselors-in-training fully understand the ongoing experiences of trauma related to and resulting from discrimination, racism, and other systemic injustice stressors and can demonstrate competence in conceptualizing the role of power, privilege, oppression, and advocacy within counseling practice (Laurencin & McClinton, 2020). While COVID-19 has given us a glimpse of discriminatory practices and inequities already embedded in our health care systems, professional counselors are ethically required to provide culturally competent care. Counselors should engage in continuous, professional development opportunities related to increasing awareness regarding diverse cultural group norms, understanding experiences of acculturation, racism, cultural mistrust, misdiagnoses in their clinical practices, oppression trauma, and methods on becoming active allies so that those who may be at risk (intentionally or unintentionally) of perpetrating and/or silencing microaggressions may be prevented from doing so (e.g., Singh et al., 2020; Sue et al., 2019). If these shifts within training, research, advocacy, and practice lead to an actual increase in mental health service utilization, we may potentially experience a reduction in health disparities as well as an increase in overall well-being for BIPOC clients and communities.
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Dailey, S.F., Talleyrand, R.M. & Goodman, R.D. Ethno-Racial Inequities of the COVID-19 Pandemic: Implications and Recommendations for Mental Health Professionals. Int J Adv Counselling 46, 441–463 (2024). https://doi.org/10.1007/s10447-024-09551-6
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DOI: https://doi.org/10.1007/s10447-024-09551-6