Tailoring TF-CBT to Black Children and Youth

If you listened to the last episode, you learned a lot about effective, evidence-based treatment—specifically, TF-CBT. But what do you do if, as a clinician and researcher, you see that a population of kids is not, perhaps, receiving the full benefit of that treatment? What Dr. Isha Metzger did in recognizing that TF-CBT could be shaped into an even more effective treatment for Black children and youth is groundbreaking work.

This work in identifying racial stressors and racial traumas as compounding other forms of trauma has led to more tailored treatment. And her work identifying the inherent strength of Black families has been life-affirming and led to better engagement with treatment. Intrigued? Take a listen.

Topics in this episode:

• Origin story (1:29)
• Racial stressors (5:06)
• The potential impact on kids (9:05)
• Racial socialization (12:05)
• A new application of TF-CBT (15:49)
• What clinicians worry about (22:51)
• Building clients’ trust (27:05)
• Examples (34:51)
• Hope for the future (43:25)
• For more information (48:36)

Links:

Isha W. Metzger, Ph.D., licensed clinical psychologist, founder and director of The EMPOWER Lab, and assistant professor at Georgia State University

Dr. Metzger previously appeared in “The Meaning of Healing for Black Kids and Families,” (Season 2, Episode 16; August 20, 2020)

TF-CBT, Trauma-Focused Cognitive Behavioral Therapy

TF-CBT and Racial Socialization implementation manual

More resources

National Crime Victims Research and Treatment Center

Michael A. de Arellano, Ph.D.

Esther Deblinger, Ph.D., Judith A. Cohen, MD, and Anthony P. Mannarino, Ph.D.

“TF-CBT: Helping Kids Get Better,” with Anthony Mannarino (Season 5, Episode 16; October 16; 2023)

SAMHSA

John Lewis

PMR—progressive muscle relaxation

The C.A.R.E. Package for Racial Healing

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at NationalChildrensAlliance.org. Or visit our podcast website at OneInTenPodcast.org. And join us on Facebook at One in Ten podcast.

Transcript

Season 5, Episode 17

“Tailoring TF-CBT to Black Children and Youth,” with Isha Metzger, Ph.D.

[Intro music begins]

[Intro]

[00:09] Teresa Huizar:
Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “Tailoring TF-CBT to Black Children and Youth,” I welcome back to the program researcher, professor, and director of The EMPOWER Lab, Dr. Isha Metzger.

Now, if you listened to the last episode, you learned a lot about effective, evidence-based treatment—specifically, TF-CBT [Trauma-Focused Cognitive Behavioral Therapy]. But what do you do if, as a clinician and researcher, you see that a population of kids is not, perhaps, receiving the full benefit of that treatment? As you will hear, what Dr. Metzger did in recognizing that TF-CBT could be shaped into an even more effective treatment for Black children and youth is groundbreaking work.

This work in identifying racial stressors and racial traumas as compounding other forms of trauma has led to more tailored treatment. And her work identifying the inherent strength of Black families has been life-affirming and led to better engagement with treatment. 

Intrigued? I certainly was. Please take a listen.

[Intro music begins to fade out]

[01:24] Teresa Huizar:
Hi, welcome back to One in Ten.  

Isha Metzger: 
Thanks for having me back. I’m glad to be here. 

[01:29] Teresa Huizar: 
Let’s start a little bit with your—I don’t know if it’s your most recent work, but most recently published work maybe. And talk to me a little bit about how you came to this work really exploring the relationship between racial trauma and racial socialization and well-known evidence-based treatments like TF-CBT.

Isha Metzger: 
So, kind of thinking about the personal and professional journey that it took to get here, I would definitely say that my early personal experiences led me to be interested in the intersection between interpersonal trauma and racial trauma. And then certainly later experiences in graduate school and building my vocabulary and really understanding what those personal experiences were led me to really wanting to research and then integrate racial socialization into the work that we do.

So I have a personal background in what I would say is what we describe as adverse childhood experiences. So I’m from Sierra Leone, West Africa, which experienced a civil war in the 80s that brought my family to the United States and certainly served as, I would say, an early risk factor. 

But through coming to the United States and being bused from a very urban area to a more diverse and affluent area, I started getting kind of early exposure to racial stressors as well. Both interpersonally through, you know, just being teased and being an “African booty-scratcher” in school for the first time, but also institutionally, almost being placed in the special ed.

Teresa Huizar:
Oh, my.

Isha Metzger: 
Having my dad having to come and navigate the school system with me and really advocate for me. As well as, like I said, those earlier experiences with what I now know is a protective process of racial socialization and really being ingrained in the African community back home and in College Park where I grew up.

So as I, you know, just went through my educational trajectory, I started to realize, wait, this is personally relevant and personally important to me, but professionally, there’s a lot of work that I can do for Black youth, for youth from our diaspora who experienced the intersection of interpersonal stressors. So not only war and, you know, being a refugee, but also just thinking about the compounding impact of those racial stressors as we’re navigating society. 

And of course, right, so I am interested in health disparities and preventing those and improving mental health outcomes. And then realizing: Wait, my dad advocating for me was one thing that he did, but also how ingrained I was in my community, my heritage, the values from back home was also really protective in face of, right?, those messages that I was receiving from my classmates—now we know from news and the media and social media, and just vicariously experiencing those racial stressors. 

I really became interested in racial socialization as a protective process. So all of the research that I did was really to solidify that process and the mechanisms by which we’re able to just build resilience and coping skills and all of the constructs that we know work in CBT, really making them relevant through integrating racial socialization for Black youth.

[05:06] Teresa Huizar: 
There’s so much I want to unpack about what you just said, but I’d like to start with making sure—for folks who may be hearing some terms for the first time—that we just kind of level up everybody and get everybody understanding exactly what we’re talking about. So first of all, let’s start with racial trauma and racial stressors and the scope of how common they are.

I have to say that when I was reading the sort of lit review that was in the manual, I just was—and I shouldn’t have been astonished, but I was astonished by the numbers. And so can you just share with our audience both sort of what we’re talking about in terms of terms, and also how kids are experiencing this?

Isha Metzger: 
Yeah, and I think, so what I’ll say for our audience is that I always try to make the connection between what people already know and then what’s new. 

Teresa Huizar: 
Mmm.

Isha Metzger: 
So we already know, right?, that up to 60% of youth are experiencing those adverse childhood experiences in general. 

Teresa Huizar: 
Yes. Mmm-hmm.

Isha Metzger: 
And we also know that there’s like 15% of those youth who are at higher risk for experiencing polyvictimization, or more than one victimization each year. So whenever I think about that, then it becomes: Who’s at 15%, right? 

Teresa Huizar: 
Mmm.

Isha Metzger: 
We know it’s low-SES [socioeconomic status] kids. We know it’s ethnically minoritized and marginalized kids. And Black youth and families are in that high-risk group. 

So even for that high-risk group, we also know that youth as young as eight are able to express their experiences and their encounters with the racial stressors. And that 90% of them—90% of Black youth—are saying that they’re experiencing at least one racial stressor a week. Before those youth as young as 8, they’re experiencing up to five a day. So we do know that these are compounding those stressors that we already know, right? So they’re already encountering adverse childhood experiences and the results of those. And they’re grappling with and having to deal with these racial stressors that are uncontrollable, they’re unpredictable. And they are oftentimes frightening. They’re fear-based. They are either threatening death or some sort of immediate danger or harm. 

[07:21] Teresa Huizar: 
I mean, when you talk about five or six times a day, you’re talking about literally potentially every hour that they’re in school in a day, or every hour that they’re in daycare in a day.

Isha Metzger: 
Right.

Teresa Huizar:
I mean, it’s just when you just think about the repeated impact of that on a person. I mean, it’s just … that would be overwhelming for an adult to deal with much less a kid or adolescent, I think. 

Isha Metzger: 
Right.

Teresa Huizar: 
And I think it’s really sobering for us to think about the fact that on top of any other adversity or trauma, or in the case of CACs, the clients we see who’ve been sexually abused, perhaps physically abused or other things, that this is layered on top of that—

Isha Metzger: 
Right.

Teresa Huizar: 
—and something they’re experiencing just over and over and over throughout the days and weeks.

Isha Metzger: 
Right. Yeah. And like I said, this is for youth as young as 8, that they’re able to really express what those experiences look like and how they’re impacting them. And that can be things from, you know, overt instances, right? I talked about being an African booty-scratcher. So we can think about like those old-fashioned jokes that are told, but also microaggressions that occur, right? Those are those ambiguous instances of racism where they do lead to rumination, they lead to problems with our ability to concentrate. They are the ones that make us question over and over in our mind. 

And when we think about PTSD and racial trauma criteria, we do know, right, that that re-experiencing and that diminished cognition and ability to concentrate are some of the most impairing parts of the impact that racism has. So you’re absolutely right in that it is compounding on top of their already ongoing stressors.

[09:05] Teresa Huizar: 
The impact of that on kids who may have already experienced varying forms of trauma—it could be lots of things, a traumatic loss, traumatic grief—like it could be a whole host of things. 

Isha Metzger: 
Mm-hmm.

Teresa Huizar: 
And then on top of it, there could be racial trauma that’s, you know, layered right on top of that. What do we know about the potential impact of kids when that’s the case?

Isha Metzger: 
That, like you said, I always use the word “compounding” to describe that process because it does just exacerbate the already ongoing stressors. We can’t diagnose racial trauma in the DSM currently, but we can look at those PTSD symptoms and see that these youth are experiencing those symptoms across each of the criteria.

So that re-experiencing, even hypervigilance in school. We think about kids who are physically abused, for example, who flinch when a teacher reaches towards them. Black youth will say, “I’m flinching too, not because I think you’re going to hit me, but because I think you’re going to touch my hair—

Teresa Huizar:
Oh, yes.

Isha Metzger: 
—or pet me, treat me like a zoo animal,” right? 

Teresa Huizar:
Mmm.

Isha Metzger: 
So that’s the micro-invalidation that also leads to hypervigilance. 

We can think about negative emotions and mood, right? So being angry, being sad. And I talked about that rumination that can lead to anxiety. 

Teresa Huizar:
Yes.

Isha Metzger: 
That’s a result of both direct instances as well as those vicarious instances. If I see a young boy who looks like me get murdered in the street, right? Kids are saying now, “I’m afraid of walking down the street,” for these very same reasons. And they are based in racism. And they’re able to identify and label that as well. 

And then the last criteria, right, is just that behavioral avoidance. And kids will say, “I’m not raising my hand in class anymore because my teacher doesn’t call on me” or “because when I speak, I’m told that either I’m not articulate or ‘while you are articulate, but you’re articulate for a Black person.’” Even those microaggressions, we’re able to recognize. And they do impact us in the ways in which we … we concentrate, we engage in class, the ways in which we even set goals for ourself in the future as well.

[11:21] Teresa Huizar: 
I mean, just hearing you say those things, I have to say I was wincing as you were saying them and I’m thinking, how much more painful would it be to have any of that directed at you? You know, you’re not just discussing it, it’s pointed right at you. 

Isha Metzger: 
Yeah.

Teresa Huizar: 
And then expecting someone to pay attention to math or science or whatever is supposed to be paying attention to in class while you’re thinking about the fact that, you know, someone is saying and doing these things. And also perhaps you’re feeling physically unsafe. 

I mean, so much of what you were talking about just reminds me of conversations I’ve had around bullying, that it’s really a sort of racial bullying— 

Isha Metzger: 
Mm-hmm.

Teresa Huizar: 
—that’s happening for so many of these kids, you know, all day long, every day. And, you know, what is the impact of that on them? 

[12:05]
 Now, on the other hand—and I just have been so interested in this aspect of your work—talking about the protective factors that exist within Black families and Black culture and the kinds of things that help kids and youth respond to, deal with, cope with these elements and parts of their lives and the things that they’ve experienced. While acknowledging that it’s wrong that they should have to deal with it at all, or that it even exists at all. So can you talk a little bit about racial socialization and what role it plays as a protective factor for Black youth?

Isha Metzger: 
Yeah, and again, I want to start by making the connection to what we already know, right? So we already know that parents socialize our kids to best navigate society and best succeed safely and as responsible citizens. So that’s to say, look both ways when you cross the street. Or say, “please” and “thank you” if someone does something for you. Or don’t put your finger in that socket, it’s dangerous or the stove is hot, right? So we talk about ways in which to best navigate society. 

We can also think about the “birds and the bees” conversation that we have with both boys and girls, right? So we build up our girls’ self-esteem so that they’re able to identify healthy partners, but also so they’re able to navigate potentially stressful situations that they might get in with boys, right? So how do you negotiate condom use, for example? 

Black families do the very same thing. So we have those series of conversations that teach Black kids how to navigate society safely, how to prepare for barriers that they might face, and how to really respond to them in the likely occurrence that they do happen, right?

So it is a preparatory process, but it’s also one that happens in response to racial stressors. So we engage in, for example, racial pride messaging to combat negative messages that we receive from news media, society, interpersonal interactions, right? If someone says, “You’re so well spoken for a Black person,” and they’re surprised by that, you’re able to challenge that with what you know about Black people who are well-spoken, right? So it shouldn’t be a surprise, but perhaps it’s surprising for you. And instead of freezing or not knowing how to respond, now you do know how to respond. 

But we also have those racial barrier messages that take the surprise away from those initial encounters with racism. So you don’t want the first time you get pulled over by the police, for instance, you are just thinking, “Oh, my goodness, this is going to definitely end in death. I’ve seen it happen on the news. I’ve seen it happen in my neighborhood.” 

Black families are having those conversations that say, “Okay, if you get pulled over, what do you do”? And they all know, right, we have this conversation: Hands at 10 and 2, “Yes, officer.” “No, officer.” Qualitative research will say we’re not keeping our registration in our glove compartments anymore. We’re keeping them in our visors, so we’re not having to reach unexpectedly. But these are conversations that we’re having. They’re evolving, but they are constant in reaction to and—like I said—in preparation for those racial stressors. 

So we do know, according to the research, that just being prepared, having messages that make up for a lack of representation or that provide accurate, not unbiased, value-based positive images and messages, do combat those stressors that we’re likely to experience as Black youth.

[15:49] Teresa Huizar: 
So we’ve been talking a little bit about both some of the sort of unique stressors that Black youth may face and also what family and community and others may do to try to both prepare and repair, in some cases I think—

Isha Metzger: 
Mm-hmm.

Teresa Huizar: 
—the damage done by those things. And what I want to talk about now is how you started thinking about kind of the issue of: How can we help a child who has experienced trauma in some form and needs a therapeutic intervention, how can we make sure that that intervention is really tailored to them uniquely in a way that’s going to be helpful? And so, now talk about how these things came together for you with TF-CBT [Trauma-Focused Cognitive Behavioral Therapy] and with these ideas about how to better help Black youth.

Isha Metzger: 
Yeah, I would just say at one point, I thought it was all serendipitous. I thought that I was just stumbling upon these opportunities and training and in clinical care. But doing reflection, I’ve realized that I have been very intentional about the types of training that I received—

Teresa Huizar: 
Mmm. Mmm.

Isha Metzger: 
—about the types of clients that I see. And about the questions that I ask clients in treatment, right, not assuming that even if it’s a gold standard treatment that it’s working for them. And just being curious about the strength that clients are bringing to their … their own healing. 

And through those conversations and through the training that I was fortunate enough to have, I was able to start seeing that the treatments do work, but they weren’t as engaging for Black families. They didn’t integrate those strengths that Black families already have and already were using across the board. So truly it was just a matter of the types of training opportunities that I sought out. 

So on internship, I made sure that I was at the National Crime Victim Center and I was drawn to that internship program because they did have that very rare protected research day. So I was able to see all the clients that I had to see. I was very particular about the rotations that I selected. I made sure that I was seeing in person clients who dealt with trauma, but also I made sure that I was doing outreach and going out into the community and being able to talk to those families that were harder to reach in session, in traditional treatment modalities.

So through having those conversations in session informally, I started to integrate that into the research hour that I had, and I was fortunate enough to just get funding to allow me to ask those questions about the care that they were receiving, their access to treatment, their experiences in treatment.

And following my internship, I just took [laughter] two postdocs. So I stayed on at the National Crime Victims Center so that I could continue doing that research. And I also got another postdoc at Yale in public health to really think about exactly what you just asked. How can I integrate what I’m learning from these clients into the evidence-based treatment that already exists?

So through that postdoc experience, I was able to really dive into different models of translating and adapting research. I selected the one that best fit for TF-CBT. And then I started along what I just call, you know, my academic pursuits, my lifelong journey, my quest to integrate client perspectives, client strengths, as well as clinician’s expertise into adapting TF-CBT for Black families.

So it was a intellectual pursuit, but it was based on, again, those kinds of personal experiences that I was having in session with these Black families. 

[19:35] Teresa Huizar: 
I just love that. You know, the way that it informed this work and what it’s going to mean, I think, for so many Black families who are, you know, in treatment or will be in treatment in the future to make sure it’s as effective as it possibly could be for them.

I think I spoke with Tony [Mannarino] earlier this week on a podcast episode. So those of you who are listening, this will be a wonderful companion piece for you. Kind of got the basics of TF-CBT, and now you’re hearing from Isha about her further work on this. But one of the things that I’ve really been struck by with the developers of TF-CBT is that they have been open to different applications and understanding that different populations may have unique needs.

And so I’m just wondering what this process has been like, in terms of, you know, trying to take what had been your own sort of personal research and clinical experience, and then to translate that into a manual that other clinicians can then use. 

Isha Metzger: 
Yeah, the process has been a long one, but it’s been very exciting. It’s been very invigorating. I’ve had opportunities to be re-inspired along the way of this journey. So I really have appreciated it. Like I said, I started off at the National Crime Victim Center. I didn’t mention, though, that my mentor was Michael de Arellano. So he is the mind behind the Latine adaptation to TF-CBT. 

Teresa Huizar: 
That’s right.

Isha Metzger: 
So he wasn’t surprised at all. When I started having these—

Teresa Huizar:
[Laughter] Yeah.

Isha Metzger: 
—conversations, he was the first one to introduce me to Esther, Judy, and Tony. 

Teresa Huizar:
That’s wonderful.

Isha Metzger: 
They were completely supportive and encouraging and said, “Yes, do all the research, go to all these places.” And they continue to encourage me now. So I’d say that early on, I was very intimidated by talking to these heavy hitters [laughter] about their research and their program of work and saying, “You know, I think it could work better for Black youth.”

Teresa Huizar:
Mmm.

Isha Metzger: 
But like you said, they’ve been so receptive throughout the entire process. 

So my research uses the eight-stage model. It’s called the adaptive model. And they got involved—the eighth stage is on testing and the seventh stage is on training. So they got involved after seeing all the work that I have been doing, and encouraging and supporting that work. And we applied for a SAMHSA grant and we did a learning community with 28 other practitioners—

Teresa Huizar:
Oh, wonderful.

Isha Metzger:
—just to talk about the adaptation and best practices for both implementing it with Black youth but also maintaining fidelity to the original TF-CBT model.

So we were very concerned with that throughout the process, making sure that they were doing each of the practice components and making sure that each of them had racial socialization integrated in them. We started off with the larger training, and then we had monthly check-ins where clinicians were able to present their work that they were doing with Black clients, we were able to problem-solve and correct course as needed throughout. 

But we also saw their efficacy and their comfort in just having these conversations increase. And at the end, we were able to see that clients benefited as well. So, truly, that wouldn’t have been possible without the support of Esther, Judy, and Tony and their previous work, but also when integrating that into the learning community as well.

[22:51] Teresa Huizar: 
Well, I just love that you had 28 clinicians that were part of the learning community. So you could see such a wide variety of what their experience had been with clients. One of the things I was thinking about when I read the manual myself was, it sort of brought home to me how there are sort of two separate things here: Of course, all that you’re trying to achieve along with your client in terms of their healing. Then you’re dealing with the clinician’s comfort level themselves because you’re introducing some conversations that are super important for the client—and family—and at the same time, depending on a clinician’s comfort level with talking about racial stressors, racial trauma, racial socialization, I can see how at first some clinicians might be a little nervous. 

So talk a little bit about sort of beyond the manual, you know, how do you talk to clinicians—

Isha Metzger: 
Yeah.

Teresa Huizar: 
—who might be a little bit uncertain about how to embark on those conversations and their worries that they might make mistakes in doing it?

Like, how do you approach that? 

Isha Metzger: 
Yeah, so particularly when I do the trainings, hopefully it’s captured in the manual, but I just start by asking: “What are your apprehensions? What are your fears? I’m telling you, you’re going to be talking to Black kids about racism and discrimination and you’re coming with whatever background you have, whatever aspects of diversity are important to you, but all you guys in this room aren’t Black,” right?

So I ask those early questions and they are, yeah, fairly open with saying, “I’m afraid of saying the wrong thing.” 

Teresa Huizar:
Mmm.

Isha Metzger:
“I’m afraid of committing a microaggression.” “I’m afraid of taking up too much therapeutic space.” 

Teresa Huizar:
Mmm.

Isha Metzger:
  “I’m afraid of my client feeling like they have to educate me.” 

Teresa Huizar:
Right.

Isha Metzger:
And I listen and, much like we do as clinicians, I validate those fears and I let them know that, you know, these are likely to happen. And the worst possible thing that can happen is if you don’t have these conversations at all.

Teresa Huizar:
Mmm. Mmm.

Isha Metzger:
Your clients are tense, your clients aren’t engaged. They’re not receptive to and certainly not practicing and utilizing our strategies in the long term. There are things that we can do to overcome you crying in session, if that’s your fear. 

Teresa Huizar:
Mmm.

Isha Metzger:
But if you’ve lost the client or if a client completes treatment and doesn’t utilize any of the strategies, I’d argue that that is the bigger detriment to that client. 

So I validate their fears and their concerns and then I say, “Well, listen, we got some scripts. We got some role plays. We got some activities. We got some readings, and we’re going to be able to deal with each of those apprehensions or each of those fears if they do come up. And hopefully, through the training and through the integration of racial socialization, you’ll see that while you’re presenting as the content expert, right, while you can do all the readings in racial trauma and racial stress and racial socialization, your client is always going to be the context expert.”

Teresa Huizar:
Yeah.

Isha Metzger:
So we talk about even conveying psychoeducation. Sure. “Use this tip sheet and make sure you’re asking the client about how relevant this information is for them.” Some are going to say, “I don’t experience interpersonal discrimination. I experienced institutional and environmental discrimination.”

Teresa Huizar:
Mmm..

Isha Metzger:
Right? So we can’t assume that any client is coming to us with any, (1) awareness of interpersonal discrimination, those encounters that they’re experiencing. But also, (2) any standardized set of racial stressors. So I always say, you know, “Keep those fears in the back of your mind and know that if they do come up, hopefully you answer questions that they were hesitant to ask. You’ve identified yourself as an ally and as an advocate. You’ve talked about personal aspects of your own diversity that will allow your client to trust you. To talk to you if you do commit a microaggression. To allow you the space in session to. Ask them about their personal experiences in a way that builds rapport but also better engages them in the materials that you’re using so that they can sustain those positive outcomes.”

[27:05] Teresa Huizar: 
You know, I just, I want to follow up on one thing that you were talking about with trust, because— well, before I do that, let me just back up a second and say that I did think that the links to the many, many resources that were included in the manual are wonderful and will be such a help, I think, to clinicians. That they’re not all having to make up all their own things and they can rely on these as trusted resources while, of course, making sure that they’re not just assuming that every client needs the same resource. 

But I think this issue of trust is a really important one. And that was also, I think, helpfully pointed out in the manual that clients come with a range of prior experiences. And those experiences inform how much trust they may initially have in their clinician.

And so there were strategies about how to help build trust with caregivers specifically, and why that was important. Can you talk a little bit about that? Because I actually thought that was such a key thing for any population that might have reason to have a little bit of nervousness about engaging in therapy or with a clinician.

Isha Metzger: 
Yeah, that’s so critically important. And what I’ll say is that it was one of the earlier stages of that adapted model and the model that we used to really integrate client and clinician perspectives into the adaptation or the application of TF-CBT. So we have Black youth and we have Black caregivers talk to us about their prior experiences in the system, their prior experiences with mental health care, and they told us what their own barriers were—

Teresa Huizar:
Mmm.

Isha Metzger: 
—and what their experiences were that kept them out or that could encourage them to better engage in session. So certainly those things that we have in the manual, those resources that are linked that do talk about fostering and facilitating trust are based on those clinician apprehensions as well as those client experiences and perspectives. And they do talk about things like making sure that investigations aren’t ambiguous, nor are the results of those investigations.

Teresa Huizar:
Mmm.

Isha Metzger: 
So we tell clinicians, whether or not a client has previously received results of their investigations, if you can see them right there in their chart, if you know that they have social service involvement, for example, follow up with them and ask them if they’re aware of their current standing, if they’re aware of any loose ends, if they’re in need of any sort of what we think of as case management, but it also helps to build that trust that is often lacking when you start to think about coordinating care and the different parts of the systems that we as clinicians are ingrained in. 

So one big point that clients made about just facilitating trust is opening the lines of communication. 

Teresa Huizar:
Yes.

Isha Metzger: 
They talk about those questions that surprisingly—and perhaps not surprisingly, now that I’ve conducted the research—but that they were uncomfortable asking in early sessions—

Teresa Huizar:
Mmm.

Isha Metzger: 
—and that they never got the answers to.

And these are clients who engage in treatment to various degrees, right? Some of these clients left after the first session. Some of these clients never followed up with an initial referral. Some of these clients completed treatment but said it wasn’t really that useful. And across the board, their experiences were that if you can help facilitate communication, you’re helping to improve trust for the overall system. And you’re helping to keep me coming back. 

So that trust, I think, is through answering those frequently asked questions. Like I said, identifying yourself within the system. So not only am I a mental health professional but I see myself as an ally or an advocate—

Teresa Huizar:
Mmm. Mmm.

Isha Metzger: 
—or a bridge between systems. Also, clarifying your role so they know that you’re a mental health provider. Some of them might know that you’re a mandated reporter. But if you don’t tell them outright and out front, “I am a mandated reporter. These are my limits of confidentiality. This is what will happen if I have to make a report. I’ll never surprise you after the fact,” right?

These kind of labeling of ourselves within the system helps to let clients see that, “Okay, this clinician is aware of reality. They’re aware of what stressors and barriers I might be experiencing. They’re not treating me like I’m a bad parent. They talked about disparities that exist with reporting corporal punishment, for example. So they’re aware of these nuances that I certainly wasn’t going to bring up as a caregiver. I just, you know, on the way up here, told my kid, ‘Listen, what happens in the family stays in the family. Don’t tell these people our business.’” But if you bring it out and you start to talk about it from your perspective and your role as an advocate within that system, then caregivers are oftentimes going to see, “Okay, not necessarily you’re one of the good ones, but certainly you’re someone who I can open up to or who wants me to trust them.”

And that does help to bridge kind of that initial apprehension if you just go ahead and answer those questions that aren’t asked. 

Teresa Huizar: 
Yeah. 

[00:32:23] 
 I think, if I’m remembering right, too, another thing that the manual talked about was, you know, sometimes parents have a concern that they’re going to be unaware of what kind of information is being given to their child, especially over sensitive topics around racism or other things.

And I thought that the advice about making sure that caregivers really knew what that was, I mean, it sounds obvious when you hear it, but then I’m like, I bet lots of times it hasn’t ever happened before, and I can see how a parent could feel, especially if they had some initial question or reservation, how they could feel very put off by that—

Isha Metzger: 
Mm-hmm.

Teresa Huizar: 
—if they thought that they weren’t fully aware of what their children were essentially going to be exposed to, you know.

Isha Metzger:
Yeah, and that’s so important. So what you just described is the difference between confidentiality and privacy. 

Teresa Huizar: 
Mmm.

Isha Metzger: 
And oftentimes, we, as clinicians, we stop at confidentiality and we assume, okay, they know, you know, my limits and my role as a mandated reporter, if I’m still being supervised, right?

Teresa Huizar: 
Yeah.

Isha Metzger: 
All the clinicians say, “You’re being watched on these cameras, and my supervisor and the rest of my team might review it.” But that next step of the conversation is exactly what you just described, privacy. So privacy between yourself as a caregiver and myself as a clinician. 

Teresa Huizar: 
Mmm.

Isha Metzger: 
“Privacy between your child and myself.” 

Teresa Huizar: 
Right.

Isha Metzger: 
As well as that joint communication, we call them conjoint sessions, but we know for Black families, right, we have those conjoint sessions, but every session is going to have a conjoint piece where you’re able to go back and say, “This is what we talked about today. Here are the resources associated with that. But also, when it comes to racial socialization, here’s the conversation that we want you to continue having at home.”

And that’s so important in terms of discussing privacy, but also facilitating that ongoing communication that we know needs to take place outside of the therapeutic space. 

[34:22] Teresa Huizar: 
And I think, you know, there’s a part of the—yes, it’s about enhancing communication—but there’s also part of it, that sort of transparency, too. You know, like, yes, it does further the therapeutic end, but also it’s just another way of sort of putting the cards out and so that nobody has to be concerned about “Is my child getting a message that I can’t support in therapy?” Especially if the clinician is not of the same racial or ethnic group as the kid who’s receiving the therapy, I think.

[34:51]
 So I just, I loved all of these practical suggestions. Now, you know, that all of our listeners are not clinicians. So I’m going to ask you a question which is probably more germane to clinicians—

Isha Metzger: 
Okay.

Teresa Huizar: 
—but I’m hoping that you can use some general terms to help those of us who are not, including myself. 

[Laughter]

But what I’m wondering is, can you give me an example? Like, in the manual, there were lots of very helpful examples, but examples of how in a given session within TF-CBT, regular—not this application—TF-CBT might be doing one thing and how it might be slightly adjusted or tweaked under this application. 

Isha Metzger: 
Yeah. So what I’ll say is we do this for each and every component. 

[Laughter]

[Cross-talk]

Teresa Huizar: 
Yeah, okay.

Isha Metzger: 
So tell me which component you want me to do it for. 

[00:35:44] Teresa Huizar: 
No, pick any one. I’m just like, all I’m trying to give is our listeners a sense of what it might be like a little bit about, like, well, then you’ve been talking about all this, but how might a session look slightly different? So, you know, pick your favorite.

Isha Metzger: 
Yeah, so let me give you two. I’m going to give you the most—

Teresa Huizar: 
Okay.

Isha Metzger: 
—the easiest, and then I’ll give you the most difficult— 

Teresa Huizar: 
Ooo, okay. 

Isha Metzger: 
—for clinicians and families. [Laughter]

Teresa Huizar: 
Excellent. 

Isha Metzger: 
The easiest one is psychoeducation. 

Teresa Huizar: 
Yeah.

Isha Metzger: 
So we do psychoeducation that is to just normalize and validate people’s experiences but also to teach them about what it is that they’re likely experiencing.

When it comes to the application specific to Black families, we’re not only going to provide psychoeducation about the incidents of racism. So what’s an interpersonal racial stressor? What’s the microaggression? What’s environmental and institutional? But we’re also going to provide that psychoeducation about what are common reactions to racial stressors?

Teresa Huizar: 
Mmm.

Isha Metzger: 
And no matter what our client tells us while we’re providing that psychoeducation, we’re validating their experience as well.

So we know that, for example, there are fight, flight, freeze, and fawn responses to stress in general. What we do is we ask, “Okay, so what are your responses to racial stressors? Do you tend to fight? Sure, we validate that. No, you’re not an angry Black woman. No, you’re not a dangerous or aggressive Black man. That’s a natural fight response. Later on, we’re going to talk about proactive and value-based ways to fight, but just know that you’re not wrong for fighting.”

Teresa Huizar: 
Mm-hmm.

Isha Metzger: 
We provide psychoeducation on racial socialization. So we ask, “What sorts of these conversations are you having in your family?” And we provide that additional information that says, “Okay, you talked about racial pride messages and racial barrier messages. Did you know that appreciation for achievement is also a racial socialization message?” And they might say, “No, what’s that?” And then you say, “You know, it’s just that common thing that we have to work twice as hard to get ahead.” And they’ll say, “Oh, yeah, totally. We have those conversations all the time.” So you provide that psychoeducation and you integrate it in.

I think that that is one of the most straightforward for families, right?

Teresa Huizar: 
Mmm. Mm-hmm.

Isha Metzger: 
Just getting new information, having their experiences validated, figuring out what’s commonly done by other Black families, according to Black families, qualitatively and quantitatively, right? Like, their stories and what we can figure out based on survey data.

That’s the simplest one. And then what I’ll say, one of the most complex is that cognitive restructuring. Typically, when we think about cognitive restructuring, we try to—so cognitive is what you think and restructuring is we try to rethink what we’re experiencing. When it comes to racism, we don’t want to restructure our perception of racism, right?

We don’t want to, instead of thinking it’s racism, think: “Oh, it’s me. It’s something I should have, would have, could have done, right? It’s a result of me being—” fill in the blank of what racism inaccurately would say. Lazy, dangerous, inarticulate, any of those things. But what we do want to do is restructure our response.

So that’s often difficult, right? Particularly, right, if I’m a fighter, I know how to fight with my fist. [Laughter] So our job now as clinicians is to say, “Okay, how else can we fight in a proactive and value-based way?” 

If I am a flight-er, I’m somebody who says, “You know what? I’m just not dealing with this. I’m not engaging.” We validate that and say, “You know, in some instances that might keep you from getting written up or suspended. Last time when you tried to speak up for yourself, it sounds like you got suspended or in trouble in some way. So how else can we disengage or flight in a way that doesn’t keep you out of class? That doesn’t way keep you from this extracurricular activity that you could benefit from.”

And we restructure that response to be something as simple as, “You’re going to go to that extracurricular activity, but you’re going to go with an ally or with a friend—

Teresa Huizar: 
Mmm.

Isha Metzger: 
“—who is a safe space and who’s like-minded. So who can we get to allow you to approach without you feeling like, ‘Oh, I’m a coward,’ or, ‘Oh, I’m fleeing these situations because I don’t know how to handle the stress.’”

So I think that that’s typically most challenging, because people just want to change their mind about things as opposed to, you know, just facing the reality and saying, “Okay, it’s a little racist around here and how can I best navigate that?” 

[40:21] Teresa Huizar: 
You know, one of the things I was thinking about is some of your other work that I’ve seen that’s about the value of youth activism—

Isha Metzger: 
Mm-hmm.

Teresa Huizar: 
—as a way of, you know, sort of activating some of these things. So that you’re not trying to pretend like the racism doesn’t exist. You’re finding a constructive outlet for actually combating it, which I think is interesting. So that’s what I was thinking of as you were talking for those kids who, you know, are trying to make sense of how they can positively—

Isha Metzger: 
Yeah. Yeah.

Teresa Huizar: 
—you know, make a difference when something’s so harmful is happening.

Isha Metzger: 
Yeah, and for us as clinicians, right, we think about behavioral activation as: “Go take a walk, do some gardening, get active!” 

Teresa Huizar: 
Mmm.

Isha Metzger: 
But what we know as Black people is, no, we have to get active in our communities as well. 

When we think about PTSD, we know that that behavioral avoidance is to say that we’re avoiding things that we could benefit from. In the case of Black people, they might avoid civic engagement. They might say, “I’m not voting. It’s not for me.” Or, “I’m not responding to this injustice by peacefully protesting because it doesn’t help anyway.”

So what we have to do is challenge those inaccuracies, provide that data that shows, you know what?, in the protests following George Floyd’s murder, all of these laws were passed. And these things did happen despite what we see on the news, the perpetrators not being criminalized or indicted.

Teresa Huizar: 
Mmm. Mmm.

Isha Metzger: 
But certainly we can go seek out that data to support the need to—what you’re describing as civic engagement and activism—to say, “Don’t give up. Don’t let racism win,” right? “We’re facing the reality. That was racist. But disengaging only prolongs that. How can we work towards eradicating racism?” I love to say “fight.” “How can we fight?” Or John Lewis calls it good trouble. 

Teresa Huizar: 
That’s right.

Isha Metzger: 
  “How can we get in good trouble.” I’ve got clients who say, right, like, “Oh, I built a bot to spam the district attorney’s office,” right? [Laughter]

And that’s to say, get into that good trouble, activate your behaviors in a response that is likely to, one, empower you, but hopefully facilitate some sort of positive change in either your local community or more broadly across our nation. 

[42:39] Teresa Huizar: 
Well, I think it’s analogous to the way in which many adult survivors, especially, want to somehow give back and help address whatever form of trauma they’ve experienced. So, we see this, you know, because of child sexual abuse, we see this in adult survivors frequently that part of their meaning-making about it at all is sort of like, “How can I advocate so this doesn’t happen to other kids coming along?” And I think that this is probably a similar thing. That part of trying to hope with difficult things that you’ve experienced is just figuring out how it can have a meaning beyond just the pain and suffering that you had—

Isha Metzger: 
Yeah.

Teresa Huizar: 
—you know, from it. So I just again, I think that there’s so much potential value in this application. 

[43:25]
 Can you talk about what you’re hoping will happen now? I mean, you’ve launched this into the world, and it’s out there, and clinicians are going to be using it.

Isha Metzger: 
Yeah.

Teresa Huizar: 
And looking down the road, five years, 10 years, what do you hope? What are your dreams for what this is going to mean for kids, for families, for clinicians, all that?

Isha Metzger: 
Yeah, so what I hope is that clinicians get more comfortable having these conversations. That clients get more comfortable receiving and staying in clinical care. And that as a result of that, we start to see a trickle-down effect to where these strategies are now being implemented in our communities. 

Teresa Huizar: 
Mmm.

Isha Metzger: 
One of the most promising things that I did see in another learning community that I did with D.C. public schools was that a client who was being seen individually in session with the school psychologist, at a school shutdown later on in the school year, they got shut down for some, you know, one of many perceived dangers in the community at the school at this time. And the school psychologist came back to the learning community and said, “You know what? I was late to school that day and I got there and they were in the middle of a shutdown. I couldn’t get into the cafeteria, but what I could do was I could look through the cafeteria window and I could see my client in a circle with his friends doing PMR.” 

Teresa Huizar: 
I love that. 

Isha Metzger: 
Oh, so truly, I would say that the best thing that we can see is these skills starting to be implemented by those individuals who aren’t even receiving clinical care, but who are just members of society and members of our communities who are also being exposed to those racial stressors. So we saw those numbers, right? Like that’s 90% of kids who I said are experiencing racial stressors. We know 90% of Black kids aren’t receiving mental health treatment. 

Teresa Huizar: 
That’s right. 

Isha Metzger: 
So I’m hoping that the more clinicians start having these conversations, the more they start talking about enhancing safety and spreading what you know, that’s one of the things that we talk about in enhancing safety and certainly at treatment graduation. “If it works for you, tell a friend to tell a friend.” “If you are going to a protest, take a friend with you. If you’re going to an extracurricular activity, take, do it with a friend. If you’re practicing PMR in response to a racial stressor, do it with”  —they don’t call it PMR, they call it “squeezing my booty cheeks,”

[Laughter]

Isha Metzger: 
  —which is hilarious.

Teresa Huizar: 
I love it!

Isha Metzger: 
But—

Teresa Huizar: 
It is hilarious!

Isha Metzger: 
Right? But that’s to say, whatever you call it, spread it to someone else.

Teresa Huizar: 
Mmm.

Isha Metzger:
And I think that as much as we’re able to do that, that’s some of the work that I’m trying to do. So we do have the TF-CBT manual. We also have The C.A.R.E. Package for Racial Healing, which is more cartoon based but it has all of the same kind of practice components for dealing with racial stressors. We really want to see Black youth start to use these within their communities.

And then what Tony will tell you, he always tells me I need to do is to take this application to other cognitive and behavioral therapies. So that’s the next step for me as well, is really thinking about the ways in which we can best improve already gold-standard treatments for individuals who are engaged in clinical care. But certainly thinking about those who aren’t as well. 

[46:45] Teresa Huizar: 
I love this. I just love it.

All right. You’re going to come back after you’ve had a little time in order to talk to me again about how it’s been playing out. 

Isha Metzger: 
[Laughter] Yes! 

Teresa Huizar: 
Because I am just, you know—and especially we want to see it, you know, deployed widely in the CAC world. We want, you know, kids to get better and have exposure to it. So I’m just—

Isha Metzger: 
I am!

Teresa Huizar: 
—so grateful.

Isha Metzger: 
I need to come back. I have been having these conversations, I’ve been doing these trainings across the nation, certainly with other members of the NCA, other CACs.

Teresa Huizar: 
Yeah.

Isha Metzger: 
They are utilizing these strategies. They always come back and say, “Oh my goodness. I was so afraid to have this conversation, but I physically saw my client’s shoulders reduce—

Teresa Huizar: 
Yeah.

Isha Metzger: 
—and their, the tension in their jaws reduce, and they even told me, ‘Wow, I’m so glad we were able to have this conversation.’” So I do, I hope to come back and to share more about client experiences as well as clinician experiences.

But what I’ll say, based on the learning community is that both have really benefited from this integration of racial socialization into TF-CBT. And being able to handle these conversations as clinicians but also in being able to engage in a treatment that you really feel like is designed for you and one in which your perspective and your expertise as an individual and your own worldview is able to be integrated.

[Outro music begins]

[48:14] Teresa Huizar: 
That was an absolutely perfect summation. [Laughter] So I’m going to let us leave it there, but you’re welcome anytime. And we just so appreciate your work and all you’re doing for kids and families. Thank you.

Isha Metzger: 
Thank you so much for reaching out. I hope, like I said, to come back and we will continue the work and continue the conversation as well. 

Teresa Huizar:
Indeed.

[Outro]

[48:36] Teresa Huizar:
Thanks for listening to One in Ten. If you liked this episode, please share it with a friend or colleague. And to get more information about this episode or any of our other ones, please visit our podcast website at OneInTenPodcast.org.

[Outro music fades out]