In 2001, the US Surgeon General issued a report about the status of mental health with respect to racial and ethnic minority groups, which stated that ethnic and racial disparities were likely due to racism and discrimination.1 Empiric investigations have linked racism to poor mental health and have shown that racism is stressful and compromises the mental health of persons of color.2
My combined professional experiences have led me to consider how mental health and legal professionals might help targets of racism and legally defined racial discrimination (as defined by disparate treatment and disparate impact). My work with people in treatment and plaintiffs in various cases led to my realization that there were few guides I could use to accurately and directly assess the psychological impact of racism. What I have developed and will briefly describe here is a model of race-based traumatic stress that has forensic and clinical applications.3,4 A target of racism can retain legal counsel, file a complaint, or seek the services of a mental health professional for relief. If a lawyer is consulted, he or she may want a mental health professional to be involved. Thus, the avenues for relief and redress clearly involve psychiatry and mental health professionals.
Consider the case of Anna, who is a healthy (no psychiatric history), lower-middle-class black woman who worked in a retail store for several years. Unlike other employees, she was denied time off, was given menial assignments (eg, mopping), was yelled at and spoken to in a demeaning manner by her store manager, and was required to follow black customers around the store. She made a number of complaints through the proper organizational channels and as a result, her store manager retaliated. Because she needed the job, she endured the mistreatment and threats of termination. She was subsequently fired and filed a lawsuit.
I conducted an interview that explored her background and responses to the Race-Based Traumatic Stress (RBTS) scale. (The scale is currently being tested for psychometric properties and validity. Preliminary analyses indicate that the scale has good and acceptable reliability and can be used effectively as part of the assessment interview process.) Among other things, Anna had symptoms of depression, generalized anxiety, low self-esteem, and feelings of humiliation. Her interpersonal relationships were impaired and her responses indicated that she had varied, previously unstated, reactions. The interview and completed RBTS scale helped me assess whether Anna had experienced race-based traumatic stress as a direct result of the discrimination at her former job.
Race-based traumatic stress injury can be a consequence of emotional pain that a person may feel after encounters with racism, which can be understood in terms of specific types of acts (as distinct types: racial harassment or hostility, racial discrimination or avoidance and/or discriminatory harassment, aversive hostility). How encounters with racism are experienced depends on many factors associated with an individual's background, health, and cognitive processing. Thus, the person who interprets and appraises his racial encounter as extremely negative (emotionally painful), sudden, and uncontrollable, may exhibit signs and symptoms associated with the stress and possible trauma of racism.
For trauma to be present, the reactions need to be associated with symptoms of intrusion, avoidance, and arousal. The reactions may be exhibited emotionally, physiologically, cognitively, behaviorally, or in combination. One may express the trauma through anxiety, anger, rage, depression, low self- esteem, shame, and guilt. While the reactions noted here can apply to many other types of experience, the point here is to outline reactions to racism that might indicate that the individual experienced traumatic stress.
As I worked with a range of racial issues in legal and mental health contexts, as illustrated by the case of Anna, I learned that targets did not have a way to delineate the encounter other than to name it racism or discrimination. They also were less able to report its emotional effects other than to say that they were upset, angry, or depressed. DSM categories (eg, depression, anxiety, and acute stress reactions) that have been used are not specific to racism, even though one may have these reactions as part of psychological distress. The current diagnostic system does not help individuals or mental health professionals recognize the mental health effects of racism, as some psychiatric scholars have noted.5-8
Some scholars and researchers will be critical of the effort to add racism to the list of human interactions that can be related to trauma, arguing that the list might be too long or that the experiences associated with racism are too vague or subjective to support the claim that such experiences can be associated with trauma. Some clinicians may use a diagnosis of posttraumatic stress disorder, but that diagnosis involves physical threat to life as its primary criterion, not emotional pain.
Consequently, what typically happens is that a psychiatric disorder is diagnosed in a person who may be affected by racism. This is something many persons of color do not welcome because it creates a stigma, may compromise any claim for redress, and may make healing difficult. In working with targets of racism, it is important that the person understand how his experience may have caused psychiatrically significant emotional and psychological harm. The approach I propose requires consideration of the target's cognitive and emotional processing, personal history, and the recognition that the power of racism can be stressful and traumatic.
In the case of Anna, a diagnosis of clinical depression and generalized anxiety could be made as a result of her experience at work, yet this would not include the racial aspects. I suspect that she would not welcome being told she was suffering from a mental disorder. From her perspective, she was treated in a hostile and unfair way that caused tremendous hardship, emotional pain, and personal humiliation. General psychiatric diagnoses may have limited value in capturing the full scope of her experience and may hamper her efforts for legal redress and healing.
The use of the term "race-based traumatic stress injury," in contrast, would mean that the person, depending on his interpretation of the encounter, had or is having a racial experience that has contributed to or is related to psychiatric impairment. The "injury" designation indicates that the rights of the person were unfairly violated and provides an option to seek redress. This is a situation that would make it easier for some people to accept the impairment and to work toward healing, as well as help establish a claim for legal or administrative redress. In the case of Anna, race-based traumatic stress injury captures the full scope of her experience and, as such, validates her perception that someone or something has contributed to her emotional distress or injury.
At the time of the interview, all Anna could say was that she was upset, unhappy, and that she felt worthless. At the same time, she was unable to recall specific aspects of events and needed to rely on written notes or her deposition testimony for accurate recall. Her responses to the specific questions on the RBTS scale revealed that she had intrusive thoughts, flashbacks, and trouble concentrating and was irritable and jumpy most of the time. These, combined with the other symptoms noted previously, indicated that she was stressed by her experience with racism and that the stress, after her attempts to cope had failed, became traumatic.