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. 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.
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
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.
Connecting racism to mental health
Generic definitions of racism do not provide concrete and specific terms that describe the types of events that may lead to emotional reactions or psychiatric symptoms. With the use of more specific types of racism, it is easier for targets, mental health professionals, and lawyers to make direct links to emotional and psychological reactions.
Anna's encounter with racism is better understood as racial harassment designed to demean and denigrate her as an employee and as a person. Thus, a mental health professional can link the racial encounter to her emotional and psychological reactions. It therefore becomes possible to assess and document race-based psychological and emotional injury and treat it, as well as assist the legal process when complaints are lodged in courts or within organizations. This begins to address the complicating factor that difficulty in obtaining legal redress for racism may itself be an additional source of psychological harm to those who are targets of racism.
The law: a source ofpsychological harm
The erosion of legal remedies makes the need for ways to think differently about racism and its mental health effects more imperative.9 It is extremely difficult, and perhaps psychologically damaging, for a person to establish a claim of racial discrimination (disparate treatment or disparate impact). Historically in the United States, many laws and legislative acts have been directed at racism, and these predate laws for other protected groups; yet, more progress has been made with respect to sexual discrimination and harassment than with racial discrimination.10 Sexual discrimination and sexual harassment are treated as distinct events; furthermore, sexual harassment claims can be established without evidence that the defendant intended to harass or discriminate.
In contrast, racial harassment is not treated as a distinct event. When a complaint is filed, the plaintiff must show that the defendant acted with intentional racial animus. It is more difficult to establish that one was psychologically harmed or experienced emotional distress in racial discrimination cases. Complicating the effort to establish claims for emotional distress is the fact that assessment criteria used by mental health professionals are not specific to the racial aspect of the experience. These difficulties are exemplified by the fact that in 2005, of the 26,740 claims of discrimination filed, 68% were dismissed by the Equal Employment Opportunity Commission because investigations found that they did not meet the requirements necessary to seek legal remedy.11
The approach I advocate distinguishes racial acts so that it is possible to connect the type of act of racism to specific psychological and emotional reactions. The specific types of racism will make it easier to label race-based encounters as avoidance (racial discrimination), such as when persons are falsely told there are no job openings; as hostility (racial harassment), for example, when they are followed in a store; or aversion/hostility (discriminatory harassment), such as being suspended from school.
Anna's experience illustrates the utility of the approach I advocate for differentiating the types of racism. She was not being avoided nor was she subjected to aversion/hostility; rather she was the target of hostility or racial harassment designed to communicate her inferior status at work. Her experience was, in part, a matter of perception, and there is considerable dispositional variation in how persons perceive their experiences in general and with race and racism in particular. One aspect of dispositional or individual differences regarding how one processes racial information is one's racial identity ego status (ie, psychological orientation to one's demographic racial group), which is distinct from one's demographic group or "race identity." Racial identity applies to members of all races in North America. Racial identity ego status is associated with a constellation of different thoughts, behaviors, attitudes, values, and emotions.
A matter of perception
Regarding perceptions, several important empiric research findings taken from the evidence I have presented are noteworthy. Researchers have shown that stress-whether objective (eg, sudden death of a loved one) or subjective (perception of harm)-affects both physical and mental health.3 Thus, when the effect of stress or trauma is a consideration, perceptions are as valid as verifiable events. The practice of relegating the experiences with racism of blacks and others of color to subjective forms of perception actually reflects subtle racism.
Mental health professionals and psychiatrists should work to affirm the person's possible harm or injury, and racism should be treated as a potentially harmful experience that warrants treatment and redress. Clark and colleagues12 have stated that "to discount perceptions of racism as stressful is inconsistent with the stress literature, which highlights the importance of the appraisal process. . . . The perception of demands as stressful is more important in initiating stress responses. . . . With this in mind, the initiation of psychological stress responses as a result of perceiving . . . racism would qualify [such] stimuli as stressors (p 810)."
In order for a person (either patient or psychiatrist) to recognize racism, he must have a developed and mature racial identity ego status. Thus, as part of the assessment process, it should be determined that the person is able to recognize racism and understand its meaning. However, to be able to appreciate racial experiences in others, clinicians must have an evolved personal understanding of their own demographic racial group, in which their race and culture are valued.
In the interview with Anna, I specifically asked about prior experiences with race and how she perceived race relations, and I questioned her about how she had coped with the situation at work. I learned that she had a mature and developed racial identity ego status and could accurately recognize her experiences as racial discrimination.
The models and concepts that I have presented regarding how to think and use race and culture in a more complex, psychologically grounded way are consistent with people's experiences. Most people recognize that skin color or socially constructed racial categories do not accurately indicate how a person thinks and behaves. Racial identity ego status treats all people as members of distinct racial and cultural groups and recognizes that there is considerable individual variation. What matters is not skin color but how individuals think and feel about their racial group.
The combination of racial identity ego status and the race-based traumatic stress approach offers mental health professionals a way to assess patients and develop treatment strategies and interventions that address the complexity of race and culture. The use of race-specific and psychologically based models will aid in the efforts to reduce mental health disparities.
Dr Carter is professor of psychology and education in the department of counseling and clinical psychology at Teachers College, Columbia University in New York. He reports that he has no conflicts of interest concerning the subject matter of this article.
References1. US Public Health Service. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/cre/. Accessed October 23, 2006.
2. Williams DR, Williams-Morris R. Racism and mental health: the African American experience. Ethn Health. 2000;5:243-268.
3. Carter RT. Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress. Counsel Psychol. 2007;35:1-93.
4. Carter RT, Forsyth J. Mazzula S, Williams B. Racial discrimination and race-based traumatic stress. In: Carter RT, ed. Handbook of Racial-Cultural Psychology and Counseling: Training and Practice. New York: Wiley; 2005;447-476.
5. Hicks JW. Ethnicity, race, and forensic psychiatry: are we color-blind? J Am Acad Psychiatry Law. 2004;32:21-33.
6. Butts HF. The black mask of humanity: racial/ethnic discrimination and post-traumatic stress disorder. J Am Acad Psychiatry Law. 2002;30:336-339.
7. Bell C. Racism: a mental illness? Psychiatr Serv. 2004;55:1343.
8. Breland-Noble AM, Bell C, Nicolas G. Family first: the development of an evidence-based family intervention for increasing participation in psychiatric clinical care and research in depressed African American adolescents. Fam Process. 2006;45:153-169.
9. Green TK. Discrimination in workplace dynamics: toward a structural account of disparate treatment theory. Harvard Civil Rights-Civil Liberties Law Rev. 2003;38:91-157.
10. Buff DM. Beyond the courts standard response: creating and effective test for determining hostile work environment harassment under title VII. Stetson Law Rev. 1995;24:719-764.
11. US Equal Employment Opportunity Commission. Race-based charges FY 1992-FY 2006. Available at: http://www.eeoc.gov/stats/race.html. Accessed October 25, 2006.
12. Clark R, Anderson NB, Clark VR, Williams DR. Racism as a stressor for African Americans: a biopsychosocial model. Am Psychol. 1999;54:805-816.