Allen was a young African American man working at a retail store. Although he enjoyed and valued his job, he struggled with the way he was treated by his boss. He was frequently demeaned, given menial tasks, and even required to track African American customers in the store to make sure they weren’t stealing. He began to suffer from symptoms of depression, generalized anxiety, low self-esteem, and feelings of humiliation. After filing a complaint, he was threatened by his boss and then fired. Allen’s symptoms worsened. He had intrusive thoughts, flashbacks, difficulty concentrating, irritability, and jumpiness – all hallmarks of posttraumatic stress disorder (PTSD). Allen later sued his employer for job-related discrimination, and five employees supported his allegations. Allen was found to be suffering from race-based trauma (from Carter & Forsyth, 2009).
Epidemiology of PTSD in Minorities
Racism can feel life-threatening.
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PTSD is a severe and chronic condition that may occur in response to any traumatic event. The National Survey of American Life (NSAL) found that African Americans show a prevalence rate of 9.1% for PTSD versus 6.8% in non-Hispanic Whites, indicating a notable mental health disparity (Himle et al., 2009). Incresed rates of PTSD have been found in other groups as well, including Hispanic Americans, Native Americans, Pacific Islander Americans. and Southeast Asian refugees (Pole et al., 2008). Furthermore, PTSD may be more disabling for minorities; for example, African Americans with PTSD experience significantly more impairment at work and carrying out everyday activities (Himle, et al. 2009).
Racism and PTSD
One major factor in understanding PTSD in ethnoracial minorities is the impact of racism on emotional and psychological well-being. Racism continues to be a daily part of American culture, and racial barriers have an overwhelming impact on the oppressed. Much research has been conducted on the social, economic, and political effects of racism, but little research recognizes the psychological effects of racism on people of color (Carter, 2007).Chou, Asnaani, and Hofmann (2012) found that perceived racial discrimination was associated with increased mental disorders in African Americans, Hispanic Americans, and Asian Americans, suggesting that racism may in itself be a traumatic experience.
PTSD in the DSM-IV
Currently, the DSM recognizes racism as trauma only when an individual meets DSM criteria for PTSD in relation to a discrete racist event, such as an assault. This is problematic given that many minorities experience cumulative experiences of racism as traumatic, with perhaps a minor event acting as “the last straw” in triggering trauma reactions (Carter, 2007). Thus, current conceptualizations of trauma as a discrete event may be limiting for diverse populations. Moreover, existing PTSD measures aimed at identifying an index trauma typically fail to include racism among listed choice response options, leaving such events to be reported as “other” or squeezed into an existing category that may not fully capture the nature of the trauma.
This can be especially problematic as minorities may be reluctant to volunteer experiences of racism to White therapists, who comprise the majority of mental health clinicians. Clients may worry that the therapist will not understand, feel attacked, or express disbelief. Additionally, minority clients also may not link current PTSD symptoms to cumulative experiences of discrimination if queried about a single event.
Implications for Treatment
Discrimination can have severe emotional effects.
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Racism is not typically considered a PTSD Criterion A event, i.e.,
a qualifying trauma. Mental health difficulties attributed to racist incidents are often questioned or downplayed, a response that only perpetuates the victim’s anxieties (Carter, 2007). Thus, clients who seek out mental healthcare to address race-based trauma may be further traumatized by microaggressions
— subtle racist slights — from their own therapists (Sue et al., 2007).
Mental health professionals must be willing and able to assess race-based trauma in their minority clients. Psychologists assessing ethnoracial minorities are encouraged to directly inquire about the client’s experiences of racism when determining trauma history. Some forms of race-based trauma may include racial harassment, discrimination, witnessing ethnoviolence or discrimination of another person, historical or personal memory of racism, institutional racism, microaggressions, and the constant threat of racial discrimination (Helms et al., 2012). The more subtle forms of racism mentioned may be commonplace, leading to constant vigilance, or “cultural paranoia,” which may be a protective mechanism against racist incidents. However subtle, the culmination of different forms of racism may result in victimization of an individual parallel to that induced by physical or life-threatening trauma.
Bryant-Davis and Ocampo (2005) noted similar courses of psychopathology between rape victims and victims of racism. Both events are an assault on the personhood and integrity of the victim. Similar to rape victims, race-related trauma victims may respond with disbelief, shock, or dissociation, which can prevent them from responding to the incident in a healthy manner. The victim may then feel shame and self-blame because they were unable to respond or defend themselves, which may lead to low self-concept and self-destructive behaviors. In the same study, a parallel was drawn between race-related trauma victims and victims of domestic violence. Both survivors are made to feel shame over allowing themselves to be victimized. For instance, someone who may have experienced a racist incident may be told that if they are polite, work hard, and/or dress in a certain way, they will not encounter racism. When these rules are followed yet racism persists, powerlessness, hyper vigilance, and other symptoms associated with PTSD may develop or worsen (Bryant-Davis & Ocampo, 2005).
Changes in the DSM-5
Proposed changes to PTSD criteria in the DSM-5 have been made to improve diagnostic accuracy in light of current research (Friedman et al., 2011). The first section involving the experienced trauma has changed moderately, reflecting findings in clinical experience as well as empirical research. If a person has learned about a traumatic event involving a close friend or family member, or if a person is repeatedly exposed to details about trauma, they may now be eligible for a PTSD diagnosis. These changes were made to include those exposed in their occupational fields, such as police officers or emergency medical technicians. However, this could be applicable to those suffering from the cumulative effects of racism as well.
The requirement of responding to the event with intense fear, helplessness, or horror has been removed. It was found that in many cases, such as soldiers trained in combat, emotional responses are only felt afterward, once removed from the traumatic setting.
The most notable change to the criterion is from a three to a four-factor model. The proposed factors are intrusion symptoms, persistent avoidance, alterations in cognition and mood, and hyperarousal/reactivity symptoms. Three new symptoms have been added – persistent distorted blame of self or others, persistent negative emotional state, and reckless or self-destructive behavior. All of these symptoms may be also seen in those victimized by race-based trauma.
The changes to the DSM increase the potential for better recognition of race-based trauma, although more research will be needed to understand the mechanism by which this occurs. Additionally, current instruments should be expanded and a culturally competent model of PTSD must be developed to address how culture may differentially influence traumatic stress. In the meantime, clinicians should educate themselves about the impact of racism in lives of their ethnic minority clients, specifically the connection between racist events and trauma (Williams et al., 2014).
This discussion was continued at HuffPost Live. Watch online!
Dr. Williams conducts PTSD research and treats PTSD cross-culturally. She offers a monthly webinar for therapists on understanding and connecting with African American clients. Visit TZK Seminars to learn more and/or register (6 CEUs).
Bryant-Davis, T., & Ocampo, C. (2005). Racist incident based trauma. Counseling Psychologist, 33, 479-500.
Carter, R. T. (2007). Racism and Psychological and Emotional Injury: Recognizing and Assessing Race-Based Traumatic Stress. The Counseling Psychologist, 35(1), 13-105.
Carter, R.T. & Forsyth, J.M. (2009). A Guide to the Forensic Assessment of Race-Based Traumatic Stress Reactions. J Am Acad Psychiatry Law, 37, 28–40.
Chou, T, Asnaani, A. & Hofmann, S. (2012). Perception of Racial Discrimination and Psychopathology Across Three U.S. Ethnic Minority Groups. Cultural Diversity & Ethnic Minority Psychology, 18(1), 74-81.
Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM‐5.Depression and Anxiety, 28(9), 750-769.
Helms, J.E., Nicholas, G., & Green, C. E. (2012). Racism and Ethnoviolence as Trauma: Enhancing Professional and Research Training. Traumatology, 18, 65-74.
Himle, J. A., Baser, R. E., Taylor, R. J., Campbell, R. D., & Jackson, J. S. (2009). Anxiety disorders among African Americans, blacks of Caribbean descent, and non-Hispanic whites in the United States. Journal of Anxiety Disorders, 23(5), 578-590.
Pole, N., Gone, J., & Kulkarni (2008). Posttraumatic stress disorder among ethnoracial minorities in the United States. Clinical Psychology: Science and Practice, 15(1), 35-61.
Sue, D.W., Capodilupo, C.M., Torino, G.C., Bucceri, J.M., Holder, A.M.B., Nadal, K.L. & Esquilin, M. (2007). Racial Microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271-286.
Williams, M. T., Malcoun, E., Sawyer, B., Davis, D. M., Bahojb-Nouri, L. V., & Leavell Bruce, S. (2014). Cultural Adaptations of Prolonged Exposure Therapy for Treatment and Prevention of Posttraumatic Stress Disorder in African Americans. Journal of Behavioral Sciences - Special Issue: PTSD and Treatment Considerations, 4(2), 102-124.