Posttraumatic stress disorder (PTSD) – the diagnosis conjures up images of hollow-eyed combat veterans or terrified rape victims, but new research indicates that racism can be just as devastating as gunfire or sexual assault. In a previous article I posed the question, Can Racism Cause PTSD? The answer is yes, and changes in the DSM-5 open the door for a better understanding of this phenomenon. Here I discuss the psychological research in this area, as well as clinical observations and how these relate to my own experiences as a person of color. Several people have asked me why I focus on African Americans, given the many similar experiences faced by other ethnic/racial groups, immigrants, sexual minorities, disabled people, and other stigmatized individuals. I want to state up front that the problems faced by those groups are real and deserve attention too, however in this article I am going to stick to what I know, the Black experience in America.
Racism-related experiences can range from frequent ambiguous “microaggressions” to blatant hate crimes and physical assault. Racial microaggressions are subtle, yet pervasive acts of racism; these can be brief remarks, vague insults, or even non-verbal exchanges, such as a scowl or refusal to sit next to a Black person on the subway. When experiencing microaggressions, the target loses vital mental resources trying figure out the intention of one committing the act. These events may happen frequently, making it difficult to mentally manage the sheer volume of racial stressors. The unpredictable and anxiety-provoking nature of the events, which may be dismissed by others, can lead to victims feeling as if they are “going crazy.” Chronic fear of these experiences may lead to constant vigilance or even paranoia, which over time may result in traumatization or contribute to PTSD when a more stressful event occurs later (Carter, 2007). In fact, one study of female veterans found that African Americans scored higher on measures of ideas of persecution and paranoia, which the authors attributed to an adaptive response to racism (C’de Baca, Castillo, & Qualls, 2012).
While most of us can understand why a violent hate crime could be traumatizing, the traumatizing role of microaggressions can be difficult to comprehend, especially among those who do not experience them. One study of racial discrimination and psychopathology across three U.S. ethnic minority groups found that African Americans experienced significantly more instances of discrimination than either Asian or Hispanic Americans (Chao, Asnaani, Hofmann, 2012). Non-Hispanic Whites experience the least discrimination (11% for Whites versus 81% for Blacks; Cokley, Hall-Clark, & Hicks, 2011). Furthermore, those African Americans who experienced the most racism were significantly more likely to experience symptoms of PTSD as well.
Make no mistake, Asian and Hispanic Americans receive their unfair share of racism too, and research shows that it may even be harder to manage for individuals in these groups. But each ethnic/racial group has its own package of negative stereotypes that impact the form of racism experienced, so it’s not surprising that PTSD prevalence differs by race and ethnicity. Findings from large-scale national studies indicate that, while African Americans have a lower risk for many anxiety disorders, they have a 9.1% prevalence rate for PTSD, compared to 6.8% in Whites (Himle et al, 2009). That means that almost one in ten Black people becomes traumatized, and I think these rates may actually be higher since diagnosticians are usually not considering the role of racism in causing trauma (Malcoun, Williams, & Bahojb-Nouri, 2015). Studies also show that African Americans with PTSD experience significantly more impairment due to trauma, indicating greater difficulty carrying out daily activities and increased barriers to receiving effective treatment.
Research has linked racism to a host of other problems, including serious psychological distress, physical health problems, depression, anxiety, binge drinking, and even disordered eating (Williams et al., 2014). A strong, positive African American identity can be potential protective factor against symptoms of anxiety and depression, but this not adequate protection when the discriminatory events are severe (Chae et al., 2011; Williams, Chapman, Wong, & Turkheimer, 2012).
I have spoken to African Americans all over the country about their experiences with race-based stress and trauma. One veteran in Colorado told me about how the bullets he faced in combat were nothing compared to the mistreatment he experienced at the hands of his fellow soldiers in arms. When he searched for treatment for his resulting mental health issues, the VA system could not find a qualified therapist to help him. I recently assessed a woman for whom the racial climate at work became so oppressive that she was no longer able to function at her job. She tearfully described the ongoing racial-harassment she experienced from her supervisor, while co-workers turned a blind eye. She carried a stack of documents to prove everything that had happened to her because she didn’t think anyone would believe it. My heart breaks because I have heard her story in many forms, more than once (Williams et al., 2014).
It’s important to understand that race-based stress and trauma extends beyond the direct behaviors of prejudiced individuals. We are surrounded by constant reminders that race-related danger can occur at any time, anywhere, to anyone. We might see clips on the nightly news featuring unarmed African Americans being killed on the street, in a holding cell, or even in a church. Learning of these events brings up an array of painful racially-charged memories, and what has been termed “vicarious traumatization.” Even if the specific tragic news item has never happened to us directly, we may have had parents or aunts who have had similar experiences, or we know people in our community who have, and their stories have been passed down. Over the centuries the Black community has developed a cultural knowledge of these sorts of horrific events, which then primes us for traumatization when we hear about yet another act of violence. Another unarmed Black man has been shot by police in our communities and nowhere feels safe.
Research shows that trauma can alter one’s perceptions of overall safety in society. Black people with PTSD have been found to have lower expectations about the benevolence of the world than Whites. When comparing Black and White Americans, one study reported that African Americans held more negative perceptions of the world, appearing more skeptical and mistrustful (Zoellner, Feeny, Fitzgibbons, Foa, 1999). Experiencing a traumatic event changed perceptions of the world in White victims from positive to negative, yet the perceptions of Black victims were not impacted by traumatic experiences. My take on this is that they are already traumatized by life in America. Most of us with dark skin know the world is not safe.
Once sensitized through ongoing racism, routine slights may take an increasingly greater toll. Microaggressions, such as being followed by security guards in a department store, or seeing a White woman clutching her purse in an elevator when a Black man enters, is just another trigger for racial stress. Social messages and stereotypes may blame the victim, and tell us that Blacks need to stop “dressing like thugs,” “get off welfare,” and assimilate into White culture to gain acceptance. But these experiences can happen to any Black person of any social status. Sometimes higher status Black people experience more discrimination because they threaten the social order and thus draw increased hate from others (e.g., Gaertner & Dovidio, 2005). I’ve experienced this myself on plenty of occasions. For example once when I was working as a psychological intern in a metropolitan hospital, I was followed by security guards to my car after work. Apparently, a co-worker was frightened by me simply because I was Black. It did not matter that I was a qualified medical professional engaged in patient care and with no history of violence. I remember feeling helpless, angry, and confused. I went over the experience in my mind repeatedly, and tried to figure out who had made the call and why. Victims often feel powerless to stop these experiences because the discrimination is so persistent. Those who are exposed to this type of racial oppression may turn their frustration inward, resulting in depression and disability, or respond outwardly through aggression or violence.
I often wonder how people can continue to remain resilient in the face of ongoing, undeserved discrimination. Within the Black community, positive coping with racism may involve faith, forgiveness, humor, and optimism. These cultural values have allowed African Americans to persevere for centuries even under the most oppressive conditions. One area we are currently studying in my research lab is how African Americans can proactively cope with racism. We are also developing treatments for race-based stress and trauma to enable those who are suffering to move beyond their painful experiences and become stronger, so they can re-engage in larger society. But patching up injured victims of racism one-by-one only goes so far. I don’t think it is reasonable to expect that we can “fix” people to enable them to manage constant, ongoing acts of prejudice with a smile, and ask them to be perpetually polite, productive, and forgiving. What we really need is a large-scale shift in our social consciousness to understand the toll this takes on the psyche of victims so that even small acts of racism become unacceptable. We need those who witnesses racism to speak out and victims to be believed.
To learn more about our work in reducing racism, measuring microaggressions, and promoting racial harmony, visit www.mentalhealthdisparities.org.
Read Dr. Williams’ interview about race-based stress and trauma in the New York Times, Racism's Psychological Toll.
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13-105.
C'de Baca, J., Castillo, D., & Qualls, C. (2012). Ethnic differences in symptoms among female veterans diagnosed with PTSD. Journal of Traumatic Stress, 25(3), 353-357.
Chae, D. H., Lincoln, K. D., & Jackson, J. S. (2011). Discrimination, attribution, and racial group identification: Implications for psychological distress among Black Americans in the National Survey of American Life (2001–2003). American Journal of Orthopsychiatry, 81(4), 498-506.
Chou, T., Asnaani, A., & Hofmann, S. G. (2012). Perception of racial discrimination and psychopathology across three U.S. ethnic minority groups. Cultural Diversity and Ethnic Minority Psychology, 18(1), 74-81.
Cokley, K., Hall-Clark, B., & Hicks, D. (2011). Ethnic minority-majority status and mental health: The mediating role of perceived discrimination. Journal of Mental Health Counseling, 33(3), 243-263.
Gaertner, S. L. & Dovidio, J. F. (2005). Understanding and Addressing Contemporary Racism: From Aversive Racism to the Common Ingroup Identity Model. Journal of Social Issues, 61(3), 615-639.
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, 578–590.
Malcoun, E., Williams, M. T., & Bahojb-Nouri, L. V. (2015). Assessment of Posttraumatic Stress Disorder in African Americans. In L. T. Benuto & B. D. Leany (Eds.), Guide to Psychological Assessment with African Americans, New York: Springer. ISBN: 978-1-4939-1003-8.
Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal Of Counseling Psychology, 59(1), 1-9.
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. 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., Chapman, L. K., Wong, J., & Turkheimer, E. (2012). The Role of Ethnic Identity in Symptoms of Anxiety and Depression in African Americans. Psychiatry Research, 199, 31-36.
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. Behavioral Sciences, 4(2), 102-124.