Race-based stress has been found to be a stronger predictor of somatic symptoms, anxiety, depression, interpersonal sensitivity and obsessive compulsiveness than common stressors (e.g., relocating, changing jobs; Klonoff et al. 1999). A growing body of research has demonstrated that trauma symptoms and trauma-related disorders, such as posttraumatic stress disorder (PTSD), can result from race-based stress for Black people. For example, in a cross- sectional study, Pieterse et al. (2010) found that race-based stress was associated with trauma- related symptoms. Another study found that among participants who reported ongoing distress related to a race-related stressor, one-third reported a potentially traumatic race-based stressor and 8% qualified for a PTSD diagnosis based on self-report measures (Waelde et al., 2010). Furthermore, in a longitudinal study over a five-year period, race-based stress was found to be significant in predicting a PTSD diagnosis (Sibrava et al. 2019).
It has been suggested that the mental health needs associated with race-based stress, trauma and PTSD lie in the acknowledgement and consideration by mental health professionals of the complexity and impact of racism (Carter, 2007). Many mental health professionals do not routinely ask about the impact of racism on their clients’ psychological health and well-being. Furthermore, Williams et al., (2018) recommended that mental health professionals overcome anxieties caused by inquiring about racism by utilizing a brief self-report measure to create a space for further inquiry about race-based stress. Several measures have been designed to assess exposure and responses to potentially traumatic experiences of race-based stress (e.g., Carter et al., 2018; Waelde et al., 2010).
Barriers to Treatment
The same race-based stressors that are predictive of trauma symptoms can also produce barriers to treatment. Stress-related arousal has been shown to result in increased cognitive load and, consequently, cognitive impairments such as less efficient working memory (Schmader et al., 2008). The experiencing of race-based threat thus increases the cognitive load experienced by Black people and has implications for how Black people might function cognitively and behaviorally (Najdowski, 2012). Race-based stress has been shown to predict less accurate self- perceptions of health when compared against objective health measures, meaning that racial stress is associated with decreased awareness of the need for treatment (Landrine et al., 2016).
Similarly, the higher the exposure to race-based stress among Black people, the greater the delay in seeking professional intervention (Pascoe & Richman, 2009).
For Black people, the road to obtaining mental health treatment is one laden with obstacles. Black people tend to have less access to health care, a lack of trust in the health care system, and, consequently, a preference for alternative treatments (Adegbembo et al., 2006; Bazargan et al., 2005; Etowa et al., 2007). Access to treatment is further impeded by lack of transportation, unavailability of adequate treatment in poor neighborhoods, and cost of services (Bringewatt & Gershoff, 2010). Not surprisingly, then, research has found that up to 75% of Black people who need mental health services remain untreated (McCrea et al., 2019).
Interventions for Race-Based Stress
The myriad manifestations of race-based stress highlights the need for an approach that addresses the potential traumatic impact of race-based stressors. A study involving veterans of color found that group therapy centering on themes of racial identity and individual and systematic racism were beneficial in that participants reported sharing race-based stressor experiences for the first time due to not fearing judgement or disbelief within the company of peers who had also experienced race-based stressors (Carlson, Endlsey, Motley, Shawahin & Williams, 2018). The authors stipulated that cognitive restructuring put race-based stressors and responses in their proper sociohistorical context. Group discussions led to reshaping of maladaptive beliefs that maintain trauma-related distress, such as hopelessness, internalized stigma and self-blame (Carlson et al., 2018).
Other research has suggested trauma-focused therapies such as prolonged exposure (PE) therapy and present-centered therapy may be helpful for Black adults, however it remains unclear whether these therapies specifically decrease symptoms stemming from race-based stress (Ghafoor & Khoo, 2019). In another study, evidence suggested modifications to a PE protocol such as adding more sessions at the beginning of treatment to increase rapport, being open about discussing race-based stressors and responses, and being deliberate in validating and incorporating these experiences into treatment can remove potential barriers to treatment. The authors proposed a culturally informed adaptation of PE to allow clients to revisit race-based stressor experiences and reprocess their meaning (Williams, Malcoun, Sawyer, Davis, Nouri, & Bruce, 2014).
Given the frequency of negative outcomes of race-based stress and the dearth of interventions targeting these issues, it is imperative for clinicians to continue to explore viable treatment options. Developing and implementing interventions building on internal resources and coping skills is extremely beneficial for people who often face limited or not readily available external resources. Mindfulness interventions may offer a promising approach to building resilience in the face of these pervasive and ongoing stressors (Waelde, in press). Because mindfulness practice can be easily integrated into activities of daily living, it could prove beneficial to further investigate the usefulness of mindfulness in interventions to address race-based stress. A study of mindfulness training for Black women found the intervention was helpful for symptoms of race-based stress (Proulx, Croff, Hebert, & Oken, 2020). The overall effectiveness of mindfulness on emotional, mental and physiological dimensions suggest that it may be an invaluable resource to address the effects of race-based stress. However, a recent systematic review found that Black people have been almost entirely neglected in clinical trials of mindfulness interventions. A review of 12,265 citations identified only 24 clinical trials that had a significant diversity focus, though none of those included Black men (DeLuca, Kelman, & Waelde, 2018). Clearly there is much work to do in order to address the lack of inclusion and adaptation of mindfulness and meditation-based interventions for race- based stress.
Addressing race-based stress requires a multilayered approach. Although this article focuses on individual interventions, it should not be assumed that the burden to address race-based stress lies with the affected individuals. Therefore, it would be remiss not to emphasize the need for continued advocacy to encourage the implementation of reforms to address race-based stress that is ever-present within society.
About the Authors
Tanya Hunt, PhD, is a postdoctoral fellow at the Palo Alto VA. She received her PhD in clinical psychology from Palo Alto University in Palo Alto, California. Her research interests include mindfulness, trauma and the impact of race-related stress and other biopsychosocial-spiritual factors on mental and physical health. Her clinical interests are in health psychology emphasizing a whole-person perspective, addressing mental health stigma, and improving health and wellness.
Richard Valencia, MS, is a fifth-year PhD candidate in clinical psychology at Palo Alto University. He is slated to begin an APA-accredited internship with the Department of Veterans Affairs in 2021. His research interests focus on investigating race-related stress and other psychosocial factors and their relation to mental and physical symptoms manifestation in primary care for adults and older adults. His clinical interests are in health psychology and trauma psychology.
Melinda Joseph is a doctoral candidate at Palo Alto University in Palo Alto, California. She was raised in a bicultural home, and through the experiences she encountered in her family and community she developed a strong interest in the mental health treatment for people of color. Ms. Joseph’s primary research interests involve the examination of aspects of ethnicity and race as they pertain to the development, maintenance and treatment of mental illness in people of color. Ms. Joseph has previously examined the role of race, ethnicity and cultural expectations in the implementation of effective psychological interventions. She has also investigated the role that the therapist plays in the expression or suppression of culturally dictated treatment outcomes in ethnic minority populations. Her dissertation examined the role of race-related stress in the development of posttraumatic stress disorder (PTSD) in ethnoracial minority young adults. These research experiences have informed Ms. Joseph’s clinical practice and have ignited in her a desire to continue to confront and address the issues faced by people of color.
Bita Ghafoori, PhD, is a professor at California State University Long Beach (CSULB) and director of the Long Beach Trauma Recovery Center. Her research and clinical interests focus on disparities in mental health care in trauma-exposed groups and dissemination and implementation of evidence-based trauma-treatments in community settings.
Lynn C. Waelde, PhD, is a professor at Palo Alto University and an adjunct clinical professor in the Stanford University School of Medicine Department of Psychiatry and Behavioral Sciences. Her research and clinical interests include mindfulness intervention and therapist training, diagnosis and assessment of trauma-related issues, and racism-related stress.
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