What is racial trauma?

In 2020 and 2021, the Center for Disease Control and Prevention (CDC), the American Medical Association (AMA), the American Psychological Association (APA), the American Heart Association (AHA), and several other highly regarded organizations identified racism as a serious threat to public health that cannot be ignored (American Psychological Association, 2020; Kuehn, Reference Kuehn2021; O'Reilly, Reference O'Reilly2020; Walensky, Reference Walensky2021). These calls to action were, in part, a response to recent police killings (i.e., George Floyd, Breonna Taylor, Atatiana Jefferson, Ahmaud Aubery, Daunte Wright, etc.) and injustice toward Black Americans that led to a societal reckoning and a widespread movement for change. As defined by Jones (Reference Jones1997), racism is a belief in the inferiority of a person or people caused by prejudice against their ethnicity, phenotypic characteristics (e.g., skin tone or hair texture), or purported biology. Jones further describes racial discrimination as the differential behavioral treatment component of racism across a variety of contexts that include interpersonal situations, systems and structures, and institutions. Research indicates that the majority of Black American children and adults report experiences of racial discrimination, with rates ranging from 73% to 90% (Helms, Nicolas, & Green, Reference Helms, Nicolas and Green2012; Pachter, Bernstein, Szalacha, & Coll, Reference Pachter, Bernstein, Szalacha and Coll2010), and up to 93% in national polling data (National Public Radio, 2017).

Bryant-Davis and Ocampo (Reference Bryant-Davis and Ocampo2005) indicated that an important feature of racism is that it “strikes at the core of one's selfhood.” There is substantial research evidence that the stress and toll of racism-related experiences negatively impacts mental health, with recent research providing rigorous evidence that greater experiences of racial discrimination lead to greater depressive symptoms 8 months later, and that elevated experiences of racial discrimination relative to one's own average experience of racial discrimination also leads to increased depressive symptoms (e.g., Lavner et al., Reference Lavner, Hart, Carter and Beach2021). In addition, there is a larger body of research indicating associations of racism with well-being across the lifespan (Brody et al., Reference Brody, Lei, Chae, Yu, Kogan and Beach2014; Brondolo et al., Reference Brondolo, Libby, Denton, Thompson, Beatty, Schwartz and Gerin2008; Pascoe & Smart Richman, Reference Pascoe and Smart Richman2009), and associations with the health disparities seen in Black American populations. However, beyond the general effect on chronic stress, depression, well-being, and health, researchers have also recently begun to consider the ways in which experiences of racism may be traumatic in nature, hence the term “racial trauma.”

Racial trauma is considered to be a form of racism-related stress and refers to stress responses and reactions to a multitude of racialized incidents including: threat of harm and injury, humiliating and shaming events, and witnessing racial discrimination or racialized violence towards other minoritized people (Comas-Díaz, Hall, & Neville, Reference Comas-Díaz, Hall and Neville2019). Several terms have been used interchangeably in the research literature to describe the construct of racial trauma including “racist incident-based trauma,” “ethnoviolence,” “racism-based trauma,” and “race-based traumatic stress.” With all of these terms there is a foundational conceptualization that exposure to racism, in itself, can produce traumatic stress reactions (i.e., hyperarousal, intrusion or re-experiencing, avoidance or numbing, and negative self-concept) that coincide with symptoms of posttraumatic stress disorder (PTSD; Carter, Reference Carter2007). Research on PTSD indicates that Black Americans have higher rates and a more severe course of PTSD symptomatology than white Americans – differences that are not accounted for by socioeconomic status or history of psychiatric disorders ( Carter, Reference Carter2007; Sibrava et al., Reference Sibrava, Bjornsson, Pérez Benítez, Moitra, Weisberg and Keller2019). Recent research by Sibrava et al. (Reference Sibrava, Bjornsson, Pérez Benítez, Moitra, Weisberg and Keller2019) longitudinally examined the influence of racial discrimination on the clinical course of PTSD in a clinical sample of Black and Latinx American adults and found that, over five years, racial discrimination significantly predicted PTSD diagnostic status.

Although empirical research continues to grow demonstrating a relationship between racial trauma and PTSD (Roberson & Carter, Reference Roberson and Carter2021; Williams, Metzger, Leins, & DeLapp, Reference Williams, Metzger, Leins and DeLapp2018), researchers have also highlighted the conceptual similarities as well as differences between racial trauma and other traumatic experiences related to PTSD. Racism is considered to be traumatic because like other traumatic experiences outlined in the DSM (i.e., sexual assault, rape, and interpersonal violence) racism is uncontrollable, unpredictable and motivated by the impulse for power (Bryant-Davis & Ocampo, Reference Bryant-Davis and Ocampo2005). Conversely, research scholars also state that racial trauma is distinct from traumatic experiences related to PTSD because racial trauma lacks a “post” trauma period for minoritized populations living in consistently oppressive environments. Racial trauma entails ongoing direct, collective, and/or vicarious injuries from exposure and re-exposure to racial stressors (Comas-Díaz et al., Reference Comas-Díaz, Hall and Neville2019; Saleem, Anderson, & Williams, Reference Saleem, Anderson and Williams2020). In addition, as noted above, due to the structural characteristics of segregated communities, racial trauma is often superimposed on other traumas, potentially amplifying and maintaining symptoms related to these other types of trauma.

Helms et al. (Reference Helms, Nicolas and Green2012) suggest that one reason that racial trauma is missing from contemporary trauma research, theory and practice is that the broad historical foundations of racial trauma, and its developmental effects, often are sufficiently diffuse and pervasive that they do not provide objective evidence that a particular individual has been harmed more than others. Researchers such as Gee, Walsemann, and Brondolo (Reference Gee, Walsemann and Brondolo2012) note the importance of implementing a life course perspective to understand the pernicious impact of racism and racial trauma, due to the complexity of the nature and intensity of racism exposure across development and across generations. Taken together, we believe that the research and theory in the area of racial trauma naturally lends itself to investigation through a RDoC framework. Though the link between racial trauma and negative psychological outcomes is quite clear, few studies have examined the biological embedding of racial trauma from a life course perspective to inform diagnostic and clinical practice.

Acute threat

The acute threat construct of the Negative Valence System identifies differences in normal versus abnormal fear that can occur suddenly due to a significant threat or dangerous situation. Normal fear is said to involve a pattern of adaptive responses to conditioned or unconditioned threat stimuli. Several neurobiological paradigms and metrics have been used to measure acute threat, including startle response, skin conductance, and heart rate responses (Maples-Keller et al., Reference Maples-Keller, Rauch, Jovanovic, Yasinski, Goodnight, Sherrill and Norrholm2019; Norrholm et al., Reference Norrholm, Jovanovic, Briscione, Anderson, Kwon, Warren and Bradley2014; Wangelin & Tuerk, Reference Wangelin and Tuerk2015). Since PTSD is a heterogeneous disorder with several subtypes, researchers have considered that multiple neurobiological mechanisms cause the development of PTSD due to trauma exposure. Researchers believe they have identified that a key deficit in individuals with PTSD is the inability to regulate fear. While the number of studies in this area continues to steadily grow, researchers who study developmental contexts of trauma and violence caution against deficit-based frameworks and contend that, particularly for minoritized populations, what is considered pathology or deficits can often be potentially adaptive responses that increase effectiveness in navigating environments with high levels of concentrated disadvantage and racialized violence (Del Giudice, Ellis, & Shirtcliff, Reference Del Giudice, Ellis and Shirtcliff2011; Gaylord-Harden, Barbarin, Tolan, & Murry, Reference Gaylord-Harden, Barbarin, Tolan and Murry2018). This leads to complex questions such as: What is optimal or normal fear in a context of chronic oppression for some Black Americans?

Fear conditioning, based on Pavlovian principles of conditioned and unconditioned stimuli, is a major paradigm within behavioral neuroscience and considered an exemplary experimental paradigm for research examining the construct of acute threat. These paradigms have been used for those with combat PTSD as well as civilian PTSD. Briefly, fear conditioning involves the pairing of a neutral conditioned stimulus (e.g., a shape) with an aversive unconditioned one (e.g., a shock), until the neutral stimulus itself produces a fear response. The inability to inhibit fear when there is apparent safety in these experimental paradigms is found to be translatable to clinical cases of PTSD whereby individuals who have deficits in fear inhibition experience arousal, intrusive reminders, and/or panic symptoms when confronted with trauma reminders (for further details see: Briscione, Jovanovic, & Norrholm, Reference Briscione, Jovanovic and Norrholm2014; Johnson, McGuire, Lazarus, & Palmer, Reference Johnson, McGuire, Lazarus and Palmer2012). Fear conditioning paradigms as well as measurement of fear conditioning through physiological responses (i.e., acoustic startle response and skin conductance response) have been employed to uncover mechanisms of fear-related dimensions of PTSD (fear extinction, fear inhibition, fear load) across multiple units of analysis, aligning with the RDoC mission. For example, in a study examining deficits in fear extinction due to high psychophysiological “over-expression of fear” (termed fear load) in a primarily Black American adult sample living in an urban and southern community, researchers found that fear load during extinction was associated with intrusive thoughts about a traumatic event and intense physiological reactions to trauma reminders (Norrholm et al., Reference Norrholm, Glover, Stevens, Fani, Galatzer-Levy, Bradley and Jovanovic2015). The authors noted excessive fear load represents a potential clinical target as it can interfere with vital attentional and cognitive processes.

There is also a growing body of research that has examined the construct of acute threat using multiple units of analyses, such as research investigating the genetic influences on the neural circuitry and physiology of acute threat (Sumner et al., Reference Sumner, Powers, Jovanovic and Koenen2016). Although this type of research is accumulating, research examining drugs targeting neural pathways in preclinical animal models of stress disorders are often found to be ineffective for human disorders; a failure to translate science to practice. In the conclusions of recent randomized control trials and reviews of the field of fear-related disorders (Jovanovic et al., Reference Jovanovic, Duncan, Kaye, Garza, Norrholm, Inslicht and Dunlop2020; Ressler, Reference Ressler2020), researchers have suggested that we are approaching a point of successfully translating neurobiological findings related to fear and threat processing into clinical practice, while also acknowledging that the field needs to continuously reassess research that is not found to be translational between the biology and targeted clinical and/or pharmacotherapy interventions.

The important potential need for reassessment to address gaps in translational understanding of acute threat and fear learning may lie within research that takes a developmental and contextual approach. When considering racial trauma as a chronic stressor with potentially similar threatening stimuli to non-race-based trauma, one could see how these experiences could align with the fear-learning literature of increased psychophysiological responses to threat and difficulties with fear inhibition. What makes racial trauma unique, however, is its uncontrollable and chronic nature as a stressor. Neblett (Reference Neblett2019) discusses possible implications for threat appraisal when it comes to studying racism and health and notes that experiences of multisystemic racism could lead to the development of negative schemas over the life course, increased threat appraisals, and inhibited neuropsychological functioning (e.g., cognitive control/flexibility) that negatively impact health outcomes. He hypothesizes that negative schemas due to racism might maintain perceptions of threat in one's environment even when there is safety, and that a developmental health framing of threat appraisal studies is needed to unpack this process. Taking this into consideration, Black Americans live in a world where ideas of threat versus safety are more complex than they may be among white Americans due to the context of longstanding oppression. The cognitive and physiological demand of identifying threats in one's environment could serve an important survival and life preservation function while over-taxing body regulatory systems, and contributing to physical and mental health problems. Therefore, perhaps labels utilized in RDoC studies of fear learning among minoritized and historically disenfranchised groups such as “dysfunction,” “impaired,” and “deficit” are inadequate descriptors to capture developmental trajectories or adaptive trade-offs when these are context dependent (Lilienfeld & Treadway, Reference Lilienfeld and Treadway2016). In addition, these considerations suggest that the most effective interventions may not always involve reducing or eliminating fear responses when these can be shown to be adaptive and aid in survival in some contexts (Hill, Reference Hill2005).

It may also be important to consider the ways in which experiences of racial trauma are connected to experiences of other forms of trauma (i.e., interpersonal violence, witnessing violence, etc.) among Black Americans, and the implications of this for threat-appraisal processes. It's possible that the symptoms that arise after experiences of non-race-related trauma are compounded by the effects of chronic exposure to racial trauma. This was examined in recent research we conducted at the Grady Trauma Project (a research team studying the clinical and physiological implications of trauma exposure; http://gradytraumaproject.com/). Results indicated a significant interaction between previous experiences of racial discrimination and experiences of interpersonal trauma (e.g., witnessing murder of a close family member/friend, being attacked with/without a weapon by a spouse/ romantic partner or stranger, etc.) among Black women living in urban contexts, such that the association between PTSD symptoms and interpersonal trauma was stronger at higher levels of racial discrimination (Mekawi et al., Reference Mekawi, Carter, Brown, Martinez de Andino, Fani, Michopoulos and Powers2021). Although this study did not examine processes of acute threat, it provides support for taking both race-related and non-race-related stressors into consideration when examining the etiology and development of PTSD among Black women. In addition, it suggests that experiences of racial discrimination may need to be explored to better understand PTSD symptoms in some contexts. To address the lack of research on racial trauma experiences, threat appraisal, and neural responses among Black Americans, we also conducted research at the Grady Trauma Project to examine the unique link between racial discrimination and neural response patterns throughout the brain during attention to threat cues in a trauma-exposed community sample of Black American women (Fani, Carter, Harnett, Ressler, & Bradley, Reference Fani, Carter, Harnett, Ressler and Bradleyin press). Findings from this study revealed that Black American women who reported more racial discrimination experiences showed heightened reactivity to trauma-relevant images in components of visual attention and emotion regulation/fear inhibition networks of the brain, even after accounting for variance associated with PTSD or trauma. This study calls attention to the need for further research examining neurobiological pathways related to the RDoC construct of acute threat through the lens of racial trauma for Black Americans across the lifespan.

Potential threat

Acute threat is differentiated from potential threat based on the immediacy and imminent presence of threat. According to the RDoC framework, the construct of potential threat activates brain systems in situations where harm may potentially occur, but is ambiguous, low or uncertain in probability, and/or depicted as a pattern of responses of hypervigilance. Weston (Reference Weston2014) argues that fear is not necessarily the main characteristic of PTSD, as evidence has shown that individuals can develop PTSD in the absence of fear at the time of trauma exposure. He further discusses the etiology of PTSD through an emphasis on peritraumatic hyperarousal (e.g., hyperarousal during or immediately after a traumatic event) that is normal and adaptive in response to a traumatic threat but abnormal when it endures after the trauma has ended. This conceptualization of hyperarousal points to a dimensional framework for the development of PTSD within the RDoC framework. However, the requirement that psychopathology related to hyperarousal and/or hypervigilance occurs in the absence of threat may fail to encapsulate Black American experiences. In the formative qualitative research by Smith and Patton (Reference Smith and Patton2016) that aimed to understand PTSD within context, researchers found that Black men living in areas of chronic violence exposure described the PTSD symptom of hypervigilance as “staying on point.” These participants further described hyperarousal and hypervigilance as adaptive rather than maladaptive coping to potential threat that protected them from future violence exposure. In a recent study by Phan, So, Thomas, and Gaylord-Harden (Reference Phan, So, Thomas and Gaylord-Harden2020) exploring the cost benefits of these constructs, research findings indicated that self-reported hypervigilance among Black American male adolescents predicted decreases in witnessing violence, but not violent victimization one year later and self-reported physiological hyperarousal predicted decreases in violent victimization at high but not low levels of participant's self-reported physical aggression one year later. In consideration of these findings from a developmental framework, scholars have proposed that adaptive calibration models are useful strength-driven approaches for understanding mental health processes of trauma-exposed Black Americans (Del Giudice et al., Reference Del Giudice, Ellis and Shirtcliff2011; Gaylord-Harden, Bai, & Simic, Reference Gaylord-Harden, Bai and Simic2017; Gaylord-Harden et al., Reference Gaylord-Harden, Barbarin, Tolan and Murry2018).

The adaptive calibration model posits that individuals show different patterns of stress responsivity in response to varying levels of chronic or potential threat within their environment (Del Giudice et al., Reference Del Giudice, Ellis and Shirtcliff2011). It also emphasizes that psychophysiological responses or behaviors that historically are interpreted as deficits or pathology can be viewed as agentic and effective responses for navigating violent and threat-laden environments over a lifespan. For example, a hypervigilant stress responsivity pattern may develop in response to growing up in an environment that has chronic unpredictable threats (Ellis, Oldehinkel, & Nederhof, Reference Ellis, Oldehinkel and Nederhof2017). Gaylord-Harden et al. (Reference Gaylord-Harden, Barbarin, Tolan and Murry2018) further convey that the adaptive calibration model allows researchers to consider the pathways to development of maladaptive stress responses among Black American young men that manifest due to efforts to cope with known structural and societal barriers in the United States. Considering that Black Americans disproportionately live in neighborhoods characterized by concentrated disadvantage and violence, with high levels of unpredictability, mechanism-driven research must consider how Black Americans living in these environments have to balance cognitive and physiological demands to gauge potential threat versus safety. Barbarin, Tolan, Gaylord-Harden, and Murry (Reference Barbarin, Tolan, Gaylord-Harden and Murry2020) further challenges researchers to utilize adaptive calibration models as a conceptual tool to redirect research that historically uses a deficit lens rather than a competency-based lens to examine the behavior of Black Americans who successfully adapt to chronically toxic environments. To our knowledge there are no known research studies that have examined the biological embedding of racial trauma from this perspective among Black Americans.

Research has also shown that racial trauma is often chronic, uncontrollable, and unpredictable. The construct of potential threat in this domain is thought-provoking when considering the US sociopolitical context and historical legacy of oppression. We are currently living in a time where the current generation of young Black Americans have been raised witnessing public, repeatedly streamed, and vivid imagery of racialized violence. From Trayvon Martin, Michael Brown, Sandra Bland, Eric Gardner, Philando Castille, and so on, images and videos from police dashcams and cell phones intrude into our homes and minds. Partially titled “That's my number one fear in life. It's the police,” a qualitative paper reveals personal narratives of 40 young Black American men's trauma and grief resulting from police violence in Baltimore, Maryland (Smith Lee & Robinson, Reference Smith Lee and Robinson2019). These participants’ stories of police violence started in childhood and continued into early adulthood, highlighting potential avenues of future research that can examine the biological embedding of racial trauma over time. Utilizing the innovative methodology of “life history calendars” that provide a time anchor for accurate participant recollection of lifetime exposures to violence and homicide death, researchers were able to consider how life course experiences of witnessing violent death(s) of a loved one and experiences of racial profiling/harassment from police influences continuous anxiety about navigating unpredictable threats to one's safety and wellbeing.

According to Helms et al. (Reference Helms, Nicolas and Green2012), the killing of unarmed Black men by police can be conceptualized under racial trauma as “racial or ethnic cultural cataclysmic events.” Research also now shows that Black adults living in states where one or more police killings of unarmed Black people occurred in the last 3 months reported experiencing a greater number of dire mental health days than white adults residing in the same state (Bor, Venkataramani, Williams, & Tsai, Reference Bor, Venkataramani, Williams and Tsai2018). Studies such as these hopefully can promote a change in RDoC-related research to more fully consider cultural context, development, and the intersection of racial discrimination with other traumas in examining mental health outcomes and particularly PTSD symptoms. This research also provides guidance for future research questions that RDoC informed research could address regarding the impact of structures of power (i.e., criminal justice/policing) on threat-appraisal and biological processes related to hypervigilance to potential threat. These research questions could: (a) examine the impact of exposures through social media on the neurobiology of experiences of racial trauma for Black Americans (Patton, Eschmann, & Butler, Reference Patton, Eschmann and Butler2013; Volpe, Hoggard, Willis, & Tynes, Reference Volpe, Hoggard, Willis and Tynes2021); (b) address how to conceptualize the construct of potential threat when the threat originates from individuals in positions of power, that is, those who are expected to protect and serve; (c) utilize multiple units of analysis to examine optimal versus suboptimal hypervigilance for Black Americans diagnosed with PTSD who report experiencing racial trauma.

Sustained threat

The last construct of the Negative Valence System domain that we want to discuss in relation to racial trauma is sustained threat. This construct involves negative emotional states that result from prolonged threat exposure to internal or external conditions, states, or stimuli for which escape or avoidance is adaptive. The psychophysiological changes or behaviors caused by prolonged threat exposure, by definition, are often chronic and persist in the absence of the threat. In studies that examine this RDoC construct in relation to trauma exposure, a common theme is examining activation of stress-response systems, such as the hypothalamic–pituitary–adrenal (HPA) axis dysregulation. The hypothalamic–pituitary–adrenal axis releases the stress hormone, cortisol, to assist in the response to acute stress; but with continuous and chronic stress, the body becomes physiologically taxed. Subsequently, the construct of sustained threat aligns with the previously discussed research related to the “weathering” hypothesis suggesting that the chronic stress of racism can influence prolonged activation of body regulatory systems over time that are linked to chronic illnesses and diseases that disproportionately affect Black Americans.

The RDoC matrix indicates that elements of sustained threat can include increased perseverative cognitions and behaviors. Perseverative cognitions are described as recurrent patterns of negative, reflective thinking (i.e., rumination) as well as anticipatory thinking (i.e., worry) after a stressful event has occurred (Brosschot, Gerin, & Thayer, Reference Brosschot, Gerin and Thayer2006). These cognitive processes can prolong both emotional and physiological reactions to stressors. In contrast to stress and coping models that typically attend to acute and short-term effects of stressors, Brosschot et al. (Reference Brosschot, Gerin and Thayer2006) theory of prolonged activation hypothesizes that perseverative cognitions and anticipatory stress mediate the link between stressors and chronic illness. Utsey et al. (Reference Utsey, Belvet, Hubbard, Fischer, Opare-Henaku and Gladney2013) built on this theoretical model of prolonged activation of stress to conceptualize how chronic stress due to racism is related to perseverative cognitions and anticipatory stress and promotes the racial health inequities seen among Black Americans. In partial alignment with this theory, research by Hoggard, Hill, Gray, and Sellers (Reference Hoggard, Hill, Gray and Sellers2015) found that heart rate variability (a physiological indicator of stress) in Black American women can remain elevated for a day after an experience of racial discrimination, suggesting that prolonged, and not acute or momentary physiological responses to stressful events influence long-term negative health outcomes. Interestingly, this study did not find evidence that cardiovascular activity two days after experiencing racial discrimination was mediated by cognitive perseveration; but the study did reveal that self-reported perseveration (intrusion) as well as avoidance of thoughts about the experience was associated with higher heart rate activity two days after experiencing racial discrimination. Moreover, the researchers note that their findings suggest that thinking about a racially discriminatory act that happened in one's life and/or returning to environments where such discrimination occurred could have dire consequences on health. When considering the biological embedding of racial trauma over the life course, studies such as these further confirm that the RDoC construct of sustained threat could be usefully contextualized in future studies to investigate how long the neurobiological effects of racial trauma linger to affect body regulatory systems after racial trauma is initially experienced. It is also important to examine how these effects differ across different stages of development. Furthermore, in RDoC-related research focused on non-race-related trauma exposure among Black Americans, it is plausible that contextualizing responses by giving greater consideration to racism as a traumatic stressor and contributor to the stress response, could provide better understanding of responses and more nuanced clinical conceptualizations of trauma-related symptoms of avoidance, rumination, and re-experiencing symptoms (Lewis et al., Reference Lewis, Cogburn and Williams2015).

In Coates (Reference Coates2015) book Between the World and Me he writes as a Black father to his Black son: “But the price of error is higher for you than it is for your countrymen, and so that America might justify itself, the story of a black body's destruction must always begin with his or her error, real or imagined—with Eric Garner's anger, with Trayvon Martin's mythical words (“You are gonna die tonight”), with Sean Bell's mistake of running with the wrong crowd.” This message aids in conceptualizing the potential roots of constructs related to sustained threat for Black Americans across generations. The historical context of perseverative cognitions is possibly related to Black Americans accrued relevant knowledge, experiences, or witnessing of the substantial costs of making “mistakes” in a racialized society. Thus, Black Americans may analyze previous encounters of racial trauma as well as expect and prepare for future encounters in order to reduce the likelihood that another racist event occurs that could substantially harm them. Although there is a lack of research that examines this process from this angle, Hope et al. (Reference Hope, Brinkman, Hoggard, Stokes, Hatton, Volpe and Elliot2021) recently explored the multidimensional nature of racism (e.g., individual, institutional, and cultural) in relation to anticipatory racism-related stress responses (e.g., prolonged negative thinking, arousal in expectation of future racism) among Black adolescents. Results indicated that more experiences of racism at each level were related to greater anticipatory racism-related stress responses, measured as more cognitive activation of racial stressors, appraisal of coping strategies, and physiological anticipation of future racism. Continued developmental and contextually-guided research is needed in this area to further explore the psychophysiological risks and benefits of engagement in sustained cognitive processes to prepare for continuous experiences of racial trauma.

RDoC Measurement and methodological considerations

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association; APA, 2013) defines trauma as exposure to actual or threatened death, serious injury, or sexual violence. The DSM-5 stipulates that individuals can directly experience a traumatic event or be indirectly exposed through: (a) witnessing a traumatic event, (b) learning that a loved one has experienced a traumatic event, (c) learning that a loved one died from a traumatic event that was violent or accidental in nature, or (d) experiencing repeated or aversive details of a traumatic event through one's occupation (e.g., first responders). The definition of what can be considered traumatic – and therefore influence trauma symptomatology – has changed over time. What diagnostic tools, as well as what society deems as traumatic, has a ripple effect on how individuals see their own life experiences and how they believe others may view those experiences as well. One impetus for the development of the term “racial trauma” was the need for acknowledgment, where research scholars of color noted that healing from racism would require recognition of its traumatic effects (Bryant-Davis, Reference Bryant-Davis2007). Perhaps one reason that racial trauma is not already considered within widely used diagnostic tools is the legacy of structural racism that avoids recognition of harm inflicted on those of color. What society views and acknowledges as traumatic can significantly influence the measurement and assessment of racial trauma as a construct. For example, traditional inventories assessing lifetime experiences of traumatic events (e.g., The Traumatic Events Inventory, Trauma History Questionnaire, Life Events Checklist for DSM-5, Brief Trauma Questionnaire) often utilize DSM-5 definitions of trauma to categorize what is traumatic in an individual's life experience and what is not. When a Black American fills out a traumatic events inventory, even a racialized violence incident that may have occurred and would meet criteria for a DSM-5 definition of “trauma” (e.g., being beaten by the police because of one's race and fearing for one's life) may not be reported because they may feel that such racism-based events do not fit within societies definition of trauma. Furthermore, contextual and cultural dynamics such as the race or positionality of the perpetrator of violence, are often not evaluated in assessments of trauma among Black Americans. This can lead to missing and inaccurate information that could negatively impact research and clinical practice. Diagnostic systems must consider their own impact in influencing what society deems as traumatic as this can influence the way minoritized populations disclose and report traumatic experiences, as well as the way researchers frame research questions around traumatic experiences. The promise of the RDoC framework is in the philosophical and science-driven perspective that the mechanisms for uncovering normal versus abnormal behavior is on a continuum of complex processes that must be examined through multiple forms of assessment. By further opening this framework to more centrally consider culture and sociostructural contexts as driving forces in mental health wellness, the RDoC framework has the potential to lead to the development of maximally useful assessment measures for Black Americans.

Another consideration associated with measuring and assessing racial trauma is grounded in the ways researchers have studied and defined this construct to date. In Reference Carter2007, R.T. Carter defined the term “race-based traumatic stress” as (a) an emotional injury that is motivated by hate or fear of a person or group of people as a result of their race; (b) a racially motivated stressor that overwhelms a person's capacity to cope; (c) a racially motivated, interpersonal severe stressor that causes bodily harm or threatens one's life integrity; or (d) a severe interpersonal or institutional stressor motivated by racism that causes fear, helplessness, or horror. In Carter's article and in subsequent research, researchers conceptualized racial trauma as a non-pathological response to racism-related stress that would not align with DSM frameworks of PTSD. Due to research indicating that racial trauma may be a unique stressor separate from other forms of traditionally studied traumatic stressors, Carter et al. (Reference Carter, Mazzula, Victoria, Vazquez, Hall, Smith and Williams2013) developed a measure called the Race-Based Traumatic Stress Symptom Scale (RBTSSS) that was designed to assess experiences of racism and related psychological and emotion reactions to this stressor. Within the development of this measure and conceptualization of racial trauma (Carter & Helms, Reference Carter and Helms2002), these researchers argued that distinct types or classes of racism are likely needed rather than a broad social definition of racism that could entail a wide range of racism experiences over time. In line with this premise, Roberson and Carter (Reference Roberson and Carter2021) recently completed a study where they utilized the RBTSSS scale to examine the link between differing levels of racism-related stress and the Trauma Symptom Checklist. These researchers created “racial stress-level groups” where the “racial trauma group” was considered to be the label for participants who scored in the highest level on the RBTSSS scale. Findings from this study further indicated that the “racial stress-level groups” were significantly different from each other and led to different trauma symptom presentations among Black Americans. Hence, this research suggests that there may be categories or hierarchical levels of distress associated with different types of racial discrimination experiences that could be explored further in future research.

Williams, Printz, and DeLapp (Reference Williams, Printz and DeLapp2018) suggest there is a cumulative nature to racial trauma experiences across the lifespan that influences the development of clinically significant distress and trauma-related reactions. Therefore, having hierarchical levels of distress related to different types of racial discrimination experiences does not account for the accumulating stings and bruises of microaggressions and/or vicarious racism that can impact clinical presentations related to trauma exposure. This aligns with work within the non-race-related trauma literature showing that clinically significant traumatic reactions from multiple traumatic events accumulate to increase the vulnerability that future traumatic events will result in PTSD (Breslau, Chilcoat, Kessler, & Davis, Reference Breslau, Chilcoat, Kessler and Davis1999; McLaughlin, Conron, Koenen, & Gilman, Reference McLaughlin, Conron, Koenen and Gilman2010). To account for these noted gaps in the assessment of racial trauma, Williams et al. (2018) introduced a measure entitled the UConn Racial/Ethnic Stress & Trauma Survey (UnRESTS) based on a life course conceptual framework of the development of clinically significant racial trauma symptoms. The UnRESTS is a clinician-administered semistructured interview for racial trauma that is intended to aid clinicians in assessing various forms of racism experienced by minoritized clients over their life course and determine whether these experiences are collectively causing traumatic stress and meet DSM-5 criteria for PTSD.

Even in our current conceptualization of racial trauma the field has differing opinions about how racial trauma can arise and how it is linked to mental health outcomes. With increasing attention to the negative impact of racism on mental health for Black Americans, particularly after the killing of George Floyd in 2020, important treatment considerations have recently been described, addressing Black American's stress related to racial trauma (Anderson & Stevenson, Reference Anderson and Stevenson2019; Metzger, Anderson, Are, & Ritchwood, Reference Metzger, Anderson, Are and Ritchwood2021). Yet, to our knowledge, no studies have been conducted to qualitatively assess Black Americans viewpoints on how they would differentially define racial discrimination, racial trauma, and trauma experiences in the United States and if these experiences are perceived as similar, hierarchical, or unique forms of stress. Qualitative research is designed to amplify the personal stories of minoritized populations and illuminate issues and concepts that are not readily captured in current methodological approaches. This valuable research methodology is not discussed as a unit of analysis for research conducted within a RDoC framework. Given that language is a dynamic process, it is possible that the current terminology and definitions of “racial trauma” do not fully capture the complex ways that these experiences influence health. Furthermore, research focused on understanding the neurobiological and developmental mechanisms connecting racial trauma over the life course to the onset of mental health difficulties and disorders is sparse. Researchers note that the solutions to multilevel and multisystemic issues like racial trauma must include mixed-method approaches that can better address and illuminate the complex ways in which racial oppression operates in the United States. (Neblett, Reference Neblett2019). The RDoC framework has the opportunity to promote research strategies that align with its goals of utilizing several units of analysis to define mechanisms underlying behaviors related to racial trauma, but can also better contextualize these research tools by listening to the voices of Black Americans who have been historically excluded from this research process.

A last consideration for the measurement of racial trauma includes the need for research examining the intergenerational effects of this construct. Interestingly, the concept of intergenerational trauma (e.g., trauma can be transferred between generations) was first introduced in the research literature with studies on the offspring of Holocaust survivors (Rakoff, Reference Rakoff1966). This initial research led to an increase in research of Holocaust survivors over time, with a case study indicating that third generations of Holocaust survivors experienced PTSD symptoms that paralleled their ancestors (Rosenthal & Rosenthal, Reference Rosenthal and Rosenthal1980). In recent years, the research enthusiasm for understanding intergenerational trauma among offspring of Holocaust survivors has remained, with research beginning to examine epigenetic mechanisms in intergenerational effects of this historical trauma (Yehuda et al., Reference Yehuda, Daskalakis, Lehrner, Desarnaud, Bader, Makotkine and Meaney2014, Reference Yehuda, Daskalakis, Bierer, Bader, Klengel, Holsboer and Binder2016). Research has also grown in this area among trauma survivors, with some documented neuroendocrine and epigenetic alterations related to maternal and paternal trauma exposure but no conclusive evidence of epigenetic transmission of trauma effect (Yehuda & Lehrner, Reference Yehuda and Lehrner2018). Yet, even with this growing research interest in intergenerational trauma, very little research has considered how the historical trauma of enslavement of Black people in the United States influences biological embedding processes across generations that have possible implications today. The term “Post-traumatic Slave Syndrome” was introduced by DeGruy Leary (Reference DeGruy Leary2005, Reference DeGruy-Leary2017) and suggested that the traumas Black people experienced during enslavement, and through continued oppression in the United States, is a historical racial trauma that has enduring psychological and behavioral effects on their descendants today. Similar to the Holocaust, it would seem that the research efforts to understand the biological mechanisms underlying the impact of the historical trauma of enslavement would have growing research interest but there is no known research in this area to our knowledge.

While the process of assessing and measuring the biological embedding of a racial trauma that occurred deep within our history is likely complex, this type of research could eventually lead to a more potent grasp of how societal stressors penetrate our biology and contribute to a range of health outcomes. In addition, by further examining the history of oppression in the United States we can consider nuanced ways to explore how context influences mental health among Black Americans across time. For example, the social environments in places where racialized US massacres occurred against Black Americans, including the Tulsa, OK massacre (1921), Colfax, LA massacre (1873), Wilmington, NC massacre (1898), Rosewood, FL massacre (1923) and several others, might be important to examine. In addition, the impact of those environments on current Black residents may be just as important and illuminating as the examination of Black descendants of those who survived the massacres. There could potentially be unforgettable memories, vigilance, avoidance, and arousal patterns that become embedded within the structures of the places where the massacres occurred to affect the health of Black Americans living within these spaces that multilevel research could examine. It is also important to acknowledge that epigenetic changes or other processes of intergenerational transmission reflect environmental exposures, and are therefore modifiable with changing conditions. This recognition allows for research in this area to also be guided by strength-based and culturally grounded principles (i.e., racial identity, racial socialization, structural policy changes, structural equity-focused interventions) that can identify buffers against the intergenerational effects of racial trauma.

Future research on the intergenerational impact of racial trauma should also focus on biological embedding processes that begin before birth and influence severe health inequities. A recent review of the literature with our colleagues suggests that racial trauma could have physiological consequences in the mother and fetus that may help explain racism-related health inequities in birth outcomes among Black American women (Conradt, Carter, & Crowell, Reference Conradt, Carter and Crowell2020). Currently in the United States, Black women have the highest rates of preterm birth, which is one of the leading causes of infant mortality and is linked to negative cognitive and neurodevelopmental health of Black children. There are currently only 11 published studies of biological changes that occur as a result of chronic racial discrimination in pregnant Black women, with noted limitations in study sample sizes and measurement of racial discrimination during pregnancy (Chaney, Lopez, Wiley, Meyer, & Valeggia, Reference Chaney, Lopez, Wiley, Meyer and Valeggia2019). No known research has examined how chronic non-race-related trauma and race-related trauma among Black pregnant women differentially exert programming influences on the mother and fetus. Overall, examining the intergenerational effects of racial trauma across generations of Black Americans with attention to time, history, and contextual influences could inform the conceptualization of racial trauma and there is evidence that the RDoC framework is a promising approach for studies of the intergenerational impact of prenatal stress (Gao et al., Reference Gao, Ostlund, Brown, Kaliush, Terrell, Vlisides-Henry and Conradt2021).