Race-Based Traumatic Stress, Racial Identity Statuses, and Psychological Functioning: An Exploratory Investigation

Abstract

To understand the impact racial experiences have on people of color, it is important to consider both whether there are any race-based traumatic stress symptoms (RBTS) and within-group psychological differences as reflected in one’s racial identity status attitudes (RISA). Moreover, if the combination of RBTS reactions and racial identity status attitudes are related to their psychological functioning? The current study explored the relationships between a person’s reactions to memorable racial encounters as assessed by the Race-Based Traumatic Stress Symptoms Scale, their racial identity status attitudes measured by the People of Color Racial Identity Attitude Scale, and psychological functioning (i.e., distress and well-being). Data from 282 adult community-based participants were used to examine the combined associations between RBTS, racial identity status attitudes, psychological well-being and psychological distress. A hierarchical cluster analysis was conducted to examine the relationships between race-based traumatic stress reactions and racial identity status attitudes. A two-cluster group solution was found that showed associations between externally defined or less mature racial identity status attitudes and higher RBTS symptoms and psychological distress. Internally defined or more mature or differentiated racial identity statuses were related to decreased psychological distress and RBTS symptoms. The findings were not expected in that lower racial identity statues were associated with higher levels of RBTS. Clinical implications and future research directions are discussed.

Full text

Race-Based Traumatic Stress, Racial Identity Statuses, and Psychological
Functioning: An Exploratory Investigation
Robert T. Carter, Veronica E. Johnson,
and Katheryn Roberson
Teachers College, Columbia University
Silvia L. Mazzula
John Jay College of Criminal Justice, City University of
New York
Katherine Kirkinis
State University of New York At Albany
Sinead Sant-Barket
Teachers College, Columbia University
To understand the impact racial experiences have on people of color, it is important to consider both
whether there are any race-based traumatic stress symptoms (RBTS) and within-group psychological
differences as reflected in one’s racial identity status attitudes (RISA). Moreover, if the combination of
RBTS reactions and racial identity status attitudes are related to their psychological functioning? The
current study explored the relationships between a person’s reactions to memorable racial encounters as
assessed by the Race-Based Traumatic Stress Symptoms Scale, their racial identity status attitudes
measured by the People of Color Racial Identity Attitude Scale, and psychological functioning (i.e.,
distress and well-being). Data from 282 adult community-based participants were used to examine the
combined associations between RBTS, racial identity status attitudes, psychological well-being and
psychological distress. A hierarchical cluster analysis was conducted to examine the relationships
between race-based traumatic stress reactions and racial identity status attitudes. A two-cluster group
solution was found that showed associations between externally defined or less mature racial identity
status attitudes and higher RBTS symptoms and psychological distress. Internally defined or more mature
or differentiated racial identity statuses were related to decreased psychological distress and RBTS
symptoms. The findings were not expected in that lower racial identity statues were associated with
higher levels of RBTS. Clinical implications and future research directions are discussed.
Keywords: racism, racial identity, race-based traumatic stress, psychological health
The negative psychological and emotional impact of experi-
ences with racism and racial discrimination (e.g., anxiety, depres-
sion, low self-esteem, and race-related stress) is well known and
has been documented by researchers for decades (cf. Pascoe &
Smart Richman, 2009;Williams & Mohammed, 2009). More
recently, scholars have begun to speculate about the severity of
ROBERT T. CARTER, PhD, is Professor of Psychology and Education in
the Department of Counseling and Clinical Psychology at Teachers
College, Columbia University. He works as an expert witness on racial
cases. His most recent area of inquiry is on the traumatic effects of
racial discrimination. He has published more than 115 journal articles
and book chapters and has authored or edited books 7 books. He has
served as Editor of the American Psychological Associations’ Society
of Counseling Psychology Journal The Counseling Psychologist,heisa
fellow in the American Psychological Association’s Divisions 17 and
45, and has received several national awards.
VERONICA E. JOHNSON, MPhil, is a Doctoral Candidate in counseling
psychology in the Department of Counseling and Clinical Psychology at
Teachers College, Columbia University. Her areas of professional and
research interests include racial discrimination, Black cultural values and
mental health, and Black racial identity.
KATHERYN ROBERSON, received her EdM and MA in psychological coun-
seling in the Department of Counseling and Clinical Psychology at Teachers
College, Columbia University. She is a Mental Health Therapist at New York
Psychotherapy and Counseling Center. Her areas of professional interest
include racial discrimination, racial identity, and anti-racism advocacy.
SILVIA L. MAZZULA, PhD, LPC, received her PhD in counseling psy-
chology from Columbia University. She is an associate professor of psy-
chology in the department of psychology at John Jay College of Criminal
Justice, City University of New York, she is the principal investigator and
executive director of the Latina Researchers Network and former President
of the Latino Psychological Association of New Jersey. Her areas of
professional interests include the intersection of racial cultural psycholog-
ical processes, racism, discrimination and mental health, Latina/o Psychol-
ogy, and PhD pipeline development.
KATHERINE KIRKINIS received an EdM and MA in psychological coun-
seling from in the Department of Counseling and Clinical Psychology at
Teachers College, Columbia University. She is currently a doctoral can-
didate in the Department of Counseling Psychology at-Albany-SUNY. Her
areas of professional interest and research include racial discrimination,
identify development, and intersections of identity, feminism, and social
justice.
SINEAD SANT-BARKET, MPhil, is a Doctoral Candidate in counseling
psychology in the Department of Counseling and Clinical Psychology at
Teachers College, Columbia University. She is currently an adjunct in-
structor in the Psychology Department at Marymount Manhattan College,
in New York. Her areas of professional interest include racial identity,
multiracial identity development, and discrimination and mental health.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Robert T. Carter, Teachers College, Columbia University, 525 West 120th
Street, Box 32, New York, NY 10027. E-mail: rtc10@tc.columbia.edu
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Professional Psychology: Research and Practice © 2017 American Psychological Association
2017, Vol. 48, No. 1, 30–37 0735-7028/17/$12.00 http://dx.doi.org/10.1037/pro0000116
30

reactions that racial discrimination can bring about—rising from
stress to trauma (Bryant-Davis & Ocampo, 2005;Carter, 2007;
Helms, Nicolas, & Green, 2010).
Stress and trauma terminology are often used interchangeably
across disciplines to describe the biological, psychological, and
social interaction of external events (stressors). Stress is the ap-
praisal (by the person) of an event as positive, unwanted, negative,
and/or taxing, that requires one to adapt or cope in some way
(Lazarus & Folkman, 1984). Trauma is a more severe form of
stress that overwhelms a person’s ability to cope (Pearlman &
Saakvitne, 1995). Traumatic stress differs still, referring to a form
of stress resulting from emotional pain, as opposed to a life-
threatening event or series of events, as the core stressor (Carlson,
1997). Stress, trauma, and traumatic stress are further complicated
by the subjective nature of such experiences: An event or enduring
condition can be experienced as stressful or traumatic by one
person, whereas another person undergoing the same or similar
experience may not feel the same way.
A diagnosis of trauma for mental health professionals is deter-
mined by the criteria for posttraumatic stress disorder (PTSD) in
the Diagnostic and Statistical Manual of Mental Disorders (5th
ed.; DSM–5;American Psychiatric Association, 2013). The
DSM–5 criteria for traumatic events to be associated with PTSD
revolve around “exposure to actual or threatened death, serious
injury, or sexual violence...bydirectly experiencing, or witness-
ing, (the) traumatic event” (p. 271).
This definition of trauma is problematic for some (i.e., Carlson,
1997), as it is not sufficient to address the array of experiences that
can cause traumatic stress reactions, and many severe stress expe-
riences may not threaten death or serious physical injury (i.e.,
homelessness, poverty, emotional abuse, neglect, racism).
Furthermore, the research on stress, life events, discrimination,
and race-related stress supports the assertion that the perception of
racial stimuli as stressors can initiate stress reactions (Pascoe &
Smart Richman, 2009). Researchers examining life-event trauma
for civilians and veterans have found that people of color experi-
ence higher rates of PTSD compared with their White counterparts
when exposed to a variety of potentially stressful life events (e.g.,
hurricanes, violence, assaults, traffic accidents, etc.)—a relation-
ship not fully explained by the event or other factors (Norris et al.,
2002;Perilla, Norris, & Lavizzo, 2002).
Carter (2007) theorizes that high rates of PTSD for people of
color could be related to racism or racial discrimination—an
association eluded to by trauma researchers, yet one that has not
been a focus of research (Loo, Fairbank, & Chemtob, 2005). When
scholars (e.g., Bryant-Davis & Ocampo, 2005;Roberts, Gilman,
Breslau, Breslau, & Koenen, 2011) have connected racism to
trauma, they have usually done so by adhering to the definition of
trauma as PTSD, thereby relating racism to physical danger and
pathology. There is evidence, however, that the stress associated
with racism (usually not threatening death or serious physical
injury) affects people of color adversely (e.g., Paradies et al., 2015;
Pieterse, Todd, Neville, & Carter, 2012).
Prior to the introduction of the race-based traumatic stress
(RBTS) model, a specific link to an experience of racism and the
symptoms associated with it did not exist (cf. Carter, 2007;Carter
& Sant-Barket, 2015;Carter et al., 2016). Carter (2007) asserted
that a racial encounter that is emotionally painful, sudden, and out
of the individual’s control results in reactions, some of which
overlap with PTSD symptoms (e.g., hypervigilance, intrusion,
and/or avoidance) and also involve other criteria unrelated to
PTSD (e.g., processing and understanding race and racism) that
can result in a RBTS injury (i.e., emotional pain after an encoun-
ter).
The ability to recognize racism is dependent on a person’s racial
identity statuses. Racial identity theorists (e.g., Helms, 1995;Sell-
ers, Caldwell, Schmeelk-Cone, & Zimmerman 2003;Thompson &
Carter, 2013) assert that the varied manner in which individuals
view the world, their affective states, and their behaviors can be
linked to the various racial identity statuses that individuals em-
brace or reject throughout a lifetime: Individuals may be ambiv-
alent about their race, racial group, and the dominant racial group,
whereas others may be more invested, and these feelings can ebb
and flow throughout a lifetime. Racial identity ego statuses can
vary from an “external,” dominant racial group identification (con-
formity), to “internal,” own-racial-group identification (internal-
ization) in a range of configurations that are nonlinear (i.e., not a
developmental or progressive stage process).
For people of color, reaching a predominant internally defined
racial identity is characterized by the abandonment of reliance on
White culture for self-definition and the development of a positive
racial identity as a member of a minority racial group. For in-
stance, regardless of racial group, individuals who have an “ex-
ternally” defined racial identity status (i.e., characterized as color
blind; conformity) may not believe race is a salient factor in their
everyday lives, and the lives of others both inside and outside of
his or her racial group or are in transition (dissonance). As such, in
order to have a subjective experience of race-based encounters as
being related to issues of racism, individuals would need to have
an “internally” defined racial identity status (Thompson & Carter,
2013).
Therefore, peoples’ awareness of the role of race becomes an
important factor in understanding and evaluating race-based
trauma. This notion has been supported by a variety of research
(cf. Burrow & Ong, 2010;Pillay, 2005;Sellers et al., 2003;Sellers,
Copeland-Linder, Martin, & Lewis, 2006). As such, in order to
assess whether an encounter with racism resulted in race-based
trauma, it would be necessary to know if the person exposed was
able to appraise the incident as being race-related. Understanding
the role of racial identity becomes important for scholars and
clinicians as they attempt to identify the specific psychological
outcomes associated with experiences of racial discrimination;
however, individuals’ awareness of the role of race as a psycho-
logical variable has yet to be tested in understanding and evaluat-
ing RBTS.
Furthermore, in the examination of the effects of racial discrim-
ination, it is important to consider within-group racial differences
and “not to treat members of racial groups as monolithic or
psychologically similar in regards to their experiences and under-
standing of racism” (Carter, 2007, p. 57). More often than not,
racial discrimination and trauma researchers use sociodemo-
graphic racial categories to infer social and psychological out-
comes from racial experiences (Helms, Jernigan, & Mascher,
2005;Smedley & Smedley, 2005). In doing so, researchers make
the assumption that people from a particular racial group are also
psychologically invested in the groups’ race and culture in similar
ways, as if there were no differences between or among them.
When trauma researchers have studied people of color and racial
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31
RBTS, RIA, AND PSYCHOLOGICAL FUNCTIONING

discrimination, they seldom examine within-group racial variation
such as ethnic or racial identity or acculturation.
The current study was designed to investigate two main areas of
inquiry: (a) to determine whether stress related to racial encounters
is associated with racial identity status attitudes, and (b) to identify
any associations between RBTS symptoms, racial identity status
attitudes, and psychological distress and well-being.
RBTS theory suggests there should be a relationship, direct or
indirect, between high levels of RBTS scores and racial identity
status attitudes, and that the “externally” defined racial identity
statuses (e.g., conformity and dissonance) may relate differentially
to RBTS than the “internally” defined or highly integrated statuses
(e.g., immersion-emersion, internalization). It was hypothesized
that higher levels of RBTS would be associated with racial identity
status attitudes, in particular with “internally” defined racial iden-
tity statuses, and that “internally” defined racial identity statuses
will be related to increased psychological distress as opposed to
psychological well-being.
Method
Participants
The 282 adult participants in the study self-reported the follow-
ing demographic information. There were 141 males (50%) and
141 females (50%). Participant ages ranged from 18 to 65 years
(M⫽39.4, SD ⫽13.5). Two hundred six participants (73%) were
Black, 42 were Hispanic (14.9%), 19 were Asian (6.7%), three
were Native American (1.1%), and 12 were biracial (4.3%). Par-
ticipants reported the following socioeconomic statuses: 68 were
lower class (25.1%), 80 were working class (24.8%), 46 were
lower middle class (15.8%), 52 were middle class (19.3%), 18
were upper middle class (9.3%), three were upper class (0.7%),
and 15 did not report social class. With regard to religion, partic-
ipants most frequently identified as Christian (65.5%), followed by
Muslim (15.2%). Participants, on average, completed 13.3 years of
education, with the majority completing between 11 and 15 years
(60.6%).
Measures
The Race-Based Traumatic Stress Symptom Scale (RBTS;
Carter et al., 2013) uses an open-ended response section for
participants to describe at least three experiences of racism that
were memorable. They select one event and indicate (yes–no)
whether that incident was emotionally painful (negative), out of his
or her control, and sudden in its occurrence. Then they follow the
instructions,
Below is a list of reactions or feelings that people sometimes have
after an upsetting event. After each reaction circle the option that best
describes your feelings right after the event (within one month) and
more recently when thinking about the event.
Examples of reaction items include “As a consequence of the
memorable encounter I had with racism,” “I felt sad,” or “I
experienced tiredness and lack of energy.” Respondents use a
5-point Likert scale with the following response options: 0 (does
not describe my reaction)to4(this reaction would not go away).
Items are summed for each of the seven scales, in which high
scores indicate greater presence of that reaction. In the current
study, the Cronbach’s alphas for the seven Immediate Reaction
scales were as follows: Depression, ␣⫽.90; Intrusion, ␣⫽.87;
Anger, ␣⫽.88; Hypervigilance, ␣⫽.88; Physical, ␣⫽.90; Low
Self-Esteem, ␣⫽.87; and Avoidance, ␣⫽.73. For the purposes
of this study, only the Immediate Reaction scales were used.
The Person of Color Racial Identity Attitudes Scale (POCRIAS;
Helms, 1995) is a 50-item measure that has four scales: Confor-
mity, Dissonance, Immersion-Emersion, and Internalization. The
scales assess racial identity statuses ranging from externally de-
fined to internally defined. Responses to each item are scored
using a 5-point Likert scale ranging from 1 ⫽strongly disagree to
5⫽strongly agree. Cronbach’s alphas in the study were as
follows: Conformity, ␣⫽.83; Dissonance, ␣⫽.80; Immersion-
Emersion, ␣⫽.79; and Internalization, ␣⫽.90.
The Mental Health Inventory (MHI-38; Veit & Ware, 1983)is
comprised of five scales that make up two global scales. Partici-
pants report the frequency of psychological symptoms for the past
month for Psychological Distress, including Depression, Anxiety,
and Loss of Control; and Psychological Well-Being, including
Positive Affect and Emotional Ties. In the current study, Cron-
bach’s alpha for the Psychological Distress scale was .94, and for
the Psychological Well-Being Scale was .92.
Procedure
Study participants were recruited through college psychology
courses; several community health centers that provided a range of
services such as medical care, alcohol and substance abuse treat-
ment, and dentistry; as well as community settings such as barber
shops and beauty salons in the Northeast. Student participants were
given extra credit toward their course grades as incentive to
participate. Community participants were compensated either with
a $10.00 (service agencies) or $20.00 (barber shops/salons) gift
card.
Results
Data Analysis Plan
We approached data analyses in steps: The first step was to
determine whether participants were similar and had no significant
demographic differences. We used multivariate analysis of vari-
ance (MANOVA) to look for differences in responding to the
measures in the study on the basis of race, gender, age, and SES.
The second analysis involved cluster analysis that is similar to
factor analysis, in that both attempt to account for similarities
among data by grouping the observations together. All cluster
analyses place participants into common groups such that they are
more similar to one another than to members of any other possible
cluster group. Factor analysis groups are based on covariance,
whereas cluster analysis is “used to group people together based on
their scores across a set of variables” (Gore, 2000, p. 299). Hier-
archical cluster analysis was selected, as it allows the researcher to
discover groups that exist within data, rather than predefining the
groups. Our hierarchical cluster analysis was conducted to create
groups of participants that shared similar configurations of RBTS
reactions and racial identity status attitudes. We then conducted
another MANOVA in which we sought to determine whether the
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32 CARTER ET AL.

groups varied in terms of their scores on the MHI-38 scales of
Psychological Well-Being and Distress.
Preliminary Analyses
A MANOVA was conducted as a preliminary analysis to deter-
mine demographic differences; independent variables were age,
gender, socioeconomic status, and race. Race was included as an
independent variable because of the racial heterogeneity of the
sample. The RBTS symptom scales of, Avoidance, Intrusion,
Depression, Hypervigilance, Physical symptoms, Low Self-
Esteem, and Anger were dependent variables, as well as MHI
Psychological Distress and Well-Being scales, and the POCRIAS
(Conformity, Dissonance, Immersion-Emersion, Internalization)
scales. Results of the MANOVA revealed no significant differ-
ences in racial identity status attitudes, psychological well-being,
psychological distress, or RBTS reactions by age (Wilks’ ␭⫽.01,
F[572, 1237.80] ⫽.95, p⫽.73, ␩
2
⫽.30), gender (Wilks’ ␭⫽
.93, F[13, 95] ⫽.54, p⫽.89, ␩
2
⫽.07), race (Wilks’ ␭⫽64,
F[52, 370.04] ⫽.87, p⫽.72, ␩
2
⫽.11), or socioeconomic status
(Wilks’ ␭⫽.40, F[78, 529.90] ⫽1.23, p⫽.10, ␩
2
⫽.14).
Primary Analyses
To examine how RBTS reactions and racial identity status
attitudes are associated with and/or varied on mental health out-
comes, a hierarchical cluster analysis was conducted to create
groups of participants that share similar scores of RBTS reactions
and racial identity status attitudes. Following the hierarchical clus-
ter analysis, a MANOVA was conducted to determine whether
there were significant differences between the cluster groups on
psychological distress and well-being. Although data reduction is
recommended prior to cluster analysis when some of the variables
are highly correlated (Gore, 2000), as is the case with the current
study, we contend that RBTS and racial identity are multidimen-
sional constructs that we would expect to be correlated. Therefore,
we refrained from reducing the variables to avoid limiting the
information provided in the analyses.
Hierarchical Cluster Analysis
Using the seven RBTS reaction types and four racial identity
status attitudes as the clustering variables, an agglomerative hier-
archical cluster analysis using Ward’s clustering method with
squared Euclidean distance was conducted. This method grouped
the participants based on their reported RBTS reactions and racial
identity status attitudes in order to create clusters to further ana-
lyze. We followed recommendations to examine agglomerative
hierarchical cluster analysis when no a priori information is avail-
able about the likely number of cluster groups to expect when the
sample is relatively small (Gore, 2000). Upon inspection of the
agglomerative schedule, which provided a proximity coefficient of
the within-group sum of squared error at each stage of the clus-
tering procedure, a two-cluster solution was found to be the opti-
mum number of clusters, with each cluster group having an ade-
quate number of cases for further analyses.
One-way follow-up ANOVAs indicated that there were signif-
icant differences between the two cluster groups on all of the
clustering variables: RBTS Depression, F(1, 190) ⫽174.88, p⬍
.001; RBTS Anger, F(1, 190) ⫽207.33, p⬍.001; RBTS Physical,
F(1, 190) ⫽187.71, p⬍.001; RBTS Avoidance, F(1, 190) ⫽
249.44, p⬍.001; RBTS Hypervigilance, F(1, 190) ⫽258.55, p⬍
.001; RBTS Intrusion, F(1, 190) ⫽170.07, p⬍.001; RBTS Low
Self-Esteem, F(1, 190) ⫽79.18, p⬍.001; POCRIAS-Conformity,
F(1, 190) ⫽34.09, p⬍.001; POCRIAS-Dissonance, F(1, 190) ⫽
23.10, p⬍.001; POCRIAS-Immersion-Emersion, F(1, 190) ⫽
9.42, p⬍.002; POCRIAS-Internalization, F(1, 190) ⫽8.86, p⬍
.003. Results indicated that there were significant between-cluster
group differences on all of the clustering variables, which sug-
gested that the clusters were interpretable and sufficient for further
analysis. The means and standard deviations of the RBTS and
racial identity scales for the two clusters are shown in Table 1.
The first cluster group—Low RBTS, Internalization—was char-
acterized by “low” RBTS scale scores, with each scale score at
least one half a standard deviation below the sample mean. With
respect to racial identity status attitude scores, the first cluster
group relied primarily on Internalization status attitudes and mod-
erately on Conformity, Dissonance, and Immersion-Emersion sta-
tus attitudes. This was revealed in the higher relative Internaliza-
tion score (slightly above the mean) compared with the remaining
racial identity mean scale scores that were each just below the
sample mean. As seen in Figure 1, RBTS scores showed a flat
pattern, with very little difference existing between levels of each
RBTS symptom.
The second cluster group—High RBTS, Conformity, Disso-
nance, Immersion-Emersion—was characterized by a pattern of
RBTS reactions, in which each scale was at least one half a
standard deviation above the sample mean. Notably, Self-Esteem
was lower than the other RBTS scores for this cluster group. In the
second cluster group, Conformity, Dissonance, and Immersion-
Emersion racial identity status attitudes scores were above the
Table 1
People of Color Cluster Group Means and Standard Deviations for Race-Based Traumatic Stress Scales, Racial Identity Status
Attitudes, Psychological Distress, and Psychological Well-Being
Cluster group M/SD DEP ANG PHY AVO HYV INTRU LSE CONF DISS IMEM INT DIST WB
Low RBTS, INT (n⫽106) M43.63 43.74 43.56 42.91 42.96 43.45 44.39 46.25 46.43 48.00 52.79 49.23 55.88
SD 4.59 6.32 6.31 4.62 5.15 4.47 5.06 7.84 10.16 10.54 8.79 16.85 11.96
High RBTS, CONF, DISS, IMEM (n⫽86) M57.81 58.63 58.10 58.56 58.46 57.14 55.07 53.87 52.99 52.27 48.83 59.83 50.53
SD 9.80 8.00 8.39 8.82 8.12 9.61 11.01 10.24 8.35 8.27 9.61 16.41 13.04
Note. RBTS ⫽Race-Based Traumatic Stress Scale; DEP ⫽Depression; ANG ⫽Anger; PHY ⫽Physical; AVO ⫽Avoidance; HYV ⫽Hypervigilance;
INTRU ⫽Intrusion; LSE ⫽Low Self-Esteem, CONF ⫽Conformity; DISS ⫽Dissonance; IMEM ⫽Immersion-Emersion; INT ⫽Internalization; DIST ⫽
Psychological Distress, WB ⫽Psychological Well-Being.
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33
RBTS, RIA, AND PSYCHOLOGICAL FUNCTIONING

sample mean, whereas Internalization scores fell below the mean.
Cluster means for RBTS reactions and racial identity status atti-
tudes are shown in Table 1.
Differences Between Cluster Groups on Mental Health
Outcomes
In order to determine whether the two clusters were significantly
different from each other with respect to psychological distress and
well-being, a MANOVA was run with the two cluster groups as
independent variables, and MHI-38 psychological distress and
well-being as dependent variables. The results of the omnibus test
indicated that there were significant differences between the two
cluster groups on the dependent variables, Wilks ␭⫽.906, F(2,
168) ⫽8.722, p⬍.001, ␩p
2⫽.09. Inspection of the follow-up
univariate analysis revealed significant cluster group differences
on both psychological distress, F(1, 169) ⫽17.25, p⬍.001, ␩p
2⫽
.09, and well-being, F(1, 169) ⫽7.84, p⬍.01, ␩p
2⫽.04. Cluster
group means and standard deviations for the mental health out-
comes are shown in Table 1. Participants in the “Low RBTS,
Internalization” cluster group endorsed less psychological dis-
tress (p⬍.01) and higher well-being (p⬍.01) than did those
in the “High RBTS, Conformity, Dissonance, Immersion-
Emersion” cluster group. Conversely, the High RBTS, Confor-
mity, Dissonance, Immersion-Emersion group reported higher
psychological distress (p⬍.01) and lower well-being (p⬍.01)
compared with the participants in the Low RBTS, Internaliza-
tion cluster group.
Overall, these results suggested that the cluster group char-
acterized by lower than average RBTS reactions and greater
relative reliance on internalization racial identity attitudes was
associated with less psychological distress and greater well-
being. On the other hand, the cluster group characterized by
elevated RBTS reactions and primary reliance on conformity
and dissonance racial identity attitudes was associated with
greater psychological distress and compromised psychological
well-being.
Discussion
A body of research has documented the adverse effects of
racism and racial discrimination (Pascoe & Smart Richman,
2009;Williams & Mohammed, 2009), and researchers have
proposed that stress associated with racial incidents can rise to
the level of traumatic stress (Bryant-Davis & Ocampo, 2005;
Helms et al., 2010;Loo et al., 2001). Carter’s (2007) model of
RBTS and scale remain the only method of linking specific
racial incidents with its resulting psychological symptoms
(Carter et al., 2013).
Researchers have argued that in order to experience RBTS,
an individual must possess some understanding of race in their
life. Racial identity researchers (Comas-Díaz, 2016;Phelps,
Taylor, & Gerard, 2001;Pillay, 2005;Sellers et al., 2003) have
shown that a person’s racial identity status attitudes comprise a
lens that is used to evaluate and determine the psychological
and emotional impact associated with life events and racial
incidents. Accordingly, it has also been argued that an individ-
ual must have an integrated, “internally” defined racial identity
to be able to appraise an event as race-related (Carter, 2007).
Therefore, the purpose of the current investigation was to
Figure 1. Race-Based Traumatic Stress Scale (RBTS) scores and People of Color Racial Identity Attitudes
Scale (POCRIAS) scores by cluster group. DEP ⫽RBTS Depression; ANG ⫽RBTS Anger; PHYS ⫽RBTS
Physical; HYP ⫽RBTS Hypervigilance; INTRU ⫽RBTS Intrusion; LSE ⫽RBTS Low Self-Esteem; CONF ⫽
POCRIAS Conformity; DISS ⫽POCRIAS Dissonance; IMEM ⫽POCRIAS Immersion-Emersion; INT ⫽
POCRIAS Internalization. See the online article for the color version of this figure.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
34 CARTER ET AL.

explore the relationships between RBTS and racial identity
status attitudes. Further, we attempted to understand how these
two variables were associated with psychological distress and
well-being. We hypothesized that higher RBTS would be asso-
ciated with “internally” defined racial identity statuses, and that
“internally” defined racial identity statuses will be related to
increased psychological distress as opposed to psychological
well-being.
In an effort to ensure that the participant group did not differ based
on their demographic characteristics, a MANOVA was conducted to
determine whether demographic differences existed for our partici-
pants on their racial identity and RBTS symptoms. The scale scores
were not significantly different. We conducted hierarchical cluster
analysis based on individuals’ RBTS symptoms and racial identity
status scores. We found two distinct cluster groups, which we named
“Low RBTS, Internalization” and “High RBTS, Conformity, Disso-
nance, Immersion-Emersion.”
Low RBTS, Internalization
The Low RBTS, Internalization cluster group consisted of in-
dividuals whose racial identity status attitudes were characterized
by the ability to define oneself by internal attributes and to have a
positive commitment to one’s racial group. The use of an inter-
nalization racial identity status attitude reflects an ability to rec-
ognize the impact of racism on people of color, while allowing for
interactions with dominant and nondominant group members that
are less defensive and more flexible in thinking about racial
climates (Helms, 1995;Sue & Sue, 2015).
These individuals’ low RBTS scores may be a product of their
ability to recognize, understand, anticipate, and cope effectively
with racial incidents, along with an increased ability to understand
ambiguous situations. The combination of confidence in the face
of race-based incidents and broader use of effective coping strat-
egies may explain the low psychological distress and high psycho-
logical well-being in this group. This is consistent with current
research on racism-related coping and racial identity. For instance,
Forsyth and Carter (2012) found that those utilizing internalization
status attitudes also used more effective coping strategies to deal
with racial incidents, and thus suffer from less psychological
distress associated with these events (Bryant-Davis & Ocampo,
2005).
High RBTS, Conformity, Dissonance,
Immersion-Emersion
The High RBTS, Conformity, Dissonance, Immersion-
Emersion cluster group consisted of individuals with reliance on
conformity, dissonance, and immersion-emersion racial identity
status attitudes. This group seems to encompass a group of indi-
viduals who vary in their orientation to their racial group mem-
berships as conformity, dissonance, and immersion-emersion sta-
tus attitudes represent an array of attitudes. Conformity racial
identity status attitudes are characterized by defining one’s racial
group by external dominant cultural norms, which results in de-
valuing their own group in favor of dominant group preferences
(Sue & Sue, 2015). Use of these status attitudes corresponds with
the viewpoint that race is an inconsequential factor in their life;
therefore, those characterized by this status are unaware of racial
differences and concerns. Dissonance racial identity status atti-
tudes represent a transition into increased awareness of racial
differences and the meaning associated with that membership
(Helms, 1996). Further, immersion-emersion status attitudes re-
flect a desire to get a better understanding of race as it relates to
one’s life, and can go from a staunch attachment to one’s racial
group membership and rejection of the dominant group, to a desire
to understand the complexities of race that is less “us versus them”
(Helms, 1995).
Forsyth and Carter (2012) have posited that integrated racial
identity is necessary for one to experience RBTS, as the individual
would need to have an understanding of race as well as how race
impacts them and society at large. However, contrary to our
hypothesis, the results showed that RBTS reaction scores were
high within this cluster. This suggests individuals may still be
psychologically harmed by racial incidents, despite little under-
standing of racial dynamics in the United States (Comas-Díaz,
2016).
The relationships in this cluster group may be explained through
the ways in which these individuals process racial incidents with-
out a sophisticated understanding of race. Experiencing intrusive
thoughts or memories of the incident may recur due to the indi-
vidual’s inability to make meaning of the event or interaction. The
person who does not see race as an important factor in their lives
may be particularly susceptible to internalizing the cause of the
event, perhaps attributing it to being some personal flaw or char-
acteristic of their own (Comas-Díaz, 2016). Hypervigilant behav-
ior following this event may be the only resource the person can
rely on due to anticipatory fear that the event will occur again.
Their lack of understanding of race dynamics may also leave them
disarmed without coping strategies specific to racial encounters
(Bryant-Davis & Ocampo, 2005). Further, these individuals may
be on alert for threats in a wide array of situations rather than
solely in similar and appropriate situations. Individuals who have
recently recognized that race may play a role in how society
functions may experience a lot of confusion around racial incidents
(Helms, 1995). They may oscillate between internalizing feelings
associated with the incident and externalizing their feelings onto
others, all the while not being entirely confident in either of these
assessments. Those who have developed a rigid concept of race,
choosing to surround themselves with members of their own racial
group and denigrate dominant group members may experience
overwhelming emotions associated with the racial incident. These
overwhelming emotions may stem from the realization that mem-
bers of their racial group have historically faced hardships as well
as that they will inevitably interact with dominant group members
(Comas-Díaz, 2016).
Findings indicate that those relying on externally defined racial
identity status attitudes have higher RBTS reactions scores and
compromised psychological functioning. Conversely, those using
internally defined racial identity status attitudes had below average
RBTS scores and higher relative psychological well-being.
Clinical Implications
The findings of this study have important clinical implications.
Racial identity is an important internal characteristic that influ-
ences who may develop elevated levels of RBTS reactions and
who may ultimately develop race-based trauma (Bryant-Davis &
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
35
RBTS, RIA, AND PSYCHOLOGICAL FUNCTIONING

Ocampo, 2005). Clients with predominantly “external” racial iden-
tity status attitudes (conformity, dissonance) may be at greater risk
of developing RBTS due to their lack of understanding about race,
its impact on their lives, and coping strategies associated with
racial incidents (Comas-Díaz, 2016). For these individuals, it is
important to assess their level of awareness to negative encounters
as racial in nature. It will also be helpful for clinicians to suggest
how individual, cultural, and institutional racism may be impacting
ambiguous incidents (Helms, 1996). This strategy may help to
clarify confusing incidents and also may interrupt the process of
internalizing feelings associated with the incident or blaming one-
self.
Clinicians may also need to be vigilant about the symptoms of
race-based trauma that a client may be displaying, despite his or
her assessment of the client’s capacity to accurately label racial
incidents as such (Sue & Sue, 2015).
Training in multicultural competence should include the impor-
tance of considering racial identity when assessing and under-
standing RBTS symptomology. Further, clinicians should have a
good understanding of the implications of one’s race in their own
lives. One difficulty that practitioners may face is their own
confusion about the various forms racism can take in the United
States, causing them to miss signs of RBTS when it enters the
therapy room.
Study Limitations
There are several study limitations, one is that the measures are
self-report instruments and rely on participants’ recall, the RBTS
use of recall could introduce possible bias into the study. The
methods may not ensure that the racial identity attitude status of
the participant that was reported coincides with their racial identity
attitude status at the time of the memorable racial experience. In
addition, self-report data can have limitations because of the de-
terioration of memory and emotional impact over time. Further-
more, participants were offered compensation for being part of the
study, which could have compromised their motivation and re-
sponses to the study’s measures. It could also be argued that the
compensation was a recognition and acknowledgment of the value
of participants’ time.
References
American Psychiatric Association. (2013). Diagnostic and statistical man-
ual of mental disorders (5th ed.). Washington, DC: Author.
Bryant-Davis, T., & Ocampo, C. (2005). Racist incident-based trauma. The
Counseling Psychologist, 33, 479 –500. http://dx.doi.org/10.1177/
0011000005276465
Burrow, A. L., & Ong, A. D. (2010). Racial identity as a moderator of daily
exposure and reactivity to racial discrimination. Self and Identity, 9,
383– 402. http://dx.doi.org/10.1080/15298860903192496
Carlson, E. B. (1997). Trauma assessments: A clinician’s guide. New
York, NY: Guilford Press.
Carter, R. T. (2007). Racism and psychological and emotional injury
recognizing and assessing race-based traumatic stress. The Counseling
Psychologist, 35, 13–105. http://dx.doi.org/10.1177/0011000006292033
Carter, R. T., Johnson, V. E., Muchow, C., Lyons, J., Forquer, E., &
Galgay, C. (2016). Development of classes of racism measures for
frequency and stress reactions: Relationships to race-based traumatic
symptoms. Traumatology, 22, 63–74. http://dx.doi.org/10.1037/
trm0000057
Carter, R. T., Mazzula, S., Victoria, R., Vazquez, R., Hall, S., Smith, S.,...
Williams, B. (2013). Initial development of the Race-Based Traumatic
Stress Symptom Scale: Assessing the emotional impact of racism. Psy-
chological Trauma: Theory, Research, Practice, and Policy, 5, 1–9.
http://dx.doi.org/10.1037/a0025911
Carter, R. T., & Sant-Barket, S. M. (2015). Assessment of the impact of
racial discrimination and racism: How to use the Race-Based Traumatic
Stress Symptom Scale in practice. Traumatology, 21, 32–39. http://dx
.doi.org/10.1037/trm0000018
Comas-Díaz, L. (2016). Racial trauma recovery: A race informed thera-
peutic approach to racial wounds. In A. N. Alvarez, C. T. H. Liang, &
H. A. Neville (Eds.), The cost of racism for people of color (pp.
249 –272). Washington, DC: American Psychological Association.
http://dx.doi.org/10.1037/14852-012
Forsyth, J., & Carter, R. T. (2012). The relationship between racial identity
status attitudes, racism-related coping, and mental health among Black
Americans. Cultural Diversity and Ethnic Minority Psychology, 18,
128 –140. http://dx.doi.org/10.1037/a0027660
Gore, P. A. (2000). Cluster analyses. In E. A. Howard Tinsley & S. D.
Brown (Eds.), Handbook of applied multivariate statistics and mathe-
matical modeling (2nd ed., pp. 297–321). San Diego, CA: Academic
Press. http://dx.doi.org/10.1016/B978-012691360-6/50012-4
Helms, J. E. (1995). An update of Helms’s White and people of color racial
identity models. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M.
Alexander (Eds.), Handbook of multicultural counseling (pp. 181–198).
Thousand Oaks, CA: Sage.
Helms, J. E. (1996). Toward a methodology for measuring and assessing
racial as distinguished from ethnic identity. In G. R. Sodowsky & J. C.
Impara (Eds.), Multicultural assessment in counseling and clinical psy-
chology (pp. 142–192). Lincoln, NE: University of Nebraska-Lincoln,
Buros Institution of Mental Measurement.
Helms, J. E., Jernigan, M., & Mascher, J. (2005). The meaning of race in
psychology and how to change it: A methodological perspective. Amer-
ican Psychologist, 60, 27–36. http://dx.doi.org/10.1037/0003-066X.60
.1.27
Helms, J. E., Nicolas, G., & Green, C. E. (2010). Racism and ethnoviolence
as trauma: Enhancing professional training. Traumatology, 16, 53– 62.
http://dx.doi.org/10.1177/1534765610389595
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New
York, NY: Springer.
Loo, C. M., Fairbank, J. A., & Chemtob, C. M. (2005). Adverse race-
related events as a risk factor for posttraumatic stress disorder in Asian
American Vietnam veterans. Journal of Nervous and Mental Disease,
193, 455– 463. http://dx.doi.org/10.1097/01.nmd.0000168239.51714.e6
Loo, C. M., Fairbank, J. A., Scurfield, R. M., Ruch, L. O., King, D. W.,
Adams, L. J., & Chemtob, C. M. (2001). Measuring exposure to racism:
Development and validation of a Race-Related Stressor Scale (RRSS)
for Asian American Vietnam veterans. Psychological Assessment, 13,
503–520. http://dx.doi.org/10.1037/1040-3590.13.4.503
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., &
Kaniasty, K. (2002). 60,000 disaster victims speak: Part I. An empirical
review of the empirical literature, 1981–2001. Psychiatry: Interpersonal
and Biological Processes, 65, 207–239. http://dx.doi.org/10.1521/psyc
.65.3.207.20173
Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A.,...Gee,
G. (2015). Racism as a determinant of health: A Systematic review and
meta-analysis. PLoS ONE, 10 (9), e0138511. http://dx.doi.org/10.1371/
journal.pone.0138511
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and
health: A meta-analytic review. Psychological Bulletin, 135, 531–554.
http://dx.doi.org/10.1037/a0016059
Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist:
Countertransference and vicarious traumatization in psychotherapy
with incest survivors. New York, NY: Norton.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
36 CARTER ET AL.

Perilla, J. L., Norris, F. H., & Lavizzo, E. A. (2002). Ethnicity, culture, and
disaster response: Identifying and explaining ethnic differences in PTSD
six months after Hurricane Andrew. Journal of Social and Clinical
Psychology, 21, 20 – 45. http://dx.doi.org/10.1521/jscp.21.1.20.22404
Phelps, R. E., Taylor, J. D., & Gerard, P. A. (2001). Cultural mistrust,
ethnic identity, racial identity, and self-esteem among ethnically diverse
Black university students. Journal of Counseling & Development, 79,
209 –216. http://dx.doi.org/10.1002/j.1556-6676.2001.tb01962.x
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, 1–9. http://
dx.doi.org/10.1037/a0026208
Pillay, Y. (2005). Racial identity as a predictor of the psychological health
of African-American students at a predominately White university.
Journal of Black Psychology, 31, 46 – 66. http://dx.doi.org/10.1177/
0095798404268282
Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C.
(2011). Race/ethnic differences in exposure to traumatic events, devel-
opment of post-traumatic stress disorder, and treatment-seeking for
post-traumatic stress disorder in the United States. Psychological Med-
icine, 41, 71– 83. http://dx.doi.org/10.1017/S0033291710000401
Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, K. H., & Zimmerman,
M. A. (2003). Racial identity, racial discrimination, perceived stress and
psychological distress among African American young adults. Journal
of Health and Social Behavior, 43, 302–317.
Sellers, R. M., Copeland-Linder, N., Martin, P. P., & Lewis, R. H. (2006).
Racial identity matters: The relationship between racial discrimination
and psychological functioning in African American adolescents. Journal
of Research on Adolescence, 16, 187–216. http://dx.doi.org/10.1111/j
.1532-7795.2006.00128.x
Smedley, A., & Smedley, B. D. (2005). Race as biology is fiction, Racism
as a social problem is real. American Psychologist, 60, 16 –26.
Sue, D. W., & Sue, D. (2015). Counseling the culturally diverse (7th ed.).
Hoboken, NJ: Wiley.
Thompson, C. E., & Carter, R. T. (2013). An overview and elaboration of
Helms’ racial identity development theory. In C. E. Thompson & R. T.
Carter (Eds.), Racial identity theory: Applications to individual, group,
and organizational interventions (pp. 15–32). New York, NY: Rout-
ledge.
Veit, C. T., & Ware, J. E., Jr. (1983). The structure of psychological
distress and well-being in general populations. Journal of Consulting
and Clinical Psychology, 51, 730 –742. http://dx.doi.org/10.1037/0022-
006X.51.5.730
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial
disparities in health: Evidence and needed research. Journal of Behav-
ioral Medicine, 32, 20 – 47. http://dx.doi.org/10.1007/s10865-008-
9185-0
Received June 21, 2016
Revision received October 18, 2016
Accepted October 19, 2016 䡲
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RBTS, RIA, AND PSYCHOLOGICAL FUNCTIONING