The Counseling Psychologist

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A Forensic and Ethics-Based View of Carter's ''Racism and

Psychological and Emotional Injury''
Ezra E. H. Griffith
The Counseling Psychologist 2007 35: 116
DOI: 10.1177/0011000006294667
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A Forensic and Ethics-Based View of

Carters Racism and Psychological
and Emotional Injury
Ezra E. H. Griffith
Yale University
The psychological effect that racism has on individuals is of significant interest to mental health professionals. But it is of particular interest to those professionals who treat the
clinical dimensions of the trauma to those who are involved in the assessment of the
trauma for forensic purposes. Robert T. Carter provides a systematic, disciplined, sciencebased review of the evidence bearing on this subject in his article in this issue. He also
adds to his review and synthesis some novel and creative recommendations that will
have considerable impact on the field. This commentary focuses on certain aspects of
Carters work from an ethics-based and forensic dimension. I also suggest slight modifications of his contributions in an attempt to make them more user-friendly for the
forensic specialist.

Racial discrimination is such a powerful and pervasive element in the

American context that, as a subject of intellectual discourse, it is difficult
ever to claim that we have seen or heard too much of it. In this issue of The
Counseling Psychologist, Robert T. Carter (2007 [this issue]) recapitulates
for us much of what we should know, but almost certainly do not, because
the knowledge base is now quite extensive and also because it requires multidisciplinary skills to appreciate fully. Students, scholars, and practitioners
from all walks of the mental health disciplines will gravitate to Carters article with alacrity and undisguised passion.
Carters (2007) article is first preoccupied with an almost elementary
claim: Racism can lead to psychological harm in the person who experiences it. However, the simplicity of this assertion belies the complexity of
the reflection it provokes. As Carter makes clear in his article, it is not obvious which specific aspects of a racist action lead to the stressful effects of
racism. Also, not everyone who experiences the same racist behavior will
suffer psychological effects. So, there is a lot that we do not really understand about the connection between racism and ensuing psychological
responses.
Correspondence concerning this article should be addressed to Ezra E. H. Griffith, Department
of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven,
CT 06511; e-mail: ezra.griffith@yale.edu.
THE COUNSELING PSYCHOLOGIST, Vol. 35 No. 1, January 2007 116-125
DOI: 10.1177/0011000006294667
2007 by the Division of Counseling Psychology.

116
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Griffith / A FORENSIC AND ETHICS-BASED VIEW 117

Carter (2007) makes at least two other claims in arguing cogently for
reconsideration of the topic. He asserts that mental health professionals
receive little guidance in their training about the clinical effects of racism.
He also notes that even the popular Diagnostic and Statistical Manual
(DSMIVTR; American Psychiatric Association, 2000) has excluded racial
discrimination from the list of stressors that can cause posttraumatic stress
disorder (PTSD). This is an argument that Butts (2002) has articulated
effectively in criticizing those who formulated the DSMIVTR for lacking
clinical familiarity with the experiences of African Americans. In other
words, despite the ubiquity of racism in this American culture, mental
health professionals have not spent as much time as they should have in elucidating the phenomenon and clarifying the mechanisms through which a
racist action works to catalyze a response in the human subject. That is
what Carter sets out to do. He marshals the direct and indirect evidence
available to help us disassemble this complicated subject and see where we
are in understanding how it works, how racism manages to have an impact
on our psyches. In every way, this is a solid advance on my early musings
concerning racism and psychological damages (see Griffith & Griffith,
1986) and provides an important science base for such reflection.
Carter (2007) cites a case used by Butts (2002) to demonstrate that
racism may result in psychological trauma. It is an apparently simple housing discrimination case. A light-skinned Hispanic male was treated courteously when he showed up to view an apartment that was up for rent. Then
he returned at a later time to view the apartment, but this time was accompanied by his African American wife. We learn that the rental agent became
aloof and informed them that the apartment was rented. Following this
rejection, apparently based on race, Butts tells us that the woman developed
symptoms that led to a diagnosis of PTSD and major depressive disorder.
This case history immediately becomes a thorny vignette because Carter
does not like what he calls the dispositional approach used by Butts.
Carter creates a model, which he labels a notion of injury, whereby one
understands that the racist insult causes a reaction in the subject, and the
reaction affects the subjects mental health. Butts is, in my view, making a
different kind of case. He is arguing that the racist act results in a manifestation of pathology. This is precisely why Butts originally urged further
research on this topic to determine why some African Americans respond
to the racist act with a manifestation of psychological or somatic pathology,
whereas other African Americans remained healthy. He also wanted to
know whether there was any correlation between preexisting personality
organization and the development of some form of pathological reaction.
This distinction between Carter (2007) and Butts (2002) is important, as
Carter himself worries that Buttss approach may lead to victim blame. So

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118 THE COUNSELING PSYCHOLOGIST / January 2007

we see quite quickly that Carter is distracted by the notion that the model he
advances for newly approaching this subject must not be used against those who
are already victims of racism. While this is a legitimate concern, he cannot be
allowed to turn his own model on its head to avoid exploring the natural questions that stare us so frankly in the face the minute we approach the topic of
racism and its derivative psychological effects. One such question is obviously
what individual dispositional attributes, which is to refer in Buttss terms to preexisting personality organization, contribute to the vulnerability of the subject
and the actual manifestation of pathology. This is traditional medical reasoning
that is helpful in formulating at least the questions in this area, with no intent to
blame the subject of the racist experience. But how can we individualize the
experience if we discount the intrinsic features of the human subject?

THE ETHICS BASE

I have said earlier that the Butts (2002) vignette, which was borrowed by
Carter (2007), is deceptively simple. When, in fact, we examine the case
example with more thoughtful eyes, we recognize that its apparent lack of
complexity is ephemeral. We are not told that the rental agent ever really
made it clear that the refusal to rent was race based. That is an assumption
made by those who tell the story so that they may reach the conclusion that
facilitates the point they want to drive home. At least Carter would like to
reach his conclusion without invoking any responsibility on the wifes part.
He avoids the question of individual dispositional attributes because he
does not wish to blame the victim. But another important point is that he
seeks to avoid clarity about what he calls race-based encounters and experiences. This is at the heart of truly understanding the complexity of the
interaction between the racist act and the subject of it.
In the forensic context (that is to say, when there is an interface between
psychology/psychiatry and the law), questions will be framed differently, as
the context is adversarial in nature. People will ask, for the sake of argument, why the couple may not have lost the apartment because on the second occasion the mans appearance was unkempt. Or there may have been
some other characteristic of the woman, beside her race, that ostensibly
made her an unfit tenant. In raising these questions, I am not seeking to cast
doubt on the likely possibility that the rental agent intended to discriminate
against the woman. In adversarial debate, however, we will not be allowed
the comfort of ignoring the possibility that there may not be a simple way
to buttress objectively the womans version of the story. We have been cautioned that we must not twist the facts in these stories to suit our own ends
(see Griffith, 1998a, 2003; Stone, 1984).

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Griffith / A FORENSIC AND ETHICS-BASED VIEW 119

Now these questions intrigue me because I am interested especially in the

forensic mental health dimensions of all that Carter (2007) says about
racism and psychological injury. In other words, what will we say in court
(in a civil or criminal case) about the phenomenon, and how will we seek to
help the judicial system reach just conclusions about incidents in which
racism is suspected to have played a role? (For example, in the very vignette
cited earlier, the woman could have claimed in court that she suffered psychological damages because of the racist conduct evinced by the realtor.) The
American Academy of Psychiatry and the Law (1995) has issued ethics
guidelines to remind us that we should contemplate these matters with our
eyes on the principle of objectivity and our efforts should be carried out honestly and with the intent to seek objectivity. Therefore, Buttss (2002) questions about the housing vignette cannot be ignored, even if they may seem to
impute some blame to the woman seeking an apartment.
I wish to emphasize my own belief that adhering to the ethics principles
imposes a substantial burden on clinicians and others who earnestly want to
integrate into their work what Carter (2007) wants to teach us. For example,
he provides us an impressive summary of definitions that clarify what many
scholars have suggested as the meaning of racism. I draw attention to two
cardinal points made by Carter here: first, that racism is an organizing principle for social relations; second, that in the systematic use of power by a
dominant group to oppress an out-group, such as people of color, the racist
act is fundamentally more than simple prejudice. These ideas help us
understand how Carter wants us conceptually to define racism.
Still, the ethics-propelled questions remain. Would Carter (2007) concede
that people of color can organize themselves internally in such a way that the
light-skinned subgroup might oppress the dark-skinned subgroup? Or is it
racism if people of color organize themselves in such a way that subgroups
may display oppressive behavior toward each other and that organization is
based on some criteria of ethnicity? These questions are important, as every
clinician knows that some people of color have relatively little interaction
with the dominant group. On occasion, these individuals experience significant oppression from nondominant group members. What are we to make of
these intrasubgroup experiences and their potential effect on the psychological terrain created by dominant group racism? Later in his article, Carter
actually discusses these issues, much to my satisfaction. He raises the matter in the discussion of a study by Din-Dzietham, Nembhard, Collins, and
Davis (2004) and its unusual results. That study found a relation between
racial discrimination and hypertension. It was striking, though, that the
increase in high blood pressure was greater when the discrimination was
caused by another African American. So Carter seems to accept the possibility that members of a nondominant group can be victims of oppressive

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120 THE COUNSELING PSYCHOLOGIST / January 2007

racism perpetrated by members of their own group. But I am not persuaded

that the intragroup racism serves as an organizing principle for relations
between members of subgroups.
One last comment must be made about these definitions of racism so
effectively delineated by Carter (2007). I do not believe that it will be as
easy to apply his final summative definition as he would have us think.
Even if we all concede that the realtor discriminated against the woman and
that her reaction was linked to this egregiously racist act, his exercise of
power may not really be a part of some organizing principle for social relations that we imagine the realtor to have in his head.

STRESS RESEARCH
Carter (2007) emphasizes a number of arguments as he reviews the
research on stress. I return to them only because they are, in my view, of
enormous practical significance. For one thing, despite his apparent disagreement with Butts (2002), which I cited earlier, Carter here concedes
that the extent to which an individual is affected by stress depends on his or
her personal characteristics and predispositions. He also agrees that the
stressor may be objective (such as an accident) or subjective (such as perceived discrimination). A final important concession is that some people
exposed to stressful situations can adapt and cope effectively while others
will not do so.
At least from a forensic perspective, these statements are not to be taken
lightly. Clearly in some cases, the claim made about a racist act may be subjectively perceived by a complainant. This means that the evaluating clinician may be wise to seek corroborating data from documents or other third
parties. Obviously, at least in the forensic arena, subjective complaints run
the risk of being trivialized or being considered suspect, which is an understandable claim when the author of the racist act may be called on to pay
hundreds of thousands of dollars for the damages wrought by his racism.
Here, the respondent may not only mean to dilute the psychological impact
of the perceived event on the complainant but may also intend, in going
about trying to determine who has responsibility for the event, to point out
that the etiology of the event is not actually verifiable. This line of argumentation may also suggest that those who are evaluating the psychological
impact of the supposed event must not be taken only by the apparent egregiousness of the act. An outrageous act may still produce different effects in
individuals due to the individuals differentiating characteristics.
The forensic professional may have simply to make do with Carters
(2007) extensive review of the research as it relates to this point. I found it

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Griffith / A FORENSIC AND ETHICS-BASED VIEW 121

difficult to be sure which studies used an overt, racist act as a study catalyst
and which studies really centered on perceived discrimination. Most troublesome of all, however, was Carters report of the findings in the study by
Guyll, Matthews, and Bromberger (2001) and the one by Bennett, Merritt,
Edwards, and Sollers (2004). These research groups both found (the former
with women and the latter with men) that subtle or ambiguous racial encounters can produce stronger negative health effects than do blatant mistreatment experiences. This evidence wrong-foots everyone in the business of
clinical forensic evaluations. It makes clear that there is not always an evident correlation between severity of the racist act and gravity of the clinical outcome in the victim. Because the victim has an obvious clinical
response to something perceived as a racist act does not mean that the act
itself was not ambiguous. Such evidence begs for dissemination, and Carter
therefore serves us brilliantly in this regard.
Carter (2007) refers to the work that underlines the importance of how
an individual cognitively appraises a potential stressor. It is this appraisal
that leads to the increasing or the mitigating of the persons psychophysiological response to the environmental event. Further work has also suggested that ones own high level of self-esteem could modify and attenuate
ones reaction to a racist event. Carter effectively teases apart further the
intimate mechanisms of the process. He brings up scholarship that suggests
the appraisal process may take place in two phases. In the first, emphasis is
placed on determining whether the event is linked to ones race. In the secondary appraisal phase, concern is about determining what can be done
about the event. This is remarkably intriguing work that Carter so effectively
explicates.
This reminded me of a little story I had heard many years ago at a conference. The Black narrator told of taking his seat early on a train so as to
avoid the rush and to obtain his preferred seat. That generally meant that he
had the car to himself. As time went by, others entered the train. The narrator then noticed that he began to watch with concern as White passengers
eyed the places next to him, but then went on to sit elsewhere. He told the
audience, with a sense of satisfied self-discovery, that he eventually recognized that he had to get on with the work in his briefcase and ignore the
question of why Whites would not sit next to him. Using his own language
of the time, he understood that the encounter with the Whites on the train,
race based as he perceived it, was using up too much of his energy and
resulted in a waste of his inner resources. His sense of helplessness aggravated things, increased his anxiety, and led to periods of inactivity and minimal achievement.
In my own descriptive account of Pierces research on racism (Griffith,
1998b), I was struck by his formulation of the problem, and I find his

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122 THE COUNSELING PSYCHOLOGIST / January 2007

vocabulary apt in this circumstance of the train story. Pierce would have
resented how Whites, even by simply passively entering the train, could
have so effectively controlled the time, space, and energy of a Black fellow
passenger. He clearly appreciated, without using those words, that seeking
to reappraise the interaction between dominant group and nondominant
group members was essential to freeing nondominant group members of
this inordinately oppressive control by the dominant group. Of course, what
is especially arresting about this train story is that the White passengers
cannot be said to have done anything in an overt sense. They certainly had
the right to enter a train and take the seats of their choice. And yet, the
Black narrator is anxiously ensconced in the place he has chosen, preoccupied with the thoughts and the intentions of the White passengers streaming past him. Pierce disliked this state of affairs, as it often led to what he
called apologetic, deferential thinking on the part of Blacks. Or it resulted
in their inappropriate reaction, fueled by anger and despair. Neither
response was characterized by thoughtful, ordered reflection, which too
often gave members of the dominant group the upper hand. This in turn perpetuated the status quo, with one group feeling inherently superior and the
other feeling inferior.

NOVEL RECOMMENDATIONS
In his incisive article, Carter (2007) makes a number of recommendations that I consider of critical importance. In the first place, he acknowledges the difficulty in connecting racist acts to mental health effects and
suggests that it would make things easier in the future if one broke racist
acts down into distinct categories that were in fact more sharply delineated
than a general, catch-all category. Therefore, he recommends the following
classes: racial discrimination, racial harassment, and discriminatory harassment. I found these categories difficult to handle, and I was clearly clumsy
as I tried to imagine using them in my clinical and forensic work. But I
assume that with practice I would eventually lose my clumsiness. I also
remain unconvinced that this suggestion will actually make it easier for
forensic professionals to carry out their evaluations and defend their conclusions in a contested judicial context. However, it is far more important
to contemplate whether the introduction of these categories would facilitate
the research in this arena and would render the results more practical and
usable. Time will tell, and I look forward to Carters being proven right.
The other recommendation that interests Carter (2007) takes us back to
a subtle difference of opinion that I suggested he was having with our distinguished colleague, Hugh Butts (2002), who took to task the DSMIVTR

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Griffith / A FORENSIC AND ETHICS-BASED VIEW 123

committees for creating criteria for PTSD that would essentially eliminate
race-based trauma from potentially leading to PTSD. Buttss point was that
the PTSD criteria required that the stressor be an event that involved actual
or threatened death or serious injury. As I understand Buttss position, he
was arguing that race-based stress could produce the syndrome of PTSD,
even though the racist act did not involve a threat of death. What Carter suggests is that, given the intransigence of the DSMIVTR system, a new
diagnostic category would fill the bill just as well. So he proposes RaceBased Traumatic Stress Injury, a category that clinicians, whose hands are tied
by the strict DSMIVTR criteria, would use instead of PTSD. However,
Carter envisages it as a nonpathological category, as he believes that invoking pathology ends up blaming the victim of the racist act. He buttresses his
argument by using a circuitous form of argumentation that distinguishes
between an injury and a disorder. Disorder, as pathology, blames the victim.
An injury does not.
There is no doubt that Carters (2007) heart is in the right place, as he
seeks to avoid putting further responsibilities on the victims of racist acts. In
the summary Figure 1, which he uses to explicate this new phenomenon of
the race-based traumatic stress injury, he wants simply to posit that this
unique type of injury may be associated with reaction signs and symptom
clusters. In his own careful review of the literature, however, Carter has made
clear that the response to race-based stress is variable from one individual to
another and may range from the nonpathological to the pathological. Indeed,
ones response may be somatic, psychological, or psychosomaticas characterized by a range of signs, symptoms, and behavioral manifestations.
Examples of these are hypertension, cardiovascular reactivity, anxiety,
depression, decreased social and vocational function, and other nonspecific
complaints such as headaches and abdominal upset. Worth repeating is the
fact that some people simply have no negative response at all to a particular
race-based insult. So my simple point is, therefore, that a race-based insult
may in some individuals produce pathology.
I have created my own Figure 1 to make clear my own suggested modification of Carters (2007) recommendation to the mental health field that
we utilize this new diagnostic category. I intend no dilution of the central
thesis of his recommendation. In the face of obstinacy that will not contemplate the seriousness of the notion that race-based insults can provoke
substantial trauma, Carter is justified in making this alternative recommendation to that of Butts (2002). However, I part company with Carter when
he becomes so preoccupied with the victim that he substitutes his injury
concept for one of disorder. He eschews the idea of pathology. However,
truth-telling requires that the forensic professional be frank about the
results of his or her evaluation. Where there is no pathology, that is the conclusion; when the pathology is evident, that is the conclusion. In my own
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124 THE COUNSELING PSYCHOLOGIST / January 2007

Race-Based
Insult
Variable in
Type and Intensity

Formation of
Psychological Substrate
Longitudinal
Pre-Insult Period

Variable among
Individuals

Adaptational
Capacity
Resilience
and
Vulnerability

Coping
Response

Modulatedby
Social Context
and
Other Elements

Variable
Responses
Ranging from
Non-Pathological
to
Pathological

FIGURE 1 Trajectory of Response to Race-Based Trauma

Figure 1, I emphasize that longitudinal experience and development lead to

personality organization that varies from one person to another and results
in a unique individual capacity to respond to a race-based insult. The ultimate result is a response that varies from one person to another and that
may range from simple irritability (nonpathological) to a profound depression that is obviously pathological. Finally, I argue that focusing on injury
will not facilitate reflection on prevention, assessment, or treatment of the
results of race-based trauma.

REFERENCES
American Academy of Psychiatry and the Law. (1995). Ethical guidelines for the practice of
forensic psychiatry. Retrieved July 11, 2006, from http://www.aapl.org/ethics.htm
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Bennett, G. G., Merritt, M. M., Edwards, C. L., & Sollers, J. J. (2004). Perceived racism and
affective responses to ambiguous interpersonal interactions among African-American
men. American Behavioral Scientist, 47(7), 63-76.
Butts, H. F. (2002). The black mask of humanity: Racial/ethnic discrimination and posttraumatic stress disorder. The Journal of the American Academy of Psychiatry and the
Law, 30, 336-339.
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35, 13-105.
Din-Dzietham, R., Nembhard, W. N., Collins, R., & Davis, S. K. (2004). Perceived stress following race-based discrimination at work is associated with hypertension in African
Americans: The Metro Atlanta Heart Disease Study, 19992001. Social Science and
Medicine, 58, 449-461.
Griffith, E. E. H. (1998a). Ethics in forensic psychiatry: A cultural response to Stone and
Appelbaum. The Journal of the American Academy of Psychiatry and the Law, 26, 171-184.

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Griffith / A FORENSIC AND ETHICS-BASED VIEW 125

Griffith, E. E. H. (1998b). Race and excellence: My dialogue with Chester Pierce. Iowa City:
University of Iowa Press.
Griffith, E. E. H. (2003). Truth in forensic psychiatry: A cultural response to Gutheil and colleagues. The Journal of the American Academy of Psychiatry and the Law, 31, 428-431.
Griffith, E. E. H., & Griffith, E. J. (1986). Psychological injury and compensable damages.
Hospital and Community Psychiatry, 37, 71-75.
Guyll, M., Matthews, K. A., & Bromberger, J. T. (2001). Discrimination and unfair treatment:
Relationship to cardiovascular reactivity among African-American and EuropeanAmerican women. Health Psychology, 20, 315-325.
Stone A. A. (1984). Law, psychiatry, and morality: Essays and analysis. Washington, DC:
American Psychiatric Press.

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