Mental Health Disparities
Persistent and serious health disparities exist in the United States. Minorities suffer poorer health outcomes when compared to the majority, their White counterparts.[1] While there is conflicting evidence in the literature as to whether minorities suffer greater mental health consequences, a general consensus is that they report more psychological symptoms. Even without official diagnoses, minorities present with more subthreshold symptoms, which may reflect the poorer functioning reported within these marginalized groups.[2]
When it comes to disparities in mental health care, the results are transparent. Numerous studies have found that individuals from minority groups, such as African Americans and Latinx, are less likely to receive treatment.[3] Even when they do receive it, they are less likely than Whites to receive the best care.[4] African Americans are also more likely to terminate treatment prematurely.[5] The most common reasons cited for dropout are not believing the treatment will work, not believing their problems are severe, and not being able to afford treatment.[6]
Racial trauma
Racial trauma (also called race-based traumatic stress) is defined as “the mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes.”[7] In the United States, BIPOC (Black, Indigenous, People of Color) individuals are at a heightened risk of experiencing this trauma. Research has shown that race-based discrimination has a profound and detrimental psychological impact. It has even been reported to result in PTSD (post-traumatic stress disorder) symptoms.[8]
Racial trauma comes in many different forms: microagressions, racism, discrimination (e.g., in the workplace), and police violence/brutality. Each of these will be defined and elaborated on further in the sections below.
Racial trauma can be a direct experience of racism towards someone or transmitted intergenerationally (from generation to generation). The latter is referred to as generational trauma, which the American Psychological Association (APA) defines as “a phenomenon in which the descendants of a person who has experienced a terrifying event show adverse emotional and behavioral reactions to the event that are similar to those of the person himself or herself.”[9] Although most intergenerational trauma work has been done on Japanese individuals whose ancestors were forced into internment camps during World War II and ancestors of Holocaust survivors, a growing body of research is focusing on current generations of African-Americans and the ongoing discrimination they face.[10] Dr. Monicca WIlliams from the University of Connecticut has extensively focused on this issue and formulated a measure to assess anxiety stemming from racial discrimination. Out of 123 African-American students who took this survey in a study conducted by Williams et al. (2018), perceived discrimination correlated with higher rates of “uncontrollable hyperarousal, feelings of alienation, worries about future negative events and perceiving others as dangerous.”[11] Additionally, a meta-analysis by Pascoe and Smart Richman (2009), which consisted of 134 studies with multiracial samples, demonstrated an association between perceived discrimination and heightened stress responses, poorer physical health, and participation in unhealthy behaviors.[12]
Microaggressions
While most people would not consider themselves to be racist (e.g., do not commit hate crimes nor express blatantly racist sentiments), they may still hold racial biases and engage in subtle racially-motivated behaviors.[13] Harvard psychiatrists have characterized these as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward People of Color.”[14] While microaggressions are often less visible than macroaggressions, they can be just as detrimental.
Examples of Microaggressions in Speech:
Can I touch your hair? It looks so exotic.
That's so gay.
You'd be pretty if you lost some weight.
You speak pretty good English, I am surprised.
You aren’t really American.
Examples of Microaggressions in Action:
A White woman clutching her purse as a Black man walks past her.
Mistaking a Person of Color as a service/blue-collar worker
Microaggressions are linked to a plethora of negative outcomes, including depression, fatigue, anger, chronic infections, and high blood pressure. Research addressing the relationship between microaggressions and mental health has consistently found that subtle forms of racism have a detrimental impact on the mental health of BIPOC individuals.[15] Participants in numerous studies reported feeling immediate stress after encountering microaggressions.[16] Additionally, the accumulation of such experiences has had a detrimental impact on their well-being.[17]
Results of a study by Nadal et al. (2014), which included 506 participants, found that higher frequencies of racial microaggressions predicted negative mental health outcomes.[18] Higher rates of racial microaggressions were also significantly correlated with depressive symptoms and negative affect. Nadal et al. also investigated whether race influenced the experience of microaggressions. Significant differences were found between White participants and all other minority group participants. Between minority groups, no difference was found, suggesting that Black, Asian, Latinx, and multiracial people experience similar amounts of cumulative microaggressions.[19] However, differences were found in the types of racial microaggressions that racial groups reported: Black and Latinx participants reported more inferiority-related microaggressions; Black participants reported more criminality-related microaggressions; and Asian participants reported more environmental (i.e., disease- and contamination-risk association) and exoticization microaggressions.[20]
In a 2015 study that focused on the psychological impact of microaggressions on Black women, Fay et al. measured their anxiety and depression symptoms. They found that the women who reported higher levels of racial microaggressions also reported greater symptoms of depression and anxiety.[21] Age or level of education caused no significant effects.[22]
In a study consisting of Black participants, Liao et al. (2016) demonstrated that perceived racial microaggression positively correlated with anxiety symptoms. Investigators were particularly interested in the roles of ethnic social-connectedness and intolerance of uncertainty as moderators between microaggressions and anxiety.[23] “Intolerance of uncertainty” has been described as a core feature of Generalized Anxiety Disorder (GAD) and can be defined as the “tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and events.”[24] Individuals with a high intolerance to uncertainty find situations that are “uncertain” catastrophically threatening and upsetting, regardless of the actual probability of a negative event to occur.[25] They also found that social connectedness to one’s ethnic community was a protective factor, while intolerance of uncertainty was an exacerbating factor.[26] The importance of social connectedness to one's community leads to clinical implications: clinicians can implement these findings into treatment plans, thus likely leading to better outcomes for their clients.
Less work has been done on microaggressions experienced by Latinx individuals. In 2020, Choi et al. sought to bridge this gap and conducted a meta-analysis to determine how microaggressions impacted Latinx well-being. They found that Latinx racial microaggressions were linked to behavioral stress, perceived stress, psychological distress, psychological well-being, and symptoms of depression.[27]
Other research has focused on the impact of microaggressions in younger populations, such as children. Children are in a particularly vulnerable developmental period and studies have shown that racism, like other physical environmental toxins and stressors, can adversely impact one’s developmental trajectory in the socioemotional and behavioral domains. For example, a meta-analysis conducted by Berry et al. (2021) found that racism can have a detrimental impact on children as young as preschoolers, particularly through intergenerational avenues.[28] In fact, it can even impact the child in utero. Racial microaggressions can increase maternal stress, which is linked to preterm delivery.[29]
Macroaggressions
Microaggressions (sometimes referred to as aversive racism) and overt racism must both be taken into account. The studies discussed in the following section focus more on overt instances of discrimination: macroaggressions.
More broadly, the APA defines racism as “generally including negative emotional reactions to members of the group, acceptance of negative stereotypes, and discrimination against individuals, with some cases even leading to violence.”[30] It is important to note that racism is also systemically embedded into existing institutions. At the end of this section are examples of both individual and systemic racism.
Studies with samples of African-American individuals have found that racism is highly correlated with both mental health issues (depression and stress) as well as physical health consequences (cardiovascular disease and obesity).[31,32] A meta-analysis by Paradies et al. (2015) synthesized the health impacts of racism (293 studies) and found that racism was associated with poorer mental health. BIPOC participants reported experiencing depression, stress, emotional distress, anxiety, PTSD, and suicidal thoughts.[33]
Studies focusing on Latinx, Asian American, and Native American individuals have indicated that perceived discrimination is correlated with mental health problems. Whitbeck et al. (2022) found that perceived discrimination was a powerful indicator of depressive symptoms in a Native American adult sample, with participants who reported experiencing discirmination being two times more likely to report a greater number of depressive symptoms.[34] Another study by Hwang and Goto (2008) found that among its Asian American and Latinx participants, those who perceived discrimination were more likely to exhibit “symptoms of psychological distress, suicidal ideation, state and trait anxiety, and clinical depression.”[35]
Stress due to racism not only elevates blood pressure, but also leads to risky coping mechanisms that further impact physical health, such as drinking and smoking. For example, Cuevas et al. (2014) found that stress (as a result of discrimination) was linked to smoking and other behavioral risk factors for cancer.[36] Racism and discrimination have also been found to impact inflammation and sleep. A study conducted in 2019 by Thames et al. found that exposure to racial and discriminatory acts activates threat-related molecular processes that stimulate inflammation, which makes people more vulnerable to heart and kidney diseases.[37] Another study by Ong and Williams (2019) found that discrimination interferes with sleep quality in middle-aged adults, further increasing the risk for systemic inflammation.[38]
Examples of Individual Racism:
COVID-19 pandemic: approximately 1,500 reported incidents of anti-Asian racism per month (e.g., physical and verbal attacks and anti-Asian discrimination in private businesses).[39]
2018: 38% of Latinx reported being verbally attacked for speaking Spanish (e.g. told to go back to their countries and racial slurs).[40]
Examples of Systemic Racism:
Despite only making up 12% of the United State’s population, Black people make up nearly 33% of the total prison population.[41]
BIPOC are less likely than Whites to own their homes regardless of level of education, income, location, marital status, and age due to previous and current policies of displacement, exclusion, and segregation.[42]
Rates of suicide in Native American communities are 3.5 times higher than racial and ethnic groups with lowest rates of suicide. Existing barriers to access appropriate mental health resources for this demographic include lack of financial incentives and cultural competence in as well as geographical isolation.[43]
Assari et al. (2017) aimed to investigate if perceived discrimination in adolescence predicted mental health deterioration a decade later.[44] This longitudinal study followed 681 Black participants from age 15 to age 32. Psychological symptoms of anxiety and depression were measured in 1999 (during adolescence) and again at the follow-up in 2012 (in young adulthood). They only found a positive correlation between perceived discrimination at adolescence and negative psychological symptoms later on for Black males, but not Black females.[45] This may be due to the internalization of masculine norms. Another study by Caldwell et al. (2013) found that masculinity moderates the relationship between discrimination and depressive symptoms plus high-risk drinking behaviors.[46] Discrimnation seems to be more harmful for Black men who hold strong masculine attitudes. Men also report higher rates of discirmination compared to Black women so this could also be another factor accounting for the gender differential.[47]
In another longitudinal study, this time with a sample of 674 Mexican-origin youth, Stein et al. (2019) investigated whether peer discrimination in 5th grade predicted greater depressive and anxiety symptoms in 12th grade. Peer discrimination was defined as “direct biased mistreatment by peers due to race/ethnicity and also indirect experiences (e.g., hearing classmates make jokes about racial groups).”[48] The results showed that peer discrimination in 5th grade did predict greater symptoms of both depression and anxiety in 12th grade, highlighting the long-term negative impact of these experiences across adolescence.[49]
Regardless of genetic risk, exposure to discrimination plays a significant role in the development of anxiety disorders. A study in 2020 by Cuevas et al. concluded that even after controlling for genetic factors, discrimination continued being a strong risk factor for anxiety and related disorders.[50] Studies like this confirm that discrimination operates like any other environmental stressor, highlighting its impact on psychiatric disorders and overall well-being.
Police violence and brutality
With the high-profile deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery, some researchers have focused on the impact of police brutality and violence as environmental stressors. One such study by Alang et al. (2021) examined the relationship between police brutality, depression, and anxiety across races. They found that negative encounters with police were associated with depressed mood and anxiety, with a stronger association among Black and Latinx participants than Whites.[51] A national survey by Graham et al. (2020) that consisted of 1000 respondents measured the extent to which different racial and ethnic groups in America worried about police brutality. The results demonstrated that Black participants were five times more likely than White people to report fear of such violence.[52] Similarly, Latinx respondents were four times more likely than White people to experience the same fear.[53] Even the anticipation of police brutality (no direct encounter, just concern that one might be a victim) was also associated with depression and anxiety.[54]
Translating these findings to therapeutic settings: racial socialization theory
Given all the data regarding the relationship between racism and mental health, it is essential to translate the findings above into therapeutic settings. Clinicians must assess and address racial discrimination within therapy sessions. Further, clinicians should be aware of racial microaggressions and their clinical implications on mental health.
Many evidence-based trauma treatments are not culturally tailored to address racism and intergenerational trauma.[55] Moreover, African-American adolescents are more likely than their peers to experience traumatic racist and discriminatory encounters. Therefore, not only is this marginalized group more likely to experience these stressors, but they also do not receive the adequate treatment for it, further exacerbating the impact of these encounters.
African American youth are disproportionately impacted by trauma. Finkelhor et al. (2013) found that 65% of African American youth report traumatic experiences.[56] However, only 30% of their peers from other racial and ethnic groups reported the same.[57] These rates may be due to the unique race-related stressors that African American communities experience. Over the course of a single year, 38% of African American teens (13-18 y/o) reported an average of six racist encounters.[58] If these experiences and their associated outcomes (poor mental health) are not addressed and treated, they are at an increased risk of developing PTSD.[59] Existing therapies that aim to provide clients with coping mechanisms (e.g., progressive muscle relaxation and diaphragmatic breathing) for traumatic experience lack culturally-specific strategies necessary to treat the racial stressors unique to African American individuals. The absence of this cultural awareness and implementation most likely reflects the tendency for poor engagement and subsequent dropout among African American patients who undergo therapy.[60]
Racial socialization is a process that transmits culture, attitudes, and values to help youth overcome stressors associated with their ethnic minority status.[61] Researchers like Metzger et al. (2021) have incorporated racial encounter coping appraisal and socialization theory into trauma-focused cognitive behavioral therapy (TF-CBT). By incorporating these techniques into the framework of an already existing evidence-based treatment for children and adolescents, racial trauma can be addressed in clinical settings.[62] Additionally, Metzger et al. integrated racial socialization (RS) into TF-CBT to improve outcomes specifically for African American youth since RS has been associated with lower internalizing and externalizing symptoms in children of color, positive parent-child interactions, self-esteem, resilience, lower rates of depression and stress, reduced behavioral problems, stronger racial identity, and better use of coping skills during race-related traumatic experiences.[63]
There are several components under the RS umbrella. For example, racial pride messages are those that teach African American children about their heritage and culture. These messages promote group unity and combat negative majority opinions.[64] An example of this is talking about important historical figures. Racial barrier messages are about discrimination and racism; they also warn about difficulties in social interactions with majority populations, such as White communities.[65] An example of this RS technique is encouraging and aiding parents in the police violence and brutality talk. This process also takes advantage of the social connectedness protective buffer mentioned under the “Microaggression” section. Incorporating religion into the TF-CBT framework as a source of resilience has also proved to be helpful for many African American families.[66]
Another important practice under RS is the acknowledgement and appreciation of extended family members, such as grandparents, aunts/uncles, and other non-blood relatives (e.g., pastor, mother’s childhood best friend who is like an aunt). In African American cultures, extended family involvement is common, with other people outside the immediate family network helping with child-rearing.[67] By including them in treatment plans, outcomes can be optimized. In TF-CBT, parents and guardians are actively involved in administration, given that they are responsible for making sure appropriate coping strategies are practiced outside of therapy sessions.
Emotion regulation
A 2015 study by Graham et al. found that the relationship between racist experiences and anxiety symptomatology was moderated by emotion regulation in a Black American sample.[68] In other words, better emotion regulation resulted in fewer anxiety symptoms due to racist experiences. Emotional regulation acted as a buffer to the development of anxiety symptoms. Some researchers even label emotional dysregulation as the core of mood and anxiety disorders.[69]
These results have clinical implications, demonstrating the importance of emotion regulation skills. Reducing racist experiences is ideal, but difficult to tackle. Systemic and institutional issues would need to be fixed, and this could take decades to improve. However, a more short-term strategy that clinicians could assist minorities implement is emotion-focused coping. This strategy could lead to reduced emotion dysregulation and subsequently lower levels of anxious arousal. Such emotion regulation skills include: curbing impulsivity; accepting emotions; and setting goals. Moreover, Graham et al. (2021) note that therapists should pay particular attention to creating a supportive context for their clients so that they can discuss race-based traumatic experiences and the effects of these experiences on their clients’ lives.”[70] By more deeply understanding the prejudicial and discriminatory injustices associated with racial trauma, clinicians can more appropriately serve their clients to create lessened suffering and better therapeutic outcomes.
If you are experiencing anxiety or depression due to racism in any form (microaggressions, intergenerational trauma, workplace discrimination), please reach out to a mental healthcare provider.
For more information, click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.
Additionally, you may click here to access an interview with Psychologist Robyn Walser on trauma & addiction.
To access our PTSD Self-Care Tips, click here.
Contributed by: Nicole Izquierdo
Editor: Jennifer (Ghahari) Smith, Ph.D.
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14 Gehrman, E. (2019, November 20). Big Impact of Microaggressions. The Harvard Gazette. Retrieved April 24, 2022, from https://news.harvard.edu/gazette/story/2019/11/microaggressions-and-their-role-in-mental-illness/
15 Nadal, K. L., Griffin, K. E., Wong, Y., Hamit, S., & Rasmus, M. (2014). The impact of racial microaggressions on mental health: Counseling implications for clients of color. Journal of Counseling & Development, 92(1), 57–66. https://doi.org/10.1002/j.1556-6676.2014.00130.x
16 Ibid.
17 Ibid.
18 Ibid.
19 Ibid.
20 Ibid.
21 Fay, C. (2015). Effects of racial microaggressions on anxiety and depression in black and african american women (Order No. 3732015). Available from ProQuest Central; ProQuest Dissertations & Theses Global. (1734864063). Retrieved from https://login.proxy.lib.duke.edu/login?url=https://www.proquest.com/dissertations-theses/effects-racial-microaggressions-on-anxiety/docview/1734864063/se-2
22 Ibid.
23 Liao, K. Y.-H., Weng, C.-Y., & West, L. M. (2016). Social connectedness and intolerance of uncertainty as moderators between racial microaggressions and anxiety among Black individuals. Journal of Counseling Psychology, 63(2), 240–246. https://doi.org/10.1037/cou0000123
24 Dugas, M. J., Buhr, K., & Ladouceur, R. (2004). The role of intolerance of uncertainty in the etiology and maintenance of generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: advances in research and practice (pp. 143–163). New York: Guilford Press.
25 Dugas, M. J., Gagnon, F., Ladoceur, R., and Freeston, M. H. (1998). Generalized anxiety disorder: a preliminary test of a conceptual model. Behav. Res. Ther. 36, 215–226. doi: 10.1016/S0005-7967(97)00070-3]
26 Liao et al. 2016
27 Choi, S., Clark, P. G., Gutierrez, V., Runion, C., & R, M. (2020). Racial microaggressions and Latinxs' well-being: A systematic review. Journal of Ethnic & Cultural Diversity in Social Work, 31(1), 16–27. https://doi.org/10.1080/15313204.2020.1827336
28 Berry, O.O., Londoño Tobón, A. & Njoroge, W.F.M. Social Determinants of Health: the Impact of Racism on Early Childhood Mental Health. Curr Psychiatry Rep 23, 23 (2021). https://doi.org/10.1007/s11920-021-01240-0
29 Ibid.
30 https://dictionary.apa.org/racism
31 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PloS one, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511
32 Ibid.
33 Ibid.
34 Whitbeck, L. B., McMorris, B. J., Hoyt, D. R., Stubben, J. D., & Lafromboise, T. (2002). Perceived discrimination, traditional practices, and depressive symptoms among American Indians in the upper midwest. Journal of health and social behavior, 43(4), 400–418.
35 Hwang, W. C., & Goto, S. (2008). The impact of perceived racial discrimination on the mental health of Asian American and Latino college students. Cultural Diversity and Ethnic Minority Psychology, 14, 325–335. doi:10.1037/1099-9809.14.4.326.
36 Cuevas, A. G., Reitzel, L. R., Adams, C. E., Cao, Y., Nguyen, N., Wetter, D. W., Watkins, K. L., Regan, S. D., & McNeill, L. H. (2014). Discrimination, affect, and cancer risk factors among African Americans. American journal of health behavior, 38(1), 31–41. https://doi.org/10.5993/AJHB.38.1.4
37 Thames, A. D., Irwin, M. R., Breen, E. C., & Cole, S. W. (2019). Experienced discrimination and racial differences in leukocyte gene expression. Psychoneuroendocrinology, 106, 277–283. https://doi.org/10.1016/j.psyneuen.2019.04.016
38 Ong, A. D., & Williams, D. R. (2019). Lifetime discrimination, global sleep quality, and inflammation burden in a multiethnic sample of middle-aged adults. Cultural Diversity and Ethnic Minority Psychology, 25(1), 82–90. https://doi.org/10.1037/cdp0000233
39 Asian Pacific Policy and Planning Council (2020). In one month, STOP AAPI HATE Receives almost 1500 incident reports of verbal harassment, shunning and physical assaults. http://www.asianpacificpolicyandplanningcouncil.org/wp-content/uploads/Press_Release_4_23_20.pdf
40 Lopez, M. H., Gonzalez-Barrera, A., & Krogstad, J. M. (2020, May 30). Latinos' experiences with discrimination. Retrieved June 25, 2020, from https://www.pewresearch.org/hispanic/2018/10/25/latinos-and-discrimination/
41 F. (2019, September 22). Table 43. Retrieved June 25, 2020, from https://ucr.fbi.gov/crime-in-the-u.s/2018/crime-in-the-u.s.-2018/tables/table-43
42 Integrated Public Use Microdata Series, U.S. Census Data for Social, Economic, and Health Research, 2013-2017 American Community Survey: 5-year estimates (Minneapolis Minnesota Population Center, 2017), available at https://usa.ipums.org/usa/
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44 Assari, S., Moazen-Zadeh, E., Caldwell, C. H., & Zimmerman, M. A. (2017). Racial discrimination during adolescence predicts mental health deterioration in adulthood: Gender differences among blacks. Frontiers in Public Health, 5. https://doi.org/10.3389/fpubh.2017.00104
45 Ibid.
46 Caldwell, C. H., Antonakos, C. L., Tsuchiya, K., Assari, S., & De Loney, E. H. (2013). Masculinity as a moderator of discrimination and parenting on depressive symptoms and drinking behaviors among nonresident African-American fathers. Psychology of Men & Masculinity, 14(1), 47–58. https://doi.org/10.1037/a0029105
47 Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity in perceived racial discrimination. Journal of Personality and Social Psychology, 84(5), 1079–1092. https://doi.org/10.1037/0022-3514.84.5.1079
48 Stein, G. L., Castro-Schilo, L., Cavanaugh, A. M., Mejia, Y., Christophe, N. K., & Robins, R. (2019). When Discrimination Hurts: The Longitudinal Impact of Increases in Peer Discrimination on Anxiety and Depressive Symptoms in Mexican-origin Youth. Journal of youth and adolescence, 48(5), 864–875. https://doi.org/10.1007/s10964-019-01012-3
49 Ibid.
50 Cuevas, A. G., Mann, F. D., Williams, D. R., & Krueger, R. F. (2020). Discrimination and anxiety: Using multiple polygenic scores to control for genetic liability. Proceedings of the National Academy of Sciences, 118(1). https://doi.org/10.1073/pnas.2017224118
51 Alang, S., McAlpine, D., & McClain, M. (2021). Police Encounters as Stressors: Associations with Depression and Anxiety across Race. Socius. https://doi.org/10.1177/2378023121998128
52 Graham, A., Haner, M., Sloan, M. M., Cullen, F. T., Kulig, T. C., & Jonson, C. L. (2020). Race and worrying about police brutality: The hidden injuries of minority status in America. Victims & Offenders, 15(5), 549–573. https://doi.org/10.1080/15564886.2020.1767252
53 Ibid.
54 Alang et al. 2021
55 Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2021). Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth. Child maltreatment, 26(1), 17–27. https://doi.org/10.1177/1077559520921457
56 Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: an update. JAMA pediatrics, 167(7), 614–621. https://doi.org/10.1001/jamapediatrics.2013.42
57 Ibid.
58 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, 44(3), 302–317.
59 Metzger et al. 2021
60 Ibid.
61 Lesane-Brown, C. L., Brown, T. N., Caldwell, C. H., & Sellers, R. M. (2005). The Comprehensive Race Socialization Inventory. Journal of Black Studies, 36(2), 163–190. https://doi.org/10.1177/0021934704273457
62 Metzger et al. 2021
63 Ibid.
64 Ibid.
65 Ibid.
66 Stevenson, H. C., Jr., Cameron, R., Herrero-Taylor, T., & Davis, G. Y. (2002). Development of the Teenager Experience of Racial Socialization scale: Correlates of race-related socialization frequency from the perspective of Black youth. Journal of Black Psychology, 28(2), 84–106. https://doi.org/10.1177/0095798402028002002
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