A. Stress and Distress
Stress has been defined as “environmental demands that tax or exceed the adaptive capacity of an organism, resulting in biological and psychological changes that may be detrimental and place the organism at risk for disease.” Essentially, stress is now recognized as harms, threats, and challenges, the quality and intensity of which depend on personal agendas, resources and vulnerabilities of the person, and environmental conditions. Stressful life events have been characterized as those situations that are tension producing and could adversely affect an individual's mental health, while distress is the state that occurs when the individual is unable to cope effectively with the stressor.
These definitions exemplify a shift in psychological theory from a focus on environmental inputs and outputs to a relational assessment of stress and its impact. This shift in focus to the subject experiencing stress implies a knowing person who construes or appraises the significance of what is happening with regard to his or her well-being. This shift also requires an approach to stress measurement that takes into account the personal and environmental variables that influence the appraisal process.
Over the past decade, critical psychologists have researched the well-established relationship between race and psychological distress. Specifically, critical psychology has revealed that race differences in psychological distress are particularly pronounced among people with low incomes. Blacks in America report lower levels of well-being than do Whites. Everyday discrimination and higher levels of stress are positively related to poorer health status.
Critical psychological findings are consistent with sociological findings that social conditions are important determinants of variations in health. High levels of stress and low socio-economic status (“SES”) are two social factors that have been identified as pathogenic. Education and especially income, two of the three considerations for SES, are related to health outcomes and play a major role in explaining racial differences in health.
The fact is, however, that poor income positioning, occupational status, and educational achievement disparately impact racialized persons. That is, SES is itself racially corrupted. This intersection of class and race is particularly important for the criminal law defenses discussed herein in light of the fact that race-related stress is more strongly related to indicators of mental health than to indicators of physical health. The research relating to social class, as an additional factor impacting stress is equally important to racialized people because of the “colored” face of American poverty. Accordingly, those most affected by the additive or interactive nature of race and poverty are the focus of this Article. In fact, critical psychologists have demonstrated that Blacks are more distressed than Whites even at low levels of income.
Differences in physical health may be due, at least in part, to differential exposure to chronic and acute life stressors. Blacks, especially those from lower social classes, often report a greater number of negative life events and greater and more frequent exposure to “generic life stressors.”Blacks also tend to perceive these events as more stressful and report greater psychological distress from these stressful life experiences than their White counterparts. As such, Blacks are likely to be particularly vulnerable to the long-term effects of high allostatic load because of their relative socio-political position. Chronic or cumulative stressors may trigger physiological response mechanisms, predispositions, and wear and tear on the system. Chronic stressors due to financial strain, inadequate housing, crowding, and violence may all contribute to more frequent activation of stress-response systems and prolonged exposure to stress hormones.
This compounding of race and class is consistent with critical race theorists' scholarship on intersectionality. For Blacks in America, the intersection of race and class produces an experience of oppression that is greater than the sum of its parts. Accordingly, it makes sense that critical psychology has demonstrated that poverty compounds and exacerbates the effects of racism and vice versa. When the interactive effects of race and class are taken into consideration, the data show that race has a substantial effect on psychological functioning among lower-class people, a result that is consistent with the view that racial discrimination exacerbates the health-damaging effects of poverty among Blacks.
Irrespective of the type of analysis conducted, race discrimination has emerged as a powerful predictor of Blacks' psychiatric symptoms at all levels of socio-economic status. Indeed, in keeping with the findings of Cose, Feagin, and Sikes, critical psychologists Kessler and Neighbors have explained that:
It is also possible that the joint effects of poverty and discrimination have synergistic effects or that financial success functions to shield blacks from the more distressing aspects of discrimination. Any of these processes would lead to an interaction in which the effects of race are most pronounced at the lower end of the social class distribution. Alternatively, race differences in distress could be most pronounced at high levels of social class, because financially successful Black-group members might experience the psychological stresses associated with this marginal position. Inferential evidence consistent with this possibility was reported in a treatment study . . . .
In stepwise regressions, racist discrimination was the best predictor of half of the symptoms measured, including somatization, anxiety, obsessive compulsiveness, interpersonal sensitivity, and depression. Racial discrimination was a more powerful predictor of those symptoms than generic stressors such as social status. In hierarchical regressions, racist discrimination was more significantly correlated to these symptoms than were contextual factors such as age, gender, education, social class, and generic stressors. Despite the enormous variability in the social class levels of Blacks researched (for example, some were high school dropouts on welfare, others had law degrees and six-figure incomes), findings indicate that racism may play a role that is as large as, or larger than, social class.
Social class marginalization exacerbates stress due to the compounding effects of racism. As Krieger has stated, “race conditions social class such that exposure to generic life stressors are not greater among the lower classes, but at equivalent levels of Socio-Economic Status, racialized persons experience higher stress burdens and poorer health outcomes.” This relationship between race and SES can have direct disparate effects on health in the form of additional stress burden and higher allostatic load, as well as indirect effects in the form of structural barriers to health care and other social resources. While blatant acts of racism and discrimination might be less commonplace today, more common insidious and aversive forms of racism have evolved. As Calmore points out:
During the 1980s and 1990s, it appears that American racism had become known throughout the world as “state of the art.” Its picaresque genius lay in developing so brilliantly the conception that it had disappeared except as it was “imagined” by its subordinated subjects, who continued to “suffer” in an unbelievable world--a color blind world of white innocence. Race neutrality, or “racism in drag” (to quote Pat Williams) had displaced race consciousness.
What are known as micro-aggressions in the critical race theory literature, or the battery of hyper-visibility or ascribed otherness, might now represent the preferred manner of discrimination and racial abuse of persons of color. The cumulative impact of micro-aggressions, those daily interferences and assaults on one's bodily and mental integrity based upon race, has the potential to be the straw that breaks the camel's back due to the relentless nature of the racialized bombardment and the difficulty of attributing racial animus, that hostility which is thought to indicate intention. Significantly, macro-aggression continues to exist in the form of structural constraints and barriers to access and control over essential resources, resulting in continued residential segregation, disparate educational access, and limited access to quality health care.
Racism has substantial pathogenic, psychological, and physical effects. Moreover, a strong relationship exists between mental health, physical health, and well-being--the connection might be even more pronounced for Blacks in America given the evidence of disparate physical health for minority populations. Current evidence indicates that while the general health for residents of the United States has improved significantly in the past decade, this improvement has not been uniform. Whites enjoy a significant health advantage over racial and ethnic minorities in virtually all major health status indicators. The notion of socially induced stress as a precipitating factor in chronic disease is gaining acceptance. Many now recognize that stress can be one of the components of any disease, not just of those designated “psychosomatic.” Indeed, chronic diseases are etiologically linked to excessive stress and, in turn, this stress is a product of specific socially structured situations inherent in the organizationof modern societies. Even susceptibility to microbial infectious diseases is now considered a function of environmental conditions that culminate in physiological stress on the individual, rather than simply a function of exposure to an external source of infection.
Current epidemiologic evidence documents the persistent health status differences in the U.S. population, in which Blacks, Native Americans, Native Hawaiians, and Southeast Asians, in particular, carry a disproportionate burden of morbidity and mortality. These facts create a vicious cycle as poor health status leads to emotional upheaval, stress, and other mental health sequelae; in turn, these disparate mental health implications lead to disparate physical health effects. A review of literature on the subject reveals that stress is a contributor to disease risk and impacts the psychosocial resources of persons such as coping and social support. Indeed such stress moderators partially account for ethnic health disparities:
[A]t the core of ethnic health disparities is differential exposure and vulnerability to psychosocial stresses moderated by inadequate access to and control over essential material, psychological, and social resources. . . . [T]his disadvantageous stress-resource imbalance is created by social status, defining attributes of race [and] ethnicity and social class that define the social hierarchy and life opportunities [in America].
Psychosocial behavioral risk factors are “nested within geographic, developmental, [and] occupational social environments.” The individual characteristics cannot therefore adequately explain environmental effects on health. Predictors of health and health differentials between groups are shaped by race, ethnicity, and social class. Accordingly, contextualization is as important an instrument of analysis in healthcare as it is in legal analysis.
Macro-social factors such as poverty and social status influence health through a variety of intermediary mechanisms, including individual health behaviors, access to and control of psychosocial resources, and exposure to chronic life stresses. For instance, doctors caring for inner-city patients have noted that such patients attend with a greater number of “sociomas,” the psychosocial bundle of burden disparately affecting people of color. The evidence shows that Blacks are generally exposed to more chronic and insidious stresses and report more distress, disease, and dysfunction than Whites. This in turn feeds into general health care issues on many levels. The circularity of physical and mental health is highlighted by the Surgeon General's remarks that, “Americans do not share equally in the best that science has to offer. . . . [D]isparities in mental health services exist for racial and ethnic minorities, and thus, mental illnesses exact a greater toll on their overall health and productivity.”
As part of his commitment to the elimination of inequality for Americans with disabilities, President George W. Bush established the President's New Freedom Commission on Mental Health in April 2002. The Commission was charged with identifying policies that could be implemented by all levels of government to maximize the utility of existing resources, improve coordination of treatment and services, and promote successful community integration for all persons with serious mental illness or emotional disturbance. The Commission began on the heals of the first ever Surgeon General's report devoted entirely to mental illness.
According to the report, mental health is essential for personal well-being, family relationships, and successful contributions to society. While documenting the disabling nature of mental illness, the Surgeon General's report also indicates that, as with access to physical health, there are racially disparate statistics with respect to mental health. Specifically, racial minorities have less access and availability to mental health care and tend to receive poorer quality mental health services. More relevant to the analysis contained in this Article, the report indicates that factors such as race, ethnicity, and culture affect all aspects of mental health and illness but have particular impact upon the nature of the stressors confronted. A growing number of researchers have emphasized that racism is a neglected but central societal force that adversely affects the health of people of color.
The cause of these adverse effects comes in two forms. First, the quality and quantity of health-enhancing resources, including medical care, are disparately distributed to members of marginalized communities. Second, racism shapes the creation and operation of societal institutions, socio-economic opportunities, mobility and access, life opportunities, and the general well-being of racialized groups and individuals.
