The year 2020 has been marked not only by collective endurance in the face of a global pandemic, but by continuing protest against the systemic murder of Black Americans at the hands of police. As grief counselors and therapists discuss how these twin horrors impact our mental health, it should be noted that systemic injustice has infected even the way we diagnose mental health conditions. While psychologists agree that the generational and ongoing trauma caused by systemic racism can engender similar physical and psychological effects to PTSD, many Black Americans are ineligible for subsidized treatment or specialized programs for PTSD. Why? For the simple reason that psychiatric professionals’ primary diagnostic tool, the DSM-5, indicates that symptoms must have originated from a unique — and usually individually experienced — event in order to be classified as PTSD. In other words, the DSM-5 leaves little room for classifying systemic, ongoing trauma as PTSD even when the individual meets all other criteria for diagnosis.
This leaves potentially millions of Black Americans out in the cold, because it denies that years of institutional barriers, micro-aggressions, discrimination, and race-based violence — not to mention threats of such violence — can result in virtually the same symptoms as PTSD. Over the summer, I worked as a chaplain at a facility serving a veteran population in the Northeast. In speaking with the licensed clinical social worker who headed up the PTSD clinic, a Black woman herself, I asked a question about collective trauma in cases of protest, state violence, or domestic terrorism. As a white woman recently diagnosed with trauma symptoms, my mind was on the 2017 invasion of white supremacists in Charlottesville, Virginia, where I lived at the time. But the conversation quickly revealed that incidents of what may be termed collective trauma, in the case of Black Americans, do not exist as stand-alone memories, but as an ongoing, lived experience. The potential for race-based discrimination and violence is continuous and unrelenting. For this reason, Black Americans often develop survival responses such as flashbacks, disassociation, and hyper-vigilance, not because they have directly experienced trauma in the way the DSM-5 defines it, but because their very existence is questioned as a matter of course in the United States.
Within the context of veteran care, Black veterans face a particularly pernicious barrier. Though the confluence of childhood trauma (very high in veteran populations), systemic racism, and military-based trauma presents like PTSD, the absence of a bounded, triggering event renders their trauma something other. For veterans making use of federal healthcare programs, service-connected diagnoses (i.e. diagnoses that can be traced directly to military service) can mean the difference between affordable treatment or no treatment at all. While being Black in America (and in the military, for that matter) heightens trauma response, Black vets in need of PTSD and trauma-care are disproportionately unable to receive financial assistance for such care, and are additionally excluded from specialized PTSD programs. After all, whatever their struggle may be, it is not considered PTSD.
The strongly individualized definition of PTSD as it currently stands normatizes trauma only as experienced by those with relatively few systemic barriers — namely white, cis-gendered, heterosexual individuals — by refusing to name systemic injustices as capable of producing the same devastating effects. In this way, unequal treatment based on race is explicitly institutionalized — the very definition of systemic racism. This is why I propose a considered reform of the clinical parameters of PTSD diagnosis to include systemic trauma caused by racism and related forms of societal marginalization.
To be sure, there are other treatments available for those experiencing trauma symptoms, and even talk therapy — which is widely available — is shown to be an effective treatment for certain kinds of PTSD. But for Black Americans, who both disproportionately experience violence and disproportionately live below the poverty line, such resources may be inaccessible due to social and financial barriers. It is also worth noting that, while subsidized PTSD programs are prevalent throughout the country, many Black Americans are barred from treatment due to lack of formal diagnosis.
By changing the language of formal PTSD diagnosis to include the ongoing trauma of racism, more Black Americans will be able to access affordable, personalized, therapeutic care. It is not the solution to injustice, but it is one step forward on the march to greater equity.
