When I first came to St. John's University in 1991, I wanted to pursue my interest in studying the ways social relationships affect the risk for heart disease. There was epidemiological evidence that there was an increased risk for heart disease among individuals who were high in hostility or low in social support--characteristics that might reflect impairments in social relationships. However, the mechanisms linking interpersonal conflict to the development of heart disease were not clear. To understand these mechanisms, our research team started by investigating experiences of on-the-job interpersonal stress. The experiences we had conducting work site studies brought the problem of racism into focus and motivated us to begin a program of research aimed at investigating the effects of racism on interpersonal relationships and health.
In the early 1990s, most of the research investigating interpersonal relationships and cardiovascular response took place in laboratory settings. I wanted to study these relationships in a real-life context. Ambulatory blood pressure monitoring technology had very recently become affordable and easy to use, and that made it reasonable to think about investigating blood pressure and heart rate responses when people were involved in real-life interpersonal conflicts.
But how could I find real people who have frequent conflicts (and of course, who would let a stranger study them)? My husband suggested that I find a way to study Traffic Enforcement Agents (TEAs) in New York City. Parking in NYC can be a nightmare, and the people who give you tickets for parking illegally are often harassed by members of the public who are angry about getting a ticket.
With the support of the Police and Transportation Departments of New York City and funded by the National Institute of Health (NIH) and the American Heart Association, we put ambulatory blood pressure monitors on hundreds of TEAs in a series of studies. These studies shed light on the way interpersonal conflict can affect blood pressure. When TEAs interacted with the public, their blood pressure was higher than it was during any other type of communication, even when the motorist was not actually harassing them. Just anticipating a potential conflict was associated with a drop in their mood and a rise in their blood pressure. And the TEA's blood pressure stayed high for a period of time after the interaction was over (Brondolo, Karlin, Alexander, Bobrow, & Schwartz, 1999).
Social support helps. Dr. William Karlin, who was a graduate student at St. John's at the time, found that TEAs who felt supported by their coworkers had smaller increases in blood pressure during high stress periods (Karlin, Brondolo, & Schwartz, 2003). Among women, those TEAs who felt supported by their immediate supervisors also had lower blood pressure during the workday.
We also provided stress management classes for the TEAs at their work sites. These classes provided a great training opportunity for the students in the clinical psychology graduate program at St. John's University. The program included exposure and response prevention exercises, based on work with individuals with posttraumatic stress disorder and other anxiety disorders. We modified these treatments for use in a work setting with healthy individuals exposed to a high stress experience.
The goal was to enhance the TEA's ability to cope with harassment from the public and to cope with their own feelings about these conflicts (Brondolo, DiGiuseppe, & Tafrate, 1997). The TEAs were upset by the public's hostile and sometimes dangerous actions, but they were also afraid of their own reactions. They were afraid they would repress their feelings and end up feeling sick and ashamed. Or they were afraid of losing their temper and consequently risk losing their job.
In this treatment, we taught all the TEAs relaxation skills. Then we asked them to develop scripts of the most difficult and troubling insults they were called by the public, particularly those insults that made the TEAs very angry or anxious. During the groups, each TEA had a turn on the hot seat. Another TEA played an angry motorist and gradually exposed the first TEA to the worst insults on his or her list (i.e., "fat pig," "stupid b****," etc). The TEA in the hot seat was encouraged by the therapist to continue to breathe and relax in the face of exposure to these nasty comments. During these exercises, the TEAs learned they could experience their own feelings without losing control. They understood that they did not have to be frightened of their own emotional reactions. They could be in charge of their own responses, and they didn't have to let some impulsively angry motorist control their experience.
The TEAs enjoyed the treatment and it was effective. Data analyses revealed the program was very effective in reducing the rates of conflicts with the public. These complaints are reported to the Civilian Complaint Review Board of the New York City Police Department, and therefore provide an objective measure of rates of interpersonal conflict (Brondolo, Eichler, & Taravella, 2003).
But we learned that we couldn't always use the exposure-based model in situations involving racism. Motorists sometimes used foul racial slurs to try to punish the TEAs for issuing tickets. Some agents listed these racial slurs on their scripts. But sometimes when we used these slurs in our exposure exercises, they evoked not only anger, but also a profound, palpable sadness. We couldn't ask people to simply let go and accept these feelings.
We began to talk about the issues of race and stress in the TEA's lives. As the TEAs made clear, there were many different perspectives on the ways to handle race-related stress. And every strategy had costs and benefits. For example, some TEA said they had been taught to ignore episodes of racism. They expressed the concern that recognizing that you are being victimized can turn you into a victim, and a victim is someone who has been damaged.
Other TEAs had a different approach. They told us stories about motorists who get angry when the TEAs don't warn them they are on the street writing tickets. These motorists expect the TEAs to come into coffee shops or to ring apartment door buzzers to let them know they are out on the street. TEAs told us that they view these complaints as silly (which they are), but some also expressed concern that the motorist' behavior is discriminatory. Some agents felt they were being treated as if they were maids or servants, not Traffic Enforcement Agents. And these TEAs were concerned that this treatment occurred because of their race/ethnicity. Some agents believed that it was important to recognize the possibility that disrespectful treatment might be a function of their race or ethnicity. Some expressed the opinion that being aware of discriminatory treatment can prevent them from accepting disrespect and coming to believe that they are inferior. The TEAs were spoke with were strong, articulate, and effective. Through our discussions with them, we could see that there were many different possible solutions to a common problem.
The ideas people had about how to handle specific interactions or racism in general appeared to be influenced by many factors, including the lessons their parents gave them and the country in which they were born. The choices they made at any given time were also influenced by the specifics of the situation: the intensity and type of maltreatment, the degree to which the racial bias was obvious, the context of the situation (i.e., at work or in public), and their access to supportive resources.
Each individual's decision made sense in the context of his or her specific situation, but it was hard to find a set of principles that would guide decision-making. We went to the library to see if existing research provided some direction, but at that time there was not enough empirical literature. Consequently, our lab decided that we would begin to investigate the ways social stressors like racism affect interpersonal relationships and health.
The first step was to figure out how to define racism. Fortunately at the same time, Rodney Clark and his colleagues (Clark, Anderson, Clark, & Williams, 1999) had just written a major article for the American Psychologist
that articulated a comprehensive model of the ways that racism might account for the significant racial disparities in health status. The authors offered a useful definition of racism: "The beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation" (Clark et al., 1999, p. 805). We decided to focus on interpersonal racism, defined by Nancy Krieger, as "directly perceived discriminatory interactions," because of our interest in interpersonal relationships (Krieger, 1999).
Now we needed a way to measure the degree to which people had been exposed to these kinds of race-related maltreatment. There were a number of self-report questionnaires that had been developed, all of which asked good questions. But most of the measures were specific to a particular group, usually African Americans. We believed that it would be important to understand whether the negative effects of race-based maltreatment generalized across ethnic groups. We needed a measure that could be used in any ethnic group.
One of my major professors from graduate school, Dr. Richard Contrada from Rutgers, had developed the Perceived Ethnic Discriminatory Questionnaire (PEDQ; Contrada, et al., 2000; Contrada, et al., 2001). He had tested this questionnaire in a large multiethnic group of college students. We decided to build on this scale so that it could be used with community dwelling adults. We simplified the language and took a modified version into the community. With the help of the Clinical Directors Network and Monica Sweeney, the Medical Director of Bedford Stuyvesant Family Health Center, and the patients and staff from her center, we further modified the scale and received suggestions for new items, reflecting the experiences participants had in their everyday lives.
The new scale was called the PEDQ-Community Version, and we developed a 34-item version and a briefer 17-item version (Brondolo, Kelly, et al., 2005). Both versions have four subscales that measure different types of discrimination. The social exclusion subscale includes items such as "Because of your ethnicity or race, have people been nice to your face, but said bad things behind your back?" The stigmatization subscale includes items such as "Because of your ethnicity, have people treated you as if you were dishonest?" The workplace discrimination subscale includes items such as "Because of your ethnicity, has your boss or a teacher treated you unfairly?" The threat or harassment subscale includes items such as "Because of your ethnicity, has someone physically hurt you?"
To validate the measure, we ran 6 different studies including almost 1,000 participants. Most were community dwelling adults, but we also tested some students as well. Most of the individuals we tested were Black or Latino(a). We translated the scale into Spanish for use with Spanish-speaking samples. Currently, we are testing the validity of the scale in South Asian and East Asian groups.
The results from this testing gave valuable information about the prevalence of interpersonal racism. We learned that most people had been exposed to the experiences listed on our scale at least occasionally over the course of their lives, although there was considerable variation in the amount of exposure. People reported significantly more social exclusion than other forms of discrimination and more workplace discrimination and stigmatization than physical threat and harassment. These findings are consistent with descriptions of modern racism, which include interactions that leave the victim feeling out of place and without access to the economic and educational opportunities enjoyed by others.
We also developed a 10-item scale that allowed us to measure experiences in the past week. Among one sample of 300 individuals, we found that 78% reported at least one event during the week and almost 60% reported 3 or more events. Our recent data in a different, larger sample confirm these findings with 79% reporting at least one event in the last week. Even relatively brief events, described by items such as "being looked at in a mean way because of your ethnicity or race," can trigger anger and sadness.
The next step involved developing a testable model of the relationship of racism to health. Our ideas about the health effects of racism were consistent with the stress and coping model proposed by Clark et al. (1999) and based on the work of Richard Lazarus and his colleagues (Lazarus & Folkman, 1984). This model suggests that exposure to race-based maltreatment could affect health by adding to an individual's overall stress burden and requiring extra efforts to cope.
Racism may add to the stress burden through its effects on negative emotions, social interactions, and coping strategies. Researchers have demonstrated that anger is a predictable outcome of exposure to racism (Landrine & Klonoff, 1996; Swim, Cohen, & Hyers, 1998). Walking around feeling angry or sad and nervous can be exhausting, because these emotions require effort to manage.
How does racism increase the risk for negative interpersonal interactions? Race-based maltreatment is, in itself, a negative social exchange. Over time, the cumulative effect of these negative exchanges could influence the way people feel about themselves and others and in turn lead to more negative exchanges overall. Recently, researchers have suggested that background social stressors, including poverty, make it more likely that ambiguous social exchanges might be interpreted more negatively (Chen, & Matthews, 2001; Gallo, & Matthews, 2003; Gump, & Matthews, 1999). Background stress wears people down and can make "the glass seem half empty, rather than half full" when interacting with other people. We hypothesized that racism was just the kind of background stressor that would make people feel potentially uncomfortable in interpersonal situations that were not completely clear.
Racism may affect health not just on the stress side, but also on the coping side of the equation. It is difficult to know how to cope with episodes of racism. The rules are clearer when the behavior is obvious and if it occurs in a work setting--we have equal opportunity laws to help guide and protect people. But as our data showed, ethnicity-related maltreatment often occurs in social or public situations, and the motivation behind the other person's behavior can be ambiguous.
In many circumstances, individuals treated in a discriminatory or exclusionary manner may hesitate to say something to avoid being attacked. They may fear becoming even more isolated, worried that other people will begin to avoid them out of fear that they will be labeled as a racist. On the other hand, it can be exhausting and defeating to hold your feelings inside. We wondered if the lack of clarity about coping made it more likely that individuals would feel as if they had to immediately suppress their anger or aggressively express their feelings. Finally, we suspected that both the added stress burden and the lack of clear coping responses would increase risk for poor cardiovascular health, specifically increasing the risk for high blood pressure.
To test our hypotheses about racism and moods and social interactions during everyday life, we conducted a series of pilot tests funded by St. John's University, and one large study, funded by the NIH. In some of these studies, participants filled out questionnaires about racism, mood, and coping; in others, they completed diaries throughout the day. In the large study, in which we have tested over 500 of a total of 720 adults, the participants completed questionnaires on racism, mood, coping, and personality; responded to the diary; and had their blood pressure measured throughout the day and into the night.
To make the process easier for our participants, we worked with a St. John's University artist, Max Hergenrother, who drew little pictures or icons (Figure 1
) that illustrated different moods and different kinds of social interactions to illustrate the concepts of feeling excluded, treated unfairly, or harassed. Using these pictures would help us work with individuals who might not be comfortable reading English. Then we worked with a computer programming consultant, Delano MacFarlane, to develop an electronic diary using these pictures that would let us ask questions about the way people felt and what they were doing each time their blood pressure was measured. He also helped us develop methods for delivering all our surveys over the computer with voice-overs to help individuals with low literacy.
Here are some of the findings. In one of our initial pilot tests, which served as the dissertation project for Dr. Risa Appel, we asked 113 participants from a community primary care practice to fill out the PEDQ and then to complete a page from a diary of moods and social interactions every 30 minutes (Appel, 2004). The data supported the hypothesis that racism is associated with more negative moods. The more individuals had been exposed to racism over the course of their lifetime, the angrier, sadder, and more nervous they felt during the day. Individuals who had been exposed to racism over the course of their lifetimes were also more likely to feel harassed, treated unfairly, or excluded in routine social interactions. This was true even when the interactions were not overtly racist. We have now replicated these findings in our larger study.
These data provided good initial evidence that racism adds to the stress burden through its association with negative mood and negative social interactions. But we also knew that people often accuse minority group members of being hypersensitive–essentially saying that perceiving racism is really a function of personality or a distortion in perception. In this case, it might be possible that being an anxious person or an angry person would make you see more racism in other people's behavior and would leave you feeling angrier or more uncomfortable in social interactions.
We looked at our data again. This time we used four different personality traits as covariates. We controlled for cynicism, hostile attributions, trait anxiety, and defensiveness–all characteristics that might influence our findings. We found that the relationships between racism and daily experiences of anger and perceptions of social interactions as harassing, unfair, or exclusionary persisted even after controlling for all four personality traits. This suggested to us that it wasn't a problem with people's attitudes or personality that accounted for the added stress burden. Instead, there were characteristics of the experience of racism that were burdensome to individuals and added to individuals' stress burden above and beyond the contributions of their own personality.
Next we wanted to see whether our ideas about the effects of racism on coping were correct. In two studies, we assessed people's experiences of racism. We also asked people to tell us how they felt when they were exposed to racism and how they coped with these experiences. Did they hold their anger in? Express it angrily? Or calm themselves down before they responded?
As we expected, we found that the more people had been exposed to racism, the more threatening they perceived these experiences to be. They did not get used to maltreatment. Instead, greater exposure sensitized them to future events. In addition, the more people were exposed to racism, the more likely they were to either quickly suppress or angrily express their feelings. Again, these relationships were significant independent of personality traits such as hostility (Brondolo, Thompson, et al., 2005).
These data suggest racism adds to the overall stress burden both by increasing stress burden and by constraining coping choices. Just as was the case for the TEAs, if individuals have been exposed to significant conflict in the past, then anticipating new conflicts becomes burdensome. Our goal now is to understand how these interpersonal burdens affect blood pressure. We hope to use these data to develop programs to reduce the health consequences of exposure.
More than 25 graduate and undergraduate students from many different ethnic backgrounds participated in developing the measures, conducting the pilot studies, and writing the grants and papers. The students and our participants know that information about the psychobiological effects of racism can help people make more informed decisions about the ways they wish to cope with this serious social stressor. Our students are excited to be using the tools of behavioral science to contribute to solutions for real world problems.Figure 1.
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(pp. 11-36). New York: Academic Press.Elizabeth Brondolo, PhD,
is a professor at St. John's University (NY). She received her PhD in clinical psychology from Rutgers University (NJ) in 1989. She specializes in the study of social stress and health and has conducted research projects on work stress, racism, and poverty and their effects on ambulatory blood pressure. Dr. Brondolo lives in Manhattan with her husband and two daughters.