The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) is the guidebook used by mental health practitioners. It outlines the criteria that mental health clinicians need to diagnose their clients’ psychological wellbeing and mental health disorders. Currently, the DSM-5 does not have a diagnosis for individuals with mental health disorder symptoms due to their racial identity, nor is there any discussion on the way an individual’s racial identity may influence or contribute to their psychological wellbeing. The purpose of this paper is to draw more attention to the effects of racial identity on the mental health of Black Americans. In therapeutic relationships little attention is given to a client’s racial identity and how it affects their mental health. Observing, discussing, and treating racial identity in the therapeutic relationship can be useful.

To gain a better insight of the effects racial identity has on the mental health of Black Americans the term has to be defined. Racial identity is “an all-encompassing term to refer to the racial and ethnic selfidentification, behaviors, affirmations, belonging, and achievements” [1] of an individual. Racial identity is also the extent to which an individual identifies with their racial group. Racial Identity “focuses on the social and political impact of a visible group membership has on an individual’s psychological functioning [2]. Ethnic identity was also linked to the mental health problems of people of color. However, this paper will focus solely on racial identity and psychological functioning.

For the purpose of this paper the racial identity models that will be used to assess the relationship between mental health and Black racial identity are the: William Cross Nigerscence Model, Janet Helms Racial Identity Model, and Robert Sellers and colleagues Multidimensional Model of Racial Identity (MMRI).

Cross was often been called a pioneer in racial identity studies because he is the first researcher to outline the progress from a psychologically unhealthy non-African American identity to a psychologically healthy African American identity. The Cross model is one of the oldest models of Black racial identity and has been widely used by many experts and academic professionals. The five stages of Cross’s racial identity model are pre-encounter, encounter, immersionemersion, internalization, and internalization-commitment. The first stage, pre-encounter, involves “individuals who do not believe race is an important component of their identity [3]. Cross characterized the pre-encounter stage through the assimilation, mis-education, and selfhatred identities. African Americans in this stage view “being White as right” and “being Black as wrong” and often have a negative viewpoint of what it means to belong to their race. The second stage, encounter, encompasses “people who are faced with a profound experience or collection of events that are directly linked to their race. This experience encourages encounter individuals to re-examine their current identity and create or further develop their Black identity.

The reaffirmation or creation of their identity can either be a positive or negative experience. This encounter event can range from the experience of a racist, discriminatory, or prejudicial event to being socially rejected by White colleagues or friends and thus encourages the individual to reassess their racial identity. The third stage, immersionemersion, “has been described as a person being extremely pro-Black and anti-White. These individuals are obsessed with identifying with Black culture, but internally; they have not made the commitment to endorse all values and traditions associated with being Black. During the immersion portion of this stage everything valued has to be linked to being Black or Blackness, individuals may seek out opportunities to learn aspects of their history and culture, such as taking African American Studies courses in college or be involved in self-education practices. Cross argued, the immersion-emersion stage encompassed intense Black involvement and anti-White identity clusters. The fourth stage, internalization, “is characterized by having a feeling of inner security and satisfaction about being Black, the positive and negative aspects of being a Black or White person are clear to individuals in this stage. Internalized individuals can establish a meaningful relationship with people who respect their racial identity. Cross defined the identities of this stage as Black Nationalist, biculturalism, and multiculturalism. He also added the internalization-commitment stage, which represents “individuals who translate their internalized identities into action. When an individual reaches this stage, they have completed the Nigrescence Racial Identity Model may be considered to have a positive racial identity.

Cross’s Nigrescence model was revised by Janet Helms. Helms’s racial identity has four stages, which are pre-encounter, encounter, immersion-emersion, and internalization, which are very analogous to the Nigrescence model. Helms stated, “The racial identity stages refer to the portion of a person’s worldview that is shaped by society’s manner of attributing value to a person’s socially ascribed racial/ethnic group [4]”. Helms described “the pre-encounter stage as devaluing Black people and culture and seeing White people and culture as superior [5]. She described “the encounter ego status as a response to high negative experiences with White people or positive experiences with other African Americans. Encounter individuals experience confusion and irritation and move into the immersion and then the emersion stage. The immersion portion of this stage occurs when “an African American person initially cautiously adopts a Black identity and then immerses him or herself in African American culture in an attempt to rid themselves of all traces of the previous pre-encounter and encounter racial identities. The emersion stage encourages people to move “to a more positive and internalized world view where they experience Black culture, engage in self-exploration, and experience positive feelings and a sense of unity with other African Americans . The final stage of Helms’s racial identity model is internalization. Similar to Cross’s model, the internalized individual can establish relationships with Whites, have a strong satisfaction with being Black, and can reject oppressive behaviors such as racism. More recently, integrative awareness was added to Helms model which is “similar to internalization, with the added dimension of appreciating one’s collective identity and establishing links with other groups that have also experienced racial and other forms of oppression [6,7]. Helms have continued to revamp this Black racial identity model and has even created identity models for other racial groups.

Robert Sellers and his colleagues created the Multidimensional Model of Racial Identity (MMRI). MMRI was produced to study the significance of race in an individual’s life and the person understands of what it means to be Black. This model has four dimensions of African American identity, which are salience, centrality, ideology, and regard. Sellers’s first identity stage.

Salience refers to the extent to which a person’s race is a relevant part of his or her self-concept at a particular moment in time. The centrality dimension refers to the extent to which a person normatively defines him or herself about race. The ideology dimension refers to an individual’s beliefs, opinions, and attitudes on the way he or she feels Black people should act.

The fourth and final dimension, regard, is divided into two types, public and private. Public regard “refers to a person’s affective and evaluative judgment of his or her race. Private regard refers to the extent to which individuals hold positive or negative attitudes towards Black people and their personal membership. Public regard refers to the extent that Black people feel others view their racial group positively or negatively. Sellers’s racial identity model differed from both Cross and Helms models because it focuses on different dimensions of racial identity and provides a different and more complex framework for examining the structures of Black racial identity.

There are many similarities in the Cross and Helms racial identity models. Both racial identity theorists use similar models, stage names, and levels. Both models start at the pre-encounter stage and end at the internalization stage. Both models agree that individuals will have a healthy identity once they reach internalization. Cross’s model differs from Helms because he has different identities within the pre-encounter and internalization stages of his model. Both Cross and Sellers use racial identity to characterize the behaviors of individuals in certain stages of their racial identity models.

Like Cross, Sellers and his colleagues’ racial identity model also had identities within the stages of his model. Under the ideology stage these ideologies or identities are the “nationalist ideology which stresses the uniqueness of being of African descent; oppressed minority ideology discusses the similarities between African Americans and other oppressed groups; assimilationist ideology stresses the similarities between African Americans and American mainstream society; and the humanist ideology stresses the commonalities of all humans [8]. Sellers and colleagues’ model differs from Cross and Helms because it focuses on how racial identity affects an individual’s life, the importance of race in a person’s life, and an individual understanding what it means to identify with their race. The MMRI has four dimensions that are independent however each dimension is related to the next; this is different from Cross and Helms models which are codependent upon one another.

There has been a substantial amount of literature examining the psychological effects of racial identity on people of color. All of the racial identity theorists discussed in this paper support the notion that a positive racial identity will result in an individual having a healthy psychological and mental health functioning. They also agree a negative racial identity will lead to psychological distress and other unhealthy mental health outcomes.

The Racial Identity Attitude Scale (RIAS) was created by Helms and Parham to operationalize the Cross and Helms racial identity models connection to mental health and psychological well-being. This racial identity scale outlines the mental health stability, disorders, or wellbeing associated with the Cross/Helms Black racial identity scales. Studies using the RIAS found African Americans in the preencounter stage of racial identity had a poorer psychological wellbeing, lower self-actualization, and lower self-esteem [3,9,10]. Individuals in the pre-encounter stage, also have more symptoms and higher levels of psychopathology, depression, anxiety, paranoia, hypersensitivity, feelings of personal inadequacy, and psychological distress in comparison to individuals in the encounter, immersion/emersion, and internalization stages. It appears that being or staying in the preencounter stage could be detrimental to a person’s mental health. Cater, Pyant and Yanico found that pre-encounter attitudes are associated with lower levels of well-being [6].

The encounter stage can result in a positive or negative experience. Therefore it makes sense that this stage could result in either a healthy or unhealthy psychological functioning. Pre-encounter attitudes were also found to be positively associated with “memory impartment, paranoia, hallucinations, alcohol concerns, and global psychological distress [11]”. The encounter stage has been correlated with self-acceptance, low rates of anxiety, higher depressive symptoms, and lower levels of selfesteem, self-well-being, and self-concept. “Although grappling with the meaning of one’s Blackness, encounter attitudes, have been found to be associated with positive psychological health, such as higher levels of self-esteem and increased self-actualization, these attitudes also have been associated with lower degrees to mental health indexes. It should be noted that people who have a healthy self-esteem could still experience signs and symptoms of stress. “Individuals with a heightened awareness of racial issues and are in the immersion/emersion stage may identify with higher levels of culture-specific stressors. African Americans who complete the racial identity process and reach the internalization stage are hypothesized to have a healthy and stable psychological wellbeing and mental health.

These individuals are also thought to “have transcended emotional reactions to their racial identity except for positive self-regard and self-acceptance. Pierre and Mahalik stated, “Internalization attitudes are positively associated with self-esteem and negatively linked to depression [12]”. Individuals who have a strong Black racial identity or those who are in the internalization stage of the Cross or Helms models are less likely to be psychologically distressed or experience the same mental health dilemmas as those in the pre-encounter, encounter, or immersion/emersion stages. Research using both Cross and Helms racial identity models showed the benefits of having an active Black racial identity and the mental health consequences of having a negative racial identity.

Sellers’ Multidimensional Model of Racial Identity also indicates and identifies the relationships between Black racial identity and mental health, depression, anxiety, and stress. However, this model is more complex in linking racial identity with other relevant issues that affect mental health outcomes. For example, Sellers and colleagues found, “one phenomenon that may play a vital role in an indirect relationship between racial identity and mental health in African Americans is the experience of racial discrimination. Numerous studies support the notion that “experiencing discriminatory events can have adverse mental health consequences for African Americans. The mental health consequences include depression, obsessive-compulsive disorder, personal sensitivity, somatization, and other stressors. Sellers and colleagues indicated a relationship between “racial identity variables and African American psychological functioning. The bivariate correlations and direct effects models suggest that individuals for whom race is a more central identity were more likely to report lower levels of subsequent psychological distress. There was also “strong evidence for an indirect relationship between racial centrality and public regard on psychological distress through the effect of racial discrimination and perceived stress. Stress caused by racial discrimination has a deleterious effect on an individual’s mental health. Researchers have found racial hassles; prejudicial events, stereotyping, and discrimination are all very stressful life events experienced by African Americans that affect their anxiety and depression levels as sellers stated.

The two components of MMRI that may be particularly relevant to understanding the link between racial identity and mental health in African American adolescents are racial centrality and private regard. First, racial centrality refers to the extent to which individuals normatively define themselves regarding race. The other component private regard involves individuals’ positive or negative evaluations of their racial group and their membership in that racial group. It is also possible racial centrality, and private regard may relate to perceived stress and other mental health outcomes in different ways.

Cross, Helms, and Sellers models of racial identity show the clear relationship between racial identity and mental health. These models added to the evidence and research, which stated racial identity is associated with the psychological well-being of African-Americans. This study implies that a positive racial identity will result in psychological health and that a negative racial identity results in psychological distress and other poor mental health outcomes.

Cross and Helms addresses the effects racial identity has on mental health differently than Sellers and his colleagues. Cross and Helms Racial Identity Models discuss ways mental health influences an individual at each stage of their Black Identity development. For example, from the pre-encounter to internalization stages of the Cross and Helms identity models clearly, outlines the impact racial identity has on a person’s mental health. The MMRI model does not directly show how racial identity affects an individual’s mental health at each dimension of the model. It discusses how mental health is affected by a person’s racial salience, centrality, ideology, and regard when stress or discrimination is present in a person’s life.

Racial identity development has been said to be “an important concept when counseling African Americans, especially if the presenting problems are related to racial issues [13]”. Neville and his colleagues stated, “the positive relationship between multicultural counseling skills and racial identity development has been noted in numerous studies [14] mainly focusing on how mental health clinicians should interact with clients. Racial identity has been called one of the staples of multicultural counseling. According to Ponterotto racial identity is important in the understanding and application of multicultural counseling [15].

Cultural competency, multicultural counseling, and racial identity are often absent in the mental health treatment and assessment of Black Americans. Cultural competency is “a therapist respecting their client’s cultural differences,” and encourages clinicians to work effectively with diverse racial, cultural, ethnic, religious, and social groups. Multicultural cultural competency is “counseling that takes place between or among individuals from different cultural backgrounds [16]”. Racial identity has a significant influence on the discipline of multicultural counseling. It is essential for mental health clinicians to understand the racial identity of their clients while treating them and use cultural competency to respect their client’s cultural differences. One way a clinician can be culturally competent is to use multicultural counseling techniques and monitor their client’s culture and racial identity. “It is important for counselors to understand the racial identity status of African American clients, which provides a framework for addressing the presenting problems in a way that facilitates growth and development of not just racial identity, but also a resolution of the presenting concerns. Accessing racial identity should be a part of the ethical practice. The American Mental Health Association (AMHA) code of ethics reinforces “the belief that counselors should not only understand a client from diverse backgrounds but also should understand their own racial, cultural, ethnic, and religious identities and how they impact their values and beliefs about the counseling process. If clinicians are not addressing the effects of racial identity or culture on their clients of color, specifically their Black clients, this means therapists are not practicing cultural competency. Good practice also requires a clinician to attend to their racial identity not just their clients. Additionally, a therapist accessing both his/her own and their client’s racial identity will allow the clinician to discuss the impact racial identity has for themselves, their clients, and the therapeutic relationship.

Culture is discussed in the DSM-5 as it relates to culturally bound syndromes. However, the impact and influence of racial identity on mental health are not considered. Clinicians provide counseling and therapy services to people from diverse cultural, ethnic, and racial backgrounds. Mental health practitioners need to know how to treat and maintain these populations adequately. In the DSM there is no discussion on the effects of racial identity. The DSM-5 does not discuss the consequences of racial identity. Despite the impact racial identity has on clients, clinicians, and the mental health system it does not appear at all in the DSM-5. The research was done on racial identity, multicultural counseling, and mental health it is evident there should be a Racial Identity Disorder in the future DSM.

The focus of this paper was to show the relationship between racial identity and mental health. This article reviewed the ways in which the Cross, Helms, and Sellers Racial Identity models affect the mental health of individuals in the Black community. A significant amount of the literature has shown a correlation between racial identity and mental health. Most of the research has shown a negative association with racial identity generates in poorer mental health, and a positive racial identity produces a healthy psychological well-being for people of color, specifically African Americans.

An important goal of this paper was to illustrate the need for a Racial Identity Disorder in future versions of the DSM. Currently, there is not a diagnosis in the DSM-5 that addresses neither racial identity nor any discussion on the effects of racial identity on the mental health of people of color. A racial identity diagnosis in the future renditions of the DSM is a way the mental health system can attempt to keep pace with the needs of people of diverse racial, ethnic, and cultural backgrounds. The impact and role racial identity play on the mental health of African-Americans and other people of color suggests it is critical and advantageous for mental health practitioners to access their clients’ racial identity, and for the American Psychiatric Association to include a Racial Identity Disorder in the DSM. In the long term, we recommend the creation of a trial period for a mental health professional to use, incorporate, and assess racial identity in their clinical practice. Finally, there should be a section in the future variations of the DSM that discusses the effects of identity disorders, especially how they affect the client’s mental health. This section would house Racial, Gender, and Identity problems disorders.

Additional research should occur on the effects of racial identity and the counseling process of diverse cultural groups. Multicultural counseling techniques will have to be created and implemented for counselors treating clients who have racial identity problems. For example, mental health practitioners need to be trained on ways to interact and deal with a client who may not want to discuss their racial or ethnic backgrounds. Clinicians should be educated on how race, ethnicity, and culture affect a client’s life without being intrusive as well as learning to treat individuals whose race or ethnicity may not be obvious or clear to the psychotherapist. More research needs to be done on the behavioral effects of not having a stable racial identity such as a client “posing as a member of a racial” group they do not belong to or not identifying with their racial culture.

Mental health clinicians will have to incorporate racial identity and multicultural counseling techniques into their therapeutic practices before this diagnosis can be put in the DSM. These practitioners could use the criterion of this Racial Identity Disorder in their mental health practice to rate how this diagnosis characterized their clients’ behaviors, experiences, mental health, and psychological wellbeing. This diagnosis should be applied to clients who racially and ethnically identify as Black, Latino/Hispanic, Native American, Asian, or Bi/Multiracial to compare and contrast the effects racial identity has on individuals of different races and ethnicities.