In the last decade much argument has been directed at what has been termed "black paranoia"about racism. For example, Dinesh D'Souza argues that middle class African Americans move too quickly to see racism and that black rage is a "dysfunctional aspect of black culture, a feature mainly of middle- class African American life" and that this rage represents "the frustration of pursuing unearned privileges" of affirmative action. In effect, this perspective suggests that African Americans have mainly themselves to blame for mental health problems associated with their racial histories.

In contrast, other researchers have found that African American "paranoia" is actually a healthy response to recurring experiences with racial discrimination. Some researchers call this response "cultural mistrust," which is a suspicion of whites that is adopted by African Americans for survival. Others have rejected the use of terms such as "mistrust" or "paranoia," which have implications of pathology, and instead use the term "racism reaction" to describe the protective orientation individual African Americans often assume in interactions with whites. Research suggests that health-care providers should be familiar with this black response in order to avoid misdiagnoses of pathological paranoia. This precaution is particularly important given the fact that, although African Americans are less likely than whites to seek mental health care, those that do seek such care are more apt to be diagnosed with more serious mental illnesses.

In a now classical study, psychiatrists Grier and Cobbs examined the extent to which individual rage and depression among African Americans were determined by racial discrimination and asserted that black mistrust of whites is a reasonable attitude based on their experiences with racial discrimination. In this study, Grier and Cobbs drew on extensive clinical experience with black patients and concluded that the treatment of enraged African Americans must center on experiences with discrimination in the workplace and other sectors of society in order for psychological healing to take place. They noted that black

[p]eople bear all they can and, if required, bear even more. But if they are black in present-day America they have been asked to shoulder too much. They have had all they can stand. They will be harried no more. Turning from their tormentors, they are filled with rage.

More recently, Cobbs reiterated the point that rage against discrimination is commonplace among African Americans, but for many, continues to be turned inward. Silent, all-consuming rage can lead to inner turmoil, emotional or social withdrawal, and physical health problems.

African Americans working or traversing historically white places often feel frustration, anguish, anger, or rage-all of which may be expressed in their words, the tone of their comments, or the character of facial expressions. All the focus group respondents indicated in one way or another that they suffer substantial and recurring stress and frustration because of racially hostile workplaces. As one Midwestern respondent put it, her symptoms of stress do not happen "on weekends or after five o'clock." In the focus group interviews there is a consensus that much of their life-damaging stress at work does not come from the performance of the job itself but from hostile work environments.

Some social science research shows that a person's job satisfaction is rooted in how much work contributes to a sense of control and to self-esteem, in how much co-workers and supervisors are helpful in supporting one's work, and in whether rewards are meritocratic. Black employees have difficulty doing their best work when conditions and rewards are inequitable. Recent data demonstrate that African Americans continue to be rewarded economically at lower levels than do white Americans. The broad economic costs of being black include continuing disparities in income, wealth, and occupational position. Some portion of these disparities stems from the accumulating impact of discrimination over centuries, while another portion comes from the well- documented patterns of discrimination in contemporary employment settings.

Black workers' lives are disrupted by lack of support and discrimination by co-workers and supervisors; these encounters can become "life crises" with a serious health impact similar to that of life crises like the death of a loved one. Recent research on 726 African American men and women showed that the amount of decision latitude they were allowed on their job was linked to the risk of hypertension. African American men who were given more control over decisions on their jobs had fifty percent less prevalence of hypertension. However, many of our respondents discussed being excluded from decision-making. As the reader will see, an African American's attempt to compensate for this lack of control can lead to specific physical health problems.

In commenting on racially hostile or unsupportive workplace climates, some focus group participants described general feelings of frustration and anger, while others told of specific incidents that generated these feelings. A common source of anger is white use of racist epithets or similar derogatory references, which can trigger painful individual and collective memories. One black professional described her reaction to an incident with a white administrator:

I have felt, I have felt extremely upset, anger, rage, I guess you would call it? One incident that comes to mind happened in a social setting. I was with some, with my former boss and some coworkers and a man who ran, like, a federal program. And we were having dinner, and he made a comment, and he had been drinking heavily. And he referred to black people as "niggers" . . . . I'm sitting-he's there, and I'm here. . . . And as soon as he said it, he looked in my face. And then he turned beet red, you know? [Laughter] And I said, "Excuse me, what did you say?" And he just couldn't say anything. And then my boss, my former boss, intervened and said, "Now, you know, move his glass, because he's had too much to drink." And you know just making all these excuses. So, of course, I got up and left. I said goodnight, and left. And the next morning, the man called me and apologized. . . . His excuse was that he had been drinking, you know. And I said, "Well [gives name], we don't get drunk and just say things that we wouldn't otherwise say. You know, I don't get drunk and start speaking Spanish. [Laughter]. This was already in you, you know, in order for it to come out. [Voices: Exactly. Yeah, yeah. ] . . . . I mean so, keep your apology, I'm not interested.

Then she concluded with a comment on what she did with her anger:

I was so angered that I wanted to get him, you know? I was out to get him. I called his boss in [names city] . . . who is black, and informed him of what happened. Because he was referring to his boss, actually. . . . And he said, "Yeah, he's out with the other niggers." You know, so he's calling his boss a nigger! And I think his boss should know that!

Similarly, a secretary in the Midwest related an incident in which she had to explain the meaning of an epithet to her supervisor, who subsequently did nothing to reprimand the white employee who used the term:

A white individual in my department was talking to me, and he referred to me as "Buckwheat." My supervisor, when I reported it to her, told me that she did not feel that I looked like Buckwheat. Nor . . . did she understand what the term meant. Then she asked me to define it for her. She felt that [the term] was not derogatory. After I told her what it meant . . . . she said "Well, you don't exemplify that, so I wouldn't worry about that." She also refused to talk to the individual.

The impact of racist epithets may be underestimated by many white observers. One older black psychologist told the first author that when he hears the epithet "nigger," in his mind's eye he sees a black man hanging from a tree. Individual and collective memories compound the damage of present-moment discrimination. The connection between hostile epithets and the brutality of racism are intimate parts of the collective memory of African Americans.

Robert Bellah and his associates have noted that communities "have a history" and "they are constituted by their past-and for this reason we can speak of a real community as a 'community of memory,' one that does not forget its past." Collective recollections are not always positive: "Remembering . . . heritage involve[s] accepting . . . origins, including painful memories of prejudice and discrimination." Past and present discriminatory actions-and the contending responses to that oppression-become inscribed in collective memory. The community passes along information from one generation to the next about how to deal with discrimination and the anger it causes. A nurse's assistant noted the importance of generational advice and collective memory: "Kindness will kill a person. My grandmother told me that so many times. 'Don't get upset. Don't fuss. Don't argue with them. Just smile at them."' [Male voice: "That's true."] After this comment, a health care professional in the focus group spoke about her rage over a traumatic workplace incident with a white coworker. She partly attributed the hostility in their relationship to racial tensions in her workplace:

Most of the time you can do that, but it comes that point where you just can't. They have backed you into a corner. It's like a mouse, if you back him into a corner he's going to come out. So, then you just explode. I had that to happen on the job and I hit this person. I physically, yes, I hit her. She's white and she called me a "bitch." [Moderator: After you hit her or before you hit her?] Before I hit her. That's why I hit her. She was abusive to the patients, and I had already had a conversation with her, with the supervisor. . . . [s]he cursed me, and I'm looking at my supervisor who was her friend. . . . Both of them are white, and this was her friend. You know, they would go out to lunch together, whatever. She cursed me in the patient area, and I'm looking to my supervisor for some kind of response to her. Well, after she didn't say anything to her, then I cursed her back. And then I thought well, "Okay, this isn't cool, let me just get away from the situation." And I went [to] the medication room just to separate myself.

Then she added this to complete the story:

Well, that wasn't good enough for that person. She had to come where I was and ask me a question that she could have asked the patient. And I wouldn't respond to her. I said I'm not going to talk to her when she just cursed me. She just cursed me, what's the point? So, then she said, "Well, you bitch." When she said that, I just really lost it and I was out of there and grabbed [her coworker] by the back of the hair and punched her in the mouth. Well, when that happened of course your job flashes before your face. It's like "God, I'm going to lose my job." Well, the supervisor had her back to us luckily. . . . I was angry with myself because I allowed this person to get me off my ground. She wasn't worth [it], I could have lost my job. She wasn't worth that and I was really angry with myself for allowing her to get me off my ground.

Many cases of discriminatory treatment entail a sequence of events which take place over time; they consist of more than one encounter. The white woman cursed the respondent, who responded in turn, triggering another curse by the white woman. The respondent was angry at her own actions because she lost control over her own space. When she finished her account, one man in the group added this: "There's no one answer to a question like that. Each situation warrants a different response. I think what helps us as being black now, we understand what these [white] people think." One consequence of racial oppression is the understanding one necessarily develops into the behavior of the oppressor, an effort and level of understanding usually not required of the latter. Some research has linked the stress caused by this bicultural stance African Americans must take to increased vulnerability to illnesses.

A female supervisor in one focus group discussed the link between black rage and unfair promotion practices in workplace settings:

I think a lot of anger and rage comes in when we . . . feel like-like I have a friend, he's been with the company twenty years, and he didn't get a promotion. And he was well over-qualified. They gave it to a [white] guy who had been there only seven [years], and knows nothing. So, of course, I was kinda angry with the process, but it was because he was the ex-boyfriend of the girl who was doing the promoting. So he was upset about it. But I told him, I felt like this: "They can only tell you 'no' so many times. Keep applying for that position."

The anger over mistreatment is more than a matter of what happens to the black person as an individual. Rage over racism is also fueled by what happens to friends and family members. Collective memories of racism against all African Americans, as well as knowledge of specific discriminatory actions against particular friends and relatives, multiply racialized stress for African American individuals.

The seriousness of black rage over discrimination was made clear by a retired professor interviewed in a recent nationwide study of African Americans. Speaking to a question about the level of his anger toward whites because of discrimination (on a scale from one to ten), this man implicitly suggests the serious health consequences of rage:

Ten! I think that there are many blacks whose anger is at that level. Mine has had time to grow over the years more and more and more until now I feel that my grasp on handling myself is tenuous. I think that now I would strike out to the point of killing, and not think anything about it. I really wouldn't care.