E D I T O R I A L

The Black Mask of Humanity:Racial/Ethnic Discrimination andPost-Traumatic Stress Disorder

Hugh F. Butts, MD

J Am Acad Psychiatry Law 30:3369, 2002

Knowledge of the impact of racism on the psyches ofAfrican-Americans is limited by the following con-siderations: the tendency among European-Ameri-cans to deny, minimize, and rationalize the existenceof racism; the tendency among European-Americansto ascribe inferior status to African-Americans; theapplication of many stereotypes and myths to Afri-can-Americans that serve to have them viewed asnonresponsive to human influences; and finally, anAfrican-American tradition which teaches one todeflect racial provocation and to master and containpain (Ref. 1, p 25).

It is not surprising that, given this disregard ofAfrican-Americans, responses to racial discrimina-tion by African-Americans are often not viewed assevere enough to indicate that these blacks may havepost-traumatic stress disorder (PTSD). Even in thoseinstances in which African-Americans are objects ofdiscrimination and describe symptoms consistentwith PTSD, their symptoms may be dismissed ortrivialized because of the view that the stressors arenot catastrophic enough, according to the Diagnos-tic and Statistical Manual of Mental Disorders(DSM), to warrant a diagnosis of PTSD.

The tendency on the part of some European-Americans to define casually the reality of African-Americans experience may be problematic in view ofthe lack of knowledge about the Black Experiencedisplayed by so many European-Americans. This

tendency led Ralph Ellison to write: Thus when thewhite American says, This is American reality, theNegro tends to answer . . . perhaps, but youve leftout this and this, and this. And most of all what youdhave the world accept as me isnt even human (Ref.2, p 111).

There are intriguing psychodynamics implicit inthe refusal by European-Americans to acknowledgeand accept that the African-American response toracial discrimination should be viewed as potentiallyclinically symptomatic. First, there is a lack of sophis-tication regarding the adaptive nature of the forma-tion of symptoms and that a symptom simulta-neously represents a mechanism of constructiveadaptation to the effects of stressors as well as (in theextreme) a maladaptive response to the effect of stres-sors. Thus, there is a great deal to be learned aboutformation of symptoms as African-Americans reactto traumatic acts of discrimination and then defineand expand their self-definition in response to thesetraumatic acts. Second, failure to characterize as se-rious trauma the symptoms that African-Americansreport as responses to discrimination tends to furtherthe emotional gulf between African-Americans andEuropean-Americans.

During four decades of psychiatric and psychoan-alytic practice, the author has treated thousands ofAfrican-American individuals, many of whom havedescribed various types of racial trauma. Most of theAfrican-American patients evaluated and treated bythe author have described multiple personal experi-ences of racial and ethnic discrimination. Consider-ing the ubiquity of racism, it is not surprising that

Dr. Butts is in private practice in psychiatry and psychoanalysis in NewYork, NY. Address correspondence to: Hugh F. Butts, MD, 350 Cen-tral Park West, Suite 13-I, New York, NY 10025. E-mail:hfbuttsmd@aol.com

336 The Journal of the American Academy of Psychiatry and the Law

instances of discrimination are as frequent as re-ported; but the devastating emotional responses tothe racist acts are unsettling. The range and intensityof emotional responses varies from mild to over-whelming, and the duration of such responses variesfrom days to months or years. With a fair degree offrequency, black individuals who experience racialdiscrimination report symptoms consistent with adiagnosis of PTSD, even though the DSM-IV re-quires, for the diagnosis, that the symptoms followexposure to extreme traumatic stress.

The essential feature of Posttraumatic Stress Disorder is thedevelopment of characteristic symptoms following exposureto an extreme traumatic stressor involving direct personalexperiences of an event that involves actual or threateneddeath or serious injury, or other threat to ones physicalintegrity; or witnessing an event that involves death, injury,or a threat to the physical integrity of another person; orlearning about unexpected or violent death, serious harm, orthreat of death or injury experienced by a family member orother close associate. . . . Traumatic events that are experi-enced directly include, but are not limited to, military com-bat, violent personal assault (sexual assault, physical attack,robbery, mugging), being kidnapped, being taken hostage,terrorist attack, torture, incarceration as a prisoner of war orin a concentration camp, natural or manmade disasters, se-vere automobile accidents, or being diagnosed with a life-threatening illness [Ref. 3, p 463 4].

It is my premise that the clinicians who formu-lated the DSM have used an extremely narrow focusin citing the traumas that may be causative of PTSD.It is my view that racial/ethnic discrimination expe-rienced by African-Americans frequently results insymptomatology consistent with a diagnosis ofPTSD. Further, it will be argued herein that the sub-jective experiences and symptoms experienced bythose African-Americans are often extreme and cata-strophic, requiring active psychotherapeutic and psy-chopharmacologic care. Recognition of this notionshould make it easier for blacks who have experi-enced intentional discrimination to bring claims thatthey have suffered psychological harm.

A Review of Selected Literature

Several behavioral scientists have sought to expandthe view held by the DSMs authors as to the natureof trauma. Charles Brenner states:

What is traumatic is the subjective experience of the trauma-tized individual. It is what the event meant to the individual. Itis the impact of the external stimuli, how they heightened fears,

intensified sexual and aggressive wishes, resonated with feelingsof guilt and remorse [Ref. 4, p 196].

Jacob Arlow in a 1984 article notes:

What constitutes trauma is not inherent in the actual event, butrather in the individuals response to a disorganizing disruptivecombination of impulse and fears integrated into a set of un-conscious fantasies. The traumatic event itself has not been atissue, only the reaction that it evokes in the survivor [Ref. 5,p 521].

Pitman and Orr, in describing the illusory objec-tivity of the stressor, write:

The assumption that there exists a range of usual human expe-rience is dubious from a cross-cultural perspective. For exam-ple, gang related shootings may be rare in rural Minnesota butall too common in urban Los Angeles. A recent study found thatat some time in their lives, 39 percent of the middle-class De-troit population was exposed to traumatic events potentiallycapable of causing PTSD, and 25 percent of exposed personswent on to develop the disorder. Another study reported thatstressors falling within the range of usual human experience aresometimes capable of resulting in the PTSD syndrome [Ref. 6,p 37].

Pitman and Orr add:

The examples presented in DSM III-R of stressors that maycause PTSD raise as many questions as they settle. Does thesudden destruction of ones home include losing ones sum-mer house in a fire? Of all the examples provided in DSM III-Rserious threat to ones life or physical integrity appears themost straightforward. However, not all experts would accept thesudden denuding of a litigants scalp by a faulty hair rinse as astressor sufficient to cause PTSD. The illusion of an objectivestressor is further evidenced by the consideration that the vic-tims appraisal constitutes a necessary link in the causal chainfrom event to stress response. An identical event may not beexperienced the same way by two people. Pilowsky has coinedthe term cryptotrauma for a situation in which a stressor thatappears innocuous to an observer may be perceived by the vic-tim as life-threatening. Retrospective discovery that the ap-praisal was incorrect doesnt erase the distress associated withthe original experience [Ref. 6, p 38].

Butts710 and Butts and Butts,11 offer cases docu-menting the appearance of PTSD symptoms in aseries of African-Americans who experienced racialand housing discrimination. Each of the patients de-scribed symptoms consistent with a diagnosis ofPTSD. Each was given the diagnosis and in severalcases, expert testimony at the time of civil trial re-sulted in findings for the plaintiffs and awards fordamages or settlements out of court.

Butts

337Volume 30, Number 3, 2002

Racial Discrimination and Post-TraumaticStress Disorder

Unconscious racism as a socio-psycho-culturalphenomenon is ubiquitous in American society andaffects the lives of all African-Americans and Euro-pean-Americans. The behavioral manifestations ofracism span a spectrum from subtle to extreme. Thegenesis of racism resides in the institution of blackslavery, myths, stereotypes regarding Africans andAfrican-Americans, and pathological thoughts andfeelings of European-Americans that use pro-white,anti-black projective mechanisms.

Discriminatory behavior by European-Americansdirected toward African-Americans represents traumaand engenders symptoms (which are for the mostpart subjective), that may be categorized in differentways and that may evoke multiple forms of behav-ioral responses. Increasing clinical evidence has shownthat discriminatory behavior can and does cause notonly psychiatric symptoms in African-Americans,but organic changes such as hypertension.

Case Presentation I

The patient, an African-American man in his thir-ties, was referred to the author after experiencing adenial of housing that he categorized as housing andracial discrimination. He had answered a newspaperadvertisement for an apartment in New York City.After several failed attempts to view the apartment,he had asked a white coworker to make a request. Shewas allowed to see the apartment and encouraged tomake application. After the alleged discrimination,the man sought legal representation, and it was sug-gested that he have a psychiatric evaluation.

His initial reaction to denial of the apartment wasshock and confusion, which were rapidly replaced byobsessive rumination in which he thought repeatedlyabout what had occurred. Within the first week, hebecame depressed and sleepless. He had repeatednightmares (example: I was searching for an apart-ment and being chased out). He slowed down onthe job because of his depression, became anorexic,and lost 25 pounds over a six-month period. He alsoexhibited gastrointestinal symptoms consisting ofabdominal pain and discomfort. He sought medicalattention, underwent gastroscopy, and received a di-agnosis of duodenal ulcer. A treatment regimen wasinstituted. He had never experienced ulcer symp-toms prior to the discrimination experience. Later,

he began to experience severe headaches, and mi-graine was diagnosed.

On mental status examination, the aforemen-tioned symptoms were elicited. In addition, he con-tinued to be depressed and anxious and to exhibitdiminished ability to concentrate. Nightmares con-tinued, as well as hypervigilance. He experiencedflashbacks of the incident.

The diagnoses were: Axis I, Major Depressive Dis-order, PTSD; Axis II, Dependent Personality Disor-der; Axis III, duodenal ulcer and migraine; Axis IV,severe housing/racial discrimination. Axis V, GlobalAssessment of Functioning score of 80.

The patient was referred for individual psycho-therapy. The legal matter was settled out of court infavor of the plaintiff.

Case Presentation II

A light-skinned Hispanic male was treated courte-ously when he made application for an apartment inNew York City. However, when he returned with hisAfrican-American wife, the renting agent becamealoof and informed them that the apartment wasrented.

In response to the denial of the apartment, the wifeimmediately became depressed, insomniac, and hy-pervigilant. She interpreted every sound during thenight as someone attempting to break into theirapartment. She had repeated nightmares. At the timeof the alleged discrimination, she noticed that herhair had begun to fall out, that her skin was dry, andthat she was constipated. Although there were nohallucinations, delusions, or ideas of reference, therewas a mild paranoid trend. There was no clinical orlaboratory evidence of hypothyroidism. All of hersymptoms were causally related to the alleged dis-crimination. Her anxiety had spread, and she experi-enced excessive fears about the welfare of her infantdaughter. She became so distraught that on severaloccasions she considered abandoning the marriageand returning to her Caribbean homeland.

Her diagnoses were: Axis I , Major Depressive Dis-order, PTSD. Both she and her husband were re-ferred for psychotherapy.

Conclusions

Racial and ethnic discrimination produce psychictrauma, and African-Americans subjected to dis-crimination frequently respond with symptoms con-sistent with a diagnosis of PTSD. The symptoms

Editorial

338 The Journal of the American Academy of Psychiatry and the Law

described fall into three categories: (1) reexperienc-ing criteria, such as distressing dreams and flash-backs; (2) avoidance criteria, such as affective restric-tion and the avoidance of thoughts and feelingsassociated with the trauma; and (3) arousal criteria,such as insomnia, hypervigilance, and startle reac-tions. The symptoms reported by African-Americansin the wake of discriminatory acts are subjectivelyperceived and may be felt as extreme and as annihi-lative, and described in catastrophic terms. Thus, it issurprising that racial discriminatory acts are not in-cluded among the stressors cited as causative ofPTSD in the DSM of the American Psychiatric As-sociation. One can only conclude that the formula-tors of the DSM lacked clinical familiarity with theexperiences of African-Americans and therefore erro-neously concluded that racial discrimination shouldbe excluded from the list of stressors leading toPTSD. This is a serious omission, however, becauseit runs counter to the clinical experience of manyAfrican- American psychiatrists, who can documentnumerous instances of discrimination resulting inPTSD. It constitutes a gross oversight that the DSMhas disregarded these valuable clinical and socialdata. These omissions may also make it difficult forAfrican-Americans who experience such discrimina-tion to succeed as plaintiffs in civil suits.

There is a paucity of accurate epidemiological dataon the incidence and distribution of PTSD. Knowl-edge of defense mechanisms and symptom formationmake it apparent that not all individuals exposed totraumas experience PTSD. Further, the personalityorganization of traumatized individuals is a signifi-cant parameter in the development of PTSD. Withrespect to African-Americans, there are no epidemi-ological data on either incidence or distribution ofPTSD. Nor are there data on exposure to trauma andthe occurrence of PTSD. As with the population atlarge, it seems reasonable to assume that not all Afri-can-Americans exposed to the trauma of discrimina-tion will develop PTSD.

The following research initiatives are recommended:1. What is the incidence and prevalence of PTSD

among African-Americans exposed to racial/ethnicdiscrimination?

2. What proportion of African-Americans exposedto racial/ethnic discrimination do not experiencePTSD? What is the psychodynamic explanation forthis?

3. Is there any correlation among African-Ameri-cans between preexisting personality organization,exposure to racial/ethnic discrimination, and the de-velopment of PTSD?

4. What is the recovery rate among African-Amer-icans who develop PTSD following exposure to ra-cial/ethnic discrimination? What factors influencethe recovery rate?

5. Are there differences between the incidence ofPTSD in European-Americans and African-Ameri-cans? If differences exist, to what are they attributable?

It is important that other behavioral scientistsshare their clinical experiences with respect to racialdiscrimination and PTSD to develop a substantial,creditable body of literature in the area. Such infor-mation will also be useful to professionals participat-ing in discrimination tort claims.

References1. Ellison RW: Twentieth-century fiction and the black mask of

humanity, in Shadow and Act. New York: Vintage Books, 1972,p 25

2. Ellison RW: The world and the jug, in Shadow and Act. NewYork: Vintage Books, 1972, p 111

3. Diagnostic and Statistical Manual of Mental Disorders (ed 4, textrevision). Washington, DC: American Psychiatric Association,2000, pp 4638

4. Brenner C: The Reconstruction of Trauma: Its Significance inClinical Work. Madison, CT: International Universities Press,1986, pp 195204

5. Arlow J: The concept of psychic reality and related problems.J Am Psychoanal Assoc 33:52135, 1984

6. Pitman RK, Orr SP: Psychologic testing for posttraumatic stressdisorder: forensic psychiatric applications. Bull Am Acad Psychi-atry Law 21:3752, 1993

7. Butts HF: Racisms link to posttraumatic stress. The MedicalHerald. July 2001, p 23

8. Butts HF: Racism can spur posttraumatic stress. The MedicalHerald. August 2001, p 23

9. Butts HF: Racism sparked posttraumatic stress. The Medical Her-ald. September 2001, p 21

10. Butts HF: Housing bias takes heavy psychiatric toll. The MedicalHerald. September 1995, p 17

11. Butts H, Butts HM: Housing bias and posttraumatic stress disor-der. Mind Hum Interact 8;2615, 1997

Butts

339Volume 30, Number 3, 2002