Task force gets mixed reviews
After the announcement, Dr. Geller named the psychiatrists who will serve, and the task force, chaired by Cheryl D. Wills, MD, assistant professor of psychiatry at Case Western Reserve University in Cleveland, got to work quickly.
The task force has conducted an online town hall and will conduct another one on Aug. 24. It also released the results of a survey of nearly 500 members about the top three areas that the task force should address.
“Access to Healthcare/Mental Healthcare” received the most votes (97) as the recommended top priority, followed by “Socio-Economic Conditions and Factors” (49). These two areas also received the most first-, second- and third-priority votes overall (173 and 166, respectively).
The other areas with high numbers of first priority votes were “Lack of Minority Psychiatrists, Faculty and Leaders” and “Education for Psychiatrists,” both tied at 46. Those areas received 142 and 122 total votes supporting them as first, second, and third priorities.
Thirty-seven members said “Racism within the APA/APA Actions” should be the top priority. A small number of respondents appeared to doubt the need for such a task force: Nineteen thought the top priority should be “Questioning the Concept of Structural Racism/Task Force.”
Meanwhile, some psychiatrists are raising questions about the task force’s makeup.
Ruth S. Shim, MD, MPH, the Luke & Grace Kim Professor of Cultural Psychiatry at the University of California, Davis, said that she was disappointed by the task force’s membership. Specifically, Dr. Shim said, the task force does not include enough APA members she sees as qualified to address structural racism.
“While many of the Black psychiatrists who are members of the task force are experts in issues of diversity, inclusion, and equity, other members of the board of trustees who were appointed to this task force do not have any expertise in this area,” said Dr. Shim, who wrote a scathing commentary7 in July about the APA’s failures regarding structural racism. “I believe the selection of members could have been more thoughtful and more inclusive of diverse perspectives and voices.”
Dr. Geller countered that the task force includes a mix of APA board members and non–board members with various types of expertise. “Certain board members were chosen because their colleagues on the board “were already involved in task forces and other projects,” he said.
How the task force is envisioned
Dr. Geller’s goals for the task force, which will operate at least through his 1-year term as president, are ambitious.
“I hope the task force will identify structural racism wherever it’s taking place – where psychiatrists practice, within the APA itself,” Dr. Geller said. “It will be an educational process so we can inform members and ourselves about clear and subtle structural racism. Then we’re going to proffer solutions in several areas that can rectify some of what we’ve been doing and the negative outcomes that have resulted in areas of leadership such as access to care, treatment, hospital and clinic administration, health insurance, and academia. It’s clear that this is a massive undertaking.”
For her part, Dr. Shim thinks the task force might chip around the edges of the structural problems in the specialty – rather than focusing on the roots. “The task force is set up to fail,” she said. “To truly dismantle structural racism in the APA, the leadership of the organization – the CEO, the executive committee, and the board of trustees – must do the hard work of deep self-reflection and self-study to recognize the role that they have played in perpetuating and upholding White supremacy in the organization.
“I do not believe the task force will be capable of doing this, as this is not what they have been tasked to do,” Dr. Shim said.
Task force member Dr. Starks said he believes there is potential for progress within the APA. While Black members have been frustrated by an APA power structure that seems both harmful and unchangeable, he said, “this is an opportunity for us to re-root and achieve equity in mental health.”
He added that the priorities of the task force are not set in stone. “Those things that are listed on the website may change and evolve over time as we report back to the board and develop our functions internally,” said Dr. Starks, who praised Dr. Shim’s commentary as “courageous.”
The website lists these initial charges for the task force:
- Providing education and resources on APA’s and psychiatry’s history regarding structural racism.
- Explaining the current impact of structural racism on the mental health of our patients and colleagues.
- Developing achievable and actionable recommendations for change to eliminate structural racism in the APA and psychiatry now and in the future.
- Providing reports with specific recommendations for achievable actions to the APA board of trustees at each of its meetings through May 2021.
- Monitoring the implementation of tasks.
Meanwhile, the task force is reporting to the APA board of directors each month. The entity is tied to the 1-year presidential term of Dr. Geller, which ends in spring 2021, but Dr. Starks said he hopes it will continue in another form – such as a formal committee.
Importance of cultural competence
Dr. Brown highlighted the importance of cultural competence – “making sure that we are looking at patients in the context of their cultural background, their religion, their race, so we can make informed decisions without jumping to conclusions too soon.”
For example, if an African American man or woman talks about hearing God’s voice, “we shouldn’t necessarily brush it off or diminish it as psychiatric illness if it’s in the context of that person’s religious background,” Dr. Brown said.
Francis G. Lu, MD, agreed. He said the task force should explore cultural competency on both clinical and systems levels.
“An antidote to structural racism would be systems cultural competence involving organizations, clinics, and teams looking beyond patient care issues,” said Dr. Lu, the Luke & Grace Kim Professor in Cultural Psychiatry Emeritus at the University of California, Davis. A good starting point, he said, is the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, also known as the National CLAS Standards.
Looking forward, Olusola Ajilore, MD, PhD, called for a focus on targeted efforts aimed at encouraging more minority medical students to become psychiatrists.
Dr. Olusola Ajilore
“We have a field with a lot of crucial questions that have yet to be answered,” said Dr. Ajilore, associate director of residency training and education at the University of Illinois at Chicago. “With more Black psychiatrists, we might be more aware of some of the research questions that affect our community, such as the mental health consequences of exposure to racism and prejudice.”
However, the role of White psychiatrists cannot be overemphasized, said Constance E. Dunlap, MD, clinical professor of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Constance E. Dunlap
“Whites can make a difference by acknowledging the racial hierarchy that ‘unfairly disadvantages some ... and unfairly advantages others’ – to use the language8 offered by Dr. Camara Phyllis Jones, said Dr. Dunlap.
“As psychiatrists – as physicians – we are obligated to help patients see themselves and the world more clearly. This starts with our own self-appraisal and extends to our work, whether it is in a psychodynamic space or a community psychiatry setting,” Dr. Dunlap said. “Bottom line, instead of focusing on guilt, I tell my White colleagues and patients: You have privilege, use it constructively to benefit the world.”
Dr. Calhoun said she hopes to see mandated integration of training about racism into psychiatric education. “Rather than a special racism lecture, I’d like to see instruction implemented throughout. It should be essential for psychiatrists to learn about the historical racism of psychiatry and the current racial inequities that exist among psychiatric patients.”
The practice of community psychiatry,9 almost by definition, is uniquely positioned to break through some of those structural issues. “The community psychiatry approach to treatment is not specific to any race or cultural group – because each person is treated as an individual,” said Stephanie Le Melle, MD, MS, director of public psychiatry education at Columbia University and the New York Psychiatric Institute. “The social determinants of health, culture, and social justice experience of each person is taken into consideration,” said Dr. Le Melle.
“Community psychiatry steps outside of the traditional medical model of symptoms and illness, and focuses on understanding the person’s strengths and goals – and helps them to live their best lives.”
Dr. Le Melle also views diversifying the psychiatric workforce as imperative.
“For many African American, Latinx, and other marginalized populations that have had to deal with systemic and structural racism, discrimination, and historical abuse at the hands of psychiatry, it can be difficult to establish trust,” said Dr. Le Melle. “Therefore, diversity of our workforce and cultural humility are also crucial for engagement.”
The APA’s decision to not go forward with this year’s Institute on Psychiatric Services: The Mental Health Services Conference undermines the group’s credibility on these issues, according to some psychiatrists.
The IPS meeting, founded in 1948, is “where we traditionally teach and present about the social determinants of health and racism,” said Dr. Le Melle. “If the APA is serious about addressing the social determinants of health, bias, and discrimination against marginalized people and cultural humility, it needs to embrace and grow community psychiatry, not cut it.”
When asked about the IPS conference, Dr. Geller said that it has been scheduled for October 2021 in New York City. He also said the decision to skip the 2020 conference was made 2 years ago. The conference’s organizing committee decided to cancel the event when hotel space in the preferred city could not be arranged, Dr. Geller said.
Meanwhile, in a widely circulated letter that was sent to the APA board of trustees on Aug. 7, numerous leaders in psychiatry from across the country are citing steps they say the APA must take from “continuing impacts of structural racism that will greatly harm underserved patients, [minority and underrepresented] (M/UR) psychiatrists, and the APA as a whole.”
One step the leaders asked the APA to take was to hire an independent entity to investigate the organization’s “workplace culture, staff morale, and experiences of staff members and M/UR psychiatrists who support and/or work at the organization or have previously been dismissed or departed.”
Dr. Calhoun said she agrees that an internal examination would be productive.
“I’d like to see multiple people in positions of power (in the APA) in order to forward agendas,” Dr. Calhoun said. “Unless we do, we’ll have no way to achieve the goal of getting rid of structural racism.”
Dr. Calhoun, Dr. Geller, Dr. Brown, Dr. Starks, Dr. Lu, Dr. Ajilore, Dr. Dunlap, and Dr. Le Melle reported no relevant disclosures. Dr. Shim disclosed receiving royalties from American Psychiatric Association Publishing. Dr. Stewart is a coeditor of “Black Mental Health: Patients, Providers, and Systems” (American Psychiatric Association Publishing, 2018).
References
1. Geller J. Psychiatric News. 2020 Jun 23.
2. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. (New York: Doubleday), 2006.
3. ”Stewart brings a robust and eventful presidential year to a close.” Psychiatric News Daily. 2019 May 18.
4. Sabshin M et al. Am J Psychiatry. 1970 Dec;127:6.
5. Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. (Boston: Beacon Press), 2009.
6. U.S. Census Bureau. Population estimates. 2019 Jul 1.
7. Shim RS. “Structural racism is why I’m leaving organized psychiatry. statnews.com. 2020 Jul 1.
8. Jones CP. Ethn Dis;28(Suppl):231-4.
9. Ewalt JR and Ewalt PA. Am J Psychiatry. 2006 Apr 1. doi: 10.1176/ajp.126.1.43.