Amanda Calhoun, MD, recalls noticing a distinct empathy gap while she trained at a youth psychiatric unit.
Courtesy Dr. Amanda Calhoun
“When the staff is not diverse, I really see differential treatment in who gets the benefit of the doubt and their empathy,” said Dr. Amanda Calhoun.
A White male patient hurled the N-word at a Black patient, and the majority White staff did nothing. “And then [they] told me the White patient was struggling and that’s why they allowed it, even though he was aggressive,” said Dr. Calhoun, psychiatry resident at Yale University in New Haven, Conn. But Dr. Calhoun noticed less restraint on the part of her colleagues while she was treating an angry female Black Latinx patient.
“I remember staff saying she was a nightmare; they called her the B-word; she was ‘a terror.’ How is that this patient isn’t viewed as struggling, where the other patient is? I don’t understand the difference here.”
And, Dr. Calhoun said, “when a patient can complain that they feel they were treated differently based on skin color, [the White majority staff] would just say they have borderline personality disorder or they’re depressed.
“When the staff is not diverse, I really see differential treatment in who gets the benefit of the doubt and their empathy.”
Psychiatrists such as Dr. Calhoun can list countless other examples of institutional racism, interpersonal racism, and prejudice in psychiatry. They see signs of institutional racism in clinical care, academia, and in research. Some are questioning the American Psychiatric Association decision to put on hiatus the Institute on Psychiatric Services, its fall annual meeting that has traditionally served as a vehicle for examining the treatment of underserved communities.
Against that backdrop – and after the killing of George Floyd and amid the disproportionate impact of COVID-19 on communities of color – the APA launched an effort the group says is aimed at reforming itself and psychiatry as a whole. In June, the APA announced the formation of the Presidential Task Force to Address Structural Racism Throughout Psychiatry, and the panel – focused on anti-Black racism – has begun its yearlong work.
A specialty with inherent contradictions
Jeffrey Geller, MD, MPH, the APA’s president, acknowledged in an interview that racism in psychiatry is older than the APA – which celebrated its 175th anniversary as an association last year.
Dr. Jeffrey Geller
As Dr. Geller pointed out recently, Benjamin Rush, MD, a founding father of the United States and the father of American psychiatry, was an abolitionist who owned one enslaved man – and thought the intelligence and morality of Black people were equal to that of their White counterparts.1 Dr. Rush also thought the skin color of Black people was a manifestation of a type of leprosy that he called “Negritude.”2 “Rush was a remarkable mix of contradictions,” Dr. Geller wrote.
Altha J. Stewart, MD, the first and only Black president of the APA, declined to be interviewed for this article.
Dr. Altha J. Stewart
But as Dr. Stewart was wrapping up her term as president, she reportedly3 said that a 1970 paper titled “Dimensions of Institutional Racism in Psychiatry” by the late Melvin Sabshin, MD, and associates was essentially a blueprint for moving the specialty forward.
That paper, published in the American Journal of Psychiatry, took psychiatry to task on many levels. One of the barriers that Black psychiatric patients must overcome, according to Dr. Sabshin and associates, is the “biases of the White therapist, who must overcome his cultural blind spots, reactive guilt, and unconscious prejudice.” They called community psychiatry paternalistic. Furthermore, Dr. Sabshin, who would later serve as medical director of the APA for almost 25 years, criticized White mental health professionals for viewing Black communities as “seething cauldrons of psychopathology”:
“They create stereotypes of absent fathers, primitive rage, psychopathy, self-depreciation, promiscuity, deficits in intellectual capacity, and lack of psychological sensitivity,” Dr. Sabshin and his associates wrote. “Gross pathological caricaturization ignores the enormous variation of behavior in black communities. ... The obsession with black psychopathology has been so great that it has retarded serious consideration of racism as it pertains to white psychopathology.”4
In other words, White American psychiatrists adopted the prevailing views of society at large toward Black people. More recently, “there was a period in this country where Black people were thought to be at higher risk of developing issues like schizophrenia5 instead of depression,” said Gregory Scott Brown, MD, of the Center for Green Psychiatry and the University of Texas in Austin.
Courtesy Dr. Gregory Scott Brown
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. Gregory Scott Brown said.
“Pharmaceutical companies developed ads for antipsychotic medications that portrayed angry Black men or women. This got into the heads of who may have been conditioned without knowing it,” he said.
In addition, psychiatry has failed to diversify its ranks. To this day, Dr. Geller said, “Black psychiatrists are underrepresented in academic settings, leadership positions, hospitals, and clinics. Black patients are suffering because of inequities in access to care in treatment, and even those who receive treatment are often misdiagnosed since we don’t account for the extended community’s trauma.” About 2% of U.S. psychiatrists are Black, and Black people make up 13% of the U.S. population.6
The low percentage of Black psychiatrists hurts the field for many reasons, said task force member Steven Starks, MD, clinical assistant professor of psychiatry at the University of Houston, and not solely because the gap forces many Black patients to be treated by non-Black psychiatrists. “The association has a large, broad impact on our field and profession through the DSM, and work in areas like government relations and access to care and insurance,” Dr. Starks said.