Psychiatry Confronts Its Racist Past, and Tries to Make Amends

Dr. Benjamin Rush, the 18th-century doctor often referred to as the “father” of American psychiatry, was a racist believer that black skin is the result of a mild form of leprosy. He called the condition “Negritude”.

His former apprentice, Dr. Samuel Cartwright, spread the lie throughout Antebellum South that enslaved people who had an unrelenting desire to be free suffered from a mental illness he called “drapetomania,” or “the disease that made negroes run away. ”

In the late 20th century, psychiatry became a receptive audience for drug manufacturers willing to capitalize on racial fears of urban crime and social unrest. (“Attacking and warlike?”, Read an advertisement with a black man with a raised fist, which appeared in the “Archive for General Psychiatry” in 1974. “The collaboration often begins with Haldol.”)

Now the American Psychiatric Association, which carried Rush’s picture on their logo until 2015, is confronting this painful story and trying to make amends for it.

In January, the 176-year-old group apologized for the first time for their racist past. The Board of Directors recognized the “horrific acts of the past” on the part of the profession and committed the association to “identify, understand and correct our injustices in the past” and promised to introduce “anti-racist practices” to address the inequalities of the past quit in nursing, research, education, and leadership.

This weekend the APA is dedicating its annual meeting to the topic of justice. During the three-day virtual meeting of up to 10,000 participants, the group will present the results of their years of efforts to educate their 37,000 mostly white members about the psychologically toxic effects of racism both in their work and in the lives of their patients.

Dr. Jeffrey Geller, the outgoing president of the APA, made these efforts the signature project of his year-long tenure.

“This is really historic,” he said in a recent interview. “We have laid the foundation for long-term efforts and long-term change.”

Dr. Cheryl Wills, a psychiatrist who led a research group that looked at structural racism in psychiatry, said the group’s work could make for a new generation of black psychiatrists who have a much greater chance of knowing they are valued , entering the profession, proving and seen as life changing. She remembered the isolation she experienced in her early years in medicine and the difficulty of finding other black psychiatrists to refer patients to.

“It’s a once in a lifetime opportunity,” she said. “In psychiatry, like in any other profession, she has to start at the top,” she said of her hope for change. “Check out our own garden before we can look elsewhere.”

For critics, however, the APA’s apology and task force is a long overdue but still inadequate attempt to catch up. They point out that in 2008 the American Medical Association apologized for its more than 100-year history of “actively reinforcing or passively accepted racial inequalities and the exclusion of African American doctors.”

“You are taking these tiny, superficial, and palatable steps,” said Dr. Danielle Hairston, a member of the task force who also serves as president of the APA’s Black Caucus and director of psychiatry at Howard University College of Medicine.

“People will be fine to say we need more mentors. People will be fine to say we are going to do these town halls, ”she continued. “This is a first step, but in terms of the real work, the APA still has a long way to go.”

The question for the organization – with its levels of bureaucracy, diverse constituencies and strong institutional tradition – is how to get there.

Critics working both inside and outside the APA say it still has high hurdles to overcome to truly address its racial equity issues – including its diagnostic biases, ongoing shortage of black psychiatrists, and a payment structure that tends to exclude people who cannot afford to pay for services out of pocket.

“All of these procedural structures in place help maintain the system and keep the system the way it is supposed to work,” said Dr. Ruth Shim, director of cultural psychiatry and professor of clinical psychiatry at the University of California Davis, who left the APA in frustration last summer.

They all add up to an “existential crisis in psychiatry”.

White psychiatrists have pathologized black behavior for hundreds of years, wrapping racial beliefs in the cloak of scientific certainty and even big data. According to Dr. Geller, who published a report on the history of structural racism in psychiatry last summer, first referred to the APA as the Association of Medical Superintendents of American Institutions for the Insane. The group came into being after the 1840 census, which included a new demographic category: “Insane and Idiotic”.

The results have been interpreted by slave-friendly politicians and sympathetic social scientists to find a significantly higher rate of mental illness among blacks in northern states than in those in the south.

In the decades following the reconstruction, prominent psychiatrists used words like “primitive” and “savage” to make the cruel racist claim that black Americans were unsuitable for the challenges of life as independent, fully disenfranchised citizens.

TO Powell, superintendent of the notorious state madhouse in Milledgeville, Georgia, and president of the American Medico-Psychological Association (the forerunner of the APA), went so far as to outrageously declare in 1897 that “before the Civil War” there were comparatively few negro madmen. After their sudden emancipation, their number of madmen began to multiply. “

Psychiatry continued to pathologize – and sometimes demonize – African Americans, with the result that by the 1970s the diagnosis of psychosis was so often made that the profession essentially “turned schizophrenia into a black aggression and agitation disorder.” said Dr. Hairston, an author of the 2019 book, Racism and Psychiatry.

Since then, numerous studies have shown that the misalignment of an almost exclusively white profession with black expressions of emotions – and the frequent amalgamation of distress and anger – has led to an underdiagnosis and overconfidence in major depression, particularly in black men Use of antipsychotics. Black patients are less likely than white patients to receive appropriate medication for their depression, according to a report published in Psychiatric Services in 2008.

To change course and better serve black patients, organized psychiatry must give higher priority to training doctors to truly listen, said Dr. Dionne Hart, Minneapolis-based psychiatrist and addiction medicine specialist and assistant professor of psychiatry at the Mayo Clinic College of Medicine and Science.

“We checked many boxes publicly,” she said in an interview. “Now we have to do the work. We need to show that we are committed to undoing the damage and working with all of our colleagues from across the country to identify trauma and recognize trauma where it exists and treat people appropriately. “

Psychiatrists are liberal and many say that people with mental illness are a marginalized and underserved group. In 1973, the APA made history by removing “homosexuality” as a psychiatric diagnosis from the second edition of its Diagnostic and Statistical Manual for Mental Disorders. But the kind of soul searching that went around that decision took much longer with the breed.

Psychiatry remains a strikingly white field to this day, with only 10.4 percent of practitioners from historically underrepresented minorities. According to a 2020 study published in Academic Psychiatry, they now make up almost 33 percent of the US population. This study found that 2013 were black Americans only 4.4 percent of practicing psychiatrists.

The history of the discipline of pathologizing black people – “viewing black communities as seething cauldrons of psychopathology,” as three reformist authors put it in the American Journal of Psychiatry in 1970 – has deterred some black medical students from entering the profession.

“Some people in my family won’t say I’m a psychiatrist even now,” noted Dr. Hairston. “A family member told me on my game day that she was disappointed that I had adjusted to psychiatry rather than some other specialty – it seemed like I was abandoning the family.”

The difficulty of finding a black psychiatrist can affect black patients’ willingness to seek treatment. And psychiatric help is conspicuously inaccessible even to patients without money.

Psychiatry is an outlier among other medical specialties for the extent to which its practitioners choose not to participate in public or private health insurance programs.

In 2019, a study by the Medicaid and CHIP Payments and Access Commission found that psychiatrists were the least likely to accept health insurers: only 62 percent accepted new patients with commercial plans or Medicare, while they were even more anemic, while 36 percent took new patients with Medicaid on. In contrast, 90 percent of all providers said they would accept new patients with private insurance, 85 percent said they would accept those with Medicare, and 71 percent were willing to see Medicaid patients.

Many psychiatrists say they don’t have health insurance because the reimbursement rates are too low. A 2019 study found that reimbursement rates for general practitioners nationwide were nearly 24 percent higher than for psychiatrists – including psychiatrists. In 11 states this gap widened to more than 50 percent.

The APA’s advocacy in this particular area of ​​justice has focused on promoting full insurers’ compliance with the Mental Insurance Equality and Addiction Act, a 2008 law that mandates health insurance plans that provide mental health coverage At a comparable level they provide physical health care.

While the profession hopes for higher reimbursement rates, the short-term gap that affects patients is unequal access to treatment. “What has always bothered me most about the practice of psychiatry is that you can talk about your commitment to things like justice. However, when you have a system where many people do not have access, so many patients are cut off from access to quality care, ”said Dr. Damon Tweedy, Duke University Associate Professor of Psychiatry and Behavioral Sciences and author of “Black Man in a White Coat: A Physician’s Considerations on Race and Medicine.”

“What are our values?” said Dr. Tweedy seeing patients in the Durham Veterans Affairs Health Care System. “We could say one thing, but our actions suggest another.”

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