In retrospect, the coronavirus pandemic should have been seen as a tip-off that overt racism was rising once again in the United States and in healthcare. It wasn’t just that African-Americans were dying at rates well above their percentage where they lived; it was a failure to proactively recognize the potential for that to happen and thereby establish measures to reduce the associated risks of being poor, living in crowded conditions, being overrepresented in frontline service workers, having other medical illnesses, and having inadequate access to medical resources.
Moreover, as time has gone on, it is clear that the pandemic has been putting people on emotional edge with its uncertainty and our tendency to scapegoat others for such problems. After a period of mass cooperation with stay-at-home guidelines, that broke down.
Perhaps these conditions help explain why the particular example of police brutality in killing an African-American male, George Floyd, spilled over with protests, riots and looting, when other similar tragedies in recent years did not. The terrible complication is that such large gatherings, with close contact of people, are a setup for increased transmission of the virus.
What is our role in mental healthcare in this ongoing and unprecedented crisis? Historically, we have been concerned and been helpful, but with a ways to go. Way back in slavery times, physicians used the diagnosis of drapetomania, or “flight from home madness,” to explain a runaway slave who was caught but not killed. At the start of my medical career 50 years ago, African-American males were being overly diagnosed as having paranoid schizophrenia, receiving more inpatient care when outpatient would have sufficed, and medicated when psychotherapy would be likely to help.
Around 1980, an African-American male psychiatric resident in training and I developed the first model curricula in cultural psychiatry. That model has held up well, though there have been local variations along the way. The time-tested key aspects seem to include:
- Having a multicultural faculty, which could necessitate bringing in a guest faculty member from elsewhere if not available locally
- Examining one’s own cultural identity and sharing that discussion in the educational group
- Having each student pick a cultural group to discuss in detail how the group’s particular values are reflected in seeking care, trusting of the clinic and treatment expectations, including an illustrative patient example
- Inviting citizen guests of various cultures to share their lived experiences
- Recognizing basic principles of cultural competence that developed over time since 1980, including cultural humility, respect, compassion and curiosity
- Spreading these seminars over each year of training and also trying to have the topic integrated a bit into other seminar topics like psychotherapy
This focus on cultural aspects of psychiatry seemed to provide a message that psychiatry desired to have more psychiatrists of diverse cultural background, which led to a significant increase in African-American psychiatrists and other mental healthcare professionals. However, even now there are disparities, the most obvious one being the undertreatment of major depression in African-American males, as well as the misdiagnosis of sociopathic personality disorder in prisons when PTSD was more accurate. Trust of our systems is crucial for care.
There have been attempts in the past to include racism as an official DSM-5 diagnosis. Those attempts, however, have been turned down. Reasons included the argument that most everyone had some degree of racism and uncertainty over where to draw the line. Should that be approached once again? I would think so. If not, perhaps we should look into a classification of social diseases that might include racism, Anti-Semitism, Islamophobia, ageism and burnout. In the International Classification of Diseases (ICD-10), which is the parent classification of the American Diagnostic and Statistical Manual (DSM), there are Z codes, which are for the social determinants of health. Clearly, the code Z60, “Problems related to social environment,” connects to racism. Unfortunately, research indicates the social codes are rarely used, especially in the United States.
With everything that we have done to try to reduce racism, is there anything more specific that we might try now? I think there is. Here are some recommendations to consider:
- Come to a consensus on terminology. The most common terms where racism is involved seem to be African-Americans, Black Americans and people of color. Because naming and terminology have psychological impact, perhaps some ongoing discussion needs to take place on what terminology may be reinforcing racism or helping to reduce it.
- Have a town hall meeting on racism. Perhaps that sounds too risky in this time of protests getting out of hand, but when things settle down, consider a town hall under the auspices of mental healthcare in order to receive ideas from the public about what to do better.
- Examine our own systems for internal racism. Structural racism can exist in the composition of staff, how patients of diverse cultures are welcomed or not, and comparing outcomes of care across cultures.
- Continuing education on cultural competence. By now, many basic principles of how to become culturally competent are available as discussed above, but because there is significant diversity in education and since cultural concerns can change, cultural psychiatry needs to be a required topic in continuing education.
- Celebrate cultural diversity. Have celebrations of festivals and holidays of diverse cultures. Have intermittent staff potluck meals of food of different ethnic groups as potluck nourishing meals may be a better metaphor than the melting pot.
- Expand the concern on racism. Be cognizant that other minority groups are also scapegoated and victimized based on factors including ethnicity, religion and sexual orientation.
- Be on the lookout and prepared for increased PTSD in the future. Given the widespread direct and indirect trauma from micro and major aggressions suffered by so many people, including the secondary trauma just from watching the news, PTSD is likely to increase over time because its expression is often delayed.
There may be other ways for us to help reduce racism. Maybe you are already trying some of them. If so, let us know.