is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

Andy McLean, MD, MPH

If anyone thought that trauma was settling down in the Middle East and the US, this weekend belied that assumption. Though these events otherwise seem separate and are of great social psychiatric concern in their own right, all occurring over the weekend may be more than coincidence. They are:

-After a year of relative “quiet,” rockets were launched from Israel to the Gaza Strip and from the Gaza Strip to Israel.

-The fourth Muslin man to be ambushed and killed in Albuquerque over the past 9 months occurred on Friday.

-Saturday night and Sunday was the Jewish commemoration of Tisha b’Av, an annual fast and study day related to several disasters in Jewish history.

-Saturday August 6th was “Hiroshima Day,” the day in 1945 when the first atomic bomb was dropped on Hiroshima.

In canvassing the members of SPIRIT, who have previously written about such traumas for 

™, there was a great diversity of opinion about whether it was the right time to respond, and what could we say of value, yet still be respectful of the mourning associated with these tragedies.

Then there are also the silent international traumas, such as in Lebanon. Two of our members recently visited Lebanon. Plagued with hunger and a lack of social services, they reported a sense of powerlessness, helplessness, resignation, and psychotic-like “zombies” walking the streets there. It seems that we in psychiatry have to avoid feelings of learned helplessness in reacting to these traumas.

Although hundreds of women dressed in white with their mouths taped shut marched in protest in downtown Chicago on Sunday, the invasion of Ukraine continues, with less attention by the media, psychiatry, and public.

Of course, the powers in the situation are beyond formal mental health, including the survival of countries and people. Oil money and politics are a major influence.

Nevertheless, we in psychiatry know how to sit, listen, and help address the harm we humans do to one another. Our trauma stories can be the source of wisdom, resilience, growth, and transformation. Our children and the continued intergenerational transmission of trauma is at stake. Trauma to children, regardless of whoever is responsible, is a psychiatric and global mental health issue.

We hope to make further comments in the near future and are always available to help and contribute our knowledge. In the meanwhile, we bear witness to these psychiatric tragedies of war and other violence.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

 is a practicing psychiatrist with Providence Healthcare System in Portland, Oregon. He is the author of 

The Wounded Healer: The Pain and Joy of Caregiving

is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences. 

 is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom. 

 serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is a clinical social worker, a visual storyteller, and a creativity consultant.

Articles

All these events that occurred over the weekend bear social psychiatric weight. 

SPIRIT (Social Psychiatry Interested in Recovery from International Trauma) Voices Some Current Concerns

The idea for this poem came as I had been giving yet another talk on pandemic resilience to my physician colleagues of various specialties. A recommendation in disaster mental health is to try to find meaning in challenges; however, everyone (including myself) seemed to feel beaten down at that point in time. My read on it was, “let somebody else sort out the self-actualization stuff; we just need a break.”

I have no plans to search for meaning in this trauma;

The tiers of Maslow’s hierarchy have crumbled down upon me

Let someone else sift for fortune or detritus among the remnants.

is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences.

Pandemic Resilience? Remnants

“We usually think of what hate does for the individual hated or the individuals hated or the groups hated. But it is even more tragic; it is even more ruinous and injurious to the individual who hates.” -Martin Luther King, Jr.

On Saturday, January 15, 2022, according to the January 16th 

I am grateful to be alive,’ says Colleyville rabbi Charlie Cytron-Walker,

” and consistent with the core principle of Judaism to welcome the stranger, a man was let into Congregation Beth Israel synagogue by the Rabbi when he knocked and asked if the synagogue was a shelter.

 As Shabbat prayer continued, the man clicked a gun, and then held the Rabbi and 3 other Jewish individuals hostage, even as he praised the Rabbi on the live-streamed audio of the service, saying “I bonded with him. I really like him.” The man also said that he himself was going to die, and he did. The additional terrible irony is that Rabbi Charlie Cytron-Walker and his wife are pillars in the area for interfaith dialogue.

As the crisis continued, the suspect was identified as a Muslim. He is a British citizen who immigrated to the United States not long ago. During the hostage situation, he was described as “extremely distressed” and making “political” demands. As information emerges after the event, it seems that he might have chosen this Jewish organization because it was close to a federal prison where he wanted a prisoner freed. This prisoner was convicted of trying to kill US Army officers in 

 and conveyed anti-Semitic sentiment during the ensuing stand-off. The standoff lasted almost 12 hours, and with the active-threat training that the hostages had for such a situation, their maneuvers to flee, and the patience of law enforcement, the hostages fortunately escaped. Given our concern with 

, how the suspect got his gun needs clarification.

The Council on the American Islamic Relations (CAIR), the largest Muslim advocacy group in the United States, condemned the incident as an act of hate: “This latest Anti-Semitic attack at a house of worship is an unacceptable act of evil. We stand in solidarity with the Jewish community. No cause can justify or excuse this crime.”

Omar Suleiman, PhD, a highly respected Dallas-based Imam, also strongly condemned the attack: “…we will be there for our Jewish neighbors as they recover. The perpetrator cannot claim to have acted for any noble cause. He held a beloved faith leader to our community and his congregants hostage with no regard. And those that will use this to stoke the flames of hatred and division will fail as he did, God willing.”

Internationally, similar attacks on houses of worship targeting Muslims, like what happened at the Al Noor and Linwood mosques in Christchurch, New Zealand, on Friday, March 15, 2019; or Christians, like on the International Pentecostal Holiness Church headquarters in Zuurbekom, South Africa on Saturday, July 11, 2020; or the gurdwara Sikh Temple in Oak Creek, Wisconsin, on Sunday, August 5, 2012—all are acts whose apparent aim is to foment social and individual hate, but may also be acts committed by persons who need psychiatric care.

Connected religiously and psychologically to this event, the Jewish Tree of Life synagogue in Pittsburgh also had disastrous loss of member lives on October 27, 2018. This current incident is also liable to be a trigger for that past trauma. So said their Rabbi, Jeffrey Myers, who, in various media interviews after the hostage crisis, also maintained getting mentally stronger through vision of purpose over millennia, combined with ripples of support.

In the United States, as well as the United Kingdom, we are in a time of great conflict and divisiveness that compromises the safety of citizens. Due to projected scapegoating, those who are different usually bear the highest risk of harm.

, an international alliance of social psychiatrists and other mental health professionals of various faiths who have previously written about other conflicts in the Middle East and Afghanistan for 

. Some of the members of this alliance have also edited and written chapters for 3 books published by Springer International over the last 2 years: 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

. SPIRIT welcomes new members interested in helping our cause.

In our mission, we have a moral, ethical, and clinical responsibility to support the survivors and tend to their visible and invisible wounds, as well as to address the ripple repercussions of the traumas as they spread out from the epicenter into society. Although there is interfaith progress, there is still entrenched cross-cultural hate. We try to research the root causes of these harmful and all too common phenomena. Though it is unlikely that psychiatry can often predict something like this by a given individual, we still might find ways to be proactive rather than reactive, try prevention rather than intervention, and instigate systemic change of the adverse social determinants of such mental problems. Psychological autopsies of perpetrators can provide valuable clues to their personal backgrounds, 

, psychological conflicts, and motives. In the case of the Congregation Beth Israel hostage situation, the perpetrator’s brother has already said he had “mental health issues.”

 and mental illness are often a volatile mix. Similarly, security reviews of what happened will hopefully provide increasingly safer guidelines for the future.

We must also reinforce the psychologically beneficial messages embedded in our current holidays. In an unusual confluence, January 17 this year includes the annual Martin Luther King Jr. Day, the Jewish Tu B’Shivat celebration of environmental sustainability, and the inaugural Muhammed Ali’s Day in Illinois celebrating peace. Together, they point the way to social and environmental justice. In the meanwhile, safety and security must be paramount at vulnerable social and political targets, including the current possibility of copy-cat attacks of faith-based communities.

But first and foremost, we must be part of the solution by refusing to be taken hostage to hate.

is a practicing psychiatrist, Providence Healthcare System, Portland,

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is an associate professor of psychiatry at Harvard Medical School and a fellowship site director for Brigham and Women's Hospital. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom.

is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

 is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences.

 is professor emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. 

 is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel. 

 is professor emeritus in psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

 is interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a fulltime research appointment as a visiting researcher at Harvard University in Cambridge, Boston.

 is medical director of the Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

1. 'I am grateful to be alive,' says Colleyville rabbi Charlie Cytron-Walker. 

. January 16, 2022. Accessed January 17, 2022. 

https://www.jpost.com/diaspora/article-692639

2. Council on the American Islamic Relations. CAIR condemns hostage-taking at Texas synagogue, working with local community leaders to learn more and provide assistance. January 15, 2022. Accessed January 17, 2022. 

https://www.cair.com/press_releases/breaking-cair-condemns-hostage-taking-at-texas-synagogue-working-with-local-community-leaders-to-learn-more-and-provide-assistance/

3. Omar Suleiman page. January 15, 2022. Accessed January 17, 2022. 

https://www.facebook.com/imamomarsuleiman

4. Gill D. Synagogue hostage-taker had ‘mental health issues,’ brother says. Daily Beast. January 16, 2022. Accessed January 17, 2022. 

https://www.thedailybeast.com/fbi-identifies-synagogue-hostage-taker-as-british-national-malik-faisal-akram

The recent hostage situation at a synagogue in Texas in indicative of a larger underlying problem. 

We Refuse to Hate

Our national attention has turned to Afghanistan, as the media shares disturbing pictures as news unfolds. Meanwhile, we in psychiatry hear related testimony from patients and colleagues, and are concerned that the withdrawal of US troops may lead to escalating mental health problems locally as well as internationally.

A recent encounter with an Afghan patient embodied the concern and brought the issue to the forefront of consciousness. The patient, who came to America years ago on a special visa based on his work with the US Army, presented with severe symptoms of posttraumatic stress disorder (PTSD). The PTSD was reactivated because of the unfortunate developments in Afghanistan.

I joined the war to act like a buffer. I wanted to protect my people, and also to serve America, the country I love and now call home. That backfired. Despite my best efforts, many people died because of wrong intelligence. Information I gave was ignored or misused. I am now left with the memories, the flashbacks, and the nightmares. How can I undo the damage I caused? I wanted to build schools, so the Afghan children might have a better future. But would God forgive me for taking part in killing?

The patient, wrestling with existential issues and navigating through many layers of shame, guilt, and taboo, was comforted by having a Muslim psychiatrist who shared his religion and aspects of culture. In turn, the cultural and religious understanding helped to create a safe therapeutic space and a sounding board for this patient in his search of meaning and healing.

We have also heard from a Jewish psychiatrist colleague, who entered the US Army as a psychiatrist in 1975, just as the Vietnam war was ending. He saw soldiers who developed unexpected symptoms after serving in Vietnam. Although PTSD as a formal diagnosis was relatively unknown at the time, Vietnam was an impetus to its deeper understanding. Upon arriving at his base in Alabama, a General told him and his physician colleagues that they needed to learn about soldiers because there would be another war in our lifetime.

Nobody could have known that the war in Afghanistan would be the longest war in American history, or that we would again abandon our allies when we left the country. However, despite all the comparisons being made with Vietnam, there is at least 1 big difference: The public has seemed relatively unconcerned with this war compared with the Vietnam war. Nevertheless, this clinician predicted a disaster when a specific Afghanistan withdrawal date was made public, (since it gave the Taliban a clear timetable to prepare for) and now is troubled by the escalating deaths, trauma, and losses, especially among families, women, and children.

Another colleague is a Muslim psychiatrist who wears a hijab. She took care of military veterans during her psychiatric residency training. Almost all of the veterans were being treated for PTSD stemming from the trauma they witnessed in the Iraq and Afghanistan wars(Operation Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF)). [Often her presence, even as a care provider, was a trigger for them. Frequently the veterans would refuse to see her at the outset of their hospitalization because, as one patient put it, “24 hours before I came back home, I killed a woman who looks like you . . . how am I expected to flip the switch and work with you?”

In time, these reactions changed. In fact, over the course of the treatment program, many veterans reported that being treated by someone who looked like the individuals they were trained to fear and distrust was an important part of their healing. There were even some who, by the end of the treatment program, refused to work with anyone but her, reporting that it changed their views of Muslim and Middle Eastern individuals.

This experience reflects many layers of complexity. Veterans following orders experienced trauma and came home with severe PTSD, making it very difficult to return to a multicultural society. Clinicians have an ethical duty to do no harm, yet many Muslim clinicians understandably feel complex emotions when treating those who took the lives of their brethren. Most importantly, the moderate Muslims may be battling for their safety on 2 fronts: there may be forces from within as well as forces thrust upon them, both ultimately contributing to their ongoing intergenerational trauma.

The current trauma can only add to the intergenerational trauma in Afghanistan. Whether or not pulling the armed forces from Afghanistan is the right decision, it seems like better plans could have been made to protect those at risk. It is reminiscent of our ethical principle of not abandoning patients. If a transfer is needed, we cannot drop a patient until a new psychiatrist is involved. Moreover, when we terminate our therapeutic alliance with a patient, we try to do that slowly, reassessing how well that is going along the way. It would be flaunting medical ethics to arbitrarily pick a date just around the corner and abruptly leave.

Psychiatrists must decide whether or not to stand up and speak out against injustice. It may be a professional obligation, in line with the ethical principles of the American Medical Association, American Psychiatric Association, and World Psychiatric Association. These principles put patient needs first, but also include the ethical needs of society.

“A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health,” the APA’s adaptation adds “Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness.”

This annotation covers our potential obligations to those at risk in Afghanistan. What can we say or, more importantly, what can we do to help them? As far as patient care goes, our troops will need special attention. How those who served feel about the sudden withdrawal may be crucial for how they process the trauma they encountered, especially from a moral injury point of view. Will they feel that their time and participation was wasted? Likewise, will this withdrawal be a trigger for troops who served in Vietnam and were traumatized and criticized for their participation?

In addition, potential patients are likely to come from those in Afghanistan who worked with the United States. If they stay alive and stay there, or become refugees, they are at risk for the repercussions of trauma, betrayal, and loss. Women and children seem to be a target of potential repression and abuse.

The World Psychiatric Association approved their first Code of Ethics for Psychiatry in October 2020, after 10 years of deliberation. That must reflect how difficult it is to come to a consensus on health and mental health values and virtues of various countries and cultures. Yet it has principles that seems relevant to Afghanistan

Psychiatrists advocate in particular for support for mental health programs, especially in but not limited to developing countries and in areas where care for persons with psychiatric disorders is non-existent or rudimentary…

Psychiatrists are aware of the deleterious consequences of family violence, emotional and sexual abuse on mental health and well-being, especially for women and children . . .

There is also another relevant professional ethical set of principles for physicians, those of bioethics, which focus on 4 main principles in individual patient care: beneficence, nonmaleficence, justice, and autonomy. However, when we speak of population health, we must insert 

 before beneficence, nonmaleficence, and justice. Social justice is population health. Social justice movements may come from outside the traditional lines of institutional power, such as Dorothy Day and the Catholic Worker Movement. Thus, although psychiatrists have their own institutional ethics, they must attend to outsiders’ voices, which may offer special guidance.

We must look inward. Have we, as the United States, had an arrogant attitude in our dealings with the rest of the world? Have we acted like we had the power to bend anyone, anywhere to our will? America is not alone in its hubris. Other nations such as the United Kingdom, for instance, played a significant role in military operations in Afghanistan and must accept some responsibility for the chaos that is rapidly unfolding.

This is not a new issue for our country and, therefore, not a specific criticism of any political administration. Instead, perhaps it is a reflection of a deeper psychological problem. This episode is reminiscent both of our withdrawal from Vietnam and our disengagement from Iraq in 2011. It is as if after we are humiliated by not winning a war, we have something to prove, and so we end up doing the same thing again.

This is very similar to a strategy that traumatized individuals often use: recreating the same traumatizing situation over and over in order to master it. Just as a traumatized individual might tend to do, sometimes impulsively and sometimes intentionally, the United States has jumped into situations we did not fully understand, leading to armed civil conflicts around the globe. Although we continue to be a world power, trust in us and our reputation may be deteriorating. Of course, in Afghanistan, we also cannot ignore that continuous wars, conflicts, and humanitarian crises have been ongoing since the Soviet invasion in 1979.

Some could argue that our intentions have always been good, that we intended to help the oppressed, to prevent bloodshed, and to democratize the world. But much of the world does not want to be democratized. Starting with Vietnam and ending with Iraq and Afghanistan (not to mention the many countries left in shambles in the aftermath of the Arab Spring and similar movements), we seem to leave behind wreckage and chaos, lots of civilian casualties, unfinished business, and collateral damage.

Reflecting on the speed with which Afghanistan has fallen, we feel overwhelmed by unfathomable human suffering and the amount of hurt we inflict on each other. Yet we can also choose to be part of the solution through healing activities. Just as our country is trying to reckon with the meaning of the death of George Floyd, we must search for actionable social justice in the midst of this tragedy.

What can be done? Individual mental health professionals can write to politicians and the public. They can raise awareness about the far-reaching effects of trauma and inform the public about the gravity of the situation in Afghanistan, which seems to be heading toward a humanitarian and refugee crisis. They can advocate for as many urgent evacuations of Americans, Coalition Forces, Afghan allies, and vulnerable women and children, as is practically possible. We can also collectively act in ways that engage, rather than shy away from, the silent pandemic of human cruelty. Perhaps the World Psychiatric Association can develop a rapid response team, a United Psychiatrists like the United Nations, to employ when international mental health is at risk. Similarly, perhaps a whole-world approach can bring in NATO and other countries, including China, Russia, and other Muslim countries.

Those who work in the military and the VA should be prepared for the troops’ reactions and be ready to provide education and care. We might anticipate and prepare for a rise in Islamophobia as the country goes through a restless stage of uncertainty and searches for someone to blame. All of these measures would be enhanced by harnessing the power of storytelling and social media to raise awareness about how important psychiatric care really is.

Besides these opportunities, the United States needs some longer-term psychological soul-searching, perhaps via a special Task Force called Operation Mental Freedom (OMF), to break the cycle of these failed invasions. Psychiatrists knowledgeable about intergenerational trauma and cross-cultural relationships are available to help.

Although the US government decides to withdraw from an issue by simply pulling our forces out of a country, it is not an easy task for mental health care professionals to withdraw emotionally and ethically. We are healers, and human suffering touches our very deep core. Thus, we must act accordingly.

–SPIRIT (Social Psychiatrists Interested in Recovery from International Trauma)

The multicultural group SPIRIT was assembled in May 2021 to publish the article “

An Interfaith Psychiatrist Prescription for Middle East Peace

. SPIRIT’s first piece was inspired by the collective concern about the escalating Palestinian-Israeli conflict.

is a practicing psychiatrist for Providence Healthcare System, Portland, Oregon. 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of 

is Professor Emeritus in Psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books. 

is Professor Emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

 serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is Chairman of the Board of Trustees of the Cobb Research Institute and is the 113th Present of the National Medical Association. 

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware. 

is Assistant Professor of Clinical Psychiatry, Columbia University; and Research Psychiatrist, New York State Psychiatric Institute, New York, NY. 

is a Clinical Associate Professor of psychiatry at the Stanford University School of Medicine where she is the Director of the Stanford Muslim Mental Health & Islamic Psychology Lab, and the Director of its community organization: Maristan.org. She also serves as the Associate Division Chief for Public Mental Health and Population Sciences as well as the Section Chief of Diversity and Cultural Mental Health in the Department of Psychiatry and Stanford. 

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences. 

is a Professor of Psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on International Medical graduates, culture, religion, family psychiatry, gender issues, etc.

is an associate professor of psychiatry at Harvard Medical School and a Fellowship Site Director for Brigham and Women's Hospital. 

is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the UK.

The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry. 

American Psychiatric Association. The American Psychiatric Association Press; 2013.

2. Code of ethics for psychiatry. World Psychiatric Association. October 2020. Accessed August 17, 2021. 

What can psychiatrists do to help veterans, Muslims, immigrants, refugees, and all those affected by the US withdrawal?

Psychiatrists Concerned With the Afghanistan Situation: Ethical and Practical Issues

“Reparations fundamentally is not about money—

; reparations are closely linked to mental health status, psychological well-being, and behavior.”

—Bertha Holliday, PhD, and Alberto Figueroa-Garcia, MD

 are difficult, the particular topic of reparations is difficult in the extreme. Some of the difficulty lies in how reparations are defined. The Oxford English Dictionary, for example, defines the term as “the making of amends for a wrong one has done, by paying money to or otherwise helping those who have been wronged.” In other words, how much money is enough, and what else can help?

For instance, as an “otherwise” form of help, does affirmative action qualify as reparations? 

 has been used for the past half century to encourage the success of African Americans in particular.

 It is a political policy designed to make amends for their underrepresentation in workplaces, contracts, and education admissions.

 Over the years, affirmative action expanded to cover many kinds of differences in a commitment to diversity. That diversity could include severely ill psychiatric patients who encountered stigma and other obstacles to recovery. The policy has also 

 However, it is currently of concern for its use as a means of discriminating against Asian American college applicants. Along with the dramatic success of Asian Americans in admission to and performance in college, a form of 

, such as the claim that Harvard has recently been manipulating their admissions process against Asian Americans.

On June 17, 2021, President Biden signed the Juneteenth National Independence Day Act into law, making June 19th a federal holiday commemorating emancipation. Of course, it does not contain any particular financial reparations, but it may provide a measure of moral and psychological reparations. It will update our Declaration of Independence, commemorated on July 4th, because that declaration was not fully inclusive of African Americans or women. Nationally celebrating July 4th alone may be an example of unintentional hidden structural racism; Juneteenth can chip away at that. What a formal societal step forward this is from June 19, 1865, when General Granger arrived in Galveston to notify slaves that the Civil War was over and that they were free—of course, this came more than 2 years after President Abraham Lincoln signed the Emancipation Proclamation.

From the psychiatric perspective, making amends would refer to supporting the mental health of the victims in any way possible, including the provision of physical and mental health care. Health, education, and child development services would therefore need improvement. Moreover, making amends seems to overlap or follow forgiveness, a psychological process that can help both the perpetrator and the victim. A clear example of that might be the man-made traumas of posttraumatic stress disorder, for which the perpetrator(s) made enough amends to help the victim, say, in a sexual abuse case, and the victim conveyed some forgiveness.

In the United States, the societal discussion about reparations seems rightly 

. However, as with affirmative action, it can pertain to other races, cultural groups, or populations across the globe. In the United States, there are groups that could convincingly claim they have been historically wronged by our government, including 

, who have been wronged since the arrival of Europeans, as well as Japanese Americans, who were interned during World War II. 

, who were not properly treated in the latter half of the 1800s, and Jews, many of whom were denied entry during the Holocaust, might also have a case. Not only have these groups suffered historical wrongs, they are still experiencing wrongs, as conveyed in the current discrimination that African Americans, Native Americans, Asian Americans, and Jewish Americans face. Resistance to reparations is common and may reflect the reluctance to accept practical responsibility for something in the past, as well as to avoid feeling worthy of blame and shame.

It seems psychiatry rarely addresses reparations. In fact, it was not mentioned in the recent apology for racism actions offered by the American Psychiatric Association. However, the psychoanalyst Melanie Klein mentioned reparations about a century ago, describing it as instrumental to the early developmental process.

 Infants could even unwittingly provide psychological reparations to the mother when they soften their inevitable angry outbursts with ensuing smiles of satisfaction.

 By extrapolation, reparations can be applied in later life from small gestures up to systematic amends.

This article will try to make amends for the psychiatric neglect, lack of education, and limited activism on racism and its danger to public mental health.

 It is also an actionable one-year follow-up to Psychiatric Times

African American Reparations - Rahn Bailey, MD

Reparations for the damage of slavery began at the end of the Civil War in 1865 with General William Tecumseh Sherman’s order to redistribute acres of land—known as the mythical 40 acres and a mule—to newly freed African American families. However, President Andrew Johnson overturned this order. Nothing more happened for 100 years. Recent efforts have been stopped and started, and have often been polarizing. Although our country’s founding principles of equality, opportunity, and freedom have been eloquently promulgated, they are applied in a markedly different way for people,

More than 4 centuries of harm has resulted in structural racism, institutional racism in organizations, and conscious or unconscious individual 

. With intergenerational transmission of trauma, fueled by epigenetic vulnerability and recurrent triggers of historical and current trauma, the collective and individual psychiatric damage must be significant.

wide divide between White and African Americans

 in terms of health, success, and prosperity.

 A small number of African Americans have achieved great success in the United States, mostly in the public eye of entertainment, sports, and government (eg, President Barack Obama). This fact has often been used as a counterargument to the disparities. Of course, these successes are the exception, not the rule.

The financial aspect of reparations tends to be the most controversial. Some scholars have devised a figure for the current descendants of slavery and ensuing discrimination. One example is the 1973 rough price tag, which was determined by multiplying the number of African Americans in the population by the difference in White and Black per capita income.

 However, reparations do not solely, or mainly, need to be in the form of monetary compensations.

A variation on financial reparations has emerged in Evanston, Illinois––the first city in the United States to 

 The plan is to use tax money from recreational marijuana sales to award $25,000 for home repairs, down payments on property, and interest or late penalties on property in the city. Eligible individuals include those who lived in or are a descendant of a Black individual who lived in Evanston between 1919 and 1969, who suffered discrimination as a result of housing policies. This plan fails to account for psychological amends, and some Black leaders are critical, mostly because they were not part of the decision-making process. They further see it as more of a housing plan than reparations.

need for reparations can be demonstrated in academic psychiatry

 Some progress has been made in this area, with African American female psychiatrists serving in leadership roles. However, those roles seem to come too often with inadequate funding and power, which in turn contributes to limited success and substantial stress for these leaders.

This is a clear example in which reparations funding and adequate authority could lead to more opportunities that would ripple out to other faculty, the education of future psychiatrists, and improved patient care for diverse populations.

“Without internal growth, we are encumbered with the destructiveness of projecting our own faults upon others and doomed to an unlimited appetite for revenge.”



Indigenous (Native) Americans Reparations - Andrew McLean, MD, MPH

Indigenous Americans, including American Indians and Alaska Natives, have been wronged by government and institutional colonialism. These wrongs include broken treaties and forced migrations to land that was often unsuitable for habitation or development.

A century ago, our own profession sanctioned 

, where individuals would be committed with such dubious disorders as horse-stealing mania.

 So-called Indian Residential Schools were built under the guise of providing education, and discouraged or banned Native culture and language. Inevitably, historical traumas remain interwoven with individual traumas, although they can vary among the 574 federally recognized tribes. More loss and trauma have occurred more recently, as Indigenous Americans have been hospitalized with COVID-19 at 

 The mental health of Indigenous Americans has suffered for decades, and the population has a high rate of incarceration. The marginalization (geographically, socially, or otherwise) of any group allows discrimination to flourish, which has been the case for Indigenous Americans.

Occasionally, reparations have been given in the form of land, cash, tax relief, and other measures, which include those taken by the Indian Claims Commission of 1946 and the Alaska Native Claims Settlement Act of 1971. Former senators Sam Brownback, JD, and Byron Dorgan, MBA, proposed a stand-alone 

 in Congress in 2009, but that effort failed. Instead, in what felt like a rather disingenuous approach, an unheralded Congressional apology was tucked away on page 45 of an unrelated military spending bill, with legalese indicating that it was not meant to support any claims against the government.

 President Obama, however, publicly acknowledged the apology.

Some governments and institutions have committed to partnering with Indigenous Peoples, engaging in positive movement. For almost 50 years, the University of North Dakota has ensured that roughly 10% of its medical school admissions are comprised of American Indian/Alaska Native individuals. The university has also developed the 

Even when financial reparations are provided, they may not change cultural narratives and mindsets, as transgressions can still be denied. For Indigenous Americans, telling, hearing, and acknowledging the truth has yet to occur. The fact that many tribes have leveraged their sovereignty to develop robust, Native-owned businesses and cultural programs does not pardon institutions from the responsibility of reparations.

Japanese American Reparations - Thomas Okamoto, MD

Calls for reparations often refer to the Japanese American World War II internment and its redress movement, which culminated in the 

 After an 18-year process filled with factious differences of opinion, the fact-finding commission found no basis for what it called “pressing public necessity,” and that “race prejudice, war hysteria, and a failure of political leadership” had led to President Franklin D. Roosevelt’s Executive Order 9066. Beginning in 1990, each surviving Japanese American citizen was awarded $20,000 in compensation.

Courtesy of the National Archives and Records Administration

Despite its apparent success, many Japanese Americans were left bitter and frustrated. They viewed Japanese American legislators, attorneys, and others working within the system as accommodating the government’s institutional racism. Collective efforts supported the negotiations for eventual reparations, but they did not stop hate-inspired crimes against surviving internees and their descendants. The efforts did not erase lost generational wealth, or the continued emotional pain. In other words, the financial reparations did not transform racism against Japanese Americans.

Psychiatry can direct the discussion on reparations toward the intrapsychic world. Psychiatrists can see

 as regressive expressions of unconscious defenses, including splitting and projections. These necessary early functions in development promote a successful negotiation of our own good and bad internal world.

Perhaps the most healing part of the Civil Liberties Act of 1987 was not the restitution, but the validation of injustice and the promotion of community grieving. In 

, survivors and their descendants heard internees verbalize the descriptions of their experiences for the first time, including shared loss and pain.

 This process reawakened painful memories that had been suppressed for decades. In a culture braced by gaman (perseverance with dignity) and shikata ga nai (it cannot be helped), the testimonies initiated the sharing of grief, thereby beginning the intrapsychic healing for this trauma.

Climate Reparations - H. Steven Moffic, MD

In these interconnected global times, a new conception applies to the 

The instability of our climate has caused harm in various countries and sometimes simultaneously around the world. For instance, the cold and snow unexpectedly hit Texas in February 2021 and also caused canals to freeze in Amsterdam.

Sabbir, Public domain, via Wikimedia Commons

Although there are calls for the development of transformational resilience and mitigation in at-risk communities, there may not be funds to do so in poor communities.

 Hence, some individuals become climate refugees, with all the mixed and ambivalent responses of potential host countries.

Climate reparations could provide amends for both past climate destruction as well as unborn future generations. Even with reduced carbon emissions, climate damage will continue for decades. The question of reparations is more challenging. In addition to the guilt of corporations—some of whom have hidden the risk and abuses for decades—and governments, how much is each individual to blame? 

A systemic approach to redistributing resources

 Perhaps countries and corporations with the most carbon pollution could contribute to international reparative funds to even out inequities in resilience capability. Such a comprehensive past, present, and future approach may also help to reduce undue anticipatory anxiety and pretraumatic stress in the most at-risk populations.

Although reparations are usually thought of in terms of financial amends to large populations and systems, they can be gestures provided on a spectrum from the small to the global. Given the ubiquity of microaggressions toward Black Americans and others, a smile, an apology, and a change in behavior by the perpetrator can have everyday psychological reparative repercussions.

However, in terms of our society, making amends is urgent. Why? Throughout history, epidemics have tended to 

Psychological reparations clearly make a difference and can be put into motion quickly if psychiatric systems recognize the need to do so. One example would be assessing and responding to disparities in patient care and staff composition.

 Essentials of a Psychiatric Reparations History

It could be argued that psychological reparations are the essence of any kind of reparations. Financial reparations, besides any needed practical repercussions, can increase feelings of self-worth because the individual and group are deemed worthy of the cost.

 On the other hand, financial reparations alone can feel tainted, like a buyout resulting from guilt. Moreover, financial reparations may be time limited, whereas self-worth is likely to be more deeply satisfying and transmittable to others.

In psychiatry, we have most control over psychological reparations. As is done for any patient care issue and disaster response, a tentative standardization of practicalities needs to be established. For starters, we need a psychiatric reparations history (

). This history can be applied to any given individual and any given system. After obtaining the history, interventions are necessary and possible (

A diverse group of psychiatrists elaborates on the difficult conversation surrounding reparations, and why our society needs to pay attention. 

Andy McLean, MD, MPH

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