H. Steven Moffic, MD

The first Monday of every September is Labor Day. The labor movement established the holiday in the late 19th century, and it is dedicated to the social and economic achievements of American workers. In essence, we psychiatrists are laborers for our patients. Moreover, as psychiatry and the rest of medicine has become more and more a business, we likely feel a closer kinship with all workers. The following, in alphabetical order, are some dedicated workers in our field who have passed away in recent months. We honor them by recognizing their achievements and the labor they loved. Much of the information below comes from various obituaries.

Bertram Brown, MD: Labored for the Intellectually Disabled and Deinstitutionalization

If he were still alive and active, Dr Brown would probably be doing whatever he could for children with intellectual disabilities, many of whom are falling behind due to online education. However, he died on May 14 at the age of 89. Actually, a study he did as a medical student in the mid-1950s helped convince the Kennedy family, who had a child with Down syndrome in custodial care, to support research for the intellectually disabled.

As his career progressed, he ended up working over 5 presidential administrations, including directing the National Institute of Mental Health from 1970 to 1977. He joined the NIMH in 1960 and then worked for the Kennedy administration on the deinstitutionalization that came with President Kennedy’s Community Mental Health Act. Unfortunately, though he fought it, much of the progress toward deinstitutionalization was halted in the 1980s with the change to block grants under President Ronald Reagan, as the states often used the funds for other things. We are still struggling to overcome these changes.

Robert J. Campbell, MD: Labored for the American Psychiatric Association

Dr Campbell, a longtime leader in American psychiatry, died on May 22nd at the age of 94. Over the years he held major leadership positions in the American Psychiatric Association and received the Distinguished Service Award in 2002 from the APA Political Action Committee.

He also was a prolific writer, best known for his seminal text, 

, which he first edited in 1956. One wonders how he would view the current concern with institutional racism within the APA.

He practiced in various psychiatric hospitals in Manhattan. His interests there spread beyond psychiatry to the arts, especially opera.

Leah Dickstein, MD: Labored for Social Relationships

I had the good fortune to follow Dr Dickstein as President of the American Association for Social Psychiatry from 1998-2000. Her work as president of the AASP was one of many social relationships that Dr Dickstein focused her expertise and advocacy upon. She was also the president of the American Medical Women’s Association and Chair of the Association of American College’s Group on Student Affairs.

Her social concern extended to the children of psychiatrists, who had the reputation of being a bit “crazy” themselves. As such, she was the co-founder with 

’ Deputy Editor Emeritus Michelle Riba, MD of the popular “Children of Psychiatrists” annual session that begun in 1998. Both of my children were asked to participate in these sessions.

When we compiled our end-of-year eulogies in 2019, she just missed the cut-off date for being included, having died on December 16 at the age of 85. Hopefully, this is making up a bit for the delay.

Richard Friedman, MD: Labored to Debunk the Myth That Homosexuality Was Curable

Although Dr Campbell, who we eulogized, also did a lot to debunk the pathological view of homosexuality, Dr Friedman, a psychoanalyst, was best known for countering the psychoanalytic belief that homosexuality was a perversion and could be cured. Though it was apparently not a personal sexual concern of his, he felt that it was his ethical obligation to counter this prejudice. His 1985 book, 

Male Homosexuality: A Contemporary Psychoanalytic Perspective

, convincingly presented the case that homosexuality was a biological variation.

Clinically, he helped many patients, both male and female, accept their homosexuality as being normal, including the well-known author Andrew Solomon, who saw him for 25 years. Last year, the American Psychoanalytic Association issued an apology for treating homosexuality as an illness. Now, we are beginning to see apologies for institutional racism.

Dr Friedman died on March 31st at the age of 78.

Bruce H. Greene, MD: Labored to Fight the Coronavirus

The notice of Dr Greene’s death was sent to us at 

 by a colleague after our series of eulogies for psychiatrists who had died of the coronavirus. He died at the age of 61 from COVID-19 on April 16, 2020. As the president of his synagogue, he was just beginning to set up the processes to respond to the pandemic.

Before that, his practice centered on children and adolescents in West Orange, New Jersey. He seemed to be unusually comfortable playing with them, and tried to follow-up with them after they went to college.

Frederick Hickling, MD: Labored to Reduce the Legacy of Colonial Racism

died on May 7 at the age of 75. Although he was based in Jamaica, his impact and reputation were global. He was elected as a Distinguished Fellow of the APA in 2008, and as a Fellow of the Royal College of Psychiatrists UK in 2011.

Besides his focus on deinstitutionalization and community mental health, he added something that seems missing from that transition in the United States. Like Frantz Fanon, MD had done in Algeria, Dr 

added a cultural focus to his practice, although Dr Fanon did that on inpatient units rather than in the community. Dr 

’s goal was to “decolonize the psyche” of Jamaica, which had a legacy of slavery and structural racism. He used a tapestry of the arts, including drama, song, and dance, to express and explore painful cultural issues.

After Jamaica finally achieved independence from Great Britain in 2002, this process began in earnest. More and more Jamaicans trained as psychiatrists and psychiatric nurses. To address the high prevalence of violence, the award-winning Dream-a-World Cultural Theory project focused on high-risk primary school children. They were encouraged to imagine a better world and their role in it. Compared to a control group, these children, especially the boys, showed improvement in academic performance and social behavior.

A second innovation was a therapeutic treatment called Psychohistoriography, which supplemented traditional psychoanalysis through focusing on race and culture, group discussion, and storytelling.

often encountered obstacles, which he attributed to discrimination, when he tried to publish his narratives in mainstream psychiatric journals. He died just weeks after writing an article for the Association of Commonwealth Universities in Jamaica summarizing his ideas and contributions. His work deserves wider distribution and seems applicable to similar challenges in the United States, as we try once again to reduce the damage from racism.

Stephen C. Scheiber, MD: Labored for Psychiatric Education

died June 20, 2006 at the age of 82. He devoted his career to psychiatric education, ranging from trainees to psychiatrists in practice. He was the Executive Director of the American Board of Psychiatry and Neurology from 1986 to 2006. Surely, he would still be concerned with our current epidemic rates of burnout (from medical school to retirement) and how education might help us to address that better.

Ronald Wintrob, MD: Labored for Cultural Psychiatry

My entrée into cultural psychiatry occurred through involvement in the Society for the Study of Psychiatry and Culture, which Dr Wintrob helped establish in 1971. He served as its president for many years. He graciously supported my concern with developing cultural psychiatry education for residents, as well as to pay more attention to cultures in the United States, besides those found in other countries. As part of his worldwide cultural reach, he was a leader in the Transcultural Psychiatry Section of the World Psychiatric Association. In the 1960s, he worked in both Liberia and Laos.

Dr Wintrob was a prolific writer and graced the pages of 

 with his posting “Introduction: Cross-Cultural Psychiatry” on January 10, 2010, which I still readily recall for its quality. (It was about the same time that I started writing regularly for 

.) His curiosity and concern for people of all backgrounds is a model that continues to be relevant for us all.

He died on August 17, 2020 at the age of 85.

In general, this group of psychiatrists collectively and courageously fought for the underserved and mis-served, not only in the United States, but around the world. One could even conclude that they were prophetic in their belief that multicultural concerns would become ever-more important as the world became more global. As it has turned out, cultures in need include our own: our own culture of being psychiatrists, as our burnout rates have escalated. We can honor them best by becoming familiar with their work and carrying it on to further completion.

As always, we welcome your recommendations of psychiatrists to potentially eulogize, such as occurred with Dr Greene. As Dr 

“If you don’t write it, you haven’t done it.”

 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 being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association (APA) in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and Anti-Semitism for a better world. He serves on the Editorial Board of 

Articles

Our eulogies remind us of how psychiatrists have worked for the underserved and misunderstood.

In Memoriam: The Labors That These Psychiatrists Loved 

Slideshows

Suggestions to assess outcomes and measure success levels in combatting racism.

10 Measures and Outcomes to Assess Progress in Eradicating Racism

(1971), I recently received an e-mail presenting the medical oath that the 2020 class of students put together and presented in a visual montage. Despite there being no live ceremony because of the pandemic, it brought tears to my eyes.

My, how medical oaths have changed over the 50 years of my psychiatric career. In the 70s, most medical school classes took the Hippocratic oath, but that is no longer the case.

Over the years, I have become more interested in medical and psychiatric ethics. A couple of my colleagues and I conducted a 

 in the late 1980s about how well medical professionals recall the Hippocratic Oath.

 At the time, responders indicated that 77% of their medical schools still recited the oath at graduation. Other than “do no harm,” people did not recall much else. That could be a clue about its potential impact. One commentator suggested some continuing education on studying the oath is in order.

Of course, we have a traditional set of principles that could be taken as an oath—the AMAs’ 

, which psychiatry has adopted and adapted.

 do not seem to be used and how well it is known by practitioners is unknown. Perhaps it is too dry or impersonal, or just taken for granted, to be used as an oath. Unfortunately, there have been times when medical ethics have been ignored, as in Nazi Germany.

 Therefore, it is important the oath is not forgotten.

Once I heard the new oath by the new class at Yale Medicine, I wondered about the status of current oath taking. An alumnus colleague at Yale sent to me several additional medical oaths recently used, as well as a review article. Students seemed to value their participation in developing their own oath. A recent book emphasized the need for current oaths to emphasize the social obligations of physicians.

 The author also made the point that unlike modern codes and principles, the Hippocratic Oath was meant to be proclaimed in the first person voice that would reflect personal commitment.

Other review articles in the last decade have 

 Most oaths were taken upon graduation, but some schools have added them upon entry. More than half recently use an oath unique to that school, and some are written by the students. Only respecting confidentiality, avoiding harm, and upholding the professional’s integrity was included by at least 80% of schools upon graduation. Most emphasized the patient-physician relationship, but only a few expressed an obligation to teach, advocate, prevent disease, or conduct research. They tended not to emphasize the ensuring of safe systems, nor the well-being of the physician.

Since medical oaths reflect the ethical principles that physicians and society are essential to clinical practice, they can and do 

 The prevalence of oath-taking varies from 100% of medical students in the Netherlands and Brazil to about 60% in the United Kingdom and close to zero in many African countries.

Perhaps because my 50th class reunion is coming next year, I began to wonder why we never take medical oaths beyond medical school. After all, that is when we actually confront the practicalities of ethical decision-making. For example, we rapidly find out that “do no harm” is virtually impossible as most treatments have adverse effects, cause pain, or complicate matters. We don’t even take a medical oath if we are testifying in a deposition for a court expert witness testimony.

It has also struck me that medical oaths could vary depending on one’s specialty. For example, the field of psychiatry is particularly stigmatized, and the Goldwater Rule comes into play.

In addition, I wondered if age and experience make a difference. I am in retirement from clinical and administration responsibility, so do I still have certain ethical obligations as a psychiatrist and physician? I think so.

All these considerations led me to decide to compose my own medical oath at this time of my career. Much of it is modeled on the Hippocratic Oath and is taken in the first person. Here it goes.

I swear by my profession of psychiatry that I will continue to live up to these ethical principles:

Although I am writing my own personal psychiatric oath, I will make sure to also always keep in mind the traditional Hippocratic oath, as much still has present relevance.

I will endeavor to thank all of my valued teachers who are still alive, which many include students and early career psychiatrists.

I will endeavor to teach any young psychiatrist the lessons I have learned in my career.

I will endeavor to do as little harm as possible in my interactions, words, and writings.

I will endeavor to maintain confidentiality unless I judge that lives are at stake.

I will endeavor to take care of my own personal wellness and do what I can to reduce the epidemic burning out of my colleagues.

I will endeavor never to use the word “provider” instead of physician, nor use any other term derogatory of my profession.

I will endeavor to participate in any community efforts to improve the mental health of our citizens.

I will endeavor to examine my own prejudices and help to reduce those in society.

I will endeavor to always remember that once a psychiatrist, always a psychiatrist, but never to use our knowledge inappropriately.

Consider writing your own oath. Or your organization create one. Put it on your wall or website. Send it to us at 

 I’m sure it will at least clarify your current psychiatric values.

 is an editorial board member and regular contributor to 

 He was a tenured professor at the Medical College of Wisconsin until he retired in 2012. Since then he has functioned as a private community psychiatrist providing pro bono services locally, nationally, and internationally. Currently, Dr Moffic is focused on 5 major advocacy initiatives: physician burnout, climate instability, Islamophobia, Anti-Semitism, and racism. He is co-editor of 

Combating Physician Burnout: A Guide for Psychiatrists

, with Sheila LoboPrabhu and Richard F. Summers.

2. Pellegrino ED. The Hippocratic oath and clinical ethics. 

The Principles of Medical Ethics, with annotations especially applicable to psychiatry.

 Washington, D.C: American Psychiatric Association; 2013.

The Nazi Doctors: Medical Killing and the Psychology of Genocide.

The Hippocratic Oath and the Ethics of Medicine.

Oath taking at U.S. and Canadian medical school ceremonies: Historical perspectives, current practices, and future considerations

Context, culture and beyond: medical oaths in a globalizing world

At one time, most medical school classes took the Hippocratic oath, but that is no longer the case.

50 Years of Medical Oaths

“Racism in America is like dust in the air. It seems invisible—even if you are choking on it—until you let the sun in.” — Kareem Abdul Jabbar

~ SPAR (Seven Psychiatrists Against Racism). To join the upcoming webinar, 

The racial dust that we often do not see has been in the air ever since our country’s beginning. As a result, the brutality of chattel slavery used for the economic growth of colonial settlers became embedded in the minds and bodies of all countrymen. That pollution, much of it still invisible, remains with us, woven into the structural, institutional, and individual racism of our nation.

Psychiatrists should be experts at hearing and seeing what is not visible. We are taught to listen with a third ear for hidden or unconscious meanings. We look to nonverbal messages to understand what is not stated. And that is exactly what we need to do to let the sun shine through the racist dust. We have to use racial hearing aides and racial visual lenses so we do not forget to look for the racism. We need to leverage our experiences to improve the experiences of those who come after us.

This is one of those times that try our souls. Or should try our souls—psychiatrists and everybody else.

You may recall those paraphrased words of Thomas Paine during other revolutionary times. In 1776, George Washington rallied his freezing and faltering troops, and the United States went on to win the war of independence. However, not everybody received the promised freedom of independence. African Americans did not. With the deaths of Mr George Floyd and others as well the persecution of so many others, we have been tragically reminded that we are still trying to unite and win the 400-year war against racism and discrimination. This unfortunate truth has been made clear not only by the recent police tragedies but also the overrepresentation of minorities among pandemic deaths, the destruction from climate-related disasters, and the continued urban gun violence.

states, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”

 Since racism harms everyone, from the victims to the perpetrators, and causes harm on multiple levels, we are ethically bound to address and reduce in order to improve public health and better our communities.

Psychiatry’s history in addressing racism has been spotty at best, sometimes promoting advances and sometimes stagnating, even in surprising places. Benjamin Rush, MD, (1745-1813) often called “the father of American psychiatry,” exemplifies the twists and turns of psychiatry’s stand on racism. Rush was an abolitionist, even though he owned a slave. In fighting for freedom for African-Americans, he also developed the diagnostic theory of “Negritude,” which was considered to be similar to a mild form of leprosy. The only cure for this disorder was to become white.

 (A possible medical explanation for this hypothetical genetic defect was that it was the fairly rare disease of vitiligo, in which the skin loses its pigment and appears to get lighter.) Do the good deeds make up for the racist actions?

Meanwhile, the field did not see the first Black psychiatrist, Solomon Carter Fuller, MD, until around 1900, more than 50 years after organized psychiatry began in the United States. Gradually, the numbers of Black psychiatrists grew and contributed their expertise to the field, including efforts to address racism. These psychiatrists introduced ideas like labeling the psychological and health effects of interpersonal racism via the concept of microaggressions. Their targeted literature contributions led to a reduction of the misdiagnosis of Black Americans.

 And, psychiatry had to wait until 2019 before it saw its first Black president—Altha J. Stewart, MD.

Despite the small advances, there have been difficulties and hurdles. Black psychoanalysts experienced challenges while navigating institutes that deemed Black patients as unanalyzable and weaponized theory to perpetuate racist stereotypes. Many of these psychiatrists had to make Campbellian heroic journeys to overcome racial obstacles along the way.

Unfortunately, these microaggressions are still common. Despite her experience, expertise, and position of authority in psychiatry, Danielle Hairston, MD, director of psychiatry residency at Howard University, 

she is still routinely questioned and doubted. She shared this experience of a white colleague ignoring her at a patient’s bedside

“He’s like, oh, well, the psychiatrist will be here to speak to you soon. And I was like, I’m right here. And he’s like, oh, my gosh. Like, I thought you were the sitter. And he’s like, oh, my God; I don’t know why I said that. And I was like, oh, it’s because I’m Black. And I don’t even necessarily think that he’s racist. It’s just that that’s the bias.”

The APA is not the only psychiatric organization that has missed the boat. Not only has the 

American Association of Community Psychiatrists

 (founded in 1985 and recently renamed as the American Association for Community Psychiatry), not had a Black president, it has not had one of any ethnic minority of color background. Yet, it is generally considered to be more liberal than the APA.

“If I love you I have to make you conscious of things you don’t see.” —James Baldwin

Similar racial challenges and contributions emerged for psychiatrists outside of the United States. The most prominent international Black psychiatrist was Frantz Fanon, MD, who practiced in Tunisia and Algeria in the 1950s.

 He espoused that colonialism had a direct negative psychic effect and that the political and psychic are intertwined. To address this with his patients, he came up with the concept of 

, meaning the environment and activities of an inpatient ward should be culturally congruent and positive.

Leveraging psychiatry to understand and address racism

Fanon’s ideas help us to understand the 3 main centers of racism in the US. His work on institutional psychotherapy highlighted 1 of the 3 centers; the others are structural and personal. All of these can have different degrees of intensity and prevalence. Institutional racism, which Fanon aimed to address, involves institutions’ policies, practices, and procedures that have a disproportionately negative effect on minorities’ access to quality goods, services, and opportunities. Structural racism relates to how it is imbedded within every aspect of the country as a consequence of chattel slavery more than 400 years ago. Internalized personal racism reflects the finding that we all have some degree of racism as a consequence of structural racism, some of which is unconscious and can be discovered by taking an Implicit Bias Test and/or feedback from others.

All 3 of these centers of racism can be addressed in various ways. From the very first model curricula on cultural psychiatry education for residents in training, self-reflection of one’s cultural background has been deemed essential in psychiatry.

 Even so, the onus is on those with the most power, which means so-called white-Americans who have benefitted from the unearned advantages captured by the term White privilege. (Interestingly, intermittent attempts to psychopathologize severe racism as a DSM disorder have failed thus far, in part due to disagreements on where to draw the line.

) We can address institutional racism by improving educational settings, policies, and our own psychiatric systems. Since these mechanisms for racism can contribute to poorer care of Black patients, especially by non-Black psychiatrists, it is essential that the field addresses them. (To learn more, it is helpful to read the allegorical gardener’s tale by Camara Jones, MD, PhD, MPH.

Black patients and psychiatrists are not alone in facing racial-ethnic disparities. Other minority groups, especially Native Americans, have also been affected. Why do these disparities and racism tendencies exist? The disparities may reflect our hard-wired brain tendencies of human nature to fear those who seem different, which contributes to tribalism and our modern ingroups. This reaction is almost like a psychological immune system but, like the physical immune system, it can go awry at times. When it does, it provides a substrate for racism, Islamophobia, anti-Semitism, and related group discriminations. Moreover, we tend to project our inadequacies onto others, scapegoating them in an attempt to feel better and gain power.

The solution, therefore, lies in our prefrontal cortex and our ability to think rationally and carefully to control our emotional tendencies and reframe our thinking, as is done formally in cognitive behavioral therapy.

 For optimal antiracist impact, we must start with parents and their children,

 and use the tools currently at our disposal.

All things considered, Black patients more often trust Black clinicians than those of other races. Unfortunately, Black patients have a much smaller chance than white or Asian-American patients of finding culturally similar clinicians. Whenever there is a cross-cultural match of patient and physician, building a positive therapeutic relationship is that much more important. In addition to providing welcoming access, careful evaluation, and appropriate treatment, this also necessitates making race and racism an open and accepted topic to discuss. Similarly, when staff and leadership reflect the cultures of the patients and communities, it sends a comforting message. Inservice training on racism should be ongoing to further promote a welcoming and appropriate environment. Moreover, the patient’s preferences in terms of racial and cultural terminology should dictate how things are discussed. Whenever the alliance is not going well, consultation with colleagues from the treatment team with a similar background can be helpful.

These words from Kai Koeber, who survived the Marjory Stoneman Douglas High School in Parkland, Florida, massacre, put this ideal into perspective

: “Finding a Black therapist really saved me some time, and there was more connection, in terms of the kinds of struggles that I might feel or the kinds of ways I might think about certain scenarios.”

Similarly, trauma-informed care is a necessity. Primary trauma is common in Black patients and clinicians; secondary trauma is common in non-Black clinicians. Often, that trauma is embedded not only in our minds, but also in our bodies. Ta-Nehisi Coates, a national correspondent, put it succinctly: “But all our phrasing . . . serves to obscure that racism is a visceral experience, that is dislodged brains, blocks airways, rips muscle, extracts organs, cracks bones, breaks teeth. You must never look away from this.”

Finally, outcome studies are crucial to better understand how racism is impacting care. When the setting is multicultural, the outcomes can be compared across races and cultures.

A century ago, jazz was among the first activities to combine our different skin hues, explained trumpeter Wynton Marsalis, arguably the most prominent jazz spokesperson. It also provided a new approach to music and new sounds. He understood that there is unity in diversity.

Just as jazz gave us a new musical vocabulary, it is clear we need to review our words and nomenclature to help address racism. Certain words with negative or positive connation are tied to color and, in turn, subconsciously impact racist views. Consider, for instance, terms like blackmail and its negativity versus white knight and its positive connotation. Similarly, how words are treated have an impact. Issues like what words should be capitalized and when they should be capitalized can further impact feelings, as discussed in a recent contentious New York Times article that generated hundreds of comments.

Technically speaking, we are all people of some color. It took a very small genetic mutation to lighten skin color when, as we now know, the original human beings left Africa. As they moved north and experienced less sunlight, they needed to absorb more of the limited sunshine. This means that, ancestrally, we are all African-Americans. Therefore, embracing the term race, other than the term human race, may be inherently racist.

Composing the piece: integrating the authors

Racism is clearly a psychological and social phenomenon in which a particular group is viewed as superior or inferior to another. Yet, race may not be something intrinsic and immutable, and the judgements and groupings may be a fluid, illusory, imposed, or sometimes insurgent concept. For instance, in World War II, the Aryans touted a so-called “master race.”

 Similarly, the 2020 US Census has a haphazard listing of races: White; Black or African American; American Indian or Alaska Native; Asian; and Native Hawaiian and Pacific Islander. Neither Hispanic or Latino, nor Jewish are listed as a race, but there is a write-in area for “Some Other Race,” acknowledging the fluidity and self-defining nature of the term race.

With that in mind, our challenge is to assemble the various voices to contribute to the dialogue. Accordingly, a multi-racial group of co-authors crafted this piece. Even so, we grappled with how to pull together our expertise and experience, especially since there has been some controversy over who has the right to have a voice in the discussion. At first, we tried to write a typical review article on racism and psychiatry. However, not only was it difficult to come to consensus on some matters, but we found our personal voices got lost. Fortunately, our secondary thinking processes of our reflective egos managed any tension

, which is one of the reasons psychiatry can and should play an important role in this discussion.

Once we decided that each co-author should present on themes important to them, complete with their own race-related terminology, the project moved along quickly. In turn, once our individual voices were preserved, returning to more general themes in the surrounding material was easier. We view this as a model for leadership and cooperation in the antiracism movement. We learned how to hear each other’s racial messages, viewed psychiatry through a racial lens, and tried to portray a variety of experiences and learned lessons.

In many ways, this structure is like an integrated jazz band playing a prototypical song: we play together in the beginning sections, then go on to different instrumental solos backed up by our colleagues, and finally conclude together. (Interestingly, Jazz, America’s contribution to the music world, was developed and led by Black musicians.) Thus, without further ado, we present the musical stylings of our diverse and passionate group.

Burnout remains an important topic of discussion in psychiatry, both because of its possible deleterious effects on our own well-being and its impact on the quality of care of our patients. Although a 2017 Medscape Psychiatrist Lifestyle Report 

a rate of burnout among Black psychiatrists at 32% compared with 43% among White respondents

, these statistics are misleading. My opinion is that the percentage of burnout among Black psychiatrists is likely higher than reported because of the pervasive elephants in the room that were not assessed—structural racism and racial microaggressions.

There must be a call to action if Black psychiatrists are to flourish professionally and personally in a system that has historically invalidated their concerns related to racial injustices, both in the form of health care disparities and exclusion from leadership positions. Proposed strategies include transforming the physician workplace to better resemble communities of color; redesigning medical education curriculum to emphasize the importance of diversity, inclusion, equity, and social determinants of health; and recognizing the value and contributions that Black psychiatrists have made to the field.

Blue genu salivates with anticipation for the kill.
Dark vessels begging for mercy while lying still.
Tick-tock, tick-tock!

Blue genu consciously aware of lifeless prey.
Witnesses’ souls weep as they relive flashbacks of Freddie Gray.
Tick-tock, tick-track!

Blue genu imposes historical privilege to the black slain.
Dysphoric chocolate seeks justice for fatigued hearts bloodied with pain.
Tick-tock, tick-tock!

Tick-tock, tick-tock!
Black longevity has a premature clock.

With one tick-tock, one of my patients’ lives was ended prematurely by the police.

I know psychiatrists are not supposed to have favorite patients, but I had one early in my career (1981). He was a young Black male with a diagnosis of schizophrenia who had been in and out of psychiatric hospitals for a few years. At that time, along with a Black male psychiatric resident, I was developing the first model curricula on cultural psychiatry. Thus, I was aware of the possibility of misdiagnosing that instead of, say, bipolar disorder.

He was charismatic and flamboyant, often acting as if he was in a karate class when he came to the clinic that I co-led with a Black female social worker. Maybe my racial countertransference was feeling entertained by his behavior. Did that lead me to not properly curtail that behavior?

One day, he was gesticulating in his karate way in front of a police station. This time, however, he was also holding a long knife. About 30 police came out and surrounded him. Yelling “Heil Hitler,” he made a move toward them and was shot dead. The case received national attention.

The good news is this event slowly but surely led the Houston Police Department to better understand and address mental health and racism, so much so that the department received awards for their work.

Unfortunately, improvement such as this is not widespread. I was triggered by the video of Elijah McClain. In 2019, right before he was choked to death by the police in Colorado, 

, “I’m an introvert. Please respect my boundaries.”

About a decade ago, I worked part-time in a medium security prison in Wisconsin. The prison population was overrepresented by young Black males diagnosed with untreatable sociopathy. However, once trust was established, it was clear most were suffering from treatable posttraumatic stress disorder. Whether from intergenerational transmission of trauma psychologically and/or epigenetically, these men were left vulnerable to being triggered to irritability, aggression, street drug usage, and the emergence of painful dissociated memories.

After World War II, when the Allied nations conquered Nazi Germany, all Nazi statues and monuments were destroyed. Why is there resistance to do the same in America? Nearly 700 remaining monuments of Confederate “heroes” stand as a reminder to African Americans of the slavery, bigotry, animosity, and the frank hatred that still exists today. There are also 109 public schools named after Confederate leaders, despite the fact that one fourth of students attending these schools are African Americans. Many in white America argue that these symbols represent their heritage. However, multiple studies show the primary factor of maintaining these symbols is racial resentment.

For our country to truly heal, we must not glorify prior racist remnants. We must not embellish the symbols of white supremacy by encouraging their adverse racist principles. There has been some progress on this front. For instance, Governor Nikki Haley removed the Confederate flag after the 2015 shootings at the AME Church in South Carolina. New York State Senator Todd Kaminsky introduced a bill to include education on hate symbols and their effects in school curricula. There is a petition, once again, in Rhode Island to remove “Providence Plantations” from the official state name. This name, incidentally, is on every professional medical license, which is often hung on the walls in doctors’ offices and potentially noticed by Black patients.

We need everyday citizens and leaders to promote fairness, equity, and a greater sense of shared humanity across our nation.

Crucial and Productive Conversations About Racism

Borrowed from the management world, the term crucial conversations is one of many helpful communication tools when the stakes are high and emotions may get the best of us.

Alas, none of these tools will emancipate us from our intellectual cages or ease our psychological discomfort. Fortunately, British psychoanalyst Wilfred R. Bion, MRCS, LRCP, can help us in this endeavor. For instance, he wrote: “If the learner is intolerant of the essential frustration of learning he indulges phantasies of omniscience and a belief in a state where things are known.”

 Language that alienates, shames, and intimidates can be seen as a subconscious attempt to avoid the greater discomfort of challenging systems that oppress, while other individuals, prone to faltering as humans, become the subjects of our outrage. Bridging racial groups then becomes too uncomfortable.

As an Indian-American, I have faced plenty of racism in my personal and professional life. Yet, I have still been the beneficiary of privilege that is not afforded to my African American colleagues. I accept that with much humility. It is time we reframe systemic racism as not only a problem for those who have been oppressed, but rather a societal problem warranting solutions driven by those who have been the beneficiaries of the flawed systems. Because systemic racism has been interwoven in our lives for generations, we require active allyship to mitigate its effects. We collectively must find ways to become comfortable with being thrust into unfamiliar territory.

Examining Racial Blind Spots in Psychiatric Practice

As we are trained to drive, the importance of paying attention to blind spots on the road is constantly underscored. We are taught to acknowledge this phenomenon and make necessary corrective actions. Like drivers, psychiatrists have the ability to reposition themselves and their tools so as to avoid collisions, maintain safety, and continue on course.

Unconscious biases dominate our everyday life. Addressing unconscious bias, however, is not outside of our control.

As physicians, we are charged with mitigating the effects of racial bias so our behaviors may mirror our conscious egalitarian values. Unfortunately, we continue to do exactly the opposite in many cases, resulting in a racially inequitable health care system supported by racialized medical decision-making that burdens non-White patients. Race is one of the primary drivers of physician behaviors, and it has been shown to contribute to medical decisions, despite lack of a biological basis. Psychiatric training both nourishes and neglects unconscious racial bias by refusing to acknowledge its presence and dismissing its influence on medical judgement.

We must mitigate the impact of unjust racial biases on our practice of psychiatric medicine. Zestcott and colleagues.

 offers a starting point for reducing the influence of implicit bias on medical decision-making. Common-group, counter-stereotyping, and bias awareness opportunities (such as leveraging the Harvard Implicit Association Test) have shown promise in reducing the impact of implicit bias and/or increasing the motivation to do so.

Only by acknowledging the blind spots can we start to make meaningful course corrections.

What baseline working knowledge of the impact of racism and others sociocultural factors on health is needed to be an effective psychiatrist in the United States?

Graduate and continuing medical education need to begin to address communication barriers caused by personal bias and ignorance. This process should include increased trainee and workforce diversity; required knowledge of and reflections on history and social sciences regarding race, and racism; diverse supervision; and explorations of unconscious bias.

Yet, graduate psychiatric training only captures psychiatrists for a short period at the beginning of their careers. Psychiatrists continue to practice for decades, and thus need refreshers and continuing education opportunities via formal and informal learning opportunities. Maintenance of Certification (MOC) requirements can and should provide tools, encouragement, and motivation for practicing psychiatrists to increase their understanding of race issues as well as guidance in working with people of diverse racial backgrounds. By increased knowledge and awareness with lived experiences, we afford more opportunities to make a difference.

These were the words of a 9-year-old Black male child in his parent’s care awaiting the start of a car-caravan protest. Inevitably, it seems, all the current racial trauma combined with the intergenerational transmission of trauma will psychologically harm our children’s future, especially Black children.

The challenges are many. How do we best talk to children about the trauma and the racism? To what should they be exposed? How can we prevent future posttraumatic symptoms and instead foster resilience and growth? We will need support, hope, and many uncomfortable talks.

I am reminded of the traditional Masai warriors greeting, “How are the children?” We know many are not fine.

A 2020 report looked at counties across the US to determine where children were most and least protected and prioritized.

 Specifically, the study looked at the factors that cut short childhood, including food insecurity, high school graduation rates, teenage pregnancy, and child homicide and suicide rates. Although results varied greatly across the country, Black and Native American children were overrepresented in the many poor counties. The authors noted, “This report uncovers an unacceptable reality in America, where one child can be exponentially more likely than another to succeed in life based solely on the county where they grow up.”

If things stay the way they are, will we ever be able to answer the Masai’s question with “They are well”?

“Intersectionality” refers to overlapping or interdependent systems of discrimination. It is a theoretical framework for understanding how various aspects of a person’s social and political identities might create unique vulnerabilities to discrimination. Race can be combined with gender, sexuality, class, nationality, ableism, and age. Using intersectionality as an analytic tool can shine a light on those who are most vulnerable to discrimination. Most likely, the more sociocultural differences each individual has, the more vulnerable they will be to discrimination, and the more difficulties they will endure.

A myriad of patients are similarly burdened with multiple issues that impact their mental health, which in turn can lead to anxiety, depression, substance abuse, and suicide. Thus, understanding intersectionality is essential for psychiatrists. It allows us to better understand our patients, their specific needs, and how best to manage their concerns for better outcomes, including offering crucial support for those who feel abandoned.

Racially Based Criminalization of Substance Abuse Disorders

For centuries, racial biases in communication have presented people of color as having inherent characterological deficits that make them seem irresponsible, lazy, and criminal. This has resulted in ideas of “weakness” and “depravity” when discussing substance misuse in this patient population.

In contrast, substance misuse by white individuals is more likely to be attributed to non-characterological traits, such as socioeconomic status, external environment, and mental health issues. This dichotomy manifests in the legal system, where Blacks are more likely to be arrested, jailed, denied bail, and charged with felonies than whites—although rates of drug use and selling/distribution are similar among both groups.

Psychiatrists should be experts at hearing and seeing what is not visible. That is exactly what we need to do to let the sun shine through the racist dust.

Dismantle Racism in Psychiatry & Society

In psychiatry, we don’t often talk about the phrase from the Declaration of Independence, “Life, Liberty, and the pursuit of Happiness.” Yet, the phrase is fitting in our field, especially during the COVID-19 pandemic.

Certainly, we try to preserve life by preventing suicide, homicide, and psychiatrically related medical problems. We will break our ethical principle of confidentiality if we make a clinical judgement that a life is in danger.

If we view liberty as psychological freedom, that is one of the essential aspects of our work. Most mental illness constrains psychological freedom of thought and action. Clinical depression, for instance, causes undue negative thinking that can even result in suicide.

Freud cautioned against patients against expecting greater happiness from treatment. Instead, he believed psychotherapy could treat neurotic misery, but a patient would still be left with ordinary human unhappiness.

Curiously, any degree of mania is one kind disorder that may increase happiness, temporarily. Since the time of Freud, we have learned more about the nature of happiness. Although the functional outcome of successful treatment should help a patient to find more happiness, it does not.

, life, liberty, and the pursuit of happiness was viewed as an “unalienable right” which our government was created to protect. It seems clear that our society has not provided enough of that protection from the pandemic. Medical experts have maintained that more lives have been lost than would have been with earlier action, delayed opening of live socializing, and much more extensive wearing of masks around other people. Fortunately, there is still time to backtrack and do better.

To combat the pandemic, our physical liberty was necessarily constricted, though that was anticipated to be temporary in order to reduce 

 and mortality. Psychological liberty has also been limited as rates of virtually all mental disorders and subclinical problems like racism have been rising in recent years and during the pandemic.

Pursuit of happiness, of course, was more difficult given the unusual restriction of activities that previously brought happiness. On the other hand, people have found other ways that contribute to happiness under restrictions, including viewing creative and new video programs. Family life can increase or decrease happiness, depending on the quality of the relationships.

limits what psychiatrists are supposed to say about our current societal leaders because analyzing them without an examination and permission to divulge a diagnosis would be unethical. However, we can—and should—comment on the outcomes of such leadership, including the life, liberty, and pursuit of happiness that our government is supposed to protect whenever practical and possible.

Psychological liberty has been constricted as rates of virtually all mental disorders and subclinical problems like racism have been rising in recent years and during the pandemic. But it's not too late.

Author | H. Steven Moffic, MD

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