H. Steven Moffic, MD

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 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 Psychiatric Times®.

Videos

Dr Steven Moffic says it well: COVID-19 Is making almost everyone tense. What can we do about this uncomfortable strain? 

Worldwide Tensions Rise 

Dr Moffic poses queries to the presidential candidates and even does a little singing. 

Two Questions for the Candidates

Slideshows

The physical and psychological symptoms of anxiety, such as feeling tense or having trouble concentrating, can be so uncomfortable that they cause behavioral changes. How might these components play out in, say, a Presidential election?

7 Steps to Alleviating Election Anxiety

A black fly on the white hair of Vice President Pence: coincidence or symbol? Dr Moffic talks combatting racism, current events, and the infamous fly. 

The Gadfly

I once heard Tom Hanks being interviewed about his acting on a TV interview. Something he said stuck with me. “We only have 3 days: yesterday, today, and tomorrow.” That insight seems to fit my own personal story about racism, from what some might say is a “white” experience and others might see as a Jewish experience.

I think my entree into racism and psychiatry started with my exposure to jazz as an adolescent. It was musical love at first hearing. Until the second year of medical school at Yale, I even reviewed jazz records for a publication under the name Dr Jazz.

I found out that jazz was developed by Black Americans and was among the first social situations in the United States where integration took place. I felt the cognitive dissonance keenly: how could a people create such an original and magnificent musical form (beloved around the world), yet be so discriminated against otherwise? When I later looked at the musical industry beyond the music, I saw that it was controlled by white executives and clearly had some racist policies, including reimbursement of the artists. One intermittent response to the lack of financial control was was for Black jazz musicians to set up their own recording companies, as I wrote about many years ago in an article for 

 titled: "Toward Self Determination: The Black Jazz Recording Companies."

When I decided upon my early focus in psychiatry, my love of jazz, combined with my Jewish value of Tikkun Olam (healing the world), naturally led me to want to serve the underserved, with Black Americans being over-represented among the underserved.

Early in my academic career in community psychiatry, I was asked to set up a cultural education series at Baylor College of Medicine for the psychiatric residents. Thankfully, my knowledge base was enhanced by the psychiatric faculty anthropologist, Charles Cheney, PhD, and faculty sociologist, Howard Kaplan, PhD. Along with a Black male psychiatry resident who was also interested in the project, we came up with 

 Moreover, in my clinical and administrative work, I benefitted greatly from co-leadership with a Black female social worker in a large community mental health clinic.

In the 1980s more Black Americans and other minorities entered the psychiatric residency at Baylor and some other medical schools. Soon, it didn’t seem that my leadership in addressing racism in psychiatry was needed, as minority psychiatrists began to make major contributions to the field. At times it felt like I was not even wanted anymore, as organizations of Black physicians developed in psychiatry and the rest of medicine.

I did, however, continue to focus on other disparities in psychiatry. I had other cultural psychiatry teachers and role models: psychiatrist Francis Lu, MD, on Asian Americans and cultural competence, Tony Arce, MD, on Hispanics and Carl Hammerschlag, MD, on Native Americans. After obtaining state and federal grants when I joined the Medical College of Wisconsin in 1989, I developed systems of care for various refugee groups, especially the Hmong and Black Somalis. When I saw many patients from the former Yugoslavia, I was shocked at the degree of trauma and cruelty they encountered, which at times seemed to rival that of Holocaust survivors.

In the 1990s, I also benefitted from writing a monthly Ethics Column for 

 with the help of a Black female editor. Improving the care of minority patients is certainly an ethical priority.

Not too many years ago, I had some ambivalent reactions about the Black Lives Matter movement, not because of the basic necessity for such a movement, but because the left political fringe seemed devoted to the BDS (Boycott, Divest, Sanction) movement against Israel, due to the plight of the Palestinians. For me, Israel’s existence seemed too crucial to endanger it in any way.

During the past year, examples of police brutality against minorities have been clearly caught on camera. How well psychiatry was addressing racism became a question. When I was asked to help assemble a feature article on racism and psychiatry, I thought that I could not possibly–or appropriately-do it myself. I would need help and a collaboration for at least 2 reasons.

One reason is that I had unfortunately drifted away from the ongoing need—despite advances—for psychiatry to address the harm of racism internally in our organizations, and in patient care. Actually, most white psychiatrists had drifted away from racial issues, as far as I knew, perhaps other than Jonathan Metzl, MD. He has continued to do innovative activities regarding racism while teaching undergraduates at his home base at Vanderbilt University. He 

 on the misdiagnosis of schizophrenia in black males.

A second reason was the question of who would be an appropriate spokesperson(s) for the issue. Young Black psychiatrists were coming up with new ideas and perhaps some of the ideas of older white psychiatrists were outdated. When I brought up the possibility of reverse racism in an online discussion, I was told that was an erroneous concept, although I am still not sure how that can be the case if a minority is in a power and uses it against white individuals. But maybe that is just a different expression of racism.

As a sort of compromise, I ended up thinking that the best model would be a multi-cultural authorship. Given that white psychiatrists seemed to have reduced concern for racism in society and psychiatry yet still had power, multi-cultural authorship seemed like a necessity. Fortunately, I found such a coalition in SPAR, 

 Although I was the senior author of the article, our youngest Black female psychiatrist moderated the follow-up webinar.

Now, I am more prepared to step aside. There seem to be more than enough qualified and concerned Black psychiatrists. New models of analysis have emerged and are helpful to find hidden societal and institutional racism that can go along with whatever personal psychological racism may be present. The key this time around, in society and psychiatry, is to maintain our focus on racism after this crisis period is over. I will contribute what I can, when I can, since I have concluded that a sustainable multicultural approach is a necessity.

 has begun publishing stories about the role racism has played in psychiatrists’ lives. We welcome more from those of any cultural background.

 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 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 

1. Moffic HS, Gani H. Toward self determination: the black jazz recording companies. 

2. Moffic HS, Kendrick EA, Lomax JW, Reid K. Education in Cultural Psychiatry in the United States. 

Transcultural Psychiatric Research Review

3. Moffic HS, Kendrick EA, Reid K, Lomax JW. Cultural education during psychiatric residency. 

The Protest Psychosis: How Schizophrenia Became a Black Disease

. Beacon Press, Illustrated Edition, 2011.

Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland

. Basic Books, Illustrated Edition, 2020.

6. Moffic HS: Dismantle racism in psychiatry and society. 

. August 10, 2020. Accessed 9/18/2020. https://www.psychiatrictimes.com/view/dismantle-racism-in-psychiatry-society

Articles

A psychiatrist considers the role of race in American culture, psychiatry, and his own life. 

Forty Years of Wrestling With Racism 

Dr Moffic talks about the impact of current political events on the public's mental health. 

Debating Our Social Psychiatric Problems

“Without a full spectrum of voices from partisan political elites, though, anxious citizens in search of protection from threats to their health and way of life may support charlatans or madmen who offer bodily protection while destroying the body politic.”

There are plenty of reasons to be anxious about the state of the nation: the 

, the economy, climate instability, physician burnout, an endless war on terrorism, returning to the classroom (or not), and racism, among other societal and personal stressors. All these major dangers are on top of the still-looming nuclear risk that could blot out human life on earth in virtually an instant. No wonder some individuals are calling 2020 “the worst year ever.”

As if that were not enough, now we have a presidential election happening in the midst of partisan political warfare, civil unrest, and frightening conspiracy theories on TV and the internet. The stakes seem sky high, perhaps because the president has so much influence on how we address every other crisis. How might mental health professionals potentially assess and address this “election anxiety”?

The polls confirm our intuition: we are a nervous nation. Earlier this year, the American Psychological Association 

, in which they found more than half (about 56%) respondents identified the 2020 election as a significant stressor. At the end of June, the Centers for Disease Control reported that the highest rising levels of anxiety were among young adults, as well as black and Latino people of all ages. The prevalence of anxiety symptoms among all populations was 3 times higher than the corresponding period in 2019.

Certain groups of minorities, especially educated and higher-earning black males, are at risk for more anxiety.

 This possibly counterintuitive finding may stem from blocked opportunities, which in turn may be related to the higher implicit bias of white men.

Anxiety also seems to differ along partisan party lines. About two-thirds of recent Joe Biden supporters say they are scared about the country’s future, compared to about one-third of President Donald Trump’s supporters.

 Of course, these sources of anxiety can change, and change quickly, depending on societal developments.

) inquiring about the upcoming elections, the trend was clearly slanted toward being very worried, with about half of respondents doing something productive about it and half not. As far as our patients are concerned, the second poll suggested a similarly strong degree of concern. If these trends hold up, the anxiety level would be even higher in our psychiatric world than in the greater society.

Anxiety refers to a prolonged state of apprehension brought on by uncertainty about future threats. Past threats logged in our memories and unconscious can also influence our view of upcoming risk. As such, anxiety is a natural emotion and vital for survival. In contrast to anxiety, fear is an acute or phasic response to an immediate and identifiable threat, as we explained in a prior article for 

FDR, the Bene Gesserit, and the Psychiatry of Fear

 Perception is a key for both anxiety and fear because the threat can be an imagined one. If anxiety is punctuated by acute episodes of fear, such as fear-mongering political campaign ads, it can feel like a one-two punch to our sense of security.

The physical and psychological symptoms of anxiety, such as feeling tense or having trouble concentrating, can be so uncomfortable that they cause behavioral changes. Fight or flight stress responses range from avoidance to aggression, as well as self-medicating with alcohol and street drugs. Peaceful protests in presidential elections can reflect a normal and appropriate expression of anxiety, such as is emerging virtually with the “Rage Moms,” who are fed up with being teacher, caregiver, employee, and parent all at the same time. When protests turn into riots, however, they may be a reflection in part of too much anxiety, an overreaction to perceived threats. Similarly, police may have appropriate anxiety for their role and risk, or not.

There are several kinds of anxiety. Given the power of the presidency, a presidential election may tend to elicit anxiety about one’s very existence and the meaning of one’s life. That is called existential anxiety.

Individuals who are more intolerant of uncertainty are especially vulnerable to excessiveanxiety.

 The brain correlate of this intolerance is an increase in striata volume, particularly in the putamen. One brain model of subclinical and clinical anxiety is the uncertainly and anticipation model.10 This is a feedback model, in which there is either a disrupted cognitive estimation of probability and cost of a future threat, or heightened subjective feelings about negative future events. That it is a feedback model suggests why it is difficult to stop until neuroplasticity develops new anxiety pathways.

Although many individuals are overly anxious, others may not be anxious enough given the circumstances. They suffer from inadequate anxiety. Inadequate anxiety can lead to ignoring various risks and, in this case, not voting. Those individuals who have sociopathic tendencies tend to have less anxiety, which in turn may allow them to manipulate individuals with higher anxiety levels.

If there is an appropriate amount of anxiety, it would be an amount proportionate to the assessment of future danger, which in itself is difficult to predict and may change over time. Therefore, appropriate anxiety is a moving target. It needs regular monitoring and recalibration.

Anxiety has apparently persisted over human history, indicating that it has an important evolutionary role. Simply put, the evolutionary advantage of anxiety could be that it leads individuals to take fewer risks, seek safety, and focus on doing things well. On the other hand, anxiety can limit the risk-taking that advances human adaptability.

In terms of evolutionary psychology, anxiety would help us survive as a species. One way that anxiety can do this is to organize our cognitive functions quickly in response to danger. Additionally, another thesis is that chronic anxiety can be a driver of genius.

 Anxiety can also be a negative reinforcer that encourages the socialization necessary for survival and reproduction, because anxiety is generally most intense when we are isolated.

Reviewing some historical elections may be informative, and perhaps reassuring, as we approach this upcoming election.

A clear parallel can be drawn between our upcoming election and the election of 1920. It was during another devastating pandemic, the so-called “Spanish flu” that began in 1918. (President Trump’s grandfather died of this flu.) The worst of it was over by 1920, and the Republican nominee, Warren Harding, ran and won on a “return to normalcy” platform. His message resonated with the electorate, and he seemed to reduce the public’s fears. He was viewed positively while president but died only about 2 years into his term. Soon after he died, his reputation fell amid multiple scandals, stemming from his habit of giving government jobs to friends.

Our society today is split along ideological, racial, and class lines. The same was true during the election of 1968. On March 31, 1968, President Lyndon Johnson announced that not only was he partially halting the United States bombing of Vietnam, but also that he would not seek the nomination for president. Although his withdrawal offered hope for reconciliation, that dissipated quickly. Only 5 days later, Martin Luther King Jr was killed. Only a couple of months after that, Robert F. Kennedy, who was running for the Democratic nominee, was murdered. The nomination of Hubert Humphrey occurred during a violent, conflictual convention in Chicago. Richard Nixon won the presidency with a law-and-order message and a (secret) plan to end the war in Vietnam. Nixon knew what millions of Americans were worried about, and he promised to eliminate the sources of their fear.

Another election that has a lesson to teach us is 1980. The incumbent, Jimmy Carter, was defeated in part because the economy was awful, which caused increased anxiety and unhappiness. In his infamous “crisis of confidence” speech, he tried to address the nation’s concerns, but the voting public concluded that President Carter was in over his head. Similarly, the COVID-19 pandemic has adversely affected our economy, although it remains to be seen if the electorate will hold the president accountable.

The concern about the economy also brings 1932 into the picture. High unemployment levels contributed to Herbert Hoover’s landslide defeat. Franklin Delano Roosevelt led the recovery with federal work projects and mobilization for World War II. In his first inaugural address, Roosevelt told Americans that that they had “nothing to fear but fear itself.” He was effective because he at once calmed the nation’s nerves and tackled the underlying sources of its anxiety: poverty, unemployment, and hunger.

For psychiatrists in particular, perhaps the most anxiety-provoking election was in 1964. Answering a poll conducted by FACT magazine on whether Barry Goldwater was mentally fit to be president, about half of the replying psychiatrists provided what Freud would call “wild analysis.” Goldwater sued the magazine, won his case, and psychiatrists were embarrassed. The result was the 1973 Goldwater Rule, set by the American Psychiatric Association. The rule barred psychiatrists from diagnosing or analyzing a public figure, an admonishment stirring anxiety and debate among psychiatrists in our time.14 Goldwater lost the 1964 election to Johnson in part because the electorate feared he might overreact to a perceived Russian threat and start a nuclear war.

poll found that two-thirds of responders preferred Hillary Clinton. We had a comment section then, and the discussion was passionate, suggesting some intense underlying anxiety in the mental health professional community.

Although less attention is given to vice presidents and vice-presidential nominees, they can make a difference, and their influence is not lost on voters or candidates. For instance, George McGovern initially added Thomas Eagleton as his vice president on the 1972 democratic ticket. Upon learning that Eagleton had clinical depressive episodes, McGovern consulted with psychiatrists who apparently advised him that a recurrence of depression was possible and could endanger the country.

 As a result, McGovern dropped him from the ticket. Interestingly, Eagleton went on to be reelected to the senate and achieved other career successes, and McGovern lost in a landslide. McGovern may have been too anxious about Eagleton’s depressive episodes, which may have cost him the seat. And, as we psychiatrists know, recurrence may be a risk, but it is not a good reason to think an individual is incapable of serving in a public office.

The vice president can represent other personal qualities that are important to the public. Joe Biden, Donald Trump, and Mike Pence are all older white males. In contrast, Biden chose Kamala Harris as his running mate. In picking a woman who is the child of Indian and Jamaican immigrants, he may be trying to assure the younger and more ethnically diverse parts of the electorate that he shares their concerns with racism, sexism, and other forms of discrimination.

Looking back on this historical survey, it appears that Americans reward politicians who are able to acknowledge their anxieties and put forth credible plans to eliminate the sources of their fears. Politicians who appear to be overly anxious, or blithely unconcerned, fare poorly.

Although you will not find “election stress disorder” in DSM 5, it has been 

 This “disorder” leads to all-or-nothing thinking and defense mechanisms of blame, denial, and avoidance. These reactions can lead to cult-like, brainwashed adherence to a one-sided perspective. Should you or your patients feel overwhelmed or anxious, many of the traditional behavioral approaches may prove to be helpful (

). We need to be especially cognizant of countertransference, reactions where our own anxiety and political beliefs intrude into the therapeutic arena.

After the election, another informal disorder may emerge: a so-called post-election stress disorder. This phrase was first 

when President Obama was elected as a result of conflict and rising anxiety, especially around the issue of race.

 Therefore, it was not surprising to see some post-election emotional fallout and backlash regarding the country’s first Black President. Did those reactions last and influence the election of President Trump?

Whatever the case, the period after the 2020 election may be more anxious still. There are already wide-spread fears of voter suppression, voter fraud, and delayed results. Post-election anxiety could escalate even more than in 2000, when a controversial Supreme Court decision ended the Bush-Gore race.

At least going back to the time of Plato, philosophers have tried to reduce the role of emotions such as anxiety in politics and promote rationality alone.

 Given the importance of anxiety in our evolution, psychiatry should not be surprised at the limitations of that approach.

Of course, undo anxiety about safety and security leads to vulnerability, a propensity to being manipulated instead of educated. Recent polls indicate that such groups as young adults, Blacks, and Latinos are becoming increasingly anxious, likely due to uncertainty about their future. Particular attention needs to be paid to the well-being of these groups in terms of family and community psychological support, which in turn can make them more resilient.

Charismatic leaders more concerned with themselves and their public image than with the public good are particularly problematic. With our 2-party system, political leadership can change suddenly, and the losing party is often afraid of what will happen to them under the new regime. Leadership for all is necessary to reassure the losing side that it does not need to panic or lash out.

Anxiety is an essential emotion that can help us assess and respond to future risks to our safety and security, a basic human psychological need as Maslow has taught us.

 However, to use anxiety successfully, people need to be able to assess risks rationally. Although the future is unknowable, educated estimates can still be made—if there are accurate information and facts. One of the psychiatric lessons from the Spanish flu and the public panic that accompanied it was the need for the government to be honest and open.

Since psychiatry has expertise in distinguishing fantasy from reality, as well as managing anxiety, we are essential for making presidential anxiety useful, rather than harmful for the public, patients, and for ourselves. Our Psychiatric Times polls indicate that both we and our patients are quite worried, with the good news that about half of us are already trying to do something productive about it.

The role of psychiatry in politics has been limited by the Goldwater Rule against commenting on public figures that we have not evaluated. As a result, psychiatry has retreated to the margins of the political arena. How might psychiatrists play a larger, more productive role in American public life? Psychiatrists could be involved in routine mental health assessments of any presidential candidate and annually for the president. Additionally, there is no prohibition against educating the public and our patients about the role of anxiety in politics. Psychiatrists could help their fellow citizens hit the sweet spot of anxiety: enlightened participation, voting, realistic hope, and improved mental well-being. In fact, it is psychiatry’s ethical responsibility to contribute what we can “to the improvement of the community and the betterment of public health.”

Psychiatric Times has featured a series looking at the psychiatric challenges for the 2020s, and it now seems that politics and psychiatry will be one of them. This is one of the social aspects of psychiatry.

 There are 2 more elections scheduled during this decade. Just like finding the right amount of anxiety, we need to find the right amount of political engagement, not too much and not too little, in the 2020s.

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 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 

Anxious Politics: Democratic Citizenship in a Threatening World. 

2. Bethune, S. Americans are stressed about the presidential election. 

51(1). January 1, 2020. Accessed September 11, 2020. 

http://www.apa.org/monitor/2020/01/news-stressed-election

3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. 

2020;69(32):1049-1057. Published 2020 Aug 14.

4. Assari S, Curry TJ. Black men face higher discrimination and depression, even as their education and incomes rise. 

5. Assari S. Interaction between race and gender on implicit racial bias against blacks.

6. Lerer L, Plott E, Gamio L. How Americans feel about the country right now: Anxious. Hopeful. 

7. Moffic HS. FDR, the Bene Gesserit, and the Psychiatry of Fear. 

https://www.psychiatrictimes.com/view/fdr-bene-gesserit-and-psychiatry-fear

9. Kim MJ, Shin J, Taylor JM, Mattek AM, Chavez SJ, Whalen PJ. Intolerance of uncertainty predicts increased striatal volume. 

10. Grupe DW, Nitschke JB. Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. 

11. Lykken DT. A study of anxiety in the sociopathic personality.

Genius & Anxiety: How Jews Changed the World, 1847-1947.

13. Dickinson MJ, Fava EJ. Anxiety and depression may have an evolutionary role as negative reinforcers, encouraging socialization. 

The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President.

16. Stosny S. Do you suffer from election stress disorder?

April 15, 2016. Accessed September 11, 2020. 

https://www.psychologytoday.com/us/blog/anger-in-the-age-entitlement/201604/do-you-suffer-election-stress-disorder

17. Stosny S: Post election stress disorder. 

November 4, 2008. Accessed September 11, 2020. 

https://www.psychologytoday.com/us/blog/do-the-right-thing/201702/post-election-stress-disorder-is-it-thing

19. Barry JM. What the 1918 flu pandemic teaches us. Yesterday’s lessons inform today’s preparedness. 

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

American Psychiatric Association Publishing, 2013 Edition.

21. Moffic HS. Should the 2020s be the psychiatric decade of the social? A debate. 

With partisan political warfare, civil unrest, and the presidential race, how can mental health professionals assess and address “election anxiety”?

Presidential Election Anxiety and the Role of Psychiatry

SPAR’s cover story for the August 2020 issue of 

.” Following its publication, the authors conducted a 

 on the subject on August 20, 2020. The audience, around 300 participants, participated with gusto, and we were left with about 50 unanswered questions. We are now embarking on answering some of them, and this column will be the first. In part, we picked this one first because of the serendipitous timing of the 

 article on the same day of the webinar. Gradually answering the questions will also help keep the focus on racism.

: What organization recently issued an apology through the 

What is so important about answering the simple question of an apology? We could have just answered with: The American Academy of Pediatrics. However, that would beg such related questions:

Why hasn’t organized psychiatry apologized?

How does apologizing apply to other societal institutions?

The American Academy of Pediatrics formally apologized for its history of internal racism in the September issue of their journal, 

. In addition, it went beyond an apology by acting to change its bylaws to prohibit discrimination based on various social and cultural identifications.

Let’s take a look at history. Roland B. Scott, MD, a nationally renowned pediatrician for his research in sickle cell disease, applied for membership numerous times beginning in 1939. The minutes from the organization’s 1944 executive committee meeting are chilling, and include:

“If they became members, they would want to come and eat with you at the table. You cannot hold them down.”

If you were not a member of a local or state medical society, you could not join the American Medical Association (AMA). For many Black physicians, exclusion from the AMA and other specialties meant the loss of career opportunities and specialty certification. The AMA also played a role in closing some of the Black medical schools, which were important since many Black applicants had trouble getting acceptance into medical schools just because they were Black.

The current president of the American Psychiatric Association, Jeffrey Geller, MD, has been writing a regular column for our organization’s newsletter, 

, detailing the APA’s extensive history of internal racism. He has also formed a Task Force to investigate the problem over the year of his presidency.

However, the APA has not yet issued a formal apology.

This column is being written as the Jewish Day of Atonement, Yom Kippur, arrives. It is the time of year when Jews are supposed to ask for forgiveness for their wrongs, committed consciously or unconsciously, from God and other people.

In that spirit, let us apologize to any reader who we have wronged in the past year.

The Jewish tradition stresses real teshuvah, literally meaning “return,” from what we did wrong. That process involves 5 parts: recognizing wrongdoing, feeling remorse, not repeating the wrongdoing, providing restitution when possible, and confession. Actually, it seems like most every religion has some version of this apology process, suggesting that it is an essential process for humans, perhaps because it can restore people’s trust in the community.

The psychiatrist Aaron Lazare, MD, examined apology in depth, culminating in his classic text, 

 (Oxford University Press; 2005). He concluded that apologies, once the typical initial reluctance to do so is overcome, have the power to heal humiliation, reduce undue guilt, eliminate vengeance, and restore broken relationships.

However, there are apologies that do not work or can make things even worse. Here are some of those ways:

Instead, say you were sorry that you were hurtful without any shadow of doubt.

If you did something wrong, do not sugarcoat it with excuses.

This is an apology when you blame the other for triggering your bad behavior.

4. “I was just being funny” when it was not funny.

In other words, you are telling the other party that they are being oversensitive.

5. “Let’s move forward” takes time.

Forgiveness should not require forgetting. That can take more time, if ever.

If the concept of structural and institutional racism is valid, it would be no surprise that racism has become embedded, covertly or overly, in all medical specialty organizations. Therefore, it seems inevitable that apologies would be needed from all.

It is unclear why the APA has not yet apologized for its internal racism, racism which has been documented over many years, as well as extensively and conclusively by Dr Geller recently. Of all specialties, we should know how psychologically harmful racism has become. Specialty organizations in psychiatry, although formed at a later date, would probably have also developed embedded internal racism and likely need to apologize. Moreover, state branches of the APA might have the right to do so even if the APA does not. Given that societal racism by definition involves most any psychiatric organization to some degree, thereby including clinical systems ranging from solo practices to hospitals, apologies might be a needed step in reducing racism clinically.

Indeed, the same antiracism principle may apply to any institution in society. Slogans, pledges, and tokenism do not suffice, but accountability, change, and outcomes will. Psychiatry, by its very expertise in the psychological aspects of racism can-and perhaps should-should lead the way. The only exceptions might be Black organizations.

Here is a timely societal example that also involves a physician. On the day before Yom Kippur, the 

published their plans for “An examination of the 

 failures on race, our apology and a path forward.” The owner of the 

, Dr Patrick Soon-Shiong, is a surgeon and medication innovator. His father fled China during World War II, and, after arriving in South Africa, became subjected to the discrimination of apartheid. Dr Soon-Shiong fled that discrimination to come to the United States in 1980. He advocates for the kind of truth and reconciliation that was used in South Africa to peacefully transition out of apartheid.

We call on the APA and other psychiatrist organizations to apologize by their next annual meetings, and then continue on a documented antiracism journey. Saying you are sorry, and meaning it, is a start, but not the required ending.

is Assistant Dean, Clinical Education, Charles Drew University School of Medicine; Chief Medical Officer, Kedren Community Health Systems, Los Angeles.

Members of SPAR (Seven Psychiatrists Against Racism).

Institutionalized racism is built into the very foundations of medical specialty organizations. The American Academy of Pediatrics recently issued an apology for said racism. Here is why other institutions should follow suit...

Answers to Your Questions on Dismantling Racism

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.

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

Author | H. Steven Moffic, MD