Jessica Isom, MD, MPH

by Robert T. Carver, PhD, and Alex L. Pieterse, PhD; Columbia University Press, 2020

Reviewed by H. Steven Moffic, MD, Jessica Isom, MD, MPH, and Rahn Bailey, MD

If you think that striving for cultural competence and humility makes you ready and able to address racism in your work, this book may tell you that is not quite so. If you think that we still need a scholarly way to classify and describe the harm from racism, this book provides it. If you think posttraumatic stress disorder is an inadequate and even misleading way to describe the ongoing trauma of systemic racism, because it is not truly post, then this book provides a different perspective. If you are unsure of how to consider racism in our clinical evaluations, a structured interview is provided in 1 of the Appendices. And if you need a way to measure racism, this book also provides that in another Appendix.

This well-researched book is written by 2 psychologists with a long history of scholarly work on racism. Beyond psychology per se, mental healthcare professionals of any discipline can benefit from this tour de force.

There are 3 main parts, though the Introduction should not be ignored. Part I, “What We Know About Racism and Stress,” lays out a new concept of trauma as applied to racism. Because race has been relatively ignored in prior studies of stress and trauma, despite the relatively greater experience of stress and trauma in those subjected to racism, the authors make a strong case that we need an appreciation of race-based traumatic stress (RBTS). The reader will note that RBTS eliminates the word “post” from the destructive trauma, as does a related conception from the psychologist Kevin Washington, called Persistent Enslavement Systemic Trauma, which refers back to the original systemic trauma of slavery.

Part II, “What We Need to Know about Racial Trauma,” seems to be the meat of the book. Here the authors offer an overview and critique of race and racism within mental health professional training, guidelines, and policy documents. Euphemistic considerations are discussed, including the erasure of race and racism within terms such as cultural difference, multiculturalism, and cultural diversity. While the authors acknowledge the overlap between PTSD and RBTS, they rely heavily on the literature base and carefully crafted empirical research to distinguish RBTS as a separate and valid phenomenon. The development of the Race Based Traumatic Stress Symptom Scale is detailed, including a focus on its construction and validity.

Part III covers “What to Do With What We Know: Practice Applications.” Racism at home, in everyday life, in mental healthcare, and in particular, in forensic assessments, is presented. The various types of interpersonal and institutional racial discrimination are associated with higher levels of negative mental health outcomes for many racial group members. It is pointed out, importantly, that clinicians, especially those from the white majority, typically believed that race did not matter, but at the same time feared that it did. Actual treatment is not covered in as much depth as the subtitle implies, though it recommends that RBTS treatment should be divided into 3 parts: containment, symptom reduction, and recovery. Recovery means that the clinician sometimes has to go beyond the traditional dyadic relationship to engage in advocacy, activism, or accessing resources for the patient. Group interventions with racially homogenous members can be particularly supportive and educational.

In conclusion, the self-knowledge of clinicians has to include their own experiences and identity as racial and cultural beings within a racialized society. At the same time, clinicians still have to remember that each patient is an individual who may or may not fit these general racial concepts. We—the public, patients, and ourselves—still face the challenge of a society with structural racism that produces an ongoing source of trauma and undue stress. We still have much work to do, and this volume provides a sound new conceptual base and some unique tools to do so successfully.

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

is a clinical instructor in psychiatry at Yale School of Medicine, psychiatrist, and racial health equity champion.

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

All 3 doctors are members of SPAR (Seven Psychiatrists Against Racism). To read more from them, see 

Articles

This book provides key tools to help combat racism in the mental health profession. 

Measuring the Effects of Racism: Guidelines for the Assessment and Treatment of Race-Based Traumatic Stress Injury 

Slideshows

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

10 Measures and Outcomes to Assess Progress in Eradicating Racism

“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

This conversation was inspired by a clinical encounter during an intern’s inpatient psychiatry rotation after which she posed the question, “Was that racist?” An attending psychiatrist offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

“Was that racist?” As two black female psychiatrists, our professional and personal development have been punctuated by this question too many times to count. We invite you to our dialogue as an early career psychiatrist and resident psychiatrist as we outline a few of these most notable junctures of racism and our personhood. This conversation was inspired by a clinical encounter during Dr Uyanwune’s intern year inpatient psychiatry rotation after which Dr. Uyanwune posed the question, “Was that racist?” As an attending psychiatrist, Dr Isom offers reflections on her own training experience and continued challenges navigating a marginalized racial identity in psychiatry.

The question rang out seemingly accompanied by a haunting echo when I first heard it from you. I thought to myself that I had asked myself this question numerous times. The answer always lay in the body. I knew I needed to explain the body-based reactions that clue those with darker skin into the realities of a racialized existence. I wanted to say, “Trust your gut!” These were important signals throughout residency. The quickening of the breath. Goosebumps on the arm. Fluttering in the chest. The body sending alarm signals meant to communicate that you, they, we, are not quite right in this moment. Something is awry.

You asked, “Was that racist?” I offered a simple “Yes,” first because it is the most important thing to say. My reply was loaded with memories, pain, and anger as I too had felt and flinched at the experience of interpersonal racism. Did you notice anything in your body during that moment on the wards? Have you felt those clues before?

Sad to say, I have felt similar feelings and asked myself the same question. However, for me, it wasn’t until I moved from my home country Nigeria and lived in Europe (Holland, specifically) at the age of 11 that I was confronted with those physical sensations more often than not. At the time, my question wasn't, “Was that racist?” Instead, I constantly felt like 

I was focused primarily on myself and what I thought I was repeatedly doing wrong on a daily basis that resulted in differential treatment amongst my peers. It wasn't until a few years later that I was able to process these experiences, and as I look back now, when I ask, “Was that racist?”, the answer is, “Yes.”

Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels.

 It is a fascinating thing, racial ethnic identity development. It is a different journey for all of us, so individualized. I remember when I was 10 or 11 and on a family trip to Walmart. I had been told by my parents I was black and the world was going to treat me differently. However, I hadn’t quite experienced the shock of it until I turned the corner in the store and came face to face with an older white woman pushing her cart. She was accompanied by her husband. She nearly spat at me, “Stupid N*****r,” before rushing past me with her husband, who stood silent, as if I were non-existent.

That is when I knew, you can feel it in the body; it’s so visceral. I was terrified. That moment was a reality check that racism had no regard for the innocence of my youth. I still cry at the memory especially when thinking about the possibility of my toddler daughter being exposed to a similar encounter at some point.

Wow, I’m sorry you had to experience that, especially at that age. After I moved from Holland where I attended a predominantly white school, I went to college in Toronto, Canada, and found myself surrounded by black and brown bodies. In Holland, I didn’t feel comfortable telling my white friends about my racialized experiences. However, in Toronto, I felt more validated amongst my friends. It was a more comfortable space where I wasn’t gaslighted but rather affirmed whenever I spoke about these difficult and traumatic experiences. This allowed me to be more vocal about the discrimination I experienced on an almost daily basis.

 I had the same experience at my historically black college. It was transformative. Wouldn’t it be wonderful to have that kind of mirroring experience anywhere we go such as residency and life in general? To be validated, affirmed, and supported in general but also to have support when processing our experiences of racism? Knowing that that isn’t always the outcome has led me to be more silent in spaces where a validating response is less likely.

The dangers of projection are always around us. We take steps to not appear angry or aggressive which saps our opportunities to assert our humanity. It is nearly surreal that we have to take extra steps to avoid rocking the boat by erasing our own experiences for the comfort of others. Black Lives Matter, right?

Yes! As a trainee in medicine, it would be healthier to feel comfortable sharing these experiences on rounds with my attendings. Instead, I have found most of the time when discussing difficult patient encounters, my attendings fail to see through a racial lens when working with black and brown residents. Rather, they often put up a defense at the mention of racial dynamics, and this hinders further discussion and subsequently deters me from mentioning future experiences with them. They don’t seem to understand that they are undermining patient care.

 That white fragility is something powerful, isn’t it? With the overwhelming majority of attendings and administrators being white in our training program, it was a concept I remember having to learn quickly. You can never quite tell, particularly early in training, how much your lived experience will be honored. As an attending, I am still navigating spaces where my racialized experience cannot be discussed openly for fear of discussing what seems to be taboo in medicine.

It is interesting to see white people and others purchasing books on white culture now out of interest. I bought the books years ago for my own survival. I needed to read about white culture to be safe and successful. Beyond those who are black, this is an essential lesson for all those who identify as persons of color.

If you could offer one piece of advice to those responsible for trainees and working alongside any psychiatric colleague, what would you say?

To attendings and supervisors, I would say, read and educate yourself on these issues and topics. It is difficult and uncomfortable work that needs to be done. Let your trainees know they can come to you with difficult racialized experiences. And when they do, listen. This applies to any psychiatrist confronting racism, not just those in training. We could use your support at all levels. Foster a liberated space that allows them to speak their truth to power.

Believe them. Validate them. Affirm them. Lastly, practice calling out injustices and inappropriate behaviors when you see and hear them.

 I echo your suggestions and invite those in the field to examine their racial identity and own the responsibilities that come along with it, for our patients and for our specialty. The cost of silence on racism in medicine must become prohibitive. The time is now.

 is a PGY-2 Resident in the Department of Psychiatry, Yale School of Medicine. 

is an Attending Psychiatrist, Codman Square Health Center and Boston Medical Center.

An early career psychiatrist and resident psychiatrist reflect on their racialized experiences in predominantly white spaces and the impact on their lives.

The Cost of Silence on Racism: A Dialogue

Dr Isom is a recent graduate of the Yale School of Medicine, Department of Psychiatry, New Haven, CT. 

After ending my appointments with the kind, elderly patients on my outpatient geriatric rotation, I often rushed to the crowded resident workstation to sit down in the weathered chairs that faced the wall computers. This frantic pace never mirrored the slow stroll of history gathering as I met with patients alongside the geriatric psychiatry fellows. It had been a wonderful rotation thus far, full of stories detailing the joys of old age juxtaposed with the grief, loss, and loneliness of some of our most vulnerable visitors. One afternoon, before I had a chance to settle into the only available seat and log into the computer, I received a text message that read, “I’m in the hospital.” It was from a patient in the VA medical emergency room who was requesting that I come down to see her.

I closed my eyes and reread the words in my head before letting out a deep groan and taking a moment to stare at the screen while debating my next steps. This patient had come in for suicidal ideation and informed me that she had ingested extra quetiapine in order to “go to sleep.” I felt a twinge of frustration as I suspected that my own words earlier that day had led to the impulsive decision. I resolved to face the music as I had already lost my focus from the medical documentation.

Knowing that I would enter the elevator as a physician in training and exit as a family member of a woman with schizophrenia and 

 was a fact that I struggled to reconcile. With little choice in the matter, I bundled up my things and snuck away from the outpatient floor to visit my mother and her emergency department clinical team.

This shedding and assuming of varying roles, as if a chameleon prepared to adjust my colors to the context, has been a thread throughout my medical training and personal life. Growing up as a black lower income child in a military family of two boys and two girls, this ability to navigate multiple roles grew alongside the increased awareness of my mother’s unique struggles and my educational achievements. Humbly positioned as the sole physician in the family, it is no surprise that my most challenging moments in medical school and residency have centered on this delicate balancing act.

My professional life as a psychiatrist has been punctuated by intersecting crises that forced me to consider which of my multiple identities would take priority along the way. On which day am I a black psychiatrist as opposed to a psychiatrist in training? During which clinical encounter does my privilege as a 

 overshadow my modest first-generation college student background or my daily questionable mastery of raising a headstrong toddler? Am I fooling myself into believing these identities are anything but intersectional and reinforcing in every way?

Arriving to my current state of residence three years ago as an intern was a transition filled with uncertainty and triumph. I had resolved myself to travel to the Northeast, in part, to distance myself from the weight of responsibilities in my home state where my family had settled. I had spent much of my medical school years traveling back and forth to my hometown to put out fires sowed and reaped by the complexities of a psychotic disorder and psychosocial stressors. I had experienced firsthand what impact poverty had on my mother’s ability to maintain her grip on reality and her connection to her family.

Far too often, I would leave the lecture hall after a hurried, hushed phone call exchange and drive the 90 minutes through rural towns and fast food strips to reach her home. Thinking aloud along the highways, I would run through the recently learned jargon of psychiatric medicine that I had picked up along the way in my studies. Once home, I wove this knowledge base into my family’s complicated dynamic through impromptu mediation sessions and hasty attempts at translating the terminology into words that would heal the wounds of repeated misunderstandings. Little did I know, these same skills would be relied upon in my management of crises as an intern and then resident on the psychiatric wards.

As I have progressed through my residency, I have wrestled with how little of this personal experience of the ramifications of mental illness are transmittable to my patients. I often struggle with the professional necessity of limited disclosure. The tender moments where true empathy, the kind that accompanies lived experience, would be essential are often failed by the demands of the traditional physician-patient relationship. This is never more clear than when I am knocking on a patient's door with my university hospital badge on full display. There is a certain level of pride that enters the room with me as I engage with my patients buttressed by the reputation of a formidable institution.

As a black, female psychiatry resident with a non-Ivy League background, I find this badge is a subtle reminder to suppress the nagging doubts of my imposter syndrome. There are moments, however, when that reminder is cloaked in guilt when confronted with the oppressive business practices familiar to large hospital systems around the country. These discussions on space, belonging, and community with patients and community activists have been difficult to navigate, and fortunately my residency program has created opportunities for these essential conversations to take place.

My appreciation for the value that psychiatry brings to the field of medicine had never been greater than when I sought our services during my lowest moments of residency. I had entered into my own psychotherapy as a second-year resident and often fumbled with how to use the privileged space. My comfort had grown over time and I began to appreciate the utility of a therapeutic relationship even when a particular crisis was not present. This relationship strengthened during my pregnancy when my mood began to dip and the familiar checkboxes of a depressive episode became my lived experience. I successfully navigated my pregnancy with the additional support of pharmacotherapy and deepened my love for this specialty that turns darkness into light. I am now raising a headstrong one-year-old and striving daily to model how wellness and happiness can be attained while pursuing my professional and personal interests alike.

My journey throughout training has been rife with challenges, triumphs and life’s lessons. I see and experience bits and pieces of my mother in every patient. I reflect daily on aspects of my identity that are uniquely privileged and am inspired by the portions of my identity that have produced a tenacious resilience. I end each of my shifts enveloping a new life in my arms as she beams and babbles learning the complexities of language. These intersecting experiences represent a beautiful portrait of one psychiatrist’s life.

Editor’s note: A health consent form has been signed by the patient discussed in this article.

The author reports no conflicts of interest concerning the subject matter of this article