Rahn K. Bailey, MD

h is important so that as Americans, we never fail to remember the democide to African Americans in this country. In addition, we should acknowledge, admire, and celebrate Black heroes for their respective contributions. Moreover, for me, it is important to respect overall humanity and improve the quality of life for all Americans. Black history is American history.

Table. Reparation Efforts to Support Equality in the United States

Mentorship: Salute to a Windy City Educator

Balkozar Adam, MD, Rameshwari V. Tumuluru, MD, and Sarah H. Arshad, MD

Why Psychiatry Training Must Include Discussions on Structural Racism

Black Americans’ Distrust of the COVID-19 Vaccine

Why Is Black History Month Important to Psychiatry?

Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

H. Steven Moffic, MD, and Rahn Bailey, MD: 

If I Had a Hammer: Advancing the Conversation in Psychiatry and Racism

Purcell Pearson: A Young Black Man Who Dreamt of Becoming a Psychiatrist

7 Black Physicians That Made History in the Mental Health Field

Racism is pervasive. Its negative impact exists in many forms. The field of psychiatry has not been exempt from this 

, past or present. Such truth is of great concern as psychiatry represents a group of professionals whose primary purpose is to assess, diagnose, and treat serious persistent mental illness. Furthermore, as trained professionals in this medical discipline, society depends on us to set definitions, criteria, and standards to treat psychiatric illnesses. Therefore, it is imperative that as leaders we understand our past, in order to move forward toward eliminating structural forms of racism within our profession.

The early treatment of psychiatric disorders in this country was a forewarning of where we are today. There was a dark period in the beginning of psychiatry in America which predates the formation of the 

 (APA) in 1844. At that time, the perception of African Americans was inhumane. American psychiatry was started by 13 white men who were superintendents of asylums at the time.

 Early on in their organizational meetings, they decided to segregate facilities for African Americans—that is, if they were to receive treatment at all. Whether you lived in the free north or the enslaved south determined the care (or lack thereof) a Black patient would receive.

Diagnoses such as drapetomania were assigned to individuals who were considered mentally ill because they wanted to run away from their slave owners. Another diagnosis, dysaesthesia aethiopica (rascality), was considered an illness that compelled slaves to commit offenses. An early founder and leader of American psychiatry, Benjamin Rush, promoted the theory that the “color” and “figure” of Blacks were derived from a form of leprosy.

 In order for our society to evolve and move forward from structural racism we must cease glorifying legacies of individuals that promoted it originally. These misconceptions were promulgated by psychiatrists for a century.

In more recent history the vestiges of racism still exist. In 1910, the 

 except for Meharry Medical College and Howard University.

 This meant less training of Black doctors and therefore less quality health care for African Americans overall. Prior to the inclusion of Title VI into Medicare, hospitals were segregated. Black hospitals were significantly underfunded compared with white hospitals. Black physicians were not given the opportunity to work at white hospitals, and Black patients were denied health care. After the enactment of Title VI of the 

, 1000 White hospitals joined the program in a mere 4 months. Then and only then were African American doctors allowed to work and African American patients treated in those hospitals. This is an indisputable example of racial discrimination, only a half century ago.

In 2015, I was invited to a research meeting being presented by a lead cancer research scientist at a medical school where I was previously employed. Local African American community doctors were invited to discuss proposals for cancer research, hopeful that several would agree to refer African American patients to our clinical site. It was eye opening the degree of distrust, feelings of betrayal, and resentment that existed within many of those senior doctors who had experienced the 

 in that setting. In fact, more than one commented on having never been invited to the university site, for any activity.

This reality is particularly important because it sets a framework for the ongoing process of mistrust that many in African American communities feel toward research—and their government. This mistrust leads to 

 participating in clinical research, therefore compromising the validity of the results. Often, studies do not accurately represent the African American population. Hence, this leads to a lack of scientific progress and advancement for African American health indices.

In terms of education, I believe every child in America should receive equal educational opportunities. Particularly, such should include comparable funding. Our current system is fundamentally flawed, as it bases resources on the variable of location. Children have no influence on factors such as where they live or which zone has the highest property taxes. Thus, this strategy of funding public education is discriminatory to African Americans and/or ethnic minority children, many of whom reside in communities with fewer financial resources. Such a system of funding and governance has evolved into a cycle of less overall educational support. This current system must change.

Reparations have been discussed to address the historical governmental mistreatment of African Americans. This topic has been particularly polarizing here in America. Since this country’s inception, the principles of equality, opportunity, and freedom have been declared and promulgated with eloquence. However, the reality of life for African Americans as citizens has been markedly different compared to Whites. Our collective history has recorded over 4 centuries of slavery, oppression, and mistreatment of African American communities.

In many statistical categories which measure health, success, and prosperity in American life, there is a 

 between white Americans and African Americans.

 Some dissenters who criticize the concept of reparations use the counterargument of highlighting extraordinarily successful African Americans (eg, Carl Lewis in track and field). Unfortunately, that analogy overlooks the fact that such does not represent the majority of people. This issue must be addressed if we are to truly exemplify the ideals of this country.

Furthermore, reparations do not solely need to be in the form of monetary compensation (see 

). A powerful beginning can be made by addressing the 2 key initial pillars that would level the playing field for ethnic minorities in this country: health care and education.

 Reparations are not a handout. The idea represents the core construct of recalibrating life in American society, changing its structure and placing our country on the correct path to fundamental fairness.

 serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc. He served as president of the National Medical Association and chair of the American Medical Association’s Commission to End Health Disparities. He currently is a member of the American Psychiatric Association Board of Trustees. Throughout his career, Dr Bailey has worked with underserved and minority populations and has authored numerous papers on the topic. 

 is a research associate with Charles R. Drew University and Kedren Health Systems Inc.

The Original Thirteen Members of the Association of Medical Superintendents of American Institutions for the Insane

Racial Formation in the United States: from the 1960s to the 1980s

. New York; London: Routledge & Kegan Paul; 1986.

Medical education in the United States and Canada. From the Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four, 1910

4. Smith DB. Eliminating Disparities in Treatment and the Struggle to End Segregation. 

 August 2005. Accessed February 16, 2021. 

https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2005_aug_eliminating_disparities_in_treatment_and_the_struggle_to_end_segregation_775_smith_ending_disparities_in_treatment_pdf.pdf

A Systematic Review on the Impact of Slavery: 400 Years of Trauma

 Doctoral dissertation, California Southern University. 2020.

6. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. 

Wealth inequality in black and white: Cultural and structural sources of the racial wealth gap

8. Office of the Legislative Counsel. May 1, 2010. Compilation of Patient Protection and Affordable Care Act. Accessed February 16, 2021. 

http://housedocs.house.gov/energycommerce/ppacacon.pdf

Articles

“Race paralyzes our natural inclination to ask certain questions and listen to the answers that follow. The inability to have honest, albeit difficult, conversations that lead to change is 

 So write past presidents of residency training and organized psychiatry. Psychiatry as a field is a place where honest conversations happen in psychologically safe spaces. It is difficult to talk about painful subjects in our lives. It is especially difficult to talk about trauma we have tried to forget. Racism has caused more than its fair share of trauma, including the intergenerational transmission of trauma. Any challenging conversation should be guided by principles of avoiding defensiveness; staying calm; being respectful; conveying curiosity; and listening deeply.

Although it is most expedient to prescribe medication like a “psychological surgeon,” psychiatrists should explore deeper and more challenging issues by first establishing a positive relationship with a patient. To overcome the understandable reluctance to talk, psychiatrists must establish a therapeutic alliance through confidentiality, concern, compassion, and competence. Indeed, achieving trust is often the most important 

It is common to hear one must accept being uncomfortable in discussions of race and racism, especially if one is being labeled white or a white supremacist. But that does not seem psychologically sound, or in line with best practices for having difficult conversations. The expectation that people in general conversation accept their own complicity with racism may well attract those who already agree, or who feel guilty and will readily take criticism as a just punishment. However, awkward discussions are likely to repel those who do not agree or feel they are being unjustly accused of being a bad individual. These non-participants may be critical to advancing the conversation. Similar to working with patients, uncomfortable dialog too early in a relationship often leads to leaving the situation entirely.

Just ask master interviewers their strategy to engage with others. Tributes poured in after Larry King recently passed away, lauding him for his ability to get his interviewees to open up to him. He has said that starting the interview with soft questions creates a comfortable environment, in which the interviewer can ask harder, more uncomfortable questions later.

Since race is a psycho-social construct, it must serve a crucial psychological function. That function may be to scapegoat the “other,” or the target, in order to maintain self-esteem and security. Human beings may be hardwired to fear the other, leading them to muster the power to ward off perceived danger. By denigrating individuals they want to control, they must exert power. Consequently, the issue of race has been used as a technique to manage human differences in politics, policing, education, health care, and elsewhere. Race and racism are not dangerous issues to talk about. There is more to gain than to lose in keeping an open mind.

Another reason race is hard to talk about is the climate of political correctness. Saying something about race that is deemed inappropriate may evoke a furious response. Calling out racism may appear to be a corrective action, but not if the recipient feels psychologically wounded or humiliated. That can lead to anger and a desire for future retaliation.

Given the structural and ubiquitous nature of racism, people of all ages, gender, and socioeconomic status should have a conversation about it. The experience of elders can supplement the values of the youth.

There are many ways for individuals to explore these topics (

). Potentially, conversations with a cultural mixture of individuals would be best, as that reflects the diversity of the United States, and hopes for its unity. In psychiatry, these conversations can occur in patient, care, collegial interactions, publicly, and within personal relationships.

Conversations on race can also happen in numerous places. It can and should be done at home, and at schools, including medical schools. It can be in casual circumstances or planned discussions. It can be done live and/or online. Whatever works for a given individual is best.

Terminology can help or hinder conversation. What words will be inviting or repellent to would-be discussants? Are the current preferred colloquial names of racial groups unifying or divisive? Are Black, white, and brown the best terms for so-called racial groups when we are all people of color, some darker, some lighter? White people generally have lighter skin, but who among the lighter colors are not white? Where do light skinned Jews, Muslims, Hispanics, or individuals of mixed racial ancestry fit into this categorization? Misidentifying someone is unlikely to contribute to an alliance. Given that so-called “white supremacy” is associated with the “alt-right” politically, does that term backfire when applied to all whites?

The term “race,” in of itself, could be considered a contribution to racism. It implies there are important differences among people who are virtually the same genetically. Ironically, it is a term of unity.

Given our country’s long history of racism against Blacks, Indigenous, and other minorities, some degree of structural, institutional, and individual racism is inevitable and ubiquitous for now. Racism is harmful. Harming another generally calls for an apology to achieve healing forgiveness and reconciliation. It is self-evident that a country and an institution cannot apologize because they are not individuals and cannot thereby talk or write. It takes those who are spokespersons for them to do so. That is what recently happened in psychiatry with the American Psychiatric Association (APA).

On Martin Luther King, Jr. Day, Monday, January 18, 2021, the 

 toward members, patients and the public who are “Black, Indigenous, and People of Color” (BIPOC). Moreover, we should be experts on how to apologize. It is a psychological process, after all. The late psychiatrist Aaron Lazare, MD, was an expert on apology.

 He warned us: apologies are often helpful, but they can be meaningless or even harmful if not done properly and well.

We all know that full apologies are difficult. Any parent will receive multiple apologies from children without a change of behavior. In medicine and psychiatry, mistakes can also be inadvertent because of the science and standards of the time, so well-intentioned professionals may still be called upon to apologize later, even though they were doing the best they could at the time.

Table 2. Six Ways to Advance the Conversation About Racism in Psychiatry

Will the APA’s apology advance or hinder the conversation? Time—and how the apology is processed—will tell. It does meet some of Dr Lazare’s criteria for an effective apology. The apology is clearly stated and explained, many historical examples are provided, and some remorse is expressed. It rather uniquely includes Indigenous and people of darker color. It did not discuss how antiracism will be monitored and reported, but there is a Task Force that has already been working on this challenge. Although the psychological impact of any apology can be helpful, follow-up up corrective actions are crucial for full impact.

For instance, perhaps the hardest racism topic to discuss and act upon is the question of reparations. Since we live in a country founded upon principles of equality, opportunity, and freedom, many individuals fail to see the continuing remnants of 400 years of slavery and discrimination that limit fulfillment of those principles. One solution is reparations, not solely in the form of monetary compensation, but in services such as quality education and health care that are key to prosperity for all. One example is 

, one of the largest health care systems in Milwaukee. It is refining the current category of vaccinating patients by prioritizing “those most vulnerable based on risk factors including age, health conditions, and those who live in zip codes disproportionately impacted by COVID.” In effect, it helps to redress some of the health care disparities putting those people at current higher health risk for COVID-19.

1. Advance the Conversation by Expanding It

 To get a sense of how psychiatrists are reacting to the apology, surveying is needed. This step is especially important because the APA membership was not canvassed in any way during the development of the apology. Be more transparent about how the apology was reached. 

2. Advance the Conversation by Monitoring It

  In past APA Annual Meetings, controversial matters such as psychiatrist burnout have been discussed in town halls. These forums for discussing racism should be set up and heavily publicized in future meetings. Other subspecialty and related psychiatric groups should consider their own apologies and discussions. Each year, on Martin Luther King Jr Day, the APA could make an annual antiracism report.

3. Advance the Conversation by Improving It.

 suggests, a key to unlock antiracist optimism is already available to all.

 It is a trial-and-error process to see if the key fits, and we must explore whether the locks have changed. Psychiatrists should try different models and share the results. In most cases, the principles for establishing a therapeutic alliance and processing difficult conversations are essential to the process. Partnerships trump rivalries.

4. Advance the Conversation by Normalizing It. 

The dialog needs to touch all levels of racism: societal, institutional, and individual. Because it may exist anywhere, from the pictures on the walls to staff composition, it needs to be routinely kept in mind for everyday activities in psychiatry. Silence generally conveys acceptance of the status quo or resistance to change.

5. Advance the Conversation by Continuing It.

 Since racism has been embedded in the United States for so long, talking about race should be ongoing. Merely responding to racial crises as they happen is inadequate and will only maintain the status quo. As Martin Luther King Jr has 

, “Shallow understanding from people of goodwill is more frustrating than absolute misunderstanding from people of ill will.”

 Thus, the basics should be tested for in certification of psychiatrists, then supplemented by continuing education. And when the conversation does not go well, as it did not between President Biden and Vice President Harris during an early debate for the Democratic nomination, gracious processing of the issues and ironing out any misunderstandings can lead to a trusted partnership. In their case, their collaboration resulted in being chosen as 

, reflective of their current unity in diversity. Could we follow their model and propose the 

Antiracist Mental Health People of the Year 2021

 Conversation should not be taken literally; it goes beyond verbal exchanges. Nonverbal communication and actions convey messages as well. We have tried to take the first step with the dedications of this article. The first dedicatee is Henry (Hank) Louis Aaron, a man of relatively few words. Nicknamed “Hammerin’ Hank,” he used his bat successfully not only for baseball, but also for hammering down the nails of racism.

 Larry King, who was white, and Hank Aaron, who was Black, died 1 day apart in January. King interviewed him several times. In 1991, right after Aaron’s autobiography came out, they talked more about racism than baseball.

 This article is dedicated to Hank Aaron. May his memory be a blessing. He bravely played baseball (1954 to 1976) for the Milwaukee Braves, and then the Atlanta Braves when the team moved to the deep South and a center of the Civil Rights struggle (1966), where he broke the home run record. At every stage of his career, he dealt with racism with dignity and determination. He kept all of the hateful letters he received, including one that said, “If you come close to Babe Ruth’s 714 homers, I have a contract out on you.” Instead, Aaron later received the Presidential Medal of Freedom and lived until January 22, 2021, the day the first draft of this article was written.

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

 serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc. He served as president of the National Medical Association and chair of the American Medical Association’s Commission to End Health Disparities. He currently is a member of the American Psychiatric Association Board of Trustees. Throughout his career, Dr Bailey has worked with underserved and minority populations and has authored numerous papers on the topic.

Can we talk? The role of organized psychiatry in addressing structural racism to achieve diversity and inclusion in psychiatric workforce development

Difficult Conversations: How to Discuss What Matters Most

The therapeutic alliance: the fundamental element of psychotherapy

How to Talk to Anyone, Anytime, Anywhere: The Secrets of Good Communication

TM. 2020;37(12)1;12-13. Accessed January 29, 2021. https://www.psychiatrictimes.com/view/optimistic-prognosis-2021

Letters to a Birmingham Jail: A Response to the Words and Dreams of Dr. Martin Luther King, Jr

Person of the year: Joe Biden and Kamala Harris

 Harper Perennial, Illustrated edition; 2007.

What are best practices for difficult conversations about racism? How can psychiatrists help? The authors present 6 ways to advance discussions about racism in psychiatry.

If We Had a Hammer

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 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 

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 

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 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®.

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

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.

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.