Sitting with a patient, I often imagine a giant jigsaw puzzle box. Together, we take out pieces, arranging and sorting to create a narrative. Family history, childhood memories, culture, biology, family systems, and especially traumatic experiences—we put together a picture, then a road map to healing. In the past 5 years or so, I have come to realize that I had been insufficient in attending to a major section of the puzzle: racism as trauma. Those pieces stayed in the box, unexamined. A psychiatrist for over 30 years, I addressed sexual trauma and gender inequity in both my practice and community. Yet I had omitted thorough examination of the regular impacts of racism as trauma.
Trauma is a relatively recent concept in our field. In 1987, I presented then newly emerging data showing an alarmingly high prevalence of childhood sexual abuse; I still remember the front row of the auditorium, white men in white coats shaking their heads, suspiciously questioning the veracity of my work. Sexual assault was unspeakable; indeed, it had been purposely erased by Freud and generations of male psychiatrists afterward. Since then, our discipline has changed; we now have an acute awareness of the cost of sexual trauma to our patients.
When it comes to race, our failings are still apparent. Our services are disproportionately inaccessible by people of color, and our discipline is predominantly white, with only 2% of psychiatrists identifying as Black.1 There are significant racial disparities in treatment, and in diagnosis, with Black patients twice as likely as white ones to be diagnosed with serious mental illness.2 Yet in the therapy room and in our academic inquiries, the topic of racism as trauma has too often been absent.
It matters that we ask about racism when taking a trauma history. Adverse Childhood Experiences (ACEs) are a metric to document the impact of physical/sexual abuse, emotional abuse and neglect, parental substance abuse and marital violence, among other adverse events, on the future medical and psychiatric health of children. From ACEs, we learned that childhood trauma and adverse events are linked not just to future psychiatric illness, but also medical illness such as diabetes, hypertension, and heart disease. More recent surveys have included experiences of racism as an ACE.3,4 It remains notably absent from the list provided by the US Centers for Disease Control,5 uncounted as an official cause of harm by some experts in our field.
A white woman, I have worked to deepen my understanding of racism by listening to friends of color, by reading Black writers: history, personal narrative, and fiction. Over decades, I have used Peggy MacIntosh’s essay, “The Invisible Knapsack of Privilege,”6 to teach my residents and medical students about racism and white privilege. I thought that was enough.However, in the past few years, I have actively brought race into the therapy room. Now I hear the myriad daily insults, the threats to the integrity of self, my patients endured as children and continue to suffer as adults.
I am learning as I go, now, towards the end of my career. I begin with delicate questioning, as I gently prod and poke, my psychiatric verbal equivalent of the physical exam: “Is this where it hurts?” or “What if I press here?” I have always taught my medical students and psychiatry residents to inquire during an initial evaluation, “Has anyone approached you sexually in a way you felt uncomfortable?” At first, patients may not feel comfortable disclosing past trauma. There is so much shame; trauma is kept hidden for years. I learned decades ago that my broaching the topic, speaking into the silence, allowed for discussion at a later date, once a therapeutic relationship had been established, when trust was greater.
Opening the door
Recently, I have attempted to create a similar space for my patients to talk about racism, where trust may be more difficult to access. I may ask about racial identity. I ask about experiences of racism with my patients of color, weaving it into the other parts of my conversational evaluation.When I hear what sound like experiences of racism to me, I ask if I am correct? I name my perception. I try to be an ally. White patients may have relatives whose racism they are uncomfortable with; I try to be open to those issues, as well. My approach may not be enough to combat the overarching trauma that is systemic racism, and it may not be perfect, but it is what I have, at the moment, opening a space for those who need to speak their truth.
Suggestions on how to speak into the silence:
1. I know that this issue may not be what brings you here today, but experiences of racism have an enormous impact on many peoples’ lives; I am open to hearing about them and understanding how those experiences have affected you.
2. Especially for white psychiatrists: I invite you to discuss any issues of racism in this room, either today or in the future.I know I’m not a person of color, but I want you to know this can be a safe space for you to bring any of that in, at any time.
Example of identifying microaggression when you hear it.
A young woman who identifies as Black discusses a work call with a regional supervisor, whom she had previously met several times when he visited her local office. During the course of the call, he assumed that she was working with the only other African American person in her division and also forgot that he had already met her. I named those encounters as microagressions and validated her experience; we then explored how she continually feels erased and belittled at work.
Microaggressions, outright cruelty, racialized violence, and the way hatred and terror shape both young souls and everyday life for people of color is unfathomable to those of us who haven’t experienced it. I thought my kindness and openness was enough, yet I was unconsciously upholding the silence around systemic racism as trauma. Now I validate, contextualize, witness, and attempt to heal. I am striving to be better, hoping the next generation is better. There is infinite room for growth.
There are myriad facets and layers in the construction of “race” to be considered when including questions in our history-taking (see Sidebar). Do we ask these questions of all patients, or just those we perceive to be patients of color? Who decides someone’s race? Do we ask everyone how they self-identify racially, rather than proceeding as we have been taught in medical school (eg, “Ms. X is a 34 yo BF”)? Have we missed someone who self-identifies as a person of color? Do we ask all our white patients if they need a safe space to explore racism, whether it be family members who are racist, or the need to self-examine their own biases? It may be less important how we ask, than that we ask, that we speak into what has been a silence.
It is also crucial that white psychiatrists self-educate about systemic racism and white fragility if we are going to work with people of color. We need to ensure that we do not ask our patients to educate or forgive us for being part of an oppressive system. I do not claim expertise in this area, but rather, speak as a clinician trying to figure it out for myself. Hopefully, this provides a starting place for others to build on.
I encourage mental health professionals, especially those of us who are white, to educate ourselves.7 In the consultation room, we must speak into the silence about race, to name its presence, to listen carefully and deeply for echoes of racist trauma, to witness and name those pieces of the puzzle. Creating a space for the heretofore unspoken must become part of psychiatric evaluation, part of the treatment relationship, and a subject of academic inquiry.
Dr. Oshrainis a consulting associate, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC.
1. Starks S. Working with African American/Black Patients. American Psychiatric Association. Accessed August 20, 2020. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/best-practice-highlights-for-working-with-african-american-patients
2.Mote J, Fulford D. Now Is the Time to Support Black Individuals in the US Living With Serious Mental Illness—A Call to Action. JAMA Psychiatry. July 17, 2020.
3. Center for Disease Control. Behavioral Risk Factor Surveillance System ACE Data Violence Prevention Injury Center. Accessed August 20, 2020. https://www.cdc.gov/violenceprevention/acestudy/ace-brfss.html. Accessed July 17, 2020.
4. Crouch E, Probst JC, Radcliff E, et al. Prevalence of adverse childhood experiences (ACEs) among US children. Child Abuse Negl. 2019;92:209-218.
5. Center for Disease Control. Adverse Childhood Experiences (ACEs). Accessed August 20, 2020. https://www.cdc.gov/violenceprevention/acestudy/index.html
6. McIntosh P. White privilege: unpacking the invisible knapsack (1989) In: On Privilege, Fraudulence, and Teaching as Learning: Selected Essays 1981–2019. Routledge; 2019:29-34. doi:10.4324/9781351133791-4
7. Anti-Racist Reading List from Ibram X Kendi Chicago Public Library. Accessed August 20, 2020. https://chipublib.bibliocommons.com/list/share/204842963/1357692923