Mass Violence and Psychiatric Values

June 3, 2020

How can psychiatry constructively address our nation’s crisis?

An unarmed black man dies at the hands of police officers, and his death is ruled a homicide.1 Largely peaceful protests follow by day but, as darkness falls, violence breaks out in dozens of US cities. Attacks on police provoke hard-line responses by voices in and out of government, amidst anguished calls to end racial injustice. More than 20,000 National Guard members are called up in 29 states to deal with the violence.2 And, as if these horrors were not enough, the nation continues to struggle with the COVID-19 pandemic, which “has scythed its way through black communities, highlighting and accelerating the ingrained social inequities that have made African-Americans the most vulnerable to the disease.”3

It is easy to throw one’s hands up in the air and conclude that the nation is falling apart and that no one knows how to stop the disintegration. And yet, as psychiatrists and physicians, we know in our bones that we cannot give in to nihilism and despair-we are made of sterner stuff than that! The psychiatric profession, in particular, needs to step up and address the nation’s violent upheaval-but how? After all, we already have our hands full, dealing with the emotional complications of the pandemic, not to mention meeting the pressing needs of our patients with serious mental illness. And, realistically, we cannot solve all of society’s injustices and inequities. Nevertheless, step up we must. In my view, we can approach the issue from the standpoint of core psychiatric values.

We can start with psychiatry’s commitment to social justice. Thus, American Psychiatric Association President Jeffrey Geller, MD, MPH, recently noted: “The demonstrations are a result of racism against Black people that has gone unchecked-and at times has been fostered by leaders of this country. APA will not stand for racism against Black Americans.”4

Similarly, Saul Levin, MD,4 Medical Director of the APA, recently observed:

The civil unrest taking place in America is a call to action to all Americans to address the longstanding racial inequalities facing the Black community. Centuries of systemic and institutional racism toward Black Americans has led to decreased access to health care and multiple adverse health outcomes-as recently seen during the COVID-19 pandemic-in addition to anxiety and lower life expectancy. We need to fight racial inequalities and discrimination that are life-threatening to so many Black Americans.

Some may read this line of reasoning as somehow excusing violence-excusing the deplorable looting and destruction of stores and the violent attacks on police officers by a minority of lawless individuals.5 That would be a serious conceptual error. To understand the root causes of violence is neither to excuse nor to condone it. One of psychiatry’s core values is nonviolence and the peaceful resolution of disputes-and we need to apply that value even-handedly to all.

Psychiatry and community violence

As psychiatrists, we typically think of mitigating the risk of violence in a forensic context or in the setting of domestic violence, eg, by reducing intimate partner violence.6 But in my view, psychiatry has a broader role to play in fostering conflict resolution in the community setting. In part, this means viewing police violence and systemic racism as a public health issue, as Physicians for Social Responsibility (PSR) recently affirmed.7

The same point was made eloquently by Rebecca Bell, MD,8 President of the American Academy of Pediatrics Vermont Chapter, who said:

Racism is a public health issue and a social determinant of health that creates toxic stress and impacts health. Children will not be able to reach their full potential until we prevent and counteract these experiences for all children–in medicine and everyday life. The AAPVT Chapter condemns violence, especially when perpetrated by authorities, and calls for a deep examination of how to improve the role of policing. Systemic violence requires systemic response.

To be clear: Acknowledging and condemning police brutality against minorities is no license to demonize the police or other law enforcement officials, who have dangerous and difficult jobs. As mental health professionals, we would do far better by helping law enforcement officials learn methods of de-escalating potential violence in the community before it erupts.

What can be done?

In this regard, I cite the intriguing PhD thesis by Natalie Todak on “de-escalation in police-citizen encounters.” Dr Todak embedded herself in the Spokane, Washington, police department, spending 85 hours in a Spokane police car “for the purpose of getting to know the officers, the agency, and the city of Spokane.” 9 Based on these experiences and observations, she concluded that:

[O]fficers tend to be more highly trained in evaluating those encounters in which things went badly (because they are required to complete a thorough use of force report). Since use of force reports are more likely to be used in a court scenario, it is likely that these exercises largely train officers to justify their use of force rather than to critique it. On the bright side, most often in the 131 observed encounters the police were successful at calming the situation. Interviews also revealed that, while officers strongly believe there are situations in which de-escalation cannot be used, there are numerous opportunities for police to de-escalate. Most acknowledged that these tactics could be better trained and systematized in their agency…The findings should be taken optimistically that opportunities abound for police to hone their skills, improve their responses in ways that reduce violence, and address some of the long-standing criticisms directed at American policing.

Finally, we, as physicians, can follow the example of Alexa Mieses Malchuk, MD, MPH, who argued that, “As protests erupt around the country in response to police violence and the death of George Floyd, we doctors have a clear role to play.” 10 She continued:

In residency, I began volunteering with the Durham Department of Public Health. I saw how race, poverty, and other social factors actively hurt the patients in my care. In 2017, I helped prepare the department's community health assessment on racial and ethnic disparities and saw the same things reflected in the wider statistics I compiled. A Racial Equity Task Force grew from that assessment. My colleagues and I in that group work to integrate antiracist principles into public health, as well as data collection and reporting processes.

Am I hopeful that we will emerge from this dark period in our history having learned some crucial lessons and implemented necessary changes? I can only cite, with great respect and enduring hope, the lines spoken by Dr Martin Luther King: “The arc of the moral universe is long, but it bends toward justice.”11

Disclosures:

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). The author reports no conflicts of interest concerning the subject matter of this article.

References:

1. Vera A. Independent autopsy and Minnesota officials say George Floyd's death was homicide.  June 2, 2020. www.cnn.com/2020/06/01/us/george-floyd-independent-autopsy/index.html

2. Miller A, Sullivan T. Protesters return to the streets as Trump decries 'lowlifes'. June 2, 2020. /abcnews.go.com/US/wireStory/us-cities-erupt-violence-amid-threats-trump-71017369

3. Taylor K-Y. Of course there are protests. The state is failing black people. New York Times. May 29, 2020. www.nytimes.com/2020/05/29/opinion/george-floyd-minneapolis.html

4. APA press release. APA Condemns Racism in All Forms, Calls for End to Racial Inequalities in U.S. June 1, 2020. www.psychiatry.org/newsroom/news-releases/apa-condemns-racism-in-all-forms-calls-for-end-to-racial-inequalities-in-u-s5. Providence protesters break into mall, loot stores, burn police cruiser. June 2, 2020. boston.cbslocal.com/2020/06/02/providence-place-mall-protests-riots-fire-police-cruiser-george-floyd/

6. APA. Intimate partner violence. A guide for psychiatrists treating IPV survivors.  www.psychiatry.org/psychiatrists/cultural-competency/education/intimate-partner-violence

7.PSR. Statement on the killing of George Floyd. June 1, 2020. www.psr.org/blog/2020/06/01/statement-on-the-killing-of-george-floyd/

8. VMS press release. Vermont Medical Society condemns police brutality and pronounces systemic racism a public health threat. June 2, 2020. https://vtdigger.org/press_release/vermont-medical-society-condemns-police-brutality-and-pronounces-systemic-racism-a-public-health-threat/

9. Todak N. De-escalation in police-citizen encounters: A mixed methods study of a misunderstood policing strategy. Dissertation. August 2017. https://de-escalate.org/wp-content/uploads/2019/02/De-Escalation-in-Police-Citizen-Encounters-A-Mixed-Methods-Study-of-a-Misunderstood-Policing-Strategy.pdf

10. Malchuk AM. Doctors should learn to fight injustice, not just pandemics. Medscape. June 2, 2020. www.medscape.com/viewarticle/931583

11. Smith MD. The truth about ‘The Arc Of The Moral Universe.’ Huffpost. January 18, 2018. www.huffpost.com/entry/opinion-smith-obama-king_n_5a5903e0e4b04f3c55a252a4