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Our ethical priorities must include the care of our colleagues as well as our patients of backgrounds subject to hate and discrimination.
Providing competent care to patients of all cultural backgrounds has always been an ethical challenge for psychiatry and society. Solutions to our most current cultural challenges are the focus of a presentation to begin the American Psychiatric Association (APA) Annual Meeting on May 18, 2019, in San Francisco. This presentation was one of several, including one by the APA President from 2018 to 2019, for the session titled “Cultural Issues in Psychiatric Administration,” chaired by Victor Buwalda, MD, PhD.
Ethical principles for cultural psychiatry
To examine what the formal ethical principles for cultural psychiatry are, all we have to do is peruse the available documents provided by the APA1 and the American Association of Psychiatric Administrators (AAPA).2 The principles established by the APA are geared to clinicians, whereas those by the AAPA are for psychiatrist administrators and their organizations.
In the APA’s ethical principles, the key reference to cultural psychiatry occurs in Annotation No. 2 to Section 1. Section 1 states:
“A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights.”
Annotation 2 follows with:
“A psychiatrist should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation.”
As good and extensive as this Annotation is, it actually does not specifically address the need to make competent care of any underserved minority group equivalent to that of all patients. That is a crucial omission given our history of having Black Americans and other minority groups being underserved or mis-served. Fortunately, there has been improvement since we developed model training programs,3 though there is still more room for improvement.
In the AAPA’s ethical principles, established in 2000, Annotation 3 of the same Section 1 is a revision of the other annotation for clinicians, but this time geared to administrators:
“Given the targeted patient population of the organization, the psychiatrist administrator should not allow discrimination of patients based on race, religion, or other sociocultural characteristics. Likewise, staff discrimination would not be tolerated.”
The crucial addition is the reference to the cultural diversity of staff. We can also take note of the importance of cultural diversity in terms of the epidemic of clinician burnout. In a 2017 Medscape report on psychiatrist race, ethnicity, bias, and burnout, the highest percentage of burnout was in self-identified Hispanic/Latino (52%), whereas Black/African American or Asian other than Chinese had the lowest rates of burnout (about 33%).4
Ever since Islamophobia escalated in the United States after the terrorist attacks by so-called Islamic extremists on 9/11/01, the mental health concerns of Muslim Americans have escalated to such an extent that this population may be the most underserved and least researched of all minority groups. That is one of the major findings in a new book on Islamophobia and psychiatry.5 Newly recognized is the paradox that in the early Middle Ages, Islam established the first psychiatric hospitals hundreds of years before Europe did the same, and their physicians developed the precursors to cognitive-behavioral therapy and Freudian theories. In other words, Islamic “psychiatry” existed well before there was even a formal field called psychiatry, and Muslim mental health care was way ahead of that of other cultural groups.
In current-day clinical practice, it appears that religiously informed psychotherapy works best for Muslim patients. Recommendations for administrators and psychiatrist leaders include the following6:
1. Reach out to the Muslim community wherever there is one, especially to the religious leaders.
2. For our own edification, we can invite experts with knowledge of Muslim cultural values and how that can translate into culturally competent care.
3. Hold a town hall meeting to discuss Islamophobia with the public.
4. Engage in the societal debates about Islamophobia and the attempts to bar Muslim “invaders” from various countries, without violating the Goldwater Rule not to analyze a public figure like the President of the United States.
It is of interest to know which cultural group is least Islamophobic in the United States. Perhaps the data will seem surprising. Over history, Muslims and Jews have had an intertwined history, often including conflict. Nevertheless, right now in the United State, despite the animosity between countries in the Middle East, a new survey indicates that Jews are the least Islamophobic religious group.7 The 2019 American Muslim Poll found that 53% of Jewish Americans had positive views of Muslims. Moreover, almost half of Muslim-American respondents had favorable views of Jews. Knowing each other in everyday life seems to be correlated with a positive outcome, similar to what can happen with exposure therapy for clinical phobic disorders.
The rise of anti-Semitism
Nevertheless, despite the relatively positive mutual regard between Muslims and Jews in the United States, what has perhaps been the most surprising development as far as current cultural psychiatry is the rise once again of anti-Semitism and its consequent harm to Jewish mental health. That has resulted in a sequel being developed to the Islamophobia and psychiatry book, titled Anti-Semitism and Psychiatry: Prevention, Recognition, and Interventions. The irony here is that Jewish psychiatrists were prominent in the development of the field of psychiatry and that the Jewish population was the least resistant to receiving treatment. In history, whenever anti-Semitism has increased, the discrimination and hatred have spread to other minority groups, inevitably resulting in increased anxiety and micro-traumas for those populations.
This surge of the longest hatred in history has even spread to Jewish mental health professionals. In 2018, a Jewish psychology professor at Columbia had the walls of the intimacy of her office invaded by spray-painted swastikas and anti-Semitic slurs.8 This professor had written about the Holocaust. Such incidents require all psychiatrist administrators and leaders to be sure that their working environments are as safe as possible for Jewish psychiatrists and other mental health care professionals, as well as all professionals whose safety is more vulnerable because of their cultural background. Therefore, we psychiatrist administrators and leaders have to realize that our ethical priorities must include the care of our colleagues as well as our patients of backgrounds subject to hate and discrimination. That is the ethical way.
H. Steven Moffic, MD, has won numerous professional awards for his administrative, clinical, educational, journalistic, and artistic work in psychiatry. Among these awards is that of the 2016 Administrative Psychiatrist Award, intermittently given jointly by the American Psychiatric Association and the American Association of Administrative Psychiatrists. He is also an Editorial Board Member of Psychiatric Times. Ever since he retired from clinical and administrative work in July 2012, he has devoted some of his advocacy work to reducing burnout in psychiatrists and other physicians through numerous articles and presentations. He also just edited a book on another underserved topic, Islamophobia and Psychiatry (Springer) and is now editing a sequel on Anti-Semitism and Psychiatry. His other current advocacy cause is the psychiatric aspects of climate and is a co-editor of a book in progress on the topic for American Psychiatric Association Publishing.
1. American Psychiatric Association. The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. Washington, DC: American Psychiatric Publishing; 2013.
2. Moffic HS, Saeed SA, Silver S, Koh S. Ethical challenges in psychiatric administration and leadership. Psychiatr Q. 2015;86:343-354.
3. Moffic HS, Kendrick EA, Reid K, Lomax JW. Cultural psychiatry education during psychiatric residency. J Psychiatr Education. 1988;12(2):90-101.
4. Peckham C. Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. Medscape. January 11, 2017.
5. Moffic HS, Peteet J, Hankir A, Awaad R, eds. Islamophobia and Psychiatry: Prevention, Recognition, and Treatment. Cham, Switzerland: Springer International; 2019.
6. Moffic HS. The psychiatric administrative ethical challenges of Islamophobia. J Psychiatric Administration Management. 2017;6(1).
7. Mogahed D, Mahmood A. American Muslim Poll 2019: Predicting and Preventing Islamophobia. The Institute for Social Policy and Understanding. May 1, 2019.
8. Gold M. Jewish professor finds swastikas spray-painted in office at Columbia. New York Times. November 29, 2018. https://www.nytimes.com/2018/11/29/nyregion/columbia-swastikas.html