If We Had a Hammer

H. Steven Moffic, MD

,
Rahn K. Bailey, MD

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.

BLACK HISTORY MONTH

-Series Editor, Frank A. Clark, MD

“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 endemic.”1 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.2

The Therapeutic Alliance

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 variable in patient improvement.3

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.4

What Makes Racism So Hard to Discuss?

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.

People and Places

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 (Table 1). 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

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.

Apologizing

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 APA apologized for its history of racism 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.5 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.

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 AdvocateAuroraHealth, 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.

Recommendations

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. (Table 2)

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. As the cover story for the December, 2020 issue of Psychiatric TimesTM suggests, a key to unlock antiracist optimism is already available to all.6 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 said, “Shallow understanding from people of goodwill is more frustrating than absolute misunderstanding from people of ill will.”7 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 Time Magazine’s Person of the Year.8 Note the person, reflective of their current unity in diversity. Could we follow their model and propose the Antiracist Mental Health People of the Year 2021?

6. Advance the Conversation by Action. 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.9 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.8

Acknowledgement: 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.

Dr Moffic 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 TimesTM. Dr Bailey 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.

References

1. Sudak D, Stewart A. Can we talk? The role of organized psychiatry in addressing structural racism to achieve diversity and inclusion in psychiatric workforce development. Acad Psychiatry. 2021.

2. Sone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. Penguin Books; 2010.

3. Stubbe DE. The therapeutic alliance: the fundamental element of psychotherapy. Focus (Am Psychiatr Publ). 2018;16(4):402-403.

4. King L, with Gilbert B. How to Talk to Anyone, Anytime, Anywhere: The Secrets of Good Communication. Three Rivers Press; 1994.

5. Lazare A. On Apology. Oxford University Press; 2005.

6. Moffic HS. An optimistic prognosis for 2021. Psychiatric TimesTM. 2020;37(12)1;12-13. Accessed January 29, 2021. https://www.psychiatrictimes.com/view/optimistic-prognosis-2021

7. Lorritts B, Editor. Letters to a Birmingham Jail: A Response to the Words and Dreams of Dr. Martin Luther King, Jr. Chicago, IL: Moody Publishers; 2014.

8. Alter C. Person of the year: Joe Biden and Kamala Harris. TIME Magazine. December 21-28, 2020.

9. Aaron H. I Had a Hammer: The Hank Aaron Story. Harper Perennial, Illustrated edition; 2007.