Structural Racism and Psychiatric Practice by articles

ORIGINAL ARTICLE

Structural Racism and Psychiatric Practice A Call for Sustained Change Rachel M. Talley, MD,*† Matthew L. Edwards, MD,*‡ Jeffrey Berlant, MD, PhD,*§|| Elizabeth S. Wagner, MD, MPH,*¶ David A. Adler, MD,*# Matthew D. Erlich, MD,*** Beth Goldman, MD, MPH,* Lisa B. Dixon, MD, MPH,*** Michael B. First, MD,*** David W. Oslin, MD,*††† and Samuel G. Siris, MD*‡‡

Abstract: Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples. Key Words: structural racism, systemic inequities in psychiatry (J Nerv Ment Dis 2021;00: 00–00)

ur nation has entered a phase of increased divisiveness (Boxell et al., 2020), which has inflamed long-standing divisions rooted in the nation's history of White supremacy and systematic oppression of racial and ethnic minorities. A convergence of societal flashpoints including a divisive presidential election cycle, the COVID-19 pandemic, and the highly publicized killings of unarmed Black Americans by police have fostered more open, dangerous expressions of the explicit and implicit racism that underlies some political ideologies. At the same time, this convergence has generated wider recognition of the persistence of these issues and a refreshingly urgent interest in addressing them. Psychiatry as a field is not immune to these societal forces. As with many institutions, psychiatry as a field has to decide how to respond to the exposure of the hidden influence of structural racism on our work (Warner, 2021). Calls to address institutional racism in psychiatry have far predated this moment (Sabshin et al., 1970), and yet,

*Group for Advancement of Psychiatry, New York, New York; †Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, California; §Optum Idaho, Boise, Idaho; ||Canyon Manor Mental Health Rehabilitation, Novato, California; ¶Department of Psychiatry, Brown University Alpert Medical School, Providence, Rhode Island; #Department of Psychiatry, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; **Department of Psychiatry, New York State Psychiatric Institute/Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; ††Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, Pennsylvania; and ‡‡Department of Psychiatry, Donna and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York. Send reprint requests to Rachel M. Talley, MD, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104. E‐mail: Rachel.Talley@pennmedicine.upenn.edu. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/21/0000–0000 DOI: 10.1097/NMD.0000000000001442

our current treatment paradigms are not sufficient to meet this moment. Consider examples drawn from our own clinical and teaching work: • A clinical team is working with a White patient who has voiced wariness of working with Black clinicians. Team members suggest that a Black psychiatrist work with this patient to provide the patient with a “corrective emotional experience.” • A White patient with refractory psychosis and chronic persecutory delusions is in urgent need of dental care. She refuses multiple dental care options, stating that all options have “Black dental assistants,” who she will not see. • In supervision, an Asian-American psychiatry resident describes multiple microaggressions that he has experienced from patients related to the origin of COVID-19. The resident and his White supervisor reflect on the complexity of responding to and experiencing these events. • A Black patient asks his Black psychiatrist about her political leanings. Before the psychiatrist can respond, the patient says, “I know you are not going to like this, Doc, but I'm thinking about voting for Trump.”

These incidents highlight how long-standing historical inequities come to the forefront in our clinical work. These issues may challenge our ability to be therapeutic. How best do we grapple with the patient who refuses to be treated by providers of a specific racial or ethnicity, balancing our service mission with our own values? How should we address explicit questions from our patients about our own political views and leanings in a time when these issues have both a heightened prominence and particular relevance to racial identity? If we bypass these questions, are we avoiding an increasingly unavoidable “elephant in the room”? Where are our tools, strategies, and skills to adequately address the burden placed on minority providers who interface with patients holding explicitly and implicitly racist views? How can supervisors support trainees as they increasingly encounter these issues (Osseo-Asare et al., 2018)? These are but a few of the questions the current environment raises. Some foundational concepts from our current treatment paradigms can help us understand and work through issues of racism and racial identity in our clinical work: • Our experienced interpersonal work with individuals in psychological distress • Attention to our self-identities and the measured use of self-disclosure • Awareness of transference in our patients triggered by having asymmetrical identities • The ability to reflect on our countertransference reactions in the face of microaggressions • The need to foster therapeutic alliance building and relate to individuals through perspective-taking.

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Talley et al.

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Although these tools are helpful in our routine clinical work with patients, we question their sufficiency to address the challenges of the current moment, endangering the therapeutic relationship with some of our patients. We sit at a flashpoint of cultural histories shaped by intergenerational trauma and the discouraging aspects of our society, breeding anger, frustration, and marginalization. We must recognize the power of group and social influences. We must also understand the power of human social networks (Christakis and Fowler, 2009) and our “[dependence] on others for understanding, feeling, and the extension of the sense of reality” (Asch, 1952). Education of our trainees and ourselves must reflect the nature and complexity of these issues. To be prepared, we need to develop strategies for confronting racialized divisiveness. Our psychological interventions must be structured to help individuals understand when and how they may feel empowered to think and act independently and when and why they may need to “yield to group pressures when these are contrary to fact” (Asch, 1952). Although these public challenges call for a broader response, we as mental health clinicians should continue our work in helping our individual patients understand their “private troubles” in the context of the broader “public issues” (Mills, 1959). Although the current environment has thrown issues of inequity into sharper relief, racial inequity among mental health outcomes has long been observed and documented. Racially and ethnically marginalized persons disproportionately lack adequate access to mental health care (Edwards et al., 2021; Ault-Brutus, 2012; Cook et al., 2017). They are disproportionately less likely to receive life-altering interventions such as clozapine (Williams et al., 2020; Kuno and Rothbard, 2002). Black patients with depression are disproportionately less likely to receive electroconvulsive therapy (ECT). Lack of availability of ECT in the treatment setting (Case et al., 2012) and other demographic/ geographic features (Breakey and Dunn, 2004) have not accounted for this disparity. Black patients are diagnosed with psychotic disorders at rates three to four times higher than their White counterparts (Schwartz and Blankenship, 2014); Black men in particular are at high risk for having affective psychosis misdiagnosed as primary psychosis (Strakowski et al., 2003). At the same time, minority populations are disproportionately exposed to social determinant factors that drive risk for psychosis (Anglin et al., 2021). Disproportionately higher use of physical restraint on minority patients has been noted in the emergency department independent of other demographic factors including history of violence (Schnitzer et al., 2020); similarly, higher use of restraint for non-White patients as compared with White patients has been observed in the inpatient psychiatric setting, despite no difference between groups in number of violent acts (Bond et al., 1988). Disparities in prescribing practices have also been noted; Black patients with schizophrenia are far more likely to be treated with first-generation antipsychotics and far less likely to receive second-generation antipsychotics than their White counterparts (Lawson et al., 2015; Mallinger et al., 2006). Thus, the urgency of the current moment is underscored by long-standing and persistent inequities in treatment that demonstrate the need to better address structural racism in our training environments and clinical practice (Shim, 2021). How do we adjust our treatment and training approaches to meet this moment? Existing literature addresses racial identity, racism, and the management of racially charged encounters in the psychiatric clinical context. In fact, detailed conceptualizations of the impact of racism-related stress on mental health far predate the current moment (Harrell, 2000), as does examination of the intersection of critical race theory and mental health (Brown, 2003). Medlock et al.'s (2018) comprehensive textbook provides an extensive overview of the history of racism in psychiatry and strategies to address race and racism in several facets of psychiatric work. Schen and Greenlee's (2018) review of the intersection of race, racial trauma, and psychotherapy provides guiding principles to discuss race in supervision. Holm and colleagues' Privilege and Responsibility Curricular Exercise (Holm et al., 2017) offers 2

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a framework for providers to examine their own biases and privilege. Others have developed frameworks and guiding principles for addressing microaggressions and racism in the clinical encounter (Shankar et al., 2019; Sue et al., 2019). Several examples of curricula directly address injustice and inequity in psychiatric training (Balasuriya et al., 2021; Medlock et al., 2017). Structural competency, a framework that directs providers to understand the upstream institutional factors driving health inequities (Metzl and Hansen, 2014), has been adapted into curricula for psychiatric residents (Hansen et al., 2018). The existence of these and other resources suggests that the lack of attention to racial identity and racism in our foundational psychiatric training and techniques is not due to the absence of potential content. Rather, our field has suffered from a lack of intentional, sustained effort to study and broadly integrate such content into our training and our ongoing practice. As educators and practitioners observing the impact of these issues in our daily lives and practice, we offer the following five steps to move toward sustained rather than superficial change, for psychiatrists, the institutions within which we work, and policy makers and funders impacting all mental health providers and our patients. These recommended steps are by no means exhaustive, given the magnitude of the challenge that faces our field, but we hope provide avenues to begin the process toward sustained change: Recommendations: 1. Broad Institutional Change in Training and Practice: Content related to racial identity, racism, and racial/ethnic disparities in diagnosis/ inequities in treatment must be more extensively incorporated into rubrics used to judge clinical competence and gatekeeping institutions for licensure/practice. The above-referenced resources already available in the literature are among several that can be considered. These topics should not be isolated to single subcategories within these rubrics—for example, their current relegation to subcategories of Professionalism and System-Based Practice in the Accreditation Council for Graduate Medical Education's (ACGME) Milestones for Psychiatry (Accreditation Council for Graduate Medical Education, 2020). Rather, this content should specifically be considered key to competence in diagnosis, treatment planning, provision of psychotherapy, etc. Examples of rubrics/institutions that should be reexamined to better include this content: a. Training i. ACGME Milestones for Psychiatry ii. The American College of Psychiatrists' Psychiatry ResidentIn-Training Exam iii. American Board of Psychiatry and Neurology Clinical Skills Verification b. Posttraining: i. American Board of Psychiatry and Neurology Maintenance of Certification ii. Credentialing and privileging processes for employment iii. State licensure requirements iv. Training requirements imposed by federal and state payers, regulatory bodies, etc. Ideally, such institutional changes will incentivize more in-depth inclusion of these topics in medical student teaching materials, clinical supervision, clinical case conference, continuing medical education materials, etc. 2. Implementation Research: Although some tools and resources already exist, psychiatry as a field must target research investment toward building a more robust evidence base on best practices to address microaggressions, interpersonal racism, and other forms of racialized thinking in the clinical psychiatric encounter. This could include studying the implementation and outcomes of the previously described tools and development of new interventions. Sustained, targeted investment from our research institutions is critical to creating © 2021 Wolters Kluwer Health, Inc. All rights reserved.

The Journal of Nervous and Mental Disease • Volume 00, Number 00, Month 2021

the best knowledge base in both our training and posttraining treatment environments. 3. Sustained Resources: Psychiatry as a field must not limit its approach to superficial fixes and “check the box” interventions. As institutions create task forces, committees, and new diversity/equity leadership roles to address these issues, these initiatives must receive real, sustainable resources in the form of time and funding to make sustained change. 4. Professional Commitment: We cannot allow our field's current focus on structural racism to be a passing trend, gone when the next “ism” captures the public's imagination. Psychiatry must commit itself to sustained efforts at foundational change that outlast broad public interest in the topic of structural racism. Our broader leadership and training structures, including professional societies and academic departments, could, for example, set 10- or 20-year racial equity goals with benchmarks specific to development of research and training to encourage accountability. 5. Personal Responsibility: During this time of increased polarization, we must challenge ourselves to incorporate the existing knowledge base into our daily teaching and clinical work. Although working to meet this moment requires systems-level corrections, individual clinicians are not excused from the necessity of doing the work as well. Each of us engages with the mental health system from different positions of privilege. Some of us need to invest more energy in evaluating our own biases and take the personal responsibility to do so. Taking personal responsibility is not a matter of participating in a one-time training or screening test. It is instead about a lifelong commitment to continuous, intentional self-examination. Choosing to remain personally unengaged with this work, or to allow personal engagement to fade away, is not a benign or passive act. It is an act that reinforces the harm of systemic inequity in clinical practice.

In sum, the current moment should drive us to more intentionally draw on existing tools and resources to address racism and racial identity in our individual clinical work while also urging our field as a collective to institutionalize such practices. Returning to the examples from our own clinical and teaching work: • To address team members who suggest the pairing of a minority provider with an explicitly racist patient as a “corrective emotional experience,” we might engage team members in a structured exercise for selfexamination of bias and privilege (Holm et al., 2017), helping team members to better understand the harm caused by such a suggestion. • When confronted with a White patient refusing to work with Black providers, we might draw on previously published concrete strategies to address racism in the clinical encounter (Shankar et al., 2019; Sue et al., 2019). • To navigate the challenge of supervising a minority trainee who has been exposed to racism from patients, we might find a starting point in previously published guiding principles for addressing race in supervision (Schen and Greenlee, 2018). • When a minority patient articulates a feeling of conflict about the tension between his racial and political identity, we might draw on Harrell's existing conceptual model of racism-related stress and well-being to consider this tension in the context of other antecedent variables, familial and socialization influences, sources of stress, internal/external mediators, and outcomes (Harrell, 2000).

This intentional individual work is necessary but not sufficient to meet the current moment. In tandem with drawing on existing resources to inform our individual work, we must challenge our larger structures and institutions to focus on sustained, foundational change. DISCLOSURE David A. Adler, MD, is the cofounder of Health and Productivity Sciences, which has no assets, and has been an investigator on research

Racism, Psychiatry, and Change

grants from Janssen Pharmaceuticals. The other authors declare no conflict of interest.

REFERENCES Accreditation Council for Graduate Medical Education (2020) Supplemental guide: Psychiatry. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/Psychiatry SupplementalGuide.pdf?ver=2020-03-10-161139-047. Accessed August 27, 2021. Anglin DM, Ereshefsky S, Klaunig MJ, Bridgwater MA, Niendam TA, Ellman LM, Devylder J, Thayer G, Bolden K, Musket CW, Grattan RE, Lincoln SH, Schiffman J, Lipner E, Bachman P, Corcoran CM, Mota NB, van der Ven E (2021) From womb to neighborhood: A racial analysis of social determinants of psychosis in the United States. Am J Psychiatry. 178:599–610. Asch SE (1952) Group forces in the modification and distortion of judgements. In Social psychology. New York: Prentiss-Hall. Ault-Brutus AA (2012) Changes in racial-ethnic disparities in use and adequacy of mental health care in the United States, 1990–2003. Psychiatr Serv. 63:531–540. Balasuriya L, Isom J, Cyrus K, Sloan A, Arnaout B, Steinfeld M, DeSouza F, Jordan A, Encandela J, Rohrbaugh R (2021) The time is now: Teaching psychiatry residents to understand and respond to oppression through the development of the human experience track. Acad Psychiatry. 45:78–83. Bond CF, DiCandia CG, MacKinnon JR (1988) Responses to violence in a psychiatric setting: The role of patient's race. Pers Soc Psychol Bull. 14:448–458. Boxell L, Gentzkow M, Shapiro JM (2020) Cross-country trends in affective polarization. National Bureau of Economic Research. Available at: https://www.nber.org/ papers/w26669. Accessed August 27, 2021. Breakey WR, Dunn GJ (2004) Racial disparity in the use of ECT for affective disorders. Am J Psychiatry. 161:1635–1641. Brown TN (2003) Critical race theory speaks to the sociology of mental health: Mental health problems produced by racial stratification. J Health Soc Behav. 44:292–301. Case BG, Bertollo DN, Laska EM, Siegel CE, Wanderling JA, Olfson M (2012) Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression. J Affect Disord. 136:359–365. Christakis N, Fowler J (2009) Connected: The surprising power of our social networks and how they shape our lives. New York: Little, Brown and Company. Pub. Cook BL, Trinh NH, Li Z, Hou SS, Progovac AM (2017) Trends in racial-ethnic disparities in access to mental health care, 2004–2012. Psychiatr Serv. 68:9–16. Edwards ML, Saenz SR, Collins R, Bandstra B (2021) Structural injustice and structural racism. In Shim R, Vinson S (Eds), Social (in)justice and mental health. Washington, DC: American Psychiatric Publishing. Hansen H, Braslow J, Rohrbaugh RM (2018) From cultural to structural competency —Training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiat. 75:117–118. Harrell SP (2000) A multidimensional conceptualization of racism-related stress: Implications for the well-being of people of color. Am J Orthopsychiatry. 70:42–57. Holm AL, Gorosh MR, Brady M, White-Perkins D (2017) Recognizing privilege and bias: An interactive exercise to expand health care providers' personal awareness. Acad Med 92:360–364. Kuno E, Rothbard AB (2002) Racial disparities in antipsychotic prescription patterns for patients with schizophrenia. Am J Psychiatry. 159:567–572. Lawson W, Johnston S, Karson C, Offord S, Docherty J, Eramo A, Kamat S, Blanchette CM, Carson W, Nasrallah HA (2015) Racial differences in antipsychotic use: Claims database analysis of Medicaid-insured patients with schizophrenia. Ann Clin Psychiatry. 27:242–252. Mallinger JB, Fisher SG, Brown T, Lamberti JS (2006) Racial disparities in the use of second generation antipsychotics for the treatment of schizophrenia. Psychiatr Serv. 57:133–136. Medlock M, Shtasel D, Trinh NHT, Williams DR (Eds) (2018) Racism and psychiatry: Contemporary issues and interventions. Cham, Switzerland: Humana Press. Medlock M, Weissman A, Wong SS, Carlo A, Zeng M, Borba C, Curry M, Shtasel D (2017) Racism as a unique social determinant of mental health: Development of a didactic curriculum for psychiatry residents. MedEdPORTAL. 13:10618.

www.jonmd.com

Talley et al.

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Metzl JM, Hansen H (2014) Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 103:126–133. Mills CW (1959) The sociological imagination. Oxford, England: Oxford University Press. Osseo-Asare A, Balasuriya L, Huot SJ, Keene D, Berg D, Nunez-Smith M, Genao I, Latimore D, Boatright D (2018) Minority resident physicians' views on the role of race/ ethnicity in their training experiences in the workplace. JAMA Netw Open. 1:e182723. Sabshin M, Diesenhaus H, Wilkerson R (1970) Dimensions of institutional racism in psychiatry. Am J Psychiatry. 127:787–793.

Shankar M, Albert T, Yee N, Overland M (2019) Approaches for residents to address problematic patient behavior: Before, during, and after the clinical encounter. J Grad Med Educ. 11:371–374. Shim RS (2021) Dismantling structural racism in psychiatry: A path to mental health equity. Am J Psychiatry. 178:592–598. Strakowski SM, Keck PE Jr., Arnold LM, Collins J, Wilson RM, Fleck DE, Corey KB, Amicone J, Adebimpe VR (2003) Ethnicity and diagnosis in patients with affective disorders. J Clin Psychiatry. 64:747–754.

Schen CR, Greenlee A (2018) Race and supervision: Let's talk about it. Psychodyn Psychiatry. 46:1–21.

Sue DW, Alsaidi S, Awad MN, Glaeser E, Calle CZ, Mendez N (2019) Disarming racial microaggressions: Microintervention strategies for targets, White allies, and bystanders. Am Psychol. 74:128–142.

Schnitzer K, Merideth F, Macias-Konstantopoulos W, Hayden D, Shtasel D, Bird S (2020) Disparities in care: The role of race on the utilization of physical restraints in the emergency setting. Acad Emerg Med. 27:943–950.

Warner J (2021) Psychiatry confronts its racist past, and tries to make amends. The New York Times. Available at: https://www.nytimes.com/2021/04/30/health/ psychiatry-racism-black-americans.html. Accessed August 27, 2021.

Schwartz RC, Blankenship DM (2014) Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World J Psychiatry. 4:133–140.

Williams JC, Harowitz J, Glover J, Tek C, Srihari V (2020) Systematic review of racial disparities in clozapine prescribing. Schizophr Res. 224:11–18.

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