“History hurts, but we cannot hide from it. My goal is to educate, not to leave you with guilt or anger.”
– Ibrahima Seck, Ph.D., academic director of the Whitney Heritage Plantation Corporation (paraphrase from audio tour)
The American Psychiatric Association held its first in-person Annual Meeting since 2019, in New Orleans May 21-25, 2022. The conference ended on the second anniversary of George Floyd’s murder in 2020, and was bookended by mass shootings in Buffalo, New York the week before, and Uvalde, Texas near the end of the meeting. Not only was there tragic loss of life in these incidents, the continuing violence in our country has profound effects on our mental health and social well-being.
The APA’s thirteen-member 2021-2022 Presidential Task Force on Social Determinants of Mental Health, a direct outgrowth of the push for racial justice that was amplified after Floyd’s murder, made its report. The organization gamely took up the challenge of turning its giant ship in the wake of enormous cultural demands, brought to the table by Black, BIPOC, and other psychiatrists representing marginalized communities. These insights about the organization and the practice of psychiatry seem to have been met with a new level of clarity and commitment by key members of the APA’s leadership, including APA CEO and Medical Director Saul Levin, M.D., past presidents Altha Stewart, M.D., Jeffrey Geller, M.D., and Dilip Jeste, M.D., outgoing APA president Vivian Pender, M.D., incoming president Rebecca Brendel, M.D., J.D, and incoming president-elect Petros Levounis, M.D., M.A. who will be the first openly gay president in the organization’s history. Dr. Stewart was the first African American president of the APA, and Dr. Jeste was the first Asian American president.
APA Annual Meeting 2022 was a great first pass at bringing approximately 5,000 members (down from 15,000 attendees pre-pandemic) together around these issues that are at the heart of mental health and social well-being. In my experience, psychiatrists are, broadly speaking, compassionate and concerned about racism, poverty, violence, and other social issues that affect mental health.
However, individual expertise at navigating points of contact with minority and marginalized communities varies dramatically, with some significant and prominent outliers who have caused distress to members and the public alike. Those belonging to the dominant culture are particularly under the spotlight, as the dominant culture of America and the world has not proven trustworthy or up to the task of change, just yet.
We are all works-in-progress. I think it’s possible to enter a transitional state with compassion and generosity, but also clear-minded focus on being allies to our patients, communities, and colleagues as we learn, grow, adapt and thrive in the possibilities that arise out of our commitments to one another as human beings on our journeys of identity, belonging, wellness, and meaning.
What better place to start this conversation than New Orleans, the city of “Nine Lives” as the book by Dan Baum recognizes. I found New Orleans equal parts thriving, striving, and barely surviving, in parallel with the APA as a whole, as well as the country and world. We are all in this together.
The boundaries between the profession and American and world culture are not distinct. I know my psychiatrist friends are committed to change and wellness at all levels. But we exist in a culture that is at once ready to embrace a diverse future, and at the same time reacting defensively against diversity and reasoned discourse about racism, LGBTQ+ rights, gun violence, and so forth. Our identities have become politicized, instead of being offered safety, understanding, and dignity, all vital to our well-being.
William Lawson, M.D., Ph.D., DLFAPA, gave a stellar, grounded, clear talk titled “Structural Racism: Biopsychosocial Consequences,” which succinctly laid out the history of anti-Black racism in the U.S,. as well as its sequelae, including:
- A drop in the life expectancy of Black Americans.
- Black Americans are less likely to receive mental health treatment.
- Black Americans face barriers to successful treatment.
- Bipolar disorder is underdiagnosed and unrecognized in Black Americans, and they are overdiagnosed with schizophrenia compared to the general population, leading to mistreatment and misunderstanding. This had its roots in biased reactions of American psychiatry to the civil rights movement. (See references.)
- PTSD and Major Depression are underdiagnosed and often unrecognized in Black Americans.
- Black Americans receive more medications on hospital wards; higher doses of psychotropics; more injections; are more likely to receive long-lasting depot injectable medications; less likely to get antidepressants and psychotherapy; and they are more likely to be prematurely terminated from therapy.
Dr. Lawson’s session will be rebroadcast at the APA Virtual Meeting on June 8th, 2022, 3:30-5 pm ET, and then will be available on-demand, along with many other sessions on SDOMH and other topics, including the actual report of the SDOMH task force itself.
In January, 2021, the American Psychiatric Association formally apologized “to Black, Indigenous and People of Color for its support of structural racism in psychiatry.” In October, 2021, the American Psychological Association (APsA) made its own formal "Apology to People of Color for APA’s Role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in U.S.” (See references for links to both.) Some declared the psychiatric association’s statement ‘too little, too late.’ That speaks to the great scar that the dominant culture has left on marginalized communities.
We are on an imperfect journey from scars and wounds to healing, though. The proof will be in the pudding of actual accomplishments and outcomes for our patients and society. Apologies and task force reports hopefully will not be seen in the future as toothless symbols against the inertia of heartless historical forces.
I still believe that the modern APA is a good-hearted, deeply skilled, and conscious organization – but it is an institution, composed of many members. While I believe the overwhelming majority are in favor of this shift in direction, not all are ready for change. And not all 28,000 psychiatrists in the U.S. are members of the APA. The APA still needs to roll out its newfound clarity on SDOMH to its entire membership and the community of psychiatrists writ large, and we as psychiatrists need to take up the challenge of deepening our knowledge base and expanding our skills to work with diverse patients and colleagues. This is not unlike the challenge that America itself faces.
The APA’s Black psychiatrists prominently raised issues of racism in the profession back in 1969, but the words and work of these trailblazers were not fully heard or integrated. I think this time is different. I have great hope that the meticulous work of the task force and many members will pay off. It’s already paid off in a substantial text revision of the DSM (with the latest edition called the DSM-5-TR.)
It’s high time we caught up with our colleagues in affiliated health professions, who have been having this conversation for years, perhaps because they have had women in leadership positions since their inception, or perhaps because they tend to be “closer to the ground” than many in academic psychiatry. (Social Workers, for example, issued a report on structural racism in 2007. See references.)
I’m here to report back that I have faith that our humanity will win the day against the dinosaurs of an outmoded yet still hurtful past.
(c) 2022 Ravi Chandra, M.D., D.F.A.P.A.
APA Apologizes for Its Support of Racism in Psychiatry, Psych.org website, January 18, 2021
Apology to People of Color for APA’s Role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in U.S., American Psychological Association website, October 29, 2021
Institutional Racism and the Social Work Profession: A Call to Action. National Association of Social Work, 2007
DSM-5-TR, American Psychiatric Association Publishing, Inc., 2022