The Past Is Present

By Jane Gagliardi, MD, a member of the Committee on Social Justice at the Group for the Advancement of Psychiatry

Last year, a study spearheaded by a junior colleague under my mentorship was published. We showed inequities in the treatment of individuals in emergency psychiatric settings. Lessons I learned over the course of a decade, culminating in the published work, sparked my desire to learn more and – because it is important to recognize past wrongs to avoid repeating them – to share with others.

Psychiatry’s History

Since its inception, the field of psychiatry in the United States has had a racially biased approach to patient evaluation. Early psychiatric diagnoses were explicit in their racialized nature, with specific diagnoses applicable only to Black (enslaved or freed) individuals.

For example, Drapetomania was defined as a mental disorder causing enslaved individuals to run away. Dysaesthesia aethiopica was a diagnosis of “dullness and lethargy” among enslaved people. For Black individuals exhibiting drapetomania or dysaesthesia aethiopica, the prescribed treatment was whipping.

Benjamin Rush, often called the “father” of American psychiatry, espoused and disseminated racist beliefs. Negritude, an anti-colonialist movement of cultural pride, was also the word used by Rush to describe an affliction, a type of leprosy causing Black skin. (In 2015 the American Psychiatric Association removed Rush’s image from their logo, in part to start to reckon with this racist past.)

In retrospect, of course, it seems as logical, rational, and human for a person to wish to be free from enslavement and proud of their heritage and accomplishments as it is for a person to be tired and listless when underfed, overworked, and mistreated.

Racial bias in diagnosis included the idea that Black individuals lacked the brain power to become depressed. In the modern era, Jonathan Metzl, in The Protest Psychosis, describes how accurate observations by Black Americans may nevertheless be characterized by psychiatrists as “psychotic.” There is evidence showing that psychiatrists are likely to diagnose Black patients with psychotic disorders such as schizophrenia, while diagnosing white patients who have identical symptoms with mood disorders like depression or bipolar disorder.

In the 1800s and 1900s, the criminalization of Blackness meant that the system was set up to justify the fact that Black patients were rarely provided with helpful treatments and were more likely to be imprisoned for behaviors that would land a white person in a mental institution or asylum.

A Psychiatrist’s History

I am white, and I was raised in Massachusetts by liberal parents. When I started medical school in the southeast, my parents exhorted me to vote out the racist individuals representing my new state and to set things right.

In retrospect, I “didn’t see race” and didn’t really know how their advice pertained to me. I had not been exposed to lessons about psychiatry’s racist past and did not question the experts who taught me about biological differences.

I absorbed lessons from classes in which I learned about presumed biological race-based differences in response to blood-pressure treatments. I developed my clinical history-taking skills with a standardized Black patient who stereotypically ate 4-5,000 calories of salty, fat-laden barbecue daily and couldn’t control their weight or cholesterol.

During clinical rotations, I accepted without question lessons that schizophrenia was prevalent among young Black men. I incorporated a perspective from my own limited clinical experience in which the vast majority of hospitalized prisoners I saw were Black men. I also learned to navigate a health care system in which “staff” or “service” patients would be seen by physicians-in-training while “private” patients were seen by more senior attending physicians in practice.

It only slowly dawned on me that “staff”/“service” and “private” could be fairly accurately replaced by “Black” and “white.”

During my intern year, one of my clinic supervisors led a study, published in the New England Journal of Medicine, demonstrating individual physicians’ bias when considering interventions for standardized patients with identical symptoms suspected of having a heart attack. The study showed that white men and women were more likely than Black men and women to be referred for an intervention that was shown to improve outcomes.

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A couple of years later—7 years after I began my medical education—the issue of racism in medicine began to come into focus for me after attending a colleague’s presentation about racialized enactments in the history of my institution in relationship to its surrounding community. Something “clicked,” and I started to make connections between seemingly isolated observations and the structure of the system in which I was learning to provide patient care.

History Lessons

Fast forward a decade. Caring for patients through hospital-based work in inpatient and emergency psychiatry and medical settings in 2014, I mentored a group of resident physicians on a project designed to improve the safety of patients and clinical care providers in the psychiatry emergency department. We planned to collect data for a brief period, implement an intervention, and collect data to see if it was effective.

One of the Black residents on the team presented the first dataset and matter-of-factly pointed out that the data reflected disparate treatment of patients.

And there it was on the spreadsheet: Over three weeks, a disproportionately high percentage of Black individuals (52%) were held in the locked area of the emergency department at a time when the county demographic included a lower percentage (38%) of Black inhabitants. The data also showed, as the medical literature depicted, a much higher likelihood of a schizophrenia diagnosis among Black patients than among white patients in the locked area.

One might be tempted to think, “But maybe patients with schizophrenia need to be locked up, and Black patients are more likely to have schizophrenia.” Therein lies the problem of systemic and structural racism that affects the way we assess and treat mental illness. Racial bias leads us to assume Black patients are more likely to have schizophrenia and therefore it is perfectly normal to again assume that more of them need to be locked up.

In other words, being diagnosed with schizophrenia means being disadvantaged in receiving treatment, even if one has private insurance. Given that Black patients are more likely to get this diagnosis, they are likely to have difficulty finding clinicians to care for them as compared to patients diagnosed with bipolar disorder. I see this kind of disparity as a reflection of structural racism.

Lessons Learned

As the late Maya Angelou famously said, “Do the best you can until you know better. Then when you know better, do better.”

As my personal story illustrates, it is possible to harbor good intentions but not recognize when one’s education lacks important details and historical context. Having started to learn some important lessons that inform my individual patient interactions—as well as my efforts to promote change—I find it helpful to think about the potential harm my profession has caused as I work to be trustworthy, therapeutic, and helpful to my patients.