Rush, who is often called the “father” of American psychiatry, believed Black skin was caused by a mild form of leprosy in the 18th century.
His one-time apprentice, Doctor, spread the falsehood throughout the antebellum South that enslaved people whose desire to be free was unyielding were suffering from a mental disorder he called “drapetomania,” or “the disease that causes Negroes to run away.”
Psychiatry’s rank and file became a receptive audience for drug companies who capitalized on racist fears about urban crime and social unrest in the late 20th century. An advertisement featuring a Black man with a raised fist appeared in the “Archives of General Psychiatry” in 1974. “Cooperation often begins with Haldol.”)
Psychiatric association, which featured Rush’s image on its logo until 2015, is confronting that painful history and trying to make amends.
In January, the 176-year-old group apologized for its racist past for the first time. The governing board of the association acknowledged the profession’s “appalling past actions” and committed the organization to “identifying, understanding, and rectifying our past injustices,” and pledged to end the inequities of the past in care, research, education, and leadership by implementing anti-racist practices.
This weekend, the A.P.A. is holding its annual meeting on the theme of equity. During the three-day virtual gathering, which could host as many as 10,000 participants, the group will present the results of its yearlong effort to educate its 37,000 mostly white members about the psychologically toxic effects of racism, both in their professional and personal lives.
During his one-year tenure as president of the A.P.A., Doctor made that effort his signature project.
In a recent interview, he said, “This is really historic.” It should be a long-term effort and a long-term change.
A psychiatrist who chaired a task force exploring structural racism in psychiatry, said the group’s work could prove life-changing for a new generation of Black psychiatrists who will have a much greater chance of knowing that they are valued and seen when they enter the profession. In her own early career in medicine, she experienced isolation, and she has found it difficult to refer patients to other Black psychiatrists.
“This is a once-in-a-lifetime opportunity,” she said. “Change in psychiatry must start at the top, just like in any profession,” she said. We must look at our own backyard before we can look elsewhere.
Doctor chaired a task force exploring structural racism in psychiatry for a year. “In psychiatry, just as in any other profession, it has to start at the top,” she said.Credit…Amber Ford for The New York Times
According to critics, the A.P.A.’s apology and task force are long overdue, but still insufficient attempts to catch up. AMA issued an apology in 2008 for its history of “actively reinforcing or passively accepting racial inequalities and excluding African-American physicians.”
“They are taking these superficial, palatable steps,” said Danielle Hairston, a member of the task force and the black caucus president of the American Psychological Association.
People will be fine with saying we need more mentors; people will be fine with saying we’re doing these town halls,” she said. It’s an initial step, but the A.P.A. has a long way to go in terms of real work.”
Considering the organization’s layers of bureaucracy, its diverse constituencies, and its heavy institutional tradition, the question is how to get there.
Both inside and outside of the A.P.A., critics say the organization still faces high hurdles in addressing its racial equity concerns — such as its diagnostic biases, a lack of Black psychiatrists, and a payment structure that tends to exclude those with limited financial resources.
“It is all these procedural structures in place that allow the system to function the way it was designed to,” said Doctor, who left the A.P.A. last summer, in frustration, is the director of cultural psychiatry and a professor of clinical psychiatry at the University of California, Davis.
Psychiatry is experiencing an existential crisis, she said.
A racist history
Black behavior has been pathologized by white psychiatrists for hundreds of years, wrapped in the mantle of scientific certainty and even big data. According to Doctor, who published an account of psychiatry’s history of structural racism last summer, the A.P.A. was first called the Association of Medical Superintendents of American Institutions for the Insane. During the 1840 federal census, a new demographic category, “insane and idiotic,” was created.
According to pro-slavery politicians and sympathetic social scientists, Black people in the northern states suffered significantly higher rates of mental illness than those in the southern states.
After Reconstruction, prominent psychiatrists used terms like “primitive” and “savage” to cruelly suggest that Black Americans were unfit for independent, fully enfranchised lives.
In 1897, T.O. Powell, superintendent of the notorious State Lunatic Asylum in Milledgeville, Ga., and president of the American Medico-Psychological Association (forerunner to the A.P.A.), outrageously claimed that there were very few Negro lunatics before the Civil War. As a result of their sudden emancipation, their number of insane multiplied.”
Doctor, director of cultural psychiatry and professor of clinical psychiatry at the University of California, Davis, left the American Psychiatric Association last summer. According to Salgu Wissmath for The New York Times, structural racism is “an existential crisis for psychiatry.”
In the 1970s, psychiatry continued to pathologize — and sometimes demonize — African-Americans, resulting in the diagnosis of psychosis being handed out so frequently that the profession was essentially “turning schizophrenia into a disorder of aggression and agitation in Black people,” said Doctor, a contributor to the 2019 book, “Racism and Psychiatry”..”
Several studies have shown that a majority-white profession is unattuned to Black expressions of emotion – and that distress is often conflated with anger – leading to an underdiagnosis of major depression, particularly in Black men, and an overreliance on antipsychotic drugs. According to a 2008 report published in “Psychiatric Services,” black patients receive less appropriate depression medication than white patients.
Fixing the problem
Doctor said organized psychiatry needs to pay more attention to training doctors to listen in order to change course and serve Black patients better. An adjunct assistant professor of psychiatry at the Mayo Clinic College of Medicine and Science, Dionne Hart is a psychiatrist and addiction medicine specialist in Minneapolis.
A recent interview showed that she “checked a lot of boxes publicly.” She said, “We need to do the work now.” We have to prove that we are committed to undoing the harm and working with all of our colleagues across the country to recognize trauma and acknowledge trauma where it exists and get people appropriate treatment…”
People with mental illness are marginalized and underserved, according to many psychiatrists. A.P.A. made history in 1973 by removing “homosexuality” from its Diagnostic and Statistical Manual of Mental Disorders second edition. Race, however, has taken much longer to undergo the kind of soul-searching that occurred around that decision.
According to a 2020 study published in the journal “Academic Psychiatry,” psychiatry remains a strikingly white field with only 10.4 percent practitioners coming from historically underrepresented minority groups, now nearly 33 percent of the U.S. population. According to the study, only 4.4 percent of psychiatrists were Black in 2013.
Doctor, outgoing president of the A.P.A. “We’ve laid a foundation for long-term efforts and change,” he said. Credit…Maddie Malhotra for The New York Times.
The discipline’s history of pathologizing Black people — to “consider Black communities as seething cauldrons of psychopathology,” as three reform-minded authors put it in 1970 in the American Journal of Psychiatry — has discouraged some Black medical students from entering the profession.
Doctor noted that some people in her family won’t admit that she’s a psychiatrist. “A family member told me on match day that she was disappointed that I had matched to psychiatry instead of another specialty – it seemed like I was disappointing them.”
Having difficulty finding a Black psychiatrist can discourage Black patients from seeking treatment. Patients without money also find it difficult to access psychiatric care.
In comparison with other medical specialties, psychiatry has a high rate of practitioners who do not participate in public or private health insurance programs.
Psychiatrists were the least likely medical providers to accept any type of health insurance, according to a study by the Medicaid and CHIP Payment and Access Commission in 2019. 62 percent of physicians accepted new patients with either commercial plans or Medicare, while 36 percent accepted Medicaid patients. Conversely, 90 percent of providers reported accepting new patients with private insurance, 85 percent accepted Medicare patients, and 71 percent accepted Medicaid patients.
The reimbursement rates for health insurance are too low, according to many psychiatrists. The reimbursement rates for primary care physicians are almost 24 percent higher than for mental health practitioners, including psychiatrists, according to a 2019 study. It widened to more than 50 percent in 11 states.
The A.P.A.’s advocacy in this particular area of equity has focused on pushing for full insurer compliance with the Mental Health Parity and Addiction Equity Act, a 2008 law requiring insurance companies to provide mental health care coverage at a level similar to what they provide for physical health care.
Short-term, patients are affected by inequitable access to treatment as the profession strives for higher reimbursement rates. “The thing that’s always bothered me in the practice of psychiatry is, even though you talk about your commitment to equity, if you don’t have a system that allows patients access to quality care, many patients are shut out.” As an associate professor of psychiatry and behavioral sciences at Duke University, Doctor Tweedy has written “Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine.”
“What do we value?” said Doctor who cares for veterans at the Durham Veterans Affairs Health Care System. There is a difference between what we say and what we do.