This transcript has been edited for clarity.
Stephen M. Strakowski, MD: Thank you so much for joining in today’s conversation. I think it’s going to be a very interesting one.
I’m Steve Strakowski, vice dean for research at Dell Medical School at the University of Texas in Austin. I’m really pleased to have two guests joining me to talk about a sometimes sensitive topic that has gotten a lot of national press but is something that it is critically important for us to continue to expand on: how systemic racism impacts mental health and mental health care.
My first guest is Roberto Lewis-Fernández, professor of clinical psychiatry at Columbia University and director of the New York State Center of Excellence for Cultural Competence. Roberto, welcome.
Roberto Lewis-Fernández, MD: Thank you.
Strakowski: Our second expert is Harold Neighbors, who goes by Woody to those of us who know him well. Woody is a professor emeritus at the University of Michigan and senior scientific advisor for the National Institute on Minority Health and Health Disparities. Woody, welcome.
Harold Neighbors, PhD: Thanks for doing this and for inviting me, Steve. I really appreciate it.
Strakowski: I’ve known both of these gentlemen for years. They’re both great people and I think they’re going to bring us a really interesting discussion.
As we look at the cultural landscape today, there’s a lot of discussion about systemic racism as it infiltrates all aspects of our lives. Roberto, does that also impact psychiatry and mental health care, and if so, how?
Lewis-Fernández: First of all, I want to emphasize that we’re talking about systemic aspects of race and racism, not only the individual aspects. We’re talking about a whole system and structure, which includes policies, institutional practices, training systems, legislation, parity issues. That’s all involved in how the delivery of psychiatric care, and mental health care more generally, can be done in a racist way.
For individual practitioners, racism can sometimes be explicit, but it can also be implicit. They may even be unaware of some of their practices. While espousing nonracist views in principle, they may still be affected by racist practices in their daily work.
Having said that, I think it’s very important to recognize that in psychiatry there are, in my view, two kinds of systemic racism: sins of commission and sins of omission. Examples of sins of commission are all around us, such as research finding less guideline-concordant care across different racial and ethnic groups. Multiple studies have shown that some groups are less detected when they show up with certain diagnoses, or are misdiagnosed. The famous example is schizophrenia among African Americans, partly because there is less time spent with certain people doing assessments or less attention paid to certain types of symptoms (eg, mood symptoms) when people present with psychosis or presentations that may be psychotic.
By sins of omission, I mean a general lack of attention to the issue of racism in how care is apportioned in this country. Despite the fact that we’ve had the same findings in research studies for decades, these problems persist. For example, there’s limited attention to language access in care, even though it’s very clear that some people require interpretation or to be worked with in a different language to be well cared for. There’s also the fact that, with some obvious exceptions, we really don’t pay enough attention to social determinants of mental health and how those affect mental health presentation, outcomes, affordability of care, etc., even though we know that not only do they affect everybody, but they affect different people differentially. Racial and ethnic groups that are underserved are particularly prone to suffering from social determinants that are unaccounted for in our care.
Although I could keep going on, I’ll stop at those examples so I can pass it on to Woody.
Strakowski: Thanks, Roberto. Woody, please expand on that. Do you feel that the systemic racism in mental health care is unique, or that it is an extension of society and medicine more generally?
Neighbors: There’s a number of things that Roberto said for which he and I are very much on the same page.
To answer your question, I consider the field of medicine to be firmly embedded within our larger society. Our society remains, and has been since the beginning, structured on the basis of racial hierarchies. Medicine, and of course psychiatry as part of medicine, is no different from any other organization, system, or structure. We should expect to see the legacy of racism within medicine and psychiatry, and I would include my field, public health, within that as well.
When I think about racism, it is fundamentally as a political ideology that was thought out and well planned to substantiate a socioeconomic structure designed to benefit some people at the tremendous devastation and cost to other groups. We can’t talk about racism without talking about White supremacy. And that’s when the conversation does get a little uncomfortable, because if you do believe in a hierarchy of superiority and inferiority, then you are flat-out racist.
I want to differentiate some of the terms that unfortunately often get used interchangeably as if they were synonymous, and they are not. I’ve just described the term racism, but racial discrimination is a more behavioral manifestation of that racist ideology. Then, of course, the one that we’re all very concerned about right now is the notion of implicit bias. That is the most challenging aspect of what I think about when considering how racism plays out presently in the interactions across race and ethnicity.
My background is psychology. Even though I think of systemic, organizational, and structural racism as being embedded in the policies of these different organizations, because I’m a psychologist, at the end of the day I’m still going to look for the people in positions of power who are enforcing those policies that disadvantage some groups of color. So while we are talking about systemic racism, I also think we need to talk about the interpersonal aspects of that.
That’s my opening statement. I’ll stop there. But of course, there’s a lot more to this story, including what it has meant for me as a Black man growing up in the United States, born in the early 1950s, who participated very personally in this grand experiment we called racial integration.
Strakowski: Without taking time from my experts today, I also wanted to mention work we’ve done together which found that practitioners who often view themselves as open-minded, liberal-minded, fair people are often shocked when you show them how they are race biased in how they make diagnoses. To your point, there’s the systemic structural component that I think even the best-intentioned people are unaware of, and then there’s implicit bias that they also don’t intend. Even people who try not to make these errors still make them.
Neighbors: What Roberto was referencing is what we call fast thinking or blind spots. When I was presenting a lot on the topic of racial diagnosis and missed diagnosis, I used to joke somewhat that I never met a culturally insensitive clinician whenever I was doing this work. Everyone was not only surprised but outraged by what the data were showing, yet it was very difficult for any of us to step up, look in the mirror, and start that deep process of introspection to figure out whether we were falling prey to some of these preconscious, subconscious, or implicit stereotypes that are embedded in us from day one because of our societal structure.
Strakowski: Woody and I actually are working together on a book about this, so this is a premature plug for when it someday will come out.
Roberto, as you hinted, this has been going on for a long time and has been recognized for decades. How do we solve it? What are some things we could do to start addressing it, at least in psychiatry and mental health, and maybe then lead other areas of the country?
Lewis-Fernández: That’s a very good question. I wanted to start off by following up on what Woody and you said, which is that the system in which we live is pervasive at all levels. It would be surprising if we were not racist when living in a system that is inherently racist and set up socioeconomically in a given way. It’s also classist, misogynistic, homophobic. There are so many ways in which the system itself needs to be challenged.
It’s a very active process that needs to happen for systemic racism to be opposed and for interpersonal racism to not be incurred. It’s not something that happens by a mere change of attitudes, even though changing attitudes is incredibly hard. It goes much beyond that. It means taking active steps in a systemic sense to look at institutional practices, to look at barriers that we may not even be aware are barriers. That necessarily involves including people who have been left out by the system in the process of change.
One obvious way of doing this is to include the people who have been most affected — be it due to race, ethnicity, gender, or sexual orientation — in the process of decision-making so they can reveal the difficulties. In psychiatry, one aspect that we often don’t take into account at the systemic institutional level is that this means including the voices of people with lived experience in the process of review and decision-making. It’s also our patients, essentially, who are in a position to let us know where we still have a long way to go. We have so much work to do at all sorts of levels to try to make an impact.
Finally, at the interpersonal level, implicit bias luckily seems to be malleable and something that can be changed. There are people who are actively working on developing training methods and approaches to make a person become aware of their implicit biases and then challenge them. Typically, these are tests and measures that you can take for assessing your implicit bias that are pretty good, and for which there’s a substantial amount of research, meta-analyses, literature reviews, and so on. I would urge people to become informed about those.
Once you are aware of your blind spots — which are blind for a reason, even with the best intentions — then you need a way to systematically train those out of you by all sorts of methods. You could have feedback and supervision across the domains where you have particular difficulty. It can be uncomfortable, but it can also be very liberating because we all carry this weight of racism on our shoulders — some groups more than others. But everybody’s affected.
It would be excellent if we, as a set of institutions, devoted our attention to it. There is attention being paid to this at both the American Psychiatric Association and the American Psychological Association, but both professional organizations, as well as many others, could still do even more than they have done so far.
Strakowski: Woody, do you have other thoughts as well?
Neighbors: I really like what I’m hearing. I do have a couple of thoughts. We have to challenge the way we’ve become comfortable in our thinking. This present period, probably going back to the spring, is the most I’ve ever talked about racism in my career, even though I have been studying and reading about racism since the early 1970s. I can choose to either be optimistic or cynical about this present conversation. When I read people telling me racism is bad for our health, part of me says, “Really? What took you so long to figure that out?” But the larger part of me says, “Great. I’m glad we’re coming to this collective realization. Now we have an opportunity to do something about it.”
For example, the fact that the three of us are actually sitting here trying to have a conversation about something that is difficult to talk about is progress. That’s number one. When we have these conversations, we’re going to challenge each other. We’re civil, we know each other, but it is very challenging because we’re not always going to agree with everything.
That’s why I think this notion of challenging ourselves to think more broadly and to be more open about the possibilities of how we are engaged in a race-based system is so important. We have to first ask, “Do I as an individual have any blind spots?”
There are things that we can do to try to look at that and challenge ourselves to think differently. That’s all very, very good, but we can’t forget that eventually we have to circle back to confront the structure, the power relationships. Who is at the decision-making table? That’s where we do have to make sure that different constituencies, different groups of color or socioeconomic position, have to be not in an advisory role, but in an executive role in these institutions so that things can indeed change. Roberto’s right: It’s not only about changing my personal attitude; it’s partially about that, but not exclusively.
Strakowski: Gentlemen, these are very insightful and challenging comments for all of us to think about. Thank you both for talking with me and each other today. I hope that people who have tuned in to this conversation have found it useful, interesting, and challenging as we start as a society to struggle and ultimately conquer our racist past. Thank you for turning in to listen to us today.
Neighbors: Thank you.
Lewis-Fernández: Thank you for having us.