This transcript has been edited for clarity.
Stephen M. Strakowski, MD: I’m Dr Stephen Strakowski, vice dean of research and associate vice president of regional mental health at the University of Texas at Austin’s Dell Medical School. I’m pleased to come to you today with a conversation that is actually a continuation of one we had around a year ago on the topic of systemic racism. As I was during that last conversation, I’m joined by a couple of friends: Dr Roberto Lewis-Fernández from Columbia University, and Dr Harold (Woody) Neighbors from now, I guess, Tulane University.
Harold Neighbors, PhD: Yes, I’m now a member of the Tulane Green Wave, or so they tell me!
Strakowski: Tulane almost beat Oklahoma over the weekend, and I think that’s because they added Woody.
We’re glad to have you both back today, because the goal is to extend the previous conversation we had about structural racism in psychiatry. We received a lot of comments back from all of you, which we appreciate. It’s always important for us to see what our viewers are thinking.
One of the frequent comments we received expressed some disagreement about the concerns around structural racism. A lot of people shared that their solution is simply to treat everyone the same. I’ve had other friends and colleagues tell me that they’re color-blind — that they just ignore race and manage people accordingly. Taken at face value, that seems like a fair and reasonable approach. But it’s something we’re going to talk about today.
I’d like to open with a question to my friends: Is being color-blind the solution to providing fair and equitable mental healthcare?
The Impossibility of Color Blindness
Neighbors: In brief, my answer is, no. Speaking as a Black man who grew up in the United States, I feel it’s impossible for people not to see color. I just don’t think it can be done. Every time I walk into the room, it’s just obvious that everybody sees a Black man coming, which is something that needs to be addressed.
The second thing I’d like to say plays a little upon the term “color-blind.” My feeling is that if you are color-blind, then you cannot see what to do, how to interact with, or how to treat the client of color. That’s where I’m coming from right now.
Strakowski: Roberto, what are your thoughts?
Roberto Lewis-Fernández, MD, MTS: I agree completely with Woody. When people say they want to treat everybody the same, there’s some part of that I appreciate. Of course, you want to treat everybody with respect, with empathy, to be meticulous in your care. That’s the good side of what people mean by treating people the same. I take that as a something of a given.
But on another level, we cannot treat everybody the same without coming to terms with the effects that implicit bias, structural racism, colonialism, sexism, homophobia, et cetera, have on clinical care. It’s these unconscious automatic mental associations between a social group, stereotypes, and a form of prejudice that is really very prevalent in most societies, if not every society. In the United States, there’s a very strong anti-Black implicit bias, particularly because of structural racism. There’s also all sorts of bias against other people by virtue of the different ways in which people have been oppressed over time. This includes the issue of structural racism, which patterns all our institutions in one form or another, and fosters inequality in opportunities and the way people are treated.
So, because we and our patients are affected by that society, we really have to explore their reactions to it and our reactions to it in the way we work together. We must do that so we can understand each other better, or, as Woody says, we risk not understanding each other at all.
Neighbors: If I could elaborate briefly on a key concept that Roberto mentioned, one of the main reasons we can’t be color-blind is because of the obvious fact of difference. In this case, differences in how people look are highly correlated with inequalities at the structural level.
Being on the public health side of this conversation, I’m always looking at population health statistics. There are persistent differences over time, going as far back as you can look. We call those “disparities,” and they’re highly related to skin color. You just can’t blind yourself to differences that are so pervasive. The issue is, what are we going to do about the differences?
And I might add that medicine has the same issue. We call it unequal treatment. When you go inside clinical populations, you see differences.
One of the interesting things today will be for us to try to figure out where does the responsibility lie for some of those treatment differences. We’re going to talk about implicit bias, which used to be called “unconscious bias”; I think part of the puzzle lies there.
Psychiatrists Aren’t Immune to Implicit Bias
Strakowski: Mental health providers often like to imagine that we don’t have implicit bias. That we, more so than many physicians, spend a lot of time with our patients trying to understand and get to know them. What happens? How does implicit bias creep into our decision-making and care?
Neighbors: Fundamentally, implicit bias is a human cognitive process. The world is really just too complicated for us to comprehend, so we have to create cognitive schemas or categories that allow us to make decisions fairly quickly, because we don’t have time to sit around and really work through all the details. Very often, I think this is a good thing, but sometimes it’s not so good.
It’s called “thinking fast.” Sometimes we need to not think so quickly. We need to slow our thinking down. I think this gets to what Roberto was talking about. We have these implicit associations in our cognitive schemas because we were raised in a country that has gone on record as accentuating not only skin color as important, but differences in skin color; in fact, establishing a hierarchy of skin colors.
That’s why this is such an important topic. I don’t think we can just automatically escape from our implicit biases. We actually have to do serious introspection about how we’re thinking and to slow our thinking down.
Lewis-Fernández: I agree completely. Implicit bias has been widely studied. It’s not as if it’s something that we can just say whatever we want about. Decades of work, if not longer, have gone into it.
It’s been found to affect communication between patients and clinicians, and therefore affect rapport — the exchange of information in clinical care and in research. In general, this interference in communication is associated with lower quality of care and patient disengagement.
There was a nicely done 2017 systematic review reporting that 83% of the articles examining the topic found implicit bias in healthcare professionals. Every one of the studies that looked at the correlation between implicit bias and quality of care found that it had a negative relationship in lowering the latter.
In terms of communication, it affects the number of questions you ask a patient, how participatory you are with them. It doesn’t have to, but it often does. And it even affects treatment recommendations. For example, in psychiatry this could affect our recommendation for psychotherapy vs meds, our perceptions of dangerousness and the use of restraints or of certain dispositions, or the use of injectable vs oral antipsychotics. These are all possibly affected by things like implicit bias.
Neighbors: As we all know well, this also heavily influences the diagnostic process. If a clinician arrives at a diagnostic conclusion much too quickly before sampling all of the relevant information, then I think they’re going to put themselves at risk for falling prey to these implicit associations. This risk is there not only in the treatment process, but also in the initial fact-gathering process to determine what might be going on with this individual.
You’ve got to slow down. I understand that not everybody’s working in a situation where they can afford to go very slow. I know my primary care physician is under a lot of pressure to keep it moving, as we say. But within that context, I think we have to be very careful about making diagnoses of African Americans in the psychiatric realm because we’re all very well aware of this persistent problem that we’ve called “misdiagnosis.”
Strakowski: That’s something I try to do in my practice, although not always successfully, because like everyone, I am also vulnerable to implicit bias. But I start with the assumption that I have implicit bias, rather than the assumption that I don’t, and at least bring that into my practice.
When It Comes to Understanding Your Patients, Context Is Everything
Strakowski: What is the role of race and clinical care in psychiatry?
Lewis-Fernández: Before we discuss that, I wanted to say something about attention to structural racism in clinical care that relates to your question about race. In terms of structural racism, I wanted to give an example, because it’s the sort of thing that often clinicians don’t do very well with by omission rather than necessarily by commission.
Some time ago, I had a patient come in who was very depressed. This was by virtue of not being able to see her children, who were in the Caribbean. She was an immigrant, and because of immigration policies, she was unable to see them at all. Her depression was very linked to her separation from her children.
It’s very easy in that moment as a clinician to focus on her symptoms rather than the contextual situation in which she found herself — the reasons behind certain immigration policies in this country, why people immigrate from the Caribbean in search of better jobs, even if illegally, even if through a series of terrible journeys and difficulties.
If you were to understand the causes of her depression, you’d have to bring in a history of slavery, colonialism, economic exploitation in the region. You’d have to consider the reasons for immigration policy, why there was a ban on certain populations until 1965, et cetera. You’d have to come up with all sorts of contextual historical reasons that are still affecting us and being perpetuated today.
It’s hard for clinicians, myself included, to do that. It’s much easier — and is how we’ve been trained — to focus on the person’s symptoms and not so much pay attention to the rest. But if I really wanted to address this woman’s depression, I’d have to get to the fact of the matter. That is, she’s separated from her children. She’s faced a very difficult situation about whether to go back and give up on the future economic opportunities she hoped to have by staying here, or conversely stay here and be very sad by being separated from them. This is a structural problem that she has that, sure, can be improved by my care, but the fundamental root causes of it are ignored if I somehow make it her own psychopathology rather than the situation.
Strakowski: She’s actually having a normal response to an abnormal situation. One of the many important points in that example is that it serves as a reminder that race is a social construct that, in medicine, we too often either ignore or treat as a biological construct. The biological aspects in our ancestry are something like if our family happen to originate in an area with malaria and may therefore have a higher risk for sickle cell anemia, but the social construct of being Black isn’t itself a risk.
Woody, do you want to comment on that?
Neighbors: I wanted to jump on that word “ignore.” I can speak from the perspective of a client, someone who has been in therapy. Most of my therapists have been white. So, in addition to this notion of color blindness and treating everybody the same, what I’ve discovered is that very often in the cross-race therapeutic relationship, when the therapist is white, there’s a level of discomfort that they have in even bringing up issues of race. This happens even though they’re looking at somebody who’s obviously a Black man. And in fact, I feel that so many of my emotional issues are tied directly to the experience of growing up in the United States, starting in the early 1950s, and being part of this grand experiment of racial integration.
So, if I had one thing to say to the therapists out there, it would be, don’t run away from race because you’re trying to be color-blind; move directly toward race and bring it up in a questioning, curious way. Don’t ignore it.
Many of us who are clients don’t really understand that we should feel more empowered to bring it up ourselves. We’re there for a lot of reasons. Some of us are there reluctantly. I think it’s the responsibility of the clinician to broach the subject of race.
Lewis-Fernández: I agree completely. In some ways, when a person in a powerful role — such as a clinician, and a white clinician in particular — signals this desire to treat everybody the same, to be color-blind, and therefore not bring up these issues, they may be unwittingly transmitting the impression to the person of color that they are unwilling to address these issues. Treating everybody the same can almost serve as a kind of a screen for actually not wanting to bring up these difficult subjects.
Neighbors: We don’t like being ignored. And if you say you’re blind and you can’t see us in that way, what that makes us feel like is that we’re invisible. And I do not want to be the Invisible Man. That’s why we just can’t afford to be color-blind in a society that is obsessed from day one with skin color.
Strakowski: By way of a summary, I think what we’re saying is that we believe you have to treat each individual in their complexity, and we have to really be careful not to use social constructs to short-circuit that evaluation and consideration.
In talking to Woody about him being Black, he already knows that. You’re not giving away a secret.
Neighbors: Yeah, I tend to look in the mirror every morning and try to figure out, what’s this day going to be like? I have it all mapped out. I’m just hoping it works reasonably according to plan. But yeah, I tell people I’m Black when I show up and I’m going to be Black all day. Another thing I can talk about is if I’m Black on the phone, but we’ll save that for the next conversation.
Strakowski: What we’re encouraging people to do is to continue to think about this. We appreciate your comments and we want to continue to have this conversation, because it’s very complicated and involves a lot of issues that we discussed today. But finding ways to get rid of disparities is going to require us to approach things differently. This is the beginning of that conversation.
Gentlemen, do you have any final words before we sign off?
Lewis-Fernández: I want to underline the importance of what you said about understanding a person in context. Contextual thinking is really good clinical care, and that is something that we need to do in order to provide quality service to patients. A person’s background race is an element of that identity and set of experiences, which we don’t know how the person has lived through. We want to explore that in order to understand them in the right context by asking them and engaging them directly. If we don’t, we just risk experiences of mistrust and miscommunication.
There’s a study that my colleague Neil Aggarwal recently completed and submitted, where we asked patients as part of the cultural formulation interviews at intake whether they have any concerns about misunderstandings in their care. Over one third of patients in this low-income, mostly immigrant, mostly BIPOC (Black, Indigenous, people of color) community said that they were concerned about issues of mistrust. This is right off the bat.
Mistrust could come in many forms. It’s race, ethnicity, religion, gender, socioeconomic status, and any number of things. So, we want to know about all that when we engage the person, to have a better relationship and also understand them better.
Neighbors: I’ll close by just emphasizing one simple thing. When it comes to Black people, people of color, and BIPOC, keep in mind that we are not all alike. Even though we’re emphasizing the importance of this categorization that our country does on the basis of what you look like, I think the clinician does have to keep in mind that there’s an individual person in front of you.
Although you should be broaching issues of race, it does not mean that race is a big deal for this particular Black person. The point is to inquire. If the person says, “My race has nothing to do with why I’m here,” then you can move on, but just don’t ignore it.
Strakowski: Gentlemen, thank you again for a great discussion. We appreciate all of you viewers for taking the time to tune into these videos. We know these discussions are sometimes a little longer than usual, but it is a complicated topic. We look forward to your comments and suggestions.
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