Race and American Psychiatry, Curley Bonds, MD, DFAPA.

 Race and American Psychiatry

By Curley Bonds, MD, DFAPA

(reprinted with permission from Dr. Bonds)

Now that I am working full time as a public sector psychiatric administrator with a daunting array of duties of responsibilities, I’m frequently asked “Why do you still do private practice?” The question usually comes from friends and colleagues who worry about my mental wellbeing and fear that I’m overworking. 

When Dr. Goldenberg asked me to write a companion piece to his article about the Central Park Five [Southern California Psychiatrist,  July issue 2019] , I readily agreed. While collecting my thoughts I realized that the primary reason I still travel to Westwood every other Saturday to do med checks and psychotherapy is that it helps me to maintain my sanity.  I spend my work week trying to help restructure and create a new level of responsibility and accountability in the largest public mental health system in the country. This is a Sisyphean task - so It helps to spend time providing care that also allows me to do advocacy at a grassroots level. The words that follow are my attempt to explain how this works.   

  

At least once a month I receive a request from a distressed family seeking something very specific - an African American psychiatrist to help them intervene with their young son or daughter in the throes   of what they perceive to be a mental health crisis. The stories that they tell are strangely predictable. The common denominator is that they have witnessed themselves or been told by an instructor/coach/neighbor that their child is exhibiting unacceptable behaviors that put them at risk for everything from school expulsion to incarceration. In the worst of these scenarios their loved one has already had an encounter with law enforcement that invariably did not go well. Their worst nightmare is to have their child become the next opening story on the evening news, another young Black suicide/homicide-by-cop statistic. (One need only watch or read the press nightly regularly to realize that their fears are not delusional).  In many cases they have already attempted to access mental health treatment, but the outcomes have been disappointing. They are sent on an endless goose chase by their insurance company as they attempt to find providers who are ‘in network’ who accept their coverage. Those who have the financial resources to afford a private psychiatrist quickly learn that the number of African American psychiatrists even in a booming metropolis like Los Angeles is very small. The most recent statistics available suggest that only about 2 percent of American Psychiatrists self-identify as being of African descent. If you apply this statistic to the roughly 1000 active SCPC members, one could estimate that about 20 would are Black. When you subtract those of us who have positions that are mostly administrative, academic or institutional – the number of APA affiliated African American psychiatrists available to see private patients can practically be counted on one hand.

One might question the necessity of having culturally congruent psychiatric treatment. Arguably any psychiatrist can treat any patient provided that they share a common language and possess basic diagnostic and treatment competencies. But another perspective is that we all harbor unconscious biases that may cause us to prejudge individuals with backgrounds different than our  own resulting in suboptimal care. A clear example is the research (replicated multiple times) that African Americans are over diagnosed with schizophrenia and other psychotic disorders than non-white patients presenting with the same constellation of symptoms. African Americans also tend to receive higher doses of antipsychotic medications than whites despite the fact that they may be at greater risk for untoward side effects like tardive dyskinesia. It is hard to pin these findings on blatant racism, but they do point to institutions that have allowed systemic discrimination to persist. 

There are multiple unmeasurable or difficult to measure aspects of care that contribute to treatment  adherence and outcomes like countertransference, comfort with disclosing private or embarrassing secrets and the ability to efficiently communicate using culturally specific language without having to provide subtitles. As an example, if a patient tells me that they grew up in Baldwin Hills, belong to an AME Church,  pledged Delta  Sigma Theta at Spellman and that they participated in Jack and Jill social clubs as a child – I instantly know volumes about their values, socioeconomic status and robustness of their social network. These things are impossible to learn by completing a mandatory 2 hour CME course on so-called cultural competence or unconscious bias. My treatment plan, crafted with the patient’s input, will incorporate culturally relevant elements that others might overlook. By these statements I do not mean to imply that only Black  psychiatrists can be effective providers for Black patients. But I would strongly argue that for some, they are much more likely to seek care, remain in care and benefit more from care if their doctor  or therapist share a similar  cultural and ethnic background. 

In 1999, Surgeon  General Dr. David  Satcher produced a groundbreaking report on Mental Health in  our country. His report highlighted the fact that despite many efforts to reduce disparities, the ability for African Americans to access mental health treatment is far below their non-Black peers. Sadly, twenty years later, this situation remains unchanged. A primary reason for the inequity is the failure of American medical schools and psychiatry residency programs to train a sufficient number of psychiatrists and other mental health professionals to meet community demands of underserved minority communities. Evidence has shown that institutions like Charles R. Drew, Morehouse and Howard that have missions dedicating them to train minority physicians do indeed produce more doctors who practice within the safety net. Since 1969 the Black Psychiatrists of America (BPA) has created a space for political activism and provided a platform supporting academics who have dedicated their careers to teaching and research focused on Black patients.  The founders of this organization saw a need for a group focused on the priorities of the African American community in a way that the APA did not. The election of Dr. Altha Stewart as the first African American president of the APA coincided with the 50^th Anniversary of the BPA and was a shining moment of optimism for our field. 

While attending the annual meeting in San Francisco I appreciated the increased volume of sessions dedicated to the notion that the APA can and should do more to highlight and address health disparities among underrepresented populations. 

While we have advanced in many ways towards parity and equality in access to care and training, the number of African Americans entering our specialty still   lags behind where it should be. Programs like the APA Minority Fellows Program and The APA Black Men in Early Psychiatry Mentorship Program (BMEPP) encouraging African  American male  undergraduate students  to consider careers in psychiatry. These programs help to reduce some of the barriers that contribute to the low percentages of African American psychiatrists. They are much needed, especially as senior psychiatrists retire or pass away. A notable recent loss to our field was Dr. Carl Bell who devoted his career to issues relevant to the African American community like the impact of interpersonal violence, trauma and fetal alcohol syndrome. Dr.  Bell was well known for raising the alarm bell through his insightful lectures about how risk factors that impact Black Americans were tempered by protective factors like strong families, spirituality and appropriate mental health care. 

The challenges facing African American patients cannot be addressed solely by minority providers. If we are to move forward towards the ultimate goal of closing the health disparity gap, we need all hands-on deck. The first step in this direction is awareness and education for all of us so that we can come together as a profession to take a stand that racial discrimination in any form is unacceptable. Advocacy is an important but underutilized tool that may at times require us to navigate territory outside of our comfort zone. 

One key question that we should all ask ourselves is “What am I doing to create access and safe spaces for patients of all backgrounds?”