Psycho-education on racism: Psychiatry’s role and responsibility in dismantling institutional racism

Medical education on racism

Today, many psychiatrists are not familiar with the different issues related to racism because racism is not usually part of the psychiatry residency curriculum. Suite et al. (2007) suggested that cultural competence training becomes mandatory through continuing medical education credits to help mental health professionals deal with matters of cultural competency, sensitivity and healthcare disparities in their clinical and academic work.

In North America, training programs in cultural and social psychiatry are available and well developed, as for example the training programs offered by the McGill University Division of Social and Cultural Psychiatry, in Quebec. ¹ However, these important courses are elective and not included in the psychiatry residency curriculum. The division of Public and Community Psychiatry of the Massachusetts General Hospital’s Department of Psychiatry (Harvard University), is one of the rare programs which have formally included education on racial inequities to the psychiatry curriculum (Medlock et al., 2017; Shtasel et al., 2019). As highlighted by Shtasel et al., to date, most medical education efforts to address health disparities have focused on the need to develop health professionals’ cultural competence. However, training in cultural competence is insufficient to address racial inequities, and training on racism is usually offered as an elective program and not developed as ‘curricular’. Shtasel et al. (2019) explain that ‘a fundamental principle in all of these activities is that they are curricular, all residents participate, rather than being elective opportunities that inevitably self-select for residents already interested and invested in these areas’.

Furthermore, Fernando (2017, p. 149) reminds that teaching psychiatry needs to be aware of potential bias related to using only western’s sources of knowledge. The author reports that even though many United Kingdom universities consider themselves as “global universities”, they often do not consider other sources of knowledge than the western’s one.

Today, Psychiatry, and, moreover, the field of Social and Cultural Psychiatry, could contribute introducing medical psycho-education on racism, including topics on racial inequities, the concept of historical trauma, the history of racism in psychiatry and the history of anti-racist psychiatry. For example, Frantz Fanon’s contribution to psychiatry during the French colonialism era, is not well known by psychiatry residents, though his work on psychology of colonization, decolonizing and humanizing marginalized populations, enables us to better understand contemporary relationships between majority and minority groups, and is today increasingly inspiring psychotherapeutic approaches (Gibson & Beneduce, 2017; Turner & Neville, 2019).

Education on racism is even more important to address as ignorance can lead to misunderstandings and sometimes adoption of wrong approaches based on good intentions, as for example the ‘race-blindness’ approach aimed as an anti-racist attitude, and that is rather counterproductive as it maintains, or even aggravates the existing racial inequities (Banerjee et al., 2020). On the other hand, it is important to underline that addressing racism through a multiculturalism focus can induce threats and hostility in the majority group that fears the anticipated demographic change with an increased diversity in the future (Craig et al., 2018).

Education on institutional racism

Even though individual racism is strongly condemned and fought in western countries, institutional racism is still controversial. Some governments and some politicians around the world still do not recognize the existence of a systemic or institutional racism. Apart from individual racial aggression, and microaggressions, systemic and institutional racism constitute a complex issue. Developed during the late 1960s by Charmichael and Hamilton (1967), the concept of institutional racism refers to a more subtle and pernicious racism, not related to individual acts, but rather based on collective acts. Macpherson (1999) explains the collective attitudes underlying institutional racism by this description:

‘Unwitting racism can arise because of lack of understanding, ignorance or mistaken beliefs. It can arise from well intentioned but patronising words or actions. It can arise from unfamiliarity with the behaviour or cultural traditions of people or families from minority ethnic communities (. . .). Furthermore such attitudes can thrive in a tightly knit community, so that there can be a collective failure to detect and to outlaw this breed of racism’ (Macpherson, 1999, p.44).

In North America, and more globally in English literature, institutional racism is usually addressed among multiple types of racism. In the French literature, the concept is more controversial as demonstrated by a current terminological debate opposing ‘institutional racism’ and ‘systemic discrimination’ (Dhume et al., 2020; Dunezat & Gourdeau, 2016).

Williams et al. (2019) highlight that research on institutional racism has been limited by the availability of data on structural levels, and analyses are limited in understanding the underlying processes. Banerjee et al. (2020) highlight that racial disparities are not only indicators of the disadvantages of the minority groups, but also a sign of the power and the privilege of the majority groups. ‘White privilege’, inherited from western colonialism and scientific racism during the eighteenth and nineteenth centuries (Fernando, 2017), is not a chosen privilege (either you are born with it, or you are not), but everyone should be aware of the potential impacts on minority groups of such a privilege, and everyone can choose what actions to take, or not, in tackling the related social injustice.

To dismantle structural racism, Hardeman et al. (2016) recommend learning and understanding racist roots through America’s history, to understand how racism has shaped false beliefs for centuries, contributing to current health inequities.The authors highlight that health care professionals have both a collective and individual responsibility to understand the historical roots of contemporary racial health disparities.

Education on historical scientific racism

Psychiatric journals provide a precious space of education worldwide accessible and an archive of past racist and anti-racist psychiatric articles. However, an education on these historical articles is essential. The history of scientific racism developed in the eighteenth and nineteenth centuries in the United States of America and Europe, during the imperial and colonialist era (Gordon-Achebe et al., 2019) should be better known by psychiatrists and the scientific community more globally. A psychiatric diagnosis of ‘drapetomania’, introduced by the American physician Samuel Cartwright in 1851, refers to a disease characterized by unvoluntery movements explaining, according to Cartwright, why some Africans escaped from slavery. ² Similarly, during the French colonial period, the psychiatrist Antoine Porot developed a theory of ‘primitivism’ and ‘criminal impusiveness’ regarding North African people.^3,4

Furthermore, anthropologists and historians highlight the importance of telling missing historical stories regarding slavery and colonialism. The historian Donald Yacovone recently reminded the need to tell differently the history of African-Americans in the United States. ⁵ By the example of the Maori minority in New Zealand, Sibley and Liu (2012) highlight how stories of history tend to favour dominant groups and how historical negation legitimate social inequalities. History of the Autochthons in Quebec (Gettler, 2016) and the history of French colonialism are similarly waiting for some stories to be told through a new perspective (Beneduce, 2019). On a psychological perspective, through the concept of transgenerational transmission of historical trauma (Kirmayer et al., 2014), we can question if past trauma related to slavery, colonialism or Nazism could be revived by today’s institutional racism.

Facing historical psychiatric articles with racist content, contextualization allows the reader to understand why a racist text may have been written and published in a scientific journal in the past. However, contextualization has some limits and education is needed also on this point. Indeed, the historical and political context of the past is insufficient to prevent the risk of offending today’s reader. The historical and political context of the past does not change the racist and dehumanizing character of a text that the reader reads today. In addition, it is above all the identity and the personal history of the reader that would determine whether or not the latter would be offended. However, historical racist psychiatric articles are available today without any written warning added for the reader. By examining the concept of racist words that are used as psychological and physiological violence, Nelson (2003) reflects that some words can inflict deep wounds based on identity, be that identity based on race, gender, culture, religion, or sexuality.

So, what should be an appropriate institutional position regarding a situation where a minority of the readership could be offended because of their ethnic origin, religion, or sexual orientation? This question has never been addressed in the past by editorial ethical codes, and yet is important to think about, moreover, in a globalization world where past racist articles are available online to everyone around the world. So, should we add a warning page to all historical racist publications that used a so-called science to dehumanize other human beings to legitimate colonialism? The question worth to reflect on it. If the aim is validating and acting on the reality that today’s minority groups could be offended by such contents, why not doing such a structural change? In addition, adding a written warning is a simple, easy to achieve and inexpensive action. In 50 or 100 years from now, our work and writings could be criticized. Perhaps someone would ask for adding a warning to the reader because of ‘too much focus on psychopharmacology’, who knows? This could be a natural evolution of psychiatry. The aim of adding a warning page for past articles either racist, anti-Semitic, Islamophobic, or homophobic, is not criticizing past authors but rather protecting today’s readership as a whole.

Conclusion

In Canada, as in many other western countries, we see efforts to give a place and a power to people of minority groups in several institutions and different professional fields. However, actions to dismantle structural, systemic and institutional racism are still vitally needed. The Canadian Association of Psychiatry’s Transcultural section calls for a global effort against racism and social injustice. ⁶

Furthermore, today, the world is witnessing an awakening of several scientific associations and editorial boards around the world, willing to change the system and to counter racism and social injustice as the Association of American Medical Colleges, ⁷ the Lancet, ⁸ the American Journal of Psychiatry’s Editors, ⁹ the Royal Society of Chemistry, ¹⁰ the Elsevier community. ¹¹ All these public statements are to be congratulated as they are encouraging more inclusion and social equity. So, let us move forward with concrete actions targeting the racial inequities whatever the institution and whatever the field. Let us implement concrete institutional intervention plans specifically aimed to tackle institutional racism and systemic discrimination without letting a terminological controversy slow or inhibit our actions. Let us bring out the huge scientific documentation already existing about racism and mental health and look at the past recommendations which often remained words on papers. Finally, let us listen to the academics when they call for a structural change in the medical and psychiatric curricula.

Sometimes, the gap between collective mentalities- which have greatly evolved through time, and collective actions- not enough evolved, can become a source of misunderstanding and even tensions, between the majority and the minority groups. To overcome this impasse, we need a broad cooperation, at different levels at the same time, all together, professionals from the majority and the minority groups, worldwide and based on mutual respect.

In the name of dismantling racial inequities and social injustice for the future generations, will Psychiatry lead to a collective awareness, allowing us to move our actions forward enough to reach the level of our thoughts and words?