Applying Anti-racism to Clinical Care and Research

The highly publicized murders of Ahmaud Arbery, Breonna Taylor, and George Floyd raised awareness of the insidious ways racism continues to manifest. This led to increased support of the Black Lives Matter movement in the US and globally. The American Psychiatric Association formally apologized for its support of structural racism and called for the application of anti-racism framework in clinical research and practice.¹ Although anti-racism requires a multilevel approach, a key component of this work is acknowledging the existence of racism and understanding how racism developed and evolved in the US and its ongoing manifestations within psychiatry. We provide a brief overview of the history of racism and its impact on the mental health field and suggest steps for engaging in anti-racism work through developing awareness of racial prejudices.

Racism is systemic, comprising beliefs, practices, and policies that advantage those with historical power based on race in the US (White people).² The racialization of people in the US was born out of the colonization of the Americas by Europeans. The belief was that White people were inherently superior and should dominate all groups (white supremacy),² which was used to justify colonizing the Americas for economic gain. People of European decent forced their language, religion, and ways of living on enslaved Indigenous and African people believing that European tradition was the best way of living (cultural racism),² that African people were subhuman, and that it was in their best interest to enslave them. Medical terminology coined in the 1800s by the "Father of American Psychiatry" Benjamin Rush supported the belief that Black people were inherently dangerous and needed to be controlled.³ Racial prejudices (eg, belief in white supremacy; believing Black people are dangerous) and racial discrimination (eg, enslaving African and Indigenous people; forcing African and Indigenous people to adopt European values) are individual-level factors that are the product of and contribute to systems of racism. Racial prejudices held by physicians in the 1800s resulted in fabricated disorders like drapetomania, used to describe Black people who fled captivity.³

Although the history of racism in the US dates back centuries, its impact persists today. Within psychiatry, racism contributes to (1) mental health disparities and the misinterpretation of causes of those disparities (eg, overdiagnosis of psychotic disorders, overprescription of antipsychotics, underprescription of pain medication among Black people⁴; "race-norming" in cognitive testing requiring Black professional football athletes with traumatic brain injuries to demonstrate more severe cognitive decline to meet eligibility for payouts), (2) underrepresentation of racially marginalized people in mental health treatment and research, and (3) discriminatory treatment of racially marginalized people when they are engaged in treatment and research.

Stressors associated with experiences of racism (eg, intergenerational trauma, economic hardship, living in unsafe neighborhoods, limited access to quality education and high-paying jobs) have been reported to be associated with differences in biological (eg, increased cortisol levels; inflammation) and mental health outcomes (eg, increased rates of posttraumatic stress disorder) between racial groups.⁵ However, when these disparities emerge in research, they are often misattributed to inherent/biological differences (scientific racism).² In the US, race has been used to group people with shared physical and social characteristics. Race is a social construct defined by the US Census Bureau, and racial categories have shifted over time (eg, Hispanic used to be considered a race but was redefined as an ethnicity). Genetic research has demonstrated there is no race gene and that people across race are more genetically similar than different.⁶ Although most past pseudoscience has been debunked, the misuse of science continues today by those who still believe in biological differences between racial groups and thus misinterpret race in their research, which serves to support scientific racism. In clinical practice, misattributing health disparities to biological differences results in blaming patients for their mental health difficulties. An anti-racist approach requires appropriately externalizing determinants of health disparities. Accurately naming the problem validates participants’ experiences and provides a road map for addressing disparities at the structural–rather than the individual–level. This is consistent with a structural competency approach to recognizing structures that affect clinical interactions and integrating structures in clinical conceptualizations.⁷

Even though racially marginalized groups experience disproportionate levels of adversity and associated mental health disparities, they are underserved in mental health treatment and underrepresented in research. Racially marginalized people have endured a long history of both scientific and medical racism, including abusive treatment and experimentation.^1–3 As a result, they may develop cultural mistrust, which can serve as a barrier to using mental health services and enrolling in clinical trials,⁵ Additionally, racially marginalized groups are disproportionately burdened by poverty, contributing to logistical barriers to care (eg, inadequate insurance coverage).⁸ Anti-racist solutions include (1) adjusting hiring practices so the health care professionals in a clinic match the demographics of the community served, which may attenuate cultural mistrust among racially marginalized patients and motivate efforts to increase racially marginalized researchers, (2) funders providing sufficient resources to support community-partnered recruitment efforts, (3) publications of studies featuring diverse participants holding more weight in grant and promotion decisions, given the additional time required to study these groups, and (4) implementing conditional cash transfers for patients with low income to address financial barriers to treatment.⁵

Racially marginalized patients engaged in treatment often receive lower quality of care compared with their White counterparts (medical racism).² Their underrepresentation in clinical trials leads to limited evidence of the efficacy of interventions for racially marginalized people with psychiatric disorders. Biases held by clinicians may lead to committing microaggressions, which can damage the working alliance, convey pessimistic expectations for outcomes, and negatively impact patient expectations and motivation.⁵

How to Become an Anti-racist Clinical Researcher

The first step in addressing racial disparities in treatment is education and acknowledgment of the problem. This includes developing structural competency, or an understanding of how sociopolitical conditions result in racial health inequities.⁷ Education includes supplemental reading, continuing education, podcasts from experts, and discussions with racially marginalized friends and colleagues about their experiences. Training in culturally informed mental health care and supervision from experts in working effectively across differences is also critical.

Developing awareness of one’s racial prejudices is essential for becoming an anti-racist. Engage in self-reflection by attending to intersecting identities (eg, race, sex, socioeconomic status) and identifying which are privileged and oppressed and how the combination of identities impacts one’s experience in the world. Reflect on implicit and explicit messages learned about race and their sources (eg, family, friends, media). Examine the social identities of close friends and consider how these relationships have impacted opinions about those with differing social identities. If one’s friend group is homogenous, prioritize developing genuine friendships with people from other backgrounds. One way to challenge racial prejudices is through repeated interactions with racially marginalized people.

Consider how racial prejudices might have inadvertently impacted clinical work (eg, conceptualization of disorders, research questions, mentoring/training, hiring practices). Attend evidenced-based workshops aimed at interrupting bias⁹ and engage in in structural-level interventions. Hire a diverse research team and seek out diverse participants.

We have outlined individual-level strategies as initial steps toward addressing broader structural racism. Although developing awareness of racial prejudices and structural competency is insufficient to eliminate racism, it is a crucial step toward engaging in structural change through considering alternative laws, policies, and practices affecting clinical care and research that will lead to the elimination of racial health inequities. Engaging in individual-level anti-racism is a critical step toward structural transformation and ultimately achieving health equity.