Race matters in psychiatry

O.J. Simpson was just awarded parole. Once again, the media has begun discussing whether race or justice prevailed in that decision.

Some in the media have also brought up whether Simpson has a psychiatric diagnosis and whether that could be along the narcissistic and/or sociopathic spectrum. For psychiatrists like myself, though not for other mental healthcare disciplines, the so-called Goldwater Rule ethically prevents speculation on those diagnostic possibilities in this situation—just as it does with President Trump.

Nevertheless, there are aspects of this decision that resonate in behavioral healthcare and should be discussed. Race does seem to matter in our field.

It’s worth noting the president-elect of the American Psychiatric Association is Altha J. Stewart, MD, and she represents the first time a Black American will hold that important post. Does that fact somehow reflect any underlying racism among psychiatrists? If we look at the lingering racial disparities in mental healthcare, perhaps it does.

Though we have improved in recent decades, Black Americans still are subject to being diagnosed erroneously, and still are underserved with certain treatment modalities like psychotherapy and overtreated with medication.

Some of the commentators in the O.J. Simpson discussion admitted his history of domestic violence was ignored. Domestic violence is not a diagnosis, but it indeed may reflect intermittent explosive disorder, for example. Though there have been intermittent attempts to have extreme racism qualify for a diagnostic classification, all have been turned down, in part because implicit bias tests indicate that we all have some racism, so where do we draw the line?

Aspects of Simpson’s history, his race and previous incidents of domestic violence deserve our renewed attention. What can we do?

For racial factors in our field:

• Given relatively equivalent qualifications, make sure that your staff is as culturally diverse as practically possible to reflect the population served;
• Make sure your staff knows how to provide culturally competent care;
• Make sure that any outcome studies include comparative cultural background as a variable to assess; and
• Advocate that Medicaid, which finances the care of so many underserved poor minorities, should not be cut in new healthcare policies.

For domestic violence:

• Recognize that neither the victim nor the perpetrator may readily admit to domestic violence occurring;
• Understand that domestic violence may be viewed as normal in some subcultures;
• Treatment of the victims of domestic violence must not only focus on the disorder, but the social safety of the victims in a comprehensive bio-psycho-social approach; and
• Educate the public that committing domestic violence is indeed a mental health issue, likely reflecting the sexism in our society.

Whatever we may believe to be the right decision for O. J. Simpson, there is more work that must be applied in providing just care in our own field.