So this is an encore performance of Dr. Shailen Mhapsekar and this Clinical Problems in Consultation Psychiatry (CPCP) presentation is about disparities in the mental health evaluation and treatment of African Americans in the United States. This is a politically sensitive topic although it’s especially relevant in view of the violence against black people that we hear about so often in the news these days.
Further, it’s also disturbing to be reminded of how difficult it is, apparently, for psychiatrists to even make accurate psychiatric diagnoses. The paper by Rosenhan raises the irony of his hope that the rise of community mental health centers would be the answer to warehousing the mentally ill in asylums . In fact, the movement never fulfilled its promise as we decry the closing of state mental hospitals in Iowa.
The emphasis on cultural competence and the reason why this is critically important today becomes clear from Dr. Mhapsekar’s presentation. His allusion to the Tuskegee syphilis experiment is apt.
And it is almost chilling to read just the abstract of the paper by Bevis on “the Southern Negro” in the American Journal of Psychiatry, published in 1921 .
It’s enough to make me wonder all the more why past president of the American Psychiatric Association, Dr. Jeffrey Lieberman gives such glowing praise to modern psychiatry in his book, “Shrinks.” I don’t want to minimize the progress so much as highlight what work yet needs to be done from a cultural as well as a scientific standpoint.
1. Rosenhan, D. L. (1973). “On being sane in insane places.” Science 179(4070): 250-258.
It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment-the powerlessness, depersonalization, segregation, mortification, and self-labeling-seem undoubtedly countertherapeutic. I do not, even now, understand this problem well enough to perceive solutions. But two matters seem to have some promise. The first concerns the proliferation of community mental health facilities, of crisis intervention centers, of the human potential movement, and of behavior therapies that, for all of their own problems, tend to avoid psychiatric labels, to focus on specific problems and behaviors, and to retain the individual in a relatively non-pejorative environment. Clearly, to the extent that we refrain from sending the distressed to insane places, our impressions of them are less likely to be distorted. (The risk of distorted perceptions, it seems to me, is always present, since we are much more sensitive to an individual’s behaviors and verbalizations than we are to the subtle contextual stimuli that often promote them. At issue here is a matter of magnitude. And, as I have shown, the magnitude of distortion is exceedingly high in the extreme context that is a psychiatric hospital.) The second matter that might prove promising speaks to the need to increase the sensitivity of mental health workers and researchers to the Catch 22 position of psychiatric patients. Simply reading materials in this area will be of help to some such workers and researchers. For others, directly experiencing the impact of psychiatric hospitalization will be of enormous use. Clearly, further research into the social psychology of such total institutions will both facilitate treatment and deepen understanding. I and the other pseudopatients in the psychiatric setting had distinctly negative reactions. We do not pretend to describe the subjective experiences of true patients. Theirs may be different from ours, particularly with the passage of time and the necessary process of adaptation to one’s environment. But we can and do speak to the relatively more objective indices of treatment within the hospital. It could be a mistake, and a very unfortunate one, to consider that what happened to us derived from malice or stupidity on the part of the staff. Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective.
2. Bevis, W. M., M.D. (1921). “Psychological Traits of the Southern Negro with Observations as to Some of His Psychoses.” American Journal of Psychiatry 78: 1.
The negro race evinces certain phylogenetic traits of character, habit, and behavior that seem sufficiently important to make the consideration of these peculiarities worth while; especially as these psychic characteristics have their effect upon and are reflected in the psychoses most frequently seen in the negro. Forming so large a part of the population and living as he does under conditions, climatic and otherwise, that are favorable and natural, the negro of the Southern states forms the basis of the observations and deductions of this brief article.
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