Addressing Social, Racial, and Economic Disparities at Psychiatry's Biggest Meeting

Nassir Ghaemi, MD, MPH


July 13, 2022

This year's 2022 American Psychiatric Association (APA) annual meeting was the first since the pandemic to be in-person. It had a virtual component also, but it wasn't live, so the meeting wasn't a truly hybrid meeting. The virtual attendees were given access for 1 week in early June, a few weeks after the live meeting.

The meeting was held in New Orleans and all attendees were vaccinated, although the majority attended most sessions without masks. Some sessions were held in close quarters without ventilation, and monitoring of the APA session app indicates that numerous attendees reported infection with COVID-19.

Although it is good for the APA to attempt to resume in-person meetings, it is my opinion — and that of some of my colleagues who attended — that the meeting was not sufficiently cautious and should have incorporated more public health measures such as social distancing and masking. Furthermore, a true hybrid meeting should incorporate livestream virtual attendance, as has been the case with other medical meetings this year.

With those limitations, the APA meeting was completed with a large in-person attendance. The theme of the meeting was social determinants of mental health. This topic was the title of the speech of the outgoing president, Vivian Pender. The keynote speaker for the meeting was the television journalist Soledad O'Brien, who held a conversation with Felix Torres, MD, on the topic "Diversity of voices is the story of America." She emphasized the toll of COVID-19 on mental health, as did numerous sessions at the meeting. In keeping with the overall meeting theme, many of those sessions emphasized the social, racial, and economic disparities which impacted worsened psychiatric conditions as a result of the COVID-19 pandemic.

O'Brien also emphasized her own diversity as a racially mixed individual and her conclusion that there are many voices in American society that are outside the White mainstream, and these voices have not been heard well until recently. They need to be heard, she emphasized, to contribute to the real story of America. And the job of journalists is to tell those stories.

In the general meeting, racism was the focus of a number of symposia, which included titles such as "Structural Racism: Biopsychosocial Consequences," "An Antiracist Approach to Teaching Social Determinants of Mental Health Curriculum for Child and Adolescent Psychiatrists," "Beyond Cultural Competency: Contemporary Psychiatry in a Raced Society", and "How Psychiatrists Can Talk with Patients and Their Families About Race and Racism: Theory and Practice Through Simulation."

The last session above was accompanied by a resource document produced by the APA. The session provided definitions for terms that should be used, some of which are common and some less so; they are "anti-Black racism, discrimination, institutional racism, microaggressions, race, racial bias, and racism." As noted, the overall term of racism is broken down into much more specific components. The concept of microaggressions, introduced by Dr Chester Pierce as explained below, is especially important: "brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile derogatory or negative prejudicial slights and insults toward any group, particularly culturally marginalized groups."

The session recommended discussing race and racism with patients of all races, and eight case vignettes are provided in the APA resource document as examples of these discussions. Besides being aware of race and its influence on oneself and one's patients, the sessions emphasized the need to "recognize the role structural factors have on patients' lives and how their current struggles and stressors determine the course of their mental illness."

These sessions were informative, but for me, the most interesting session was a presidential symposium which involved a conversation with Dr Ezra Griffith of Yale University. The program centered around a discussion of his book, Race and Excellence: My Dialogue with Chester Pierce, originally published in 1998, about his relationship with his mentor, Dr Chester Pierce. Both psychiatrists are African American, and Pierce, who died in 2016, was a founding figure for many in the African American psychiatric community. Pierce was a founder of Black Psychiatrists of America (created after Martin Luther King's assassination in 1968), president of the American Board of Psychiatry and Neurology, a commander in the US Navy, and for many years was a professor of psychiatry at Harvard Medical School and a senior faculty member at Massachusetts General Hospital. He even was a consultant to the Sesame Street television show.

Despite these high-ranking accomplishments, Pierce kept a low profile. One of the things that Griffith noticed was that Pierce refused to have public debates about his ideas, and he had a degree of humility that might be deemed excessive. When he retired in 1999, he refused to have any public events in his recognition.

Among Pierce's contributions to psychiatry and the larger culture was the now widely accepted concept of racial "microaggressions." He coined the term and described the idea: Racism isn't something you just experience now and then in some huge event, like a lynching; it's present every day in many small ways — in a person looking at you askance, or someone crossing the street when you approach, or getting stopped by a policeman when driving your car while others pass by.

Pierce also introduced the concept of racism as an "environmental pollutant." It's always there, in the environment, like pollution. You can't avoid it, and it worsens everyone's quality of life.

Pierce was a mentor to Griffith and many others younger than him who entered the largely White profession of American psychiatry. He was an example to them of how to survive and advance in a largely White establishment. For Pierce, that process didn't involve explicit conflict, but it also didn't involve subservience. The process never would be comfortable because Black psychiatrists were a minority and would have to engage with White colleagues, in an environment of racism as a pollutant in the larger culture.

In the Navy, Pierce worked for some time in Antarctica, and he later used that experience as a metaphor for racism as an "extreme environment," which requires a great deal of resilience. An interview late in his life brings out his concern for the unconscious harms of racism, even in environments that are much less racist than in the past.

All of these concepts, microaggressions and racism as an environmental pollutant, bring out Pierce's view of what we might call the social psychology of racism: Racism is an individual psychological matter; I may or may not have conscious or unconscious racial or ethnic biases. It's also part of the social environment, part of the larger culture all around us, like pollution in the environment, and we can't help being influenced by it, if only unconsciously.

Today people use the phrase "systemic racism" for the latter social presence of racism in institutions or social structures, as opposed to individual psyches. Pierce started the process of understanding this dual aspect of racism: the personal and individual in the context of the social and structural.

This event wasn't the first time that Pierce had been recognized at the APA meeting. Another symposium had been given in his honor in 2017, with various speakers. One, the late Carl Bell, commented: "Nearly every white person you meet is going to tell you, 'I believe in the American ideal of judging people by the content of their character, not the color of their skin.' But when you get left out of something or micro-insulted or locked up for breathing-while-black, you know we've not reached the ideal."

In our current polarized environment, some are pushing back against the concept of microaggressions; as others have noted, they should read where that concept originated in the work of Pierce and in Pierce's own life experiences.

In recent years, the APA had its first Latina president and its first Black president. Clearly, the organization is taking steps to combat structural racism within itself. Chester Pierce would have been proud.

A complete program guide to the American Psychiatric Association Annual Meeting can be found here.


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