Electronic Spring 2022 | Issue 50

IPS Sets the HEAT Series Ablaze with Session on Bias and Cultural/Structural Humility

By:Jasleen Singh, MD

IPS ignited the spark towards continued discussions regarding important themes of equity and diversity with its virtual series. The Health Equity Anti-Racism Training (HEAT) series will occur monthly and feature expert panelists who will discuss topics of Bias and Cultural/Structural Humility, Social Determinants of Health and Health Disparities in Psychiatry, Social Justice in Psychiatry, and Community Partnership/Engagement.

This goal of this series is to assist Illinois psychiatrists in furthering awareness and fostering skills to address and overcome the psychosocial challenges and disparities that regularly affect our patients. Attendees will have the opportunity to learn to incorporate best practices in anti-racism on a daily basis as they engage in this important conversation and even have an opportunity to get their questions answered at the end of each session.

The first event of the HEAT series set the stage ablaze with a phenomenal set of panelists who discussed Bias and Cultural/Structural Humility. The first panelist, Dr. Sheila Caldwell, is the Vice President of Antiracism, Diversity, Equity and Inclusion and the Chief Diversity Officer at SIU. She began by discussing structural racism, embedded in all parts of life and contrasted to structural humility. She noted the broad impact on several fields, including education, economics, healthcare, politics, and religion. Emphasis was placed on utilizing a structural lens to examine these enduring systems so that we can “dismantle the system as we find areas of inequity”. Dr. Caldwell also discussed how structural humility tells the story of why African American males are incarcerated at higher rates in the south, invites us to examine why there is 1 billion dollars more in public funding for white students, and perhaps explains why African American kids are trailing behind in every marker in the education system. Within healthcare, structural humility begs the question of why more African Americans and Native Americans have died from more alarming rates, double their representation in the American population, not due to genetic factors but their limited access to healthcare.

The second panelist, Dr. Danielle Hairston, President of the APA Black Caucus and Psychiatry Residency Training Director at Howard University, went on to provide a comprehensive overview of the multiple levels of racism, noting that “all racism is not overt” but that bias is part of all levels of racism. She used examples to facilitate understanding of explicit and implicit racial biases, noting that implicit racial bias is an unconscious association of stereotypical attributes with particular racial groups which can manifest in stressful, fast paced situations. Given her background as a C/L psychiatrist, she incorporated a clinical example relating to use of higher antipsychotic doses in African American males. She demonstrated how an individual physician’s bias can become systemic when such practice is taught to residents or others within an institution, who then learn to follow and accept such biased practices. Yet, as Dr. Hairston pointed out, this phenomenon pervades other specialties. She then transitioned to discuss how such bias can become a cultural norm that can contribute to misdiagnosis and inappropriate treatment. Of note, she clearly distinguished cultural humility from cultural competency by highlighting cultural humility as a lifelong process that begins with self-reflection of one’s beliefs and cultural identities. On the other hand, cultural competency centers around whiteness and treats other groups as the “other”, which ultimately continues to marginalize these groups.

The third panelist, Dr. Kemia Sarraf serves as Adjunct Assistant Professor in the Office of Equity, Diversity, and Inclusion at SIU. As a trauma mitigation specialist, she took the conversation into a different direction, discussing the spectrum of the learning process and highlighting that “when we are conscious of all the things we don’t know, it’s a high energy…anxiety provoking state that’s not permanent”. She stated this is important to consider because stress exists on a continuum of stress, toxic stress, and ultimately trauma. She pointed out that “we are living in times of unrelenting toxic stress, and exposure matters”. Dr. Sarraf discussed her experiences working at SIU and the impact of stress related to the pandemic, racial violence, and isolation. She noted it’s not realistic to think we can be untouched by this, which gives us an expanded framework to understand how such trauma affects us. She noted it can be experienced as primary, secondary, or vicarious trauma and highlighted that “racism is trauma” – with the presence of institutional, intergenerational traumas that last in time. As a faculty member of SIU, she provided unique insight into “working with students, residents, colleagues who are trying to learn in a high stress environment”, noting that there must be a sensitivity, awareness, and understanding of the impact of these intergenerational and systemic experiences and their effect.

The final panelist of the night was Dr. Cheryl Wills, a forensic psychiatrist who is Chairperson of the APA Presidential Task Force on Structural Racism, Member of the APA Board of Trustees, and Associate Professor of Psychiatry at Case Western Reserve University. Dr. Wills started off her discussion by noting that given her forensic training, she “looks at things in shades of gray”, to decrease risk of being biased or prejudicial. She warn that “if cultural competence is used as a finite process, you approach other cultures as if you know everything you need to, but if used towards increasing cultural humility, you take the knowledge you derived to pose questions to learn”. Dr. Wills discussed barriers within the judicial system, and later transitioned to discussing a study from Yale regarding bias in preschool education, and how the effects of teacher, parent, and child relationships can have “profound implications” on a child’s development. She noted that in June 2020, AMA designated racism as a “threat to public health” and in November 2020 they declared that race is a “social construct” distinct from ethnicity, genetic ancestry or biology, which meant that race is not a biological determinant of health. She notes the AMA focused on the “experience of racism” not race itself, as pertinent for considering risk factors for disease. She further delved into the experience of racism in medicine as well as systemic and implicit bias relating to behavioral disorders through discussion of several pertinent studies.

The night concluded with a brief Q&A. In response to a question regarding embedding these discussions in residency curricula, Dr. Hairston identified the importance of a structural competency curriculum which incorporates discussion of systemic racism, systemic vulnerability. She also mentioned other resources available to residency programs including a racism webinar on APA, and other curricula that are available through APA and MedEd portals. In addition to formalized processes, Dr. Hairston discussed importance of incorporating these concepts in daily practice, such as calling underserved populations as intentionally marginalized.

Each panelist concluded by offering a lasting piece of advice. Dr. Wills noted that cultural humility and cultural formulation interview is a good place for many to start. Dr. Caldwell recommended several books including: Medical Apartheid, Protest Psychosis, My Grandmother’s Hands, and Developing Cultural Humility. Dr. Sarraf highlighted the transactional nature of medicine and the importance of relationships, which can be fostered by allowing others time and space. Finally, Dr. Hairston emphasized the importance of asking difficult questions and practicing evidence-based medicine. She also offered another resource, as she has a podcast called “The Next 72 Hours”.

Overall, a wonderful set of panelists set the HEAT series ablaze, with even more information planned for the series in these coming months!

Register for the next session on Social Justice in Psychiatry.

Contact Kristen Malloy at kmalloy@ilpsych.org for a recording of previous sessions.