Structural racism is why I’m leaving organized psychiatry

The killings of George Floyd, Ahmaud Arbery, Breonna Taylor, and so many others are leading many Americans to reflect on structural racism in society and resolve to do things differently. They have led me to make the difficult decision to end my membership with organized psychiatry, specifically the American Psychiatric Association.

After years of committing myself to the APA and believing that organized psychiatry was an effective vehicle by which progress could be made, racism is driving me and other Black physician leaders out of organized psychiatry, just as it has pushed Black physician leaders out of academic medicine.

As a physician, I grew up in the APA. During my residency, I was selected to receive the APA/GlaxoSmithKline Fellowship (now known as the APA/American Psychiatric Association Foundation Leadership Fellowship). Its goal is “to prepare future leaders in the field of psychiatry.” I was delighted, and proud, until I read the press release bearing the headline that 10 residents had been awarded the fellowship. Yet only nine names were listed in the release. The name of the only Black person in the fellowship class, mine, was left off. I was hurt but didn’t at the time feel the need to correct this “oversight,” and remained silent.

The fellowship itself exposed me to the many opportunities that the APA had to offer. I met important colleagues, mentors, and leaders with whom I still collaborate. In 2007, through the fellowship, I attended the APA’s annual meeting in San Diego. There, for the first time, I attended a Black psychiatrists’ caucus meeting and heard the pain and frustration of my colleagues, who were deeply committed to organized psychiatry but felt strongly that organized psychiatry did not have the same commitment toward them or their patients.

At that meeting I learned that Black psychiatrists had stormed the APA board of trustees meeting in 1969, demanding racial equity. One year later, a collection of seven articles on racism appeared in the American Journal of Psychiatry (pages 787 to 818) and included clear recommendations for white psychiatrists “to become increasingly aware of how their everyday practices continue to perpetuate institutional white racism in psychiatry and to support the search for realistic solutions,” and to make available “the necessary resources of money, manpower, and authority — and not just in the current token amounts.”

Unfortunately, these recommendations were not followed in any significant way, despite the fact that they are still as relevant today as they were 50 years ago.

I left the APA’s 2007 meeting vowing to continue to fight for racial equity from within the organization.

Over the next few years, as a junior faculty member, I dedicated myself to this effort. I submitted abstracts on topics related to improving outcomes for minority populations with serious mental illnesses. I was careful, though, in how I presented these issues in submissions to the APA’s annual meeting scientific program committee. I hid my interest in “minority issues” through coded language such as health disparities and social determinants of mental health. Many times, despite my great efforts to make my interests more “palatable” to a wide audience, these submissions were rejected.

I found acceptance with the Institute on Psychiatric Services (IPS), APA’s smaller fall meeting, which is marketed for public-sector psychiatrists — those who primarily care for poor patients of color. I began to incorporate discussions about discrimination in psychiatry into my submissions for this meeting. Presentations that were routinely rejected for the APA’s annual meetings were often accepted and well-received at IPS meetings.

I was grateful to have the IPS as an outlet to grapple with complex issues of structural racism in psychiatry. Sadly, prominent APA leaders have expressed concern that IPS unfairly caters to one group of the APA — public-sector psychiatrists — and have explored the financial viability of continuing the IPS meeting.

My direct interactions with APA leaders made me wonder about gaslighting. I often questioned whether unwritten policies were deliberate attempts to impede progress toward achieving racial equity. As co-chair of the 2018 Workgroup on the Future of the IPS Meeting, I and other members of the group volunteered extensive time to develop six recommendations to ensure the financial and logistical stability of future meetings, only to be left doubting if any of these recommendations were ever realistically considered. For the first time in my career, no IPS meeting was scheduled for fall 2020, a decision made long before the emergence of Covid-19.

I have also experienced countless microaggressions. APA leaders have confused me with other Black women psychiatrists bearing no resemblance to me, interrupted one-on-one conversations I was engaged in without acknowledging my presence to speak with the white man I was conversing with, and have “accidentally forgotten” to acknowledge me when publicly recognizing members for their service to the organization. In each instance, I remained silent. I did not want to make a big deal out of something that seemed so small.

Over time, I achieved some leadership roles in the APA. I am a distinguished fellow of the APA and served several terms on the IPS’s scientific program committee. I am a member of the editorial boards of APA Publishing and the journal Psychiatric Services. I have gained much from these experiences, especially under the excellent leadership of these publications’ editors-in-chief. I participate in the APA Mentoring Program, although curiously I have never been paired with a Black resident, despite firsthand knowledge of how essential this type of early connection is to career development. I encourage residents to apply for the APA/APAF Substance Abuse and Mental Health Services Administration Minority Fellowship, even as the APA has quietly instituted unwritten policies that race and ethnicity cannot be considered in selecting minority fellowship recipients, and despite there being no federal mandates that uphold this policy.

These practices have the subtle effect of making it more difficult for psychiatry residents who are underrepresented in medicine to receive these fellowships, although I can’t point to any verifiable evidence available to support this suspicion, leaving me again to question whether I am being gaslighted.

Although the discrimination I have personally experienced is a problem, the real issue is structural racism, which the Aspen Institute defines as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity.”

Organized psychiatry has repeatedly refused to examine its contributions to this system. It has not prioritized the needs of minority patients, especially Black patients. In our mental health system, people of color are overrepresented, misdiagnosed, and mistreated, and organized psychiatry has no plan to guide the correction of these well-studied and long-standing inequities.

Although there is adequate representation of Black psychiatrists on the APA’s board of trustees, there are no people of color on the executive committee of the board of trustees, the highest level of leadership in the organization. The organization’s most critical leadership position for undoing structural racism in psychiatry — the director of the division of diversity and health equity – has been vacant for more than a year.

Attempts to give voice to psychiatrists who are underrepresented in medicine resulted in the creation of an elected minority and underrepresented trustee who serves on the APA board of trustees. Unfortunately, the APA has expanded the concept of underrepresented in medicine beyond the traditional definition of the Association of American Medical Colleges to include women and international medical graduates, groups not traditionally underrepresented in psychiatry. The end result is that all identity groups that are not heterosexual white males are pitted against each other to vie for representation and voice in leadership.

Common arguments for lack of appropriate representation in leadership include low numbers of qualified Black psychiatrists and other psychiatrists of color. Yet when Dr. Altha Stewart became president of the APA in May 2018 — the only Black president in the organization’s 176-year history — she appointed many psychiatrists of color to prominent leadership positions throughout the organization.

Sadly, these gains did not persist once her one-year term ended, so recent public statements and town hall events about the APA’s commitment to ending structural racism seem disingenuous.

I will miss the aspects of my professional identity that were forged in organized psychiatry, but I look forward to a time in the future when APA leadership truly understands that the structural racism that pervades the organization must be dismantled. There are clear steps that can be taken. A reasonable plan was eloquently articulated 50 years ago in the organization’s flagship journal.

What is needed now is financial commitment, coupled with accountability, to implement action to begin to systematically dismantle structural racism in organized psychiatry. I have decided, however, that I can no longer fight this battle. I choose to devote my time and loyalty to organizations that share my values and my commitment to achieving racial equity. Even so, I look forward to the day when I can return to the organization that I grew up in and owe so much to — after I am assured it has made significant progress in addressing systemic racism.

I have been afraid to speak out because of a fear of what it might mean for my career, but I can no longer be silent. My colleagues of all races, ethnicities, and identities have inspired me to use my voice to effect change. I often use this quote from poet and activist Audre Lorde in presentations, but I realize today that I also need to live by it: “When we speak, we are afraid our words will not be heard or welcomed. But when we are silent, we are still afraid. So it is better to speak.”

Ruth S. Shim is a physician, director of cultural psychiatry, and professor of clinical psychiatry in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis. She would like to acknowledge helpful feedback and support from Sarah Vinson, Altha Stewart, and Annelle Primm in writing this essay.