Hello, and welcome everybody. I'm Nitin Gokte, and I'm the Chief of Research and Deputy Medical Director at the American Psychiatric Association. I'm pleased that you're joining us for today's Striving for Excellence series. Today's title is Distinguishing White Normativity Within Psychiatric Care and Academic Writings. Next slide, please. This is the next one, please. Nothing. So, this, today's conversation, today's lecture will have, is designated for one AMA PRA Category 1 credit for physicians and credit for participating in today's webinar will be available for 60 days. Next slide, please. The PDF of the slides will be available in the chat tab. Next slide, please. Captioning for today's presentation is available. To enable the captions, click show captions at the bottom of the screen. Click the arrow and select view full transcript to open the captions in a side window. Next slide, please. Please feel free to submit your questions throughout the presentation by typing them into the question area that is in the attendee control panel. We'll reserve last 10 to 15 minutes at the end for the question and answers. Next slide, please. It's my great pleasure to introduce Dr. Carmen Black. She's a proud Black American woman who descended from persons enslaved within the United States. She's an assistant professor of psychiatry at Yale School of Medicine and director of social justice and health equity curriculum for Yale psychiatry. Her work expands the notion of iatrogenesis to include how medical racism and bias against people living with mental illness precipitate avoidable patient harms and behavioral emergencies during real-time clinical practice. She's a national advocate for removing police involvement from hospital medicine, including sponsoring YSM and an Association of Medical Colleges education grant to reduce carceral practices at the Yale New Haven Hospital. Dr. Black's medical teaching philosophy upholds culturally authentic approaches to physician excellence by openly refusing to code switch in academic and clinical spaces and by conducting research to better safeguard minoritized representation within medical professionalism. Her leadership in academic and popular media spaces is evidenced by serving on multiple editorial boards, providing over 500 hours annually in clinical and didactic education at Yale School of Medicine, numerous national and international presentations, and making over 45 public media appearances, including National Public Radio, Newsweek, USA Today, and more. It's my honor and pleasure to welcome Dr. Black. Thank you for joining us today, Dr. Black. Next slide. And I'll let you take it from here. Thank you so much. And thank you for Morehouse School of Medicine for creating space for me to come chat with you all today. I hope you've had your coffee. I have mine sitting off screen. So let's get started. I have no financial disclosures to make, but if you want to pay me for something, I am here for you. So by the end of this lecture, I want you to be able to define white normativity, colorblind racism, aversive racism. I want you to be able to critically interrogate the white normativity all around us in clinical practice. And I want you to find two ways where your writing and communication styles can uphold representative approaches to physicianhood as opposed to white normative ones. And so in all things I do, I state very openly that I'm speaking from a historically excluded perspective. And for that, I say that according to AAMC, Black folks are only 3.6% of medical faculty, although we are 14% of the US population. Female identifying ones are 60% of that, so about 2% of all faculty. And then Black faculty who've been in this country for all 400 years of its anti-Black trauma are much less than that. We're about half of the Black people in academia, experientially speaking. So today I'm speaking from someone with centuries of all-American trauma on my back who represent maybe about 1% of women and 2% of faculty all over. So let's get into a historical framework of white normativity. So I am totally a fangirl of Archbishop Desmond Tutu, who is very involved in the apartheid movement. And he said, we need to stop just pulling people out the river. We need to go upstream and find out why they're falling in. I'm going to say that again. My mom is an AME preacher, so sorry, y'all. I gotta, you know, say it again. We need to stop just pulling people out the river. We need to go upstream and figure out why they're falling in. Now, what is downstream? Downstream are all the racialized health inequities we see every day. And downstream medicine are our efforts to mitigate those. So that's like best practices, statements, webinars, like today's webinar, disparities, statistics, position statements, diversity work. It's all the things like after the inequity is created that we do to try to mitigate it. But what's further upstream? What are we hiding up there? Well, I think it looks something like Maslow's hierarchy of needs. Psych 101, anyone at the APA? So it is a pyramid where at the bottom of the pyramid, you have physiological needs, the most basic needs of all, breathing, food, procreation, sleep, homeostasis, excretion. And the further up you go, the more enlightened you get. So at the top, you say self-actualization, morality, spontaneity, problem solving, lack of prejudice. E, except it's a fact. E, okay, we're going to talk about all that today. And we're going to use an example of the town I reside in. That would be Hampton, Connecticut, super popular commuter district for Yale School of Medicine. And it's this boot shaped structure you see here. So universities right here where it says New Haven and this boot shape is Hampton. But there's two Hamptons. So relating to the hierarchy for privileged people, energy invested into your life is translated into upward momentum up the pyramid you go. So I put in effort and I move towards self-actualization. So you get to the top where you're like, look, mom, I made it, right? Your effort is translated into mobility. But what is the minoritized pyramid in relation to the privileged? Well, let's talk about food. So here are the elementary schools in Hampton, Connecticut, and you'll see a very disparate array of subsidized lunches, whereas we're going to take that as a proxy of food insecurity. So Westwood School here at the top, only 14.8% need help getting food. Fine. But what's going on with Church Street and Helen Street? Their numbers are a lot higher. Well, why would that be? Hmm. It's the same Hampton, right? Well, let's talk about sleep. Well, sleep doesn't work so well if you're minoritized as well. All the road noise and having to be secure, like worried about your safety. So folks in poverty don't get that much sleep to be taken for granted either. Or if you're Breonna Taylor, you're not even allowed to sleep in your own bed at night, just minding your own business. So sleep can't be taken for granted on the minoritized pyramid. Well, what about breathing? Ah, all these factories, highways, interstates, pollute the air for those who are being minoritized by society. You can't take breathing for granted either. Or if you're George Floyd, you literally are allowed to be snuffed out for eight minutes in broad daylight and there's no intervention. Prophetically, Malcolm X said, that's not a chip of my shoulder, that's your foot in my neck. Okay. So breathing literally can't be taken for granted. Well, let's go up the pyramid. Like, do things get better the further we go? Let's check out safety and security. Neighborhood violence for the boot of Hampton. So light is good. Light is lovely. The top half of the boot is where the calf would be. It's very, okay, there's not much going on. But the heel of the boot, that's so dark. Well, that's also where the hungry kids are at Church Street and Hellish Street School. So what's going on in the heel of the boot where there's violence? Well, let's check out employment. Okay. Again, where there's no crime and where all the food is. Median income of $120,000, $70,000. But that heel, that heel of the boot again, in the same Hampton, this Southern part is $45,000. Okay. What happened? But let's look at resources. Perhaps there's no greater resource than school for upward mobility up the pyramid. So again, at the top, you have lovely schools, ranked six, seven out of 10. Even now they're eight out of 10. They're lovely. But that heel, that stubborn heel of Hampton, in the same Hampton, we got schools with a one in three ranking. Why? Well, there's one middle school and one high school in Hampton. So as these elementary schools with the disparate needs merge, do the disparities disappear? Well, in the most recent school district, black kiddos were six times more likely to be suspended than white kiddos and almost double that of our Latinx brothers and sisters. So, oh, okay. So they're from the low school, income low. Okay. Okay. Okay. Let's keep it moving because that's better than the 2018 school district where black kiddos were seven times more likely to be expelled, suspended than white peers. So I don't know what's going on. Okay. Well, what about family? Oh, black families have been separated since the auction block. Great sale, bargain, sale of Negroes, horses, cattle, and other property. Oh, okay. So family literally can't be taken for granted. Mass incarceration continues to separate minoritized families today. And although there is solidarity in BIPOC, meaning black indigenous people of color, I want to point out that the anti-black racism is often the most severe of whatever metric you're looking at. And that is because we have 400 years of explicit anti-black prejudice being baked into our system. So families can't be taken for granted. Now I also want to look at descendants. I proudly identified as a descendant of persons enslaved within the U.S. Representative of the women right here. Well, today we represent less than 2% of all faculty, but the descendants and representatives and beneficiaries of the salesmen, well, they went on like the good doctor men, Benjamin Rush to sign a declaration of independence, who was a slave owner, purchased an enslaved child on the logo of the APA until very recently. But he also thought any of his abolitionist ideologies were thought thinking that blackness could be cured. He thought my blackness was a form of leprosy. And if you cured me, I would go back to our God leader, natural state of whiteness. So what about morality on the minoritized hierarchy? Well, after our families are so efficiently separated by the child welfare system, says Dorothy Roberts, from all these medicalized injustices, from all these tropes of dead beats and baby mamas, we get these non-marital birth rates talking about black folks ain't got no intact families, but did not just say we had a little help. Where's the explanation of all the assistance we had without having intact families? It's not their health. Okay. Well, everything we just talked about in South Hamden turns into dark blue and equity here on this health map, diabetes, heart disease, blood pressure, asthma, because being minoritized sucks life from your health. Okay. So we're going to say that the top of Hamden is wealthy and white. And as you probably guessed, the South of Hamden has a very different social status in racialization than the top. Let's talk about property. Why did this come to be? Well, let's check out a property deed. And one of the slivers of awesomeness, high income, best schools, no hunger. Let's check out the property deeds from 1937. And that says no person of any race other than the white race shall use or occupy any building or any lot, except that this covenant shall not prevent the occupancy of domestic servants of a different race. Oh, okay. So this, this looks like it was by design that whiteness could, oh, y'all it's not just Hamden, Connecticut. This is a red lining map of New Haven from 1937, but there's an entire website where you can look at almost any city, major city in America and find this story again and again and again. And like here, we say there was an infiltration of Negroes. Oh, okay. Well, that's very vivid language of the explicit anti-Black nature of this. Let's take a closer look at the property deed as I discern which parts got circled in red to be defunded and which parts got circled in green to be catered to privilege. And it says, clarifying remarks, this is an old section of the city containing a few singles, but doubles and multifamily dwellings predominate. Area is now given over to the laboring class and is rapidly filling up with Negroes. Vandalism may be expected. Oh, so let's recap this pyramid thing, because I'm not going to stray away from the pyramid. So privileged communities, straight on up the hierarchy you go. Your effort into your life goes up because society has taken care of the remedial needs for you. But fighting racism at every single right to our wellbeing diverts energy from upward momentum and to carrying this boulder on our back. And the longer a Black person is in this country, the bigger the all-American anti-Black boulder on our back becomes. My boulder for my lineage is 400 years large. What might my family, my community call the boulder on my back? Well, Maya Angelou may say, you may shoot me with your words, you may cut me with your eyes, you may kill me with your hatefulness, but still, like air, I'll rise. So Maya Angelou might call this boulder hateful. And Malcolm X already told you, that's not a chip on my shoulder, that's your foot on my neck. So he might call that your foot to his wellbeing. But what does medicine call the hateful foot on our neck? It gets translated into something a little less jarring. We call it social determinants of health. Now I'm not against the term social determinants of health, but the societal forces that concentrate, over-represent racially minoritized persons into that social determinant, now that's racism. So me, I like to say racism if it's racism. I'm not going to say social determinants of health, if it's socially determined by racism. If social determinants had equal representation of all racialized groups in the US, then social determinants would be an adequate explanation. But by itself, it leaves out the active processes of the boulder on our neck. But still like air, I rise, Maya, I hear you, girlfriend, we're working. I got you, I got you, so we're up that pyramid we go. And finally, we get to the top and this big old boot knocks us down after all this work. Now, what might black communities call the bootification process, the process where we're getting booted off the pyramid? What do these flailing people represent? Well, to us, we might call them beloved, mom, dad, missing ones from the Christmas dinner table, broken dreams. For me, I call it a dead brother. What does medicine call the ones flailing off the mountain here? We turn into something less personal. We become data points of racial disparities. So here we are after 400 years of this process, concentrated here at the bottom of the pyramid with all these boots still on our neck trying to keep us down. But some of us, we got families, we're resilient, we keep fighting back. Medicine does all these studies about resiliency. We are in action with the boulders on our back. But some of us, after 400 years, we say, ah, why bother? I see you getting booted off. I tried last year, something happened, like I just, the system was not designed for me. And then those of us in privilege at the top of the mountain with 2% representation, we look down on those below and say, oh, y'all got a case of the social determinants. And then once someone says, ah, I found another racial disparity. Oh my goodness, we need to come study. Hey doc, come over and let's study it. Then the cop comes over. But, oh, let's publish it. This is terrible. But those people have too much cultural distrust to join our research studies. But those of us enduring the bootification, we say, we're the problem. You'll earn my trust when you stop the boot. But 96% of not black physicians say, we don't talk about that boot. Oh, no, no, no, no, no. There is no boot by 96% consensus. But some of us, we know after all these years, we recognize we're traumatized, we're depressed, we're anxious, we're stressed out. We go seek a therapist. And according to the normativity in the DSM, we say, oh, my privilege lets me interpret your lived experiences as psychotic. So the person in the chair says, forget it. Why bother? I'm leaving. And then the therapist looks at us and says, oh, I see stigma. Your stigma amongst the black people keeps you from accessing our totally equitable mental health treatment. And on and on it goes. Because 96% not black physician consensus says, we don't talk about the boot. Oh, no, no, no, we don't talk about that boot. Seven foot frame. Okay. If you don't know what I'm singing right now, I'm really going to need you to turn on Disney+. The point is, we won't talk about that boot, but we'll talk about a thousand disparities paper giving evidence to the boot without naming it. The boot of systemic racism. And so it is the boot that sustains white normativity in all of society, but especially in psychiatry. Because according to us with our good intentions, no one went through all this process to harm other people, right? That's ridiculous. I'm sitting on $325,000 of student loan debt. Anybody raise your hand in the chat if you got that student loan debt too. And we're saying racism is bad. We love diversity. Why are y'all here? The bootification people are like, seriously, we're asking where we're at and we're not talking about that boot. Now that is especially relevant in medicine. I clearly say I am proud to be a descendant of persons enslaved within the U.S., but even amongst Black people in medicine, my nameless ethnicity is not proportionately represented because we've got a 400-year boulder of educational deprivation of everything we just went through. And until medicine actively names the population with the 400-year boulder and actively works to undo its intentional harm, we're not going to make it past this boot. So let's be clear, chronicity of that boulder makes it bigger. So I'm going to share a metaphor to help folks understand white normativity. All right, back to our parable, and we preach to mama, we need to stop just pulling people out the river. We need to go upstream and find out why they're falling in. So what's upstream? White normativity. And of course, we don't know why racial disparities are getting better, because according to a limited mindset, as I said, it makes sense. I said we love Black people now, why aren't there more in medicine? And we don't have enough representation to say why there's not more of us here, and around and around and around it goes. And so 2% representation, y'all like chocolate milk, I need you to think about the 400 years of intentionality that goes into this. And so through the beautification process of the Maslow's hierarchy needs, boulders in our back, getting rejected from normative viewpoints. Now this signal here, 2% representation. Now let's bring in Paul-Michel Foucault, who said knowledge is a form of power. So he said, power, knowledge, language are not seen as independent entities, they are always intertwined. Knowledge is always an exercise of social power, because who writes the textbooks? It's not the ones flailing off the mountain struggling to eat. The ones writing the textbooks are the ones in societal privilege. And Winston Churchill might say, history is written by the victors. I want to take a pause and think about some of what's going on in our country about Black history. Who gets to write it? Who gets to alter it? Who gets to print it? Okay. African proverb, until lions have their own historians, tales of the hunt will always glorify the hunters. Until lions have their own historians, tales of the hunt will always glorify the hunters. And so now, as we trickle on downstream, as we start at the top of the stream trickling down, now we have knowledge as a form of social power that you can't do without representation. So even the representation we have is not going to represent 400 years, like only indigenous Americans and the nameless ethnicity of people of 400 years have been during every single minute of racial minoritization in this country. Without representation, the knowledge we produce is one-sided. And now, Medeza's problem is not white people. That is, that's an oversimplification that's going to hinder dismantling white normativity. The problem is white normativity, not white people. What's the difference? Let me tell you. Aren't these some pretty apples? Ooh, they're organic too. Those are some beautiful apples and they're everywhere. Oh my goodness. Look at these apples all over the place. We even have sweet apples, Gala, Fuji, Anna, I've never heard of an Anna apple. Okay. All the way to my favorite, Granny Smith, tart and tangy. Love it. But there's a spectrum of apples too. Did you know that there's like a whole apple-ology? Like there's a whole thing for apples, y'all. Empire apples, Jonathan apples, Northern spy. That sounds like a science fiction movie, but that's really cool. And we got more apples, Granny Smith, Gala, Golden Delicious. Now, if this were your only concept of a produce section in the grocery store, you might think that apples represent fruit or apples are the quintessential fruit or apples are the best fruit. Because according to this glimpse that I have given you, your glimpse of reality, apples are like the bee's knees, right? But what about the diversity of fruit? Apple, watermelon, strawberries, grapes, bananas. Okay. But what about these more exotic fruit? Coconuts, pomegranates, some things I can't even name. What about this thing? This is some type of Japanese thing I Googled, but Google tells me this is a fruit too. Is it less of a fruit because it looks nothing like an apple? And what about all the times we tell fruit or vegetables? We get half the fruit wrong, y'all. Squash? That's a fruit. Bell peppers? Those are fruit too, even though I typically consider them veggies, but they're not less of a fruit just because I can't name them well according to their reality. Now, how would you describe our purple friend right here? Just describe it. Picture it to yourself. Some might say it's got like a purpley skin with like a white inner lining and the seeds are looking white. I don't quite know, but I'm gonna get there by describing it according to its own properties. But how would you describe this fruit if the only language you had was in relation to all those apples? Oh, okay. Well, it's more oblong than an apple. It's less popey than an apple. It's seedier than an apple. It's weighs more than an apple. The shelf life is less than... I can't describe it for itself because I'm trying to use apple normative words. And this is apple normativity. So according to apple normativity, we're gonna have apples and non-apples. And so if I were to categorize fruit by their relation to apple normativity, I would group these luscious tomatoes here with a pineapple, even though they look nothing alike, I would group a tomato with a pineapple faster than I would group this red tomato with this red golden delicious apple right here, simply because neither the tomato nor the pineapple are apples. So according to apple normativity, instead of just categorizing things according to shapes, features, all this fun stuff, the language of apple and non-apple means I'm grouping stuff together that makes no sense just because neither are apples. And this is what we do in psychiatry day in, day out. So I want to talk about the difference between race and racialization. Many of the folks I try to support don't quite grasp the difference. So race is a social category, has very little to do with ancestry. It's just what you look like and according to society, what we tell you, you look like. Racialization is the process of assigning meaning according to how you look. So racialization is someone with blonde hair, blue eyes, fair skin gets racialized as white, even though their identity might be biracial of anything, right? So racialization is the process of society assigning a nomenclature to your appearance. Now I could have couple A right here, black excellence right next to here, the neighbors in white, neither of them, neither of the folks on the left-hand side here are white, none of them. And so according to white normativity, even though these folks might have grown up next door to each other, these two gentlemen here might share a job at the same facility, but according to white normativity, this black family who shares every aspect of their identity short of white privilege, the whiteness would categorize blackness 400 years of it potentially with someone who just got off the plane from another country. Why? Because neither of them would be white. It's the same thing as the pineapple and the tomato, right? Neither of you are apples. So off to grouping together, even though this black family probably won't share a culture, they might not share language, nothing about what makes an ethnicity an ethnicity, nothing about what makes culture a culture would be shared between these black folks and someone straight off the plane, just because neither is white. And to the flip side, if I have an immigrant from Italy, they might not share much in culture with the black Americans, or they might share more in culture with somebody else. But the point is, because they are now racialized as white, society says, ha ha, welcome to whiteness. Someone straight off the plane from Italy never had more than five minutes of American experience would get categorized with the white family faster than someone else who immigrated of a different country. And this is again, white normativity. And so diversity isn't diverse. Diversity is normal. We're already here. So fruit is diverse, but diversity is normal because it already exists. It's not like I'm creating new fruit to fulfill some type of diversity requirement. I'm just better representing what already exists. And an individual apple might be, oh, the best apple of my life. But that doesn't exclude every other fruit. And if I have an apple allergy, bump apples, I'm not even thinking about you. You're not good for me. I might have a different preference, right? But the quality, the character, the uniqueness, the wonderfulness of the individual apple is not tarnished by apple normativity. But you don't get to define every other fruit's existence according to apples just because you got one good one or the flip side, one bad one. Now people are diverse too. An individual white person might be superb. We all know amazing white folks, but that does not excuse medicine's white normativity and the character and quality of non-white people or however you want to describe it. Our experiences are valid regardless of if we have a stem red pulp and all this stuff, right? Our experiences are valid even if we're not white. And to the flip side, diversity is a limited construct. Our goal is not diversity. Our goal should be representation because technically apples are diverse. You can get a bazillion different types of apples, but a bazillion different types of apples would be diverse, but it would not be representation. So a lot of this diversity conversation is skewed because we need to talk about representation. And as I mentioned, especially amongst Black folks in medicine, there is a skew of folks who do not have the same proportionate makeup of U.S. Black folks, those descended of slavery. And my diaspora brothers and sisters who immigrated more recently, we are all valid. Only whiteness would say we're in competition. But yes, there is a skew to the lack of representation of the folks who built this country because diversity is not the same as guaranteeing representation. Now, how does this play out in psychiatry? Aversive racism, one of your learning objectives. Now, I admit acknowledging personal bias is horrible. It sucks because none of us came here and got this debt and dedicated our lives to the stress to be nasty to people. So aversive racism develops when providers don't want to or don't think they have racial bias, even though their behaviors independently indicate that they do. And these studies are typically they're observing language patterns, observing amount of time spent with patients, observing charge language. So aversive racism is where the frontal lobe, cognitively, oh, no, we disavow racism. That's bad. Oh, no, no, no. But our behaviors say we do. And the research says that people who are explicit with their racism have better patient outcomes, even amongst Black folks than those who disavow their racism, because I can't avoid it if I'm not willing to name it. So aversive racism is just like, oh, nobody wants racism. So, nope, I don't have racism. How can you prove I have racism? Oh, nope. Now, what's colorblind racism? It's similar, but it's different. Colorblind racism was developed by Eduardo Bonilla-Silva. Now, Jim Crow racism, back in the day, once upon a time, colored hospital, white hospital, back of the bus, front of the bus, colored school, white school. It was the segregation was very explicit. But nowadays we do the segregation without ever naming race. One technique is abstract liberalism. This idea that we have free will and equal opportunity. So if you have a disparity, if you don't have something you need, something you chose was just inadequate because we have free will and equal opportunity. Now, this assumption says that health outcomes for Black folks would be good as white folks if we just chose to be less this and more that, seemingly chose to act whiter and chose to act less Black or chose to have a smaller boulder. What do folks want us to do? And the problem with this construct is Black folks are getting booted off the mountain, even when we're minding our own business, says Breonna Taylor, even when we're putting our effort into climbing the hierarchy as we're trying to everybody else, now me, myself. To be your APA presenter today, I was remediated in my residency as the only Black resident in five years worth of match for clinical incompetency and subordination. If I disagreed, being unprofessional, if I cried for injustice, I was remediated as the only chocolate sprinkle to be here as your 2% representative today. Now, I made it out, even still. Within five months of becoming faculty at Yale University, racism came for me again. They cast my oldest daughter as a slave in a school play where she was going to get whipped, whipped by her white classmates and pretend to get on a slave ship and then drown and die. The school system, somewhat like medicine, didn't have accountability to inequity in the moment. So it required going to outside forces of accountability because my kid was now coming home in tears every day because the teacher, when they canceled the play, didn't say, oops, my bad, that's not an appropriate way of representing genocide. It was, oh, a parent complained and now I'm taking your super fun play away. And so it turned into this whole shebang that was completely unnecessary, resulting in an international media fiasco and a protest because the school, like medicine, was not willing to take accountability for what they did. And it ended with the superintendent calling police on me, right here, Hampton police, because we had a scheduled meeting to uneducate, reeducate the class. And other mad and angry black people were going to show up in daytime and protect the child. What about protecting the children, the black children, protecting the other children? And so when I say abstract liberalism doesn't work, I have done everything. I'm a third generation doctoral degree holder. My pedigree was better than the ones accusing me of being incompetent, but the black don't rub off. So let go of abstract liberalism. It's not that we weren't polite enough or let it go. Let it go. Because that's colorblind racism. Now, naturalization is where we commit a lot of faults of race-based medicine, because this is the assumption that that's just the way things are. Think of it as a metaphorical shoulder shrug. So the core problem is when we talk about inequity without explicitly naming the boot of racism as the root cause, as if these inequities just appeared. So the South of Hampton has the bigger boulders and all these worse outcomes, not without an active cause. That'd be crazy. Who wants to hurt South Hampton? It's just, it's just, I don't know, it's just there. Pulmonary function test. Little black lungs ain't got no air. I guess it's a biological thing. GFR. I guess those big black muscles. Naturalization is where we get a lot of our race-based clinical algorithms. And even still, we're doing it on race-based versus oppression-based. When my partner gets off the plane from Nigeria, he's never set foot in this country. If you took a blood pressure cuff to his arm, he has no reason to have elevated blood pressure because race is not the problem. Blackness is not the problem. Blackness under attack in the U.S. is the problem, right? So when we're doing these race-based disparities models, we're not doing it according to longevities of oppression. Our models are still fundamentally race-based. That's naturalization. Cultural racism is, well, the culture just values different things. So if they don't succeed in school and don't become doctors, well, they just don't, black folks don't like being doctors. Okay, so that the problem there is that it tries to fix blackness instead of the locus of control, which is ourselves. So this might sound, oh, well, black folks don't trust medicine, even though I'm totally trustable. So they don't enroll in research studies. Hey, you, go convince black people to trust me. Black folks don't trust medicine, so they don't follow up to their treatment. Oh, those cultural people, they just don't value being healthy. Black folks don't want to seek psych care, not because there's anything wrong with psych care, but, you know, it's just go fix blackness. That's cultural racism. Now, how does this shore up in our clinical measures? Well, let's think of the Beck Depression Inventory. The Beck Depression Inventory, there's nothing wrong with it, but we're not going to attack individuals. We're going to talk about white normativity as a system. Now, Beck Depression Inventory was developed in 1959 and 1961. History-based, this was when Tuskegee experiments were in full swing. They were actively publishing studies rooted in Tuskegee in medical literature. It wasn't done in some dark, dank basement nobody knew. They were actively making 15 publications from their data. This is all the same era where prominent APA members were still endorsing the eugenics movement, which is very popular at Yale. And forced sterilization of minoritized women. And black men were increasingly being associated with psychosis. See the work of Jonathan Metzl. Now, the studies of the original Beck Depression Inventory had 409 patients, and they're described as 64.7% white and 35.3% Negro. The datedness is already here. I'm still being called a Negro. Now, you can guarantee a lack of representation how psychiatry crafted this expectations of what depression should look like, because the researchers had no representation and their patient population had no representation. So the heiress white heterosexual cisgender male dominant gaze cannot be extracted from the 21 indices that providers knew at the time to represent depression. Now, more recent versions of the Beck Depression Inventory were developed, but they were 84% middle to upper class suburban white folks. And literally, this study was too heavily white for precise statistical analysis. So they bypassed those pesky statistical barriers by lumping everybody who wasn't white into a label of non-white. Now, anytime you see a non-white study, or you're thinking about doing a non-white study, I want you to think of a tomato sitting next to that pineapple. It'll make a darn bit of sense to categorize a tomato with a pineapple just because it's not an apple. But this is what we do in our studies all the time, non-white, non-apples. Now, what does white normativity look like in psychosis? Let's check out the schizotypal personality questionnaire. This is not a problem of the researchers. We're going to look at whiteness in all of mental health. The original study was published in 1991 on 497 predominantly white undergrads. It was updated in 2010, but it was still predominantly white undergrads. Now, very recently in a special edition of Schizophrenia Research, where I was a guest editor, Wolny found that black folks scored higher than white folks on almost every single paranoia question even though they had the same clinical manifestation. Which is to say, this questionnaire, overestimated, misinterpreted, got suspiciousness wrong for black Americans. Not because there's something wrong with blackness, but there's something unique about the black experience. Let's check out some of the questions that had a problem. Do you feel that other people have it in for you? Two percent representation. Things happen to the two percent, but let's keep it moving. Do you often have to keep an eye out to stop people from taking advantage of you? We have a whole language of minority texts. That's not paranoia, that's microaggressions, that's my experience. Do you ever get nervous when someone is walking behind you? Do you feel like when you're shopping, you have to stop other people from taking notice of you? Yes, said every black man in America. That's not paranoia, that's what society does to me. But from a privileged white normative perspective, if I were Lily White in the suburbs, I have no reason to think these things. But y'all, these questions are even failing white folks with trauma. Anyone without the quintessential silver spoon, someone who's been through trauma, no matter the racialization, they're going to have more vigilance. That's not because they're paranoid or psychotic, that's because life has had a different set of experiences. Now, I made sure this page was still here. This is from the APA, which is awkward to talk about when I'm giving a webinar for the APA. This is the page for mental health disparities. I want you to look as best practices for treating diverse patient populations. They got a page for working with black folks, Appalachian folks, Asian folks, Latino folks, LGBTQ folks, Muslim folks, indigenous folks, refugee and forced displacement folks, queer folks, questioning folks, women. They have a whole thing for women. This is cultural psychiatry. I want you to know a little bit about everybody. Great. But this is cultural psychiatry without anti-racism in history. Because did you notice that there is a page for everyone, but the wealthy, hetero, cis, white man, like the researchers who built American psychiatry? Because we don't need to state that they're the prototype, but it's unstated in the statement. This is white normativity. Like Appalachia, that's white folks, but they don't have the privilege of being wealthy. There's literally, we're not saying it, but we're saying it. Whiteness, white maleness, white wealthy maleness, cishet is the prototype. Think of my purple fruit here. I can't describe the population, the fruit for itself because I'm so busy referring it back to this unstated template of apple-ness, of this unstated template of whiteness. Now, even amongst all these different pages, there were themes. Each one of these folks said, we value kinship more than the standard. Standard two, whiteness. Community, we value. We value spirituality, we value family, and we have reasons that our community isn't inclined to trust traditional mental health care systems like everybody else. These were themes even amongst the diversity because diversity is not different. Diversity is normative. We're already here. And so let's have a frame shift. Instead of thinking about diverse expressions of mental illness, perhaps our current criteria only center the experiences of a single societally privileged group in the first place. So maybe it's not everybody else is different than our gold standard. Maybe our gold standard is only gold for apples. So let's have a frame shift. If we were to re-norm our idea of the Beck Depression Inventory today, maybe one of the 21 indices would have been excluded because it didn't predict depression as well in diverse people living in the US. Maybe it only predicted healthy experience of depression for a singular group. Now, yes, the Beck Depression Inventory has been taken to other groups and found to be good enough, right? But we are sharing the human experience. There's gonna be a lot of overlap in how people experience depression. So it's not whether the white normative model works in non-white people, it's does a white normative model hold the experiences of what America looks like? So maybe if we were to re-norm the BDI, we would need a 22nd index that measured disconnection from family since that's such a common theme in folks who added together are over half the country. Maybe we'd need a 23rd index talking about disconnection from spirituality. Maybe we'd need a 24th index measuring feeling overwhelmed by discrimination. So medicine is still written by those racialized into privilege. And until the oppressed have their own clinicians, medical knowledges will always glorify the privileged. We can't get it right without representation even with good intentions. So this is our conclusion. How can our language hold the active process of minoritization to dismantle white normativity? First thing I need folks to do is stop the narrative that blames white individuals instead of white normativity. We're not doing that. It's the system that upholds whiteness as the gold standard, not white people. And I want us to practice naming diversity as normative. We already exist. I'm not diverse into myself. We're already here. And I want you to start thinking about representation more than diversity. I could have a room with 50 different types of apples but that would not represent the beauty that is fruit. And I want you to blame white normativity if I openly acknowledges the intentional historical and modern structures that sustain it such as the process of beautification, practice naming what that beautification is. To even give this webinar to you today, my kid was a slave and I was remediated as a third generation doctoral degree holder. Let go of colorblind and aversive racism. Linguistically, having the iced version of words, the verb version. So racialized disparities is better than racial. Racialized means there's a process assigning value. Racial means it's inherent to my blackness. That's a naturalization colorblind fault. Minoritized is the process of holding us back, not a minority. This is not a quantity. This is a process of oppression. Racialized determinants of health or racism is better when it's based on race versus social determinants. Now, if we're talking about something where a sample is representative of the US population, social determinants is fine. But if we're talking about people concentrated into the social determinants, that's racism. Similarly, underrepresented in medicine or underserved communities, that's kind of like the shoulder shrug. Underrepresented, where'd they go? I don't know. It takes the active process of minoritization out of the equation. Excluded, historically excluded, actively excluded, but some type of verb that shows is not in the past and is not passive. There's an active boot process. That language can uplift your writing and start generating ideas worthy of increasing representation. And that's it. Thank you. Thank you so much for this riveting and incredibly articulate and eloquent explanation of white normativeness. For the audience, there is a Q&A box. So please feel free to type in any questions that you may have. So that would be, we'll give the audience a minute to answer questions, to ask questions, and then we'll get... So there's one question. So I think that's, again, a suggestion, instruction to put the questions in Q&A section. So in the meantime, before the audience starts to think about the questions, maybe I could get started. This was incredibly helpful to structure, to formulate thought processes as well. And I particularly liked your conclusion slide where you suggest foundational and linguistic work that needs to be done in order to sort of move away from this white normativeness. One of the things I want to mention is that before the DSM-5TR came out, what we had done at the APA, as we had created a work group of race, ethnicity, and cultural diversity work group where we brought together experts who have worked in these areas from the early 2000s and worked in these areas with different expertise and diverse backgrounds. And we went actually through the entire DSM line by line and created a giant spreadsheet, Excel spreadsheet, essentially, wherever there was any mention of race, ethnicity, culture, gender, or these terms. And this group met for, I would say, two hours, after hours, twice a week for three months, and deliberated on every single of these terms. And I was glad to see that many of this happened organically in that work group because everywhere in the DSM where the term race was used was changed to racialized, as you also indicated. The term minority was changed to minoritized and so on. So many of these things were adapted. So my question is, you mentioned, again, incredibly lucidly about moving upstream and going upstream and looking at the root causes of all of these things. I think it would be great if you were able to elaborate on some of the potential solutions, as you see, which could, in addition to what you have mentioned about changing the language in foundational and linguistic structure, any other thoughts that come to your mind that can be done at a more practical, immediate level to move this work forward even further? Yes, gladly. What I'm doing in my research life is several fold. On one hand, I'm talking a lot about professionalism as also white normative. So our professional values say we value health equity, but we don't have a mechanism for those who speak out, the whistleblower, so to speak, the change agent. The language of medical professionalism is, I am the expert and I will teach you, newcomer, welcome, how to be as expert as me. But the issue is medicine has a very hard time holding that it is actively harming people. We don't want to, but we do, myself included. I am part of this system. So aversive racism means it's very easy to look away from the things we don't want to see. And when we dominate the narrative of our own field, it's very easy to say, well, those disparities, shoulder to shoulder naturalization, I don't know where they come from because my hospital is awesome. And so professionalism work, I'm finding, we know the cumulative debts. We know that racially minoritized people are being expelled from medicine at rates disparate compared to white peers, especially black people are getting lost to medicine. And one of the mechanisms I'm identifying is that through professionalism, our unique perspectives are being ejected as non-normative. Well, that's not how it works. This is how it works. Or if we're trying to advocate for someone in the moment, that can be seen as insubordination. So my own remediation, I wasn't even, I was a mom. I had a one-year-old baby during residency. I wasn't thinking nothing about dismantling nobody. I was just trying to survive. But my perception is still a black woman in America. And so through professionalism, we are losing our change agents because as they try to bring the knowledges that we say we need, we're using these normative lenses to live in the realm of the already. I've already got professionalism figured out. I've already got equity figured out. So we're actually minoritizing the minoritized, which we ironically recruit to medicine through languages of professionalism. Second, I mentioned that this race-based notion, we're using identity as the risk factor instead of accumulated oppression. And that's not true. There's nothing, if I were to go do all of these disparities research studies in Wakanda or Zamunda or some black normative society where racial oppression is not there, I have no reason to think that asthma or disease, I have no reason, blackness is not the problem. Blackness under duress is the problem. And so I would say that our studies need to fundamentally stop this white, non-white, black, white comparison. The better terminology would be racially centered, racially privileged versus generationally minoritized. And then I also wanna figure out how much time in the US does it take before your blood pressure starts to tweak? How much minoritization does it take before your millimeters of mercury go up? And that means taking away racial identity as the risk factor and naming racial oppression. And lastly, I would say, if I could re-norm every rubric, I would. Even notwithstanding the white normativity of the original studies, the phenotype, the face of America looks very different than it did even 50 years ago. So I would love to inherently go back and re-norm studies with representation, not diversity with representation. So if I had a magic wand, those would be my three ask, to change medical professionalism, to uphold the physician excellence of those who point out problems, instead of labeling us as disruptors, label us as like change agents. And then like, let's figure out how to change the system that we know is broke. Moving away from race-based ideology and also investing in the generationally minoritized neighborhoods who have endured every minute of this. So because of that 400-year boulder on our back, getting indigenous people into medicine, that takes more effort than a diversity recruitment fair. We ain't even thinking about medicine because we thinking about surviving. Same way, going down to the red line, MLK Boulevard, the underfunded high school, right? Getting them into medicine, their lived expertise could change the shape of medicine. But that boulder on their back is not removed with diversity recruitment there. So I would make intentional investments to the generationally minoritized, not just those with a smaller boulder, to make sure that we have the full gamut of generational, cultural, all the diversity represented in medicine. Fantastic, thank you so much. I think this generates a lot more questions in my mind, but keeping an eye on the, and I would love to carry this conversation further because I would love to discuss with you some specific examples and what could you think as the potential solutions. Just to give you an example, the NIH grants, it's now well-documented that the minoritized individuals are less successful in getting NIH grants. But I don't want to lose my sight about, there's a question in the audience, I want to prioritize that. Claire is asking, I'm horrified about the casting decision for your daughter's class play and the school's response. I wonder whether you offered a similar presentation to faculty and administration at the school. Your use of Maslow's hierarchy of needs and Apple metaphor make concepts against which we are defended too clear to avoid ignore. I appreciate that. I'm glad the scars in my back are being translated for good. So the way things work with white normativity is the privileged don't have to humble themselves to hear what the rest of folks think, feel, experience. And so both within certain aspects of my own university doing de-policing work and within the community in which I live, space for education, space for dialogue, space to talk is denied. Because if we've used policing as a brief example, the world is a scary place. Gun violence is very rampant, but through my research that I'm doing in hospital spaces, very akin to school spaces, mass shootings, like no one has ever turned in their automatic assault rifle at the metal detector, even though the metal detectors are siphoning so many of our resources. And so the narrative of policing keeps you safe is 400 years strong, policing being created to patrol the enslaved folks who got on the hand. But the data, if we turn our clinician brains back on, if we use public health principles, number needed to treat, number needed to harm, prevalence, justice of scarce resources, if we turn our clinical brains back on, which is what my work does, none of this makes any sense. The only true solution is doing that really slow foundational restoration. And so the places where I work in my clinic that are very policed and that my daughter's school, they exclude opportunity for education because then they'd be held accountable. That's why I had to turn to the media to get my daughter's safety as opposed to internal mechanisms. And it's very similar for medicine. Medicine rejects internal mechanisms where we have conversations and representation of people who can point out the holes and we're more comfortable writing disparities papers about. Same with my daughter's school. So no, space has not been created. Thank you so much. Unfortunately, we are at time, so I'll need to stop, but I wish we had given you two hours instead of one hour to continue this conversation further. Hopefully we'll get a chance to talk to you more about this. Thank you again. Thanks on behalf of the APA, Dr. Black, for participating and giving such a wonderful talk. And then I think the next slide is just an announcement about our next webinar, which will be happening on Thursday. So hopefully you all can join us for that. Thank you so much, Dr. Black. ♪♪

webinar

Dr. Carmen Black

white normativity

psychiatric care

racial disparities

representation

aversive racism

language used

clinical measures

healthcare professionals