Sahana Malik, MD

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

Prior to George Floyd’s death, Officer Thomas Lane reportedly said, “I am worried about excited delirium or whatever” to his colleague, Officer Derek Chauvin.¹ For those of us who frequently work with law enforcement and in correctional facilities, “excited delirium” is a common refrain. It would be too facile to dismiss the concept as an attempt by police officers to inappropriately use medically sounding jargon to justify violence. “Excited delirium” is a reminder of the complex situations faced by police officers and the need for better medical training, as well as the attention of research on this commonly used label.

Many law enforcement facilities, in particular jails that receive inmates directly from the community, will have large posters educating staff on the “signs of excited delirium.” The concept is not covered in residency training programs, or many of the leading textbooks of psychiatry. Yet, it has become common parlance in law enforcement. Officers in training receive education programs on excited delirium, although those are rarely conducted by clinicians.

In our practice and experience, “excited delirium” has been used by law enforcement officers to describe mood lability from the stress of arrest, acute agitation from stimulant or phencyclidine intoxication, actual delirium from a medical comorbidity, sociopathic aggression for the purpose of violence, and incoherence from psychosis, along with simply describing a person not following direction from a police officer.

Our differential diagnosis when informed that someone was described by a nonclinician as having so-called excited delirium is wider than the Diagnostic and Statistical Manual (DSM). In addition, the term comes at a cost. Its use has been implicated in police-related deaths and brutality.² There is also concern of its disproportionate application to Black people.^3,4

Nonetheless, the term “excited delirium” can sometimes accurately describe critical medical situations. We particularly remember a case of altered mental status from serotonin syndrome, a case of delirium tremens from alcohol withdrawal, and a case of life-threatening dehydration in the context of stimulant intoxication. Each of those cases was appropriately recognized as problematic by perceptive and caring police officers. It is important for police officers to recognize these life-threatening conditions, and they need the language to do so. Having a common label that can be used across professional fields and law enforcement departments to express medical concern in the context of aggressive behavior has value. The question is: can psychiatry help law enforcement describe situations more accurately?

As physicians, it would be overly simple to point out the limited understanding of medical information by police and correctional officers. Naming many behaviors poses significant challenges for psychiatrists and nonclinicians. Examples include the use of the word “agitation” to describe mild restlessness, “delusional” for uncooperative, and “irritable” for opinionated. We must also be cognizant of the infinite demands placed on police officers and that labels must be available to them to express complex situations without being forced to use medical diagnosis and terminology for which they do not have the license or expertise. It is possible that “excited delirium” serves an important role; the problem may not be as much “excited delirium,” the term itself, as the diversion of its use to justify poor policing.

It must be acknowledged that debates, concerns, poor nomenclature, confusing labels, and different interpretations of diagnoses and symptoms are not unusual things in psychiatry, even among professionals. In the 1970s, the famous American and British study of diagnostic criteria,showed that psychiatrists used the diagnosis of schizophrenia to describe vastly different patients.⁵ The findings of the study were a significant cause of the paradigm shift of the DSM in its 3rd edition. More recently, the DSM-5 field trials suggested that the field of psychiatry continues to struggle with this problem.⁶ Nonetheless, each edition of the DSM presents a new opportunity to discuss, refine, and improve our ability to communicate while emphasizing the importance of improving our common language.

Emergency physicians face delirious patients brought to them from the community on a regular basis. As such, it makes sense that they have been at the forefront of this issue and the American College of Emergency Physicians has recognized excited delirium as a condition since 2009.⁷ The emergency physician literature points out that death from excited delirium also happens in hospitals and is not a unique consequence of law enforcement. There is no accepted definition. Reported symptoms include agitation, bizarre behavior, tirelessness, unusual strength, pain tolerance, noncompliance, attraction to reflective surfaces, stupor, fear, panic, hyperthermia, inappropriate clothing, tachycardia, tachypnea, diaphoresis, seizure, and mydriasis. Etiology is suspected to be from catecholaminergic endogenous stress-related catecholamines and exogenous catecholaminergic drugs. In particular is the importance of dopamine through the use of stimulants, specifically cocaine. The literature makes some reference to management, including recommendations aimed at keeping patients on one of their sides, using de-escalation techniques, and performing evaluation in quiet rooms.

We certainly condone and commend efforts to understand and define this condition in the medical literature. The indiscriminate use of “excited delirium” to represent all sorts of behaviors by nonmedical personnel warrants intelligent, relevant, and researched commentary by physicians. There are several potentially appropriate ways forward. First, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting and does not belong in the DSM. That distinction in itself would be potentially useful to law enforcement officers, who might welcome the opportunity to create their own nomenclature and classification. Second, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting but warrants a definition nonetheless, akin to the ways homelessness and extreme poverty are defined in the DSM; this definition could take into account the wide use of the term by nonclinicians. Third, psychiatry may decide that excited delirium warrants a clinical diagnosis that warrants a distinction and clarification from the current delirium diagnosis with the hyperactive specifier.

At this time, the status quo doesn’t protect or help clinicians in their respective fields of work. “Excited delirium” is routinely used by law enforcement officers without clear meaning. Experts have difficulty pointing out the poor or ill-intended use of the term without a precise or accepted definition to rely on. Some of the proposed criteria, such as “unusual strength,” have unclear scientific legitimacy. Some, such as agitation or bizarre behavior, often have different meanings to nonphysicians. Some, such as poor clothing, may facilitate discrimination. The current state allows some professionals to hide their limited attempts at de-escalation by describing the person of interest as having excited delirium. On the other hand, the current state also prevents well-intended officers from using proper terminology that is understood by others as describing a concerning behavior reliably.

We wonder whether excited delirium is an important facet of the current dilemma of reconsidering the role of law enforcement in society. Frequent use of “excited delirium” by police officers is itself a testament to their desire to have assistance or delegation of certain duties to other social services, such as health care. In some ways, police officers face a difficult position: Admission that a behavior may be attributable to excited delirium should warrant a medical evaluation and, thus, render the person of interest a patient rather than a suspect. As such, this person interacting with police officers should be treated as someone in need of medical care, which makes many interventions – including neck compression – seemingly inappropriate. The frequent use of “excited delirium” suggests that law enforcement is ill-equipped in handling many situations and that an attempt to diversify the composition and funding of emergency response might be warranted. Psychiatry should be at the forefront of this research and effort.

References

1. State of Minnesota v. Derek Michael Chauvin (4th Judicial District, 2020 May 29).

2. J Forensic Leg Med. 2008 May 15(4):227-30.

3. “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today. 2020 Jan 20.

4. J Forensic Sci. 1997 Jan;42(1):25-31.

5. Arch Gen Psychiatry. 1971;25(2):123-30.

6. Am J Psychiatry. 2013 Jan;170(1):59-70.

7. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force. 2009 Sep 10.
 

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures. Dr. Abrams is a forensic psychiatrist and attorney in San Diego. He is an expert in addictionology, behavioral toxicology, psychopharmacology, and correctional mental health. He holds teaching positions at the University of California, San Diego. Among his writings are chapters about competency in national textbooks. Dr. Abrams has no disclosures. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Prior to George Floyd’s death, Officer Thomas Lane reportedly said, “I am worried about excited delirium or whatever” to his colleague, Officer Derek Chauvin.¹ For those of us who frequently work with law enforcement and in correctional facilities, “excited delirium” is a common refrain. It would be too facile to dismiss the concept as an attempt by police officers to inappropriately use medically sounding jargon to justify violence. “Excited delirium” is a reminder of the complex situations faced by police officers and the need for better medical training, as well as the attention of research on this commonly used label.

Many law enforcement facilities, in particular jails that receive inmates directly from the community, will have large posters educating staff on the “signs of excited delirium.” The concept is not covered in residency training programs, or many of the leading textbooks of psychiatry. Yet, it has become common parlance in law enforcement. Officers in training receive education programs on excited delirium, although those are rarely conducted by clinicians.

In our practice and experience, “excited delirium” has been used by law enforcement officers to describe mood lability from the stress of arrest, acute agitation from stimulant or phencyclidine intoxication, actual delirium from a medical comorbidity, sociopathic aggression for the purpose of violence, and incoherence from psychosis, along with simply describing a person not following direction from a police officer.

Our differential diagnosis when informed that someone was described by a nonclinician as having so-called excited delirium is wider than the Diagnostic and Statistical Manual (DSM). In addition, the term comes at a cost. Its use has been implicated in police-related deaths and brutality.² There is also concern of its disproportionate application to Black people.^3,4

Nonetheless, the term “excited delirium” can sometimes accurately describe critical medical situations. We particularly remember a case of altered mental status from serotonin syndrome, a case of delirium tremens from alcohol withdrawal, and a case of life-threatening dehydration in the context of stimulant intoxication. Each of those cases was appropriately recognized as problematic by perceptive and caring police officers. It is important for police officers to recognize these life-threatening conditions, and they need the language to do so. Having a common label that can be used across professional fields and law enforcement departments to express medical concern in the context of aggressive behavior has value. The question is: can psychiatry help law enforcement describe situations more accurately?

As physicians, it would be overly simple to point out the limited understanding of medical information by police and correctional officers. Naming many behaviors poses significant challenges for psychiatrists and nonclinicians. Examples include the use of the word “agitation” to describe mild restlessness, “delusional” for uncooperative, and “irritable” for opinionated. We must also be cognizant of the infinite demands placed on police officers and that labels must be available to them to express complex situations without being forced to use medical diagnosis and terminology for which they do not have the license or expertise. It is possible that “excited delirium” serves an important role; the problem may not be as much “excited delirium,” the term itself, as the diversion of its use to justify poor policing.

It must be acknowledged that debates, concerns, poor nomenclature, confusing labels, and different interpretations of diagnoses and symptoms are not unusual things in psychiatry, even among professionals. In the 1970s, the famous American and British study of diagnostic criteria,showed that psychiatrists used the diagnosis of schizophrenia to describe vastly different patients.⁵ The findings of the study were a significant cause of the paradigm shift of the DSM in its 3rd edition. More recently, the DSM-5 field trials suggested that the field of psychiatry continues to struggle with this problem.⁶ Nonetheless, each edition of the DSM presents a new opportunity to discuss, refine, and improve our ability to communicate while emphasizing the importance of improving our common language.

Emergency physicians face delirious patients brought to them from the community on a regular basis. As such, it makes sense that they have been at the forefront of this issue and the American College of Emergency Physicians has recognized excited delirium as a condition since 2009.⁷ The emergency physician literature points out that death from excited delirium also happens in hospitals and is not a unique consequence of law enforcement. There is no accepted definition. Reported symptoms include agitation, bizarre behavior, tirelessness, unusual strength, pain tolerance, noncompliance, attraction to reflective surfaces, stupor, fear, panic, hyperthermia, inappropriate clothing, tachycardia, tachypnea, diaphoresis, seizure, and mydriasis. Etiology is suspected to be from catecholaminergic endogenous stress-related catecholamines and exogenous catecholaminergic drugs. In particular is the importance of dopamine through the use of stimulants, specifically cocaine. The literature makes some reference to management, including recommendations aimed at keeping patients on one of their sides, using de-escalation techniques, and performing evaluation in quiet rooms.

We certainly condone and commend efforts to understand and define this condition in the medical literature. The indiscriminate use of “excited delirium” to represent all sorts of behaviors by nonmedical personnel warrants intelligent, relevant, and researched commentary by physicians. There are several potentially appropriate ways forward. First, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting and does not belong in the DSM. That distinction in itself would be potentially useful to law enforcement officers, who might welcome the opportunity to create their own nomenclature and classification. Second, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting but warrants a definition nonetheless, akin to the ways homelessness and extreme poverty are defined in the DSM; this definition could take into account the wide use of the term by nonclinicians. Third, psychiatry may decide that excited delirium warrants a clinical diagnosis that warrants a distinction and clarification from the current delirium diagnosis with the hyperactive specifier.

At this time, the status quo doesn’t protect or help clinicians in their respective fields of work. “Excited delirium” is routinely used by law enforcement officers without clear meaning. Experts have difficulty pointing out the poor or ill-intended use of the term without a precise or accepted definition to rely on. Some of the proposed criteria, such as “unusual strength,” have unclear scientific legitimacy. Some, such as agitation or bizarre behavior, often have different meanings to nonphysicians. Some, such as poor clothing, may facilitate discrimination. The current state allows some professionals to hide their limited attempts at de-escalation by describing the person of interest as having excited delirium. On the other hand, the current state also prevents well-intended officers from using proper terminology that is understood by others as describing a concerning behavior reliably.

We wonder whether excited delirium is an important facet of the current dilemma of reconsidering the role of law enforcement in society. Frequent use of “excited delirium” by police officers is itself a testament to their desire to have assistance or delegation of certain duties to other social services, such as health care. In some ways, police officers face a difficult position: Admission that a behavior may be attributable to excited delirium should warrant a medical evaluation and, thus, render the person of interest a patient rather than a suspect. As such, this person interacting with police officers should be treated as someone in need of medical care, which makes many interventions – including neck compression – seemingly inappropriate. The frequent use of “excited delirium” suggests that law enforcement is ill-equipped in handling many situations and that an attempt to diversify the composition and funding of emergency response might be warranted. Psychiatry should be at the forefront of this research and effort.

References

1. State of Minnesota v. Derek Michael Chauvin (4th Judicial District, 2020 May 29).

2. J Forensic Leg Med. 2008 May 15(4):227-30.

3. “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today. 2020 Jan 20.

4. J Forensic Sci. 1997 Jan;42(1):25-31.

5. Arch Gen Psychiatry. 1971;25(2):123-30.

6. Am J Psychiatry. 2013 Jan;170(1):59-70.

7. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force. 2009 Sep 10.
 

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures. Dr. Abrams is a forensic psychiatrist and attorney in San Diego. He is an expert in addictionology, behavioral toxicology, psychopharmacology, and correctional mental health. He holds teaching positions at the University of California, San Diego. Among his writings are chapters about competency in national textbooks. Dr. Abrams has no disclosures. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Prior to George Floyd’s death, Officer Thomas Lane reportedly said, “I am worried about excited delirium or whatever” to his colleague, Officer Derek Chauvin.¹ For those of us who frequently work with law enforcement and in correctional facilities, “excited delirium” is a common refrain. It would be too facile to dismiss the concept as an attempt by police officers to inappropriately use medically sounding jargon to justify violence. “Excited delirium” is a reminder of the complex situations faced by police officers and the need for better medical training, as well as the attention of research on this commonly used label.

Many law enforcement facilities, in particular jails that receive inmates directly from the community, will have large posters educating staff on the “signs of excited delirium.” The concept is not covered in residency training programs, or many of the leading textbooks of psychiatry. Yet, it has become common parlance in law enforcement. Officers in training receive education programs on excited delirium, although those are rarely conducted by clinicians.

In our practice and experience, “excited delirium” has been used by law enforcement officers to describe mood lability from the stress of arrest, acute agitation from stimulant or phencyclidine intoxication, actual delirium from a medical comorbidity, sociopathic aggression for the purpose of violence, and incoherence from psychosis, along with simply describing a person not following direction from a police officer.

Our differential diagnosis when informed that someone was described by a nonclinician as having so-called excited delirium is wider than the Diagnostic and Statistical Manual (DSM). In addition, the term comes at a cost. Its use has been implicated in police-related deaths and brutality.² There is also concern of its disproportionate application to Black people.^3,4

Nonetheless, the term “excited delirium” can sometimes accurately describe critical medical situations. We particularly remember a case of altered mental status from serotonin syndrome, a case of delirium tremens from alcohol withdrawal, and a case of life-threatening dehydration in the context of stimulant intoxication. Each of those cases was appropriately recognized as problematic by perceptive and caring police officers. It is important for police officers to recognize these life-threatening conditions, and they need the language to do so. Having a common label that can be used across professional fields and law enforcement departments to express medical concern in the context of aggressive behavior has value. The question is: can psychiatry help law enforcement describe situations more accurately?

As physicians, it would be overly simple to point out the limited understanding of medical information by police and correctional officers. Naming many behaviors poses significant challenges for psychiatrists and nonclinicians. Examples include the use of the word “agitation” to describe mild restlessness, “delusional” for uncooperative, and “irritable” for opinionated. We must also be cognizant of the infinite demands placed on police officers and that labels must be available to them to express complex situations without being forced to use medical diagnosis and terminology for which they do not have the license or expertise. It is possible that “excited delirium” serves an important role; the problem may not be as much “excited delirium,” the term itself, as the diversion of its use to justify poor policing.

It must be acknowledged that debates, concerns, poor nomenclature, confusing labels, and different interpretations of diagnoses and symptoms are not unusual things in psychiatry, even among professionals. In the 1970s, the famous American and British study of diagnostic criteria,showed that psychiatrists used the diagnosis of schizophrenia to describe vastly different patients.⁵ The findings of the study were a significant cause of the paradigm shift of the DSM in its 3rd edition. More recently, the DSM-5 field trials suggested that the field of psychiatry continues to struggle with this problem.⁶ Nonetheless, each edition of the DSM presents a new opportunity to discuss, refine, and improve our ability to communicate while emphasizing the importance of improving our common language.

Emergency physicians face delirious patients brought to them from the community on a regular basis. As such, it makes sense that they have been at the forefront of this issue and the American College of Emergency Physicians has recognized excited delirium as a condition since 2009.⁷ The emergency physician literature points out that death from excited delirium also happens in hospitals and is not a unique consequence of law enforcement. There is no accepted definition. Reported symptoms include agitation, bizarre behavior, tirelessness, unusual strength, pain tolerance, noncompliance, attraction to reflective surfaces, stupor, fear, panic, hyperthermia, inappropriate clothing, tachycardia, tachypnea, diaphoresis, seizure, and mydriasis. Etiology is suspected to be from catecholaminergic endogenous stress-related catecholamines and exogenous catecholaminergic drugs. In particular is the importance of dopamine through the use of stimulants, specifically cocaine. The literature makes some reference to management, including recommendations aimed at keeping patients on one of their sides, using de-escalation techniques, and performing evaluation in quiet rooms.

We certainly condone and commend efforts to understand and define this condition in the medical literature. The indiscriminate use of “excited delirium” to represent all sorts of behaviors by nonmedical personnel warrants intelligent, relevant, and researched commentary by physicians. There are several potentially appropriate ways forward. First, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting and does not belong in the DSM. That distinction in itself would be potentially useful to law enforcement officers, who might welcome the opportunity to create their own nomenclature and classification. Second, psychiatry may decide that excited delirium is not a useful diagnosis in the clinical setting but warrants a definition nonetheless, akin to the ways homelessness and extreme poverty are defined in the DSM; this definition could take into account the wide use of the term by nonclinicians. Third, psychiatry may decide that excited delirium warrants a clinical diagnosis that warrants a distinction and clarification from the current delirium diagnosis with the hyperactive specifier.

At this time, the status quo doesn’t protect or help clinicians in their respective fields of work. “Excited delirium” is routinely used by law enforcement officers without clear meaning. Experts have difficulty pointing out the poor or ill-intended use of the term without a precise or accepted definition to rely on. Some of the proposed criteria, such as “unusual strength,” have unclear scientific legitimacy. Some, such as agitation or bizarre behavior, often have different meanings to nonphysicians. Some, such as poor clothing, may facilitate discrimination. The current state allows some professionals to hide their limited attempts at de-escalation by describing the person of interest as having excited delirium. On the other hand, the current state also prevents well-intended officers from using proper terminology that is understood by others as describing a concerning behavior reliably.

We wonder whether excited delirium is an important facet of the current dilemma of reconsidering the role of law enforcement in society. Frequent use of “excited delirium” by police officers is itself a testament to their desire to have assistance or delegation of certain duties to other social services, such as health care. In some ways, police officers face a difficult position: Admission that a behavior may be attributable to excited delirium should warrant a medical evaluation and, thus, render the person of interest a patient rather than a suspect. As such, this person interacting with police officers should be treated as someone in need of medical care, which makes many interventions – including neck compression – seemingly inappropriate. The frequent use of “excited delirium” suggests that law enforcement is ill-equipped in handling many situations and that an attempt to diversify the composition and funding of emergency response might be warranted. Psychiatry should be at the forefront of this research and effort.

References

1. State of Minnesota v. Derek Michael Chauvin (4th Judicial District, 2020 May 29).

2. J Forensic Leg Med. 2008 May 15(4):227-30.

3. “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today. 2020 Jan 20.

4. J Forensic Sci. 1997 Jan;42(1):25-31.

5. Arch Gen Psychiatry. 1971;25(2):123-30.

6. Am J Psychiatry. 2013 Jan;170(1):59-70.

7. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force. 2009 Sep 10.
 

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures. Dr. Abrams is a forensic psychiatrist and attorney in San Diego. He is an expert in addictionology, behavioral toxicology, psychopharmacology, and correctional mental health. He holds teaching positions at the University of California, San Diego. Among his writings are chapters about competency in national textbooks. Dr. Abrams has no disclosures. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.