What all physicians need to know about race and racism in mental health care
In episode 12 of Quick Takes, Dr. David Gratzer hosts Drs. Amy Gajaria and Saadia Sediqzadah in a compelling conversation on the importance of addressing race and racism in mental health care.
The conversation covers ways to better understand the needs of racialized patients by:
- understanding that race is important to your patients, make it important to you as well
- recognizing that there is a need to formalize diversity in mentorship and leadership
- engaging in art, television, movies and books by people of colour to help understand their lived experiences
- working towards talking about race in a psychiatric interview by simply practicing.
March 3, 2021
What all physicians need to know about race and racism in mental health care
[Edited for grammar and clarity by CAMH]
Quick Takes podcasts are typically short and focused but this is a big topic and so today we’re going to have a longer conversation.
David Gratzer: My name is Dr. David Gratzer and welcome to Quick Takes. Today, we're talking about race and health and health care and mental health care. Certainly it's a topic that seems perhaps, unfortunately, even more relevant than ever before. As you know, with the pandemic, we've seen different groups affected differently. In fact, 83 percent of people diagnosed with COVID in the greater Toronto area have been black people or people of colour.
Joining me today to talk about these weighty matters we have two doctors. Dr. Amy Gajaria is a child and adolescent psychiatrist at the Center for Addiction and Mental Health. She's also inaugural associate director EDI Education and training with the University of Toronto's department of Psychiatry. She's been very vocal on these issues and has written for a variety of publications, including The Globe and Mail. Also joining me is Dr. Saadia Sediqzadah, who is a psychiatrist at St. Michael's Hospital. She is with the Department of Psychiatry at the University of Toronto, where she's co-lead of Underserviced/Marginalized/Selective and curriculum. And she's somebody who's been very prolific in her writing, including for the New England Journal of Medicine. Welcome to you both.
Saadia Sediqzadah: Thank you for having us.
Amy Gajaria: Thank you for having us. We're excited to be here.
David Gratzer: And we're excited for you to be here. Let's start with a not so simple question. Why does this matter?
Amy Gajaria: I can start that. I think that it matters because it matters to patients, you know, patients always tell us about how important it is to feel like they're in a setting where they can talk about who they are as whole people. And when you're a racialized person, your experience of being a racialized person is super relevant to your experience, your life, your life experiences and to your mental health. So I think the primary thing that we should always think about is that this matters because it matters to our patients. And I think Dr. Sediqzadah, Saadia, as I will call her, you might want to talk a little bit about how you came to this work and how we came to work together?
Saadia Sediqzadah: I also wanted to add that certainly a huge part of it, at the end of the day, it's ultimately about patient care. And I'd also add that it's important for our training as psychiatrists. You know, we're taught to approach our psychiatric assessment and our treatment plans using a bio psychosocial cultural approach. And so I feel that if we don't know something about race and racism and don't have that within our assessment and within our consideration, our treatment plans, I really think we're missing something.
And so there's a whole layer of intimacy that comes with going with a psychiatrist, a staff psychiatrist, or a resident to do a rural elective, and not only to provide clinical care, but we kind of spend so much time together otherwise. And it was my first time spending, first of all, one of the few opportunities where I had a woman of colour as my supervisor. And then on top of that, to have all this time outside of the clinical interaction, to have conversations about race and racism is something that I extremely valued … because she's a woman of colour I didn't feel like I need to really explain so much about my concerns and some of my thoughts on race and racism and how it affects mental health care. And it was such an impactful experience having her as a supervisor and then as a mentor, so much so that it informed part of my career planning. And in addition to my St. Mike's work, I also work in youth homeless shelters where most of the patients are black, indigenous or people of colour.
Amy Gajaria: And I think, to jump on what Saadia said, we've had this kind of dialog recently about this idea of like aunties, that there's like aunties are getting reclaimed. The biggest thing within racialized communities where there's like a wise older woman or somebody who provides guidance – and there's also like negative parts of aunties so we won't focus on that we'll focus on the positive components of aunties. But I think I feel I can give back to Saadia because I had people ahead of me that I could go to. You know that really kind of helped me understand that I'm allowed to talk about racism, that I'm allowed to talk about that with patients. It's always felt like my personal life, but I needed someone to give me that permission to do it clinically. And so I was able to give that to Saadia because I had people in my life that I think that speaks so much to the idea of mentorship, the idea of, you know, having supervision and the idea of having diversity in our leadership and in various parts, you know, in clinicians and in allied health and supervisors and the people that lead things, because you need people to show you guidance along the way and you need people to help you tap into your own strength. We all have that strength. We have that resiliency. We have those skills. But if someone doesn't lend you a hand and say, like, hey, let me let me help you tap into that, then it becomes, it feels impossible to do. And you get more and more divorced from your own identity. You know, as a racialized health care provider, as a racialized person.
David Gratzer: Both of you talked about training and mentorship. What do we do right on those topics?
Amy Gajaria: It's a hard question because I think right now is a really great moment where we're starting to talk about this and think about this. I would say that in the ways that you see a lot of really good work done by people of colour and racialized people, a lot of that's been happening underground, you know, outside of the mainstream, outside of the formal structures. So for a long time I think you just had to figure out who your people were and you had to, like, get to know them in this informal network. And there was sort of this informal network that's been around for a few years. And now there's been this conversation about formalizing it. And I think that's really new. I think this idea that we recognize how important this is and we're formalizing it is actually quite a new concept instead of one that you have to go and find your safe people. One program that I really love, though, is the Diversity Mentorship Program in the Faculty of Medicine, which is so wonderful. It's a way for people who occupy marginalized identities to support learners who also occupy marginalized identities and for them to be matched. And we know that in mentorship, people who are underserved often lack mentorship because they don't see people like them, they're not picked for mentorship. They're not hooked into the same formal networks that other people are who might have had, you know, relatives or other people that are in medicine. So that program is so, so helpful and it's new and it's out of the Faculty of Medicine. I'm a diversity mentor and I love it.
Saadia Sediqzadah: I totally agree, especially the comment around the informal aspect. So I certainly found throughout my residency training, you kind of find your people. You kind of find those racialized either co-learners, as in other residents, or staff psychiatrists who, again, it's an informal way, it wasn't any formal like this is a mentorship program, it's more like reaching out in situations where something felt amiss. Or I might have been struggling with a particular case because there was an element that I thought was missing in terms of race or culture, ethnicity, religion, et cetera. And so that was very informal. And Amy was one of those mentors and supervisors to me in the beginning part of my residency. And I do agree with Amy that I think that's a step in the right direction of normalizing. You know, it's funny because Amy I are quite active on Twitter and I have found, you know, I was quite active during my PGY5 year and now entering as staff, I've had quite a few people in general, but especially women of colour, young women of colour, reaching out to me at the undergraduate medical school and residency level and not necessarily in psychiatry, but also family medicine, internal medicine, et cetera, who turned to me and say, like, and it's pretty generic. It's just like, can I chat with you? I just like to get to know you better. You know, I feel like you care about a lot of the things that I can't really talk about otherwise within my department. And we'll schedule conversations on a Friday evening or the weekend. And it not only is it hopefully helpful for them, but I find it incredibly rewarding too. So this is kind of what I think Amy's alluding to about that informal sort of mentorship and allyship that's been going on for a while that's formalized in something like the Diversity Mentorship Program at U of T medicine.
Amy Gajaria: I think also it's always this tension that we think of and we think about engaging racialized communities in this kind of speaks to mentorship, to supervision, to clinical care, to all of these things. There is such strength in community, there's such strength in these informal networks. These are parts of how racialized people engage. And this is natural, I think, to a lot of racialized folks about how you build community and how you know who your people are. The flipside, though, is we work in an institution that is structured in a certain way. It isn't structured in that way. And so how do you both be true to that and recognize that people who are people of colour often do a lot of unpaid labour? Often do these things quietly, are often on the sidelines, are often doing it on Twitter where they're not it's not part of your promotions package? You can't include your Twitter chat like in a dossier and showing how much mentorship you're doing. And yet that is really relevant to underserved populations and racialized people in terms of engaging them. So that tension is something that you see kind of over and over again in kind of supporting and caring for racialized people and also supporting and caring for racialized trainees and early career staff within the institution.
Saadia Sediqzadah: One other piece I'd like to add is, while we are not formally involved in this per say, but I take a lot of inspiration from the different chapters of the black medical student’s associations across the country, so not just at the University of Toronto, but across the country.
What I can say at U of T, because I'm here, is that for years now that the MSA has been organizing Black Mental Health Series a few times a year, have a variety of events that are relevant for medical students and medical trainees, but especially targeted towards the community. And I've attended a few of them, they're really powerful. And something that I really appreciate is I think this is one of the benefits and the fruits of the labour that come with something like the BSAP and ISAP programs at U of T medicine, which are the Black Student Application Program and the Indigenous Student Application Program, where there's a focused recruitment effort and support, recruiting more black and indigenous residents into medicine.
And one of the fruits and effects of that is having these wonderful organizations, who I think educate us and educate the majority about the importance of community engagement. I know I've certainly learned a lot from the MSA events, and I think that's another example of something I don't want to say we are doing right, because I don't feel like I'm formally involved in it, but I think medicine is moving in that sort of direction.
Saadia Sediqzadah: So, Amy, one of the pleasures of becoming staff now is I get to work with you on curriculum for at least the postgraduate level in our department, and we have this brand new underserved and marginalized curriculum for PGY1, PGY2 residents here at U of T, and one of those half days I had the pleasure of working with you developing, which is called Racialized Experiences in the Mental Health System. We had you come and give a talk and we also had Donna Alexander, who she herself is a black racialized woman and a social worker working with you at CAMH. So I wanted to ask you I mean, I know, but I think it would be great for the viewers to hear a little bit about your presentation, especially around why this is why we feel that this is clinically relevant and why future psychiatrist should know about this.
Amy Gajaria: Yeah, I can speak about that. And then I can also speak a little bit about my journey in terms of learning how to work with racialized people.
I think that it's great to be able to do this training because it wasn't something that I had when I was in residency. Even just getting to know the people who are doing this work, I think it's really helpful for people. I think for me, I'm from the GTA like I grew up in Mississauga and I'm from a very diverse community. You know, that was my life growing up. And I came into residency and I didn't see patients that looked like the GTA. I would see a lot of patients in clinical practice in the traditional clinics and it just wouldn't be the people that are my friends that I grew up with or that I was surrounded by in my life and that I know are in the GTA. And it really bothered me because it felt like two separate lives. And right now, having a practice that is like nearly 80%, like it's huge, hugely geared towards racialize young people, is such a gift. And I sometimes forget and I have to look back and reflect on the fact that that didn't happen in training. And now I get to work with people that look like the GTA, that are diverse, where I can have this shared experience with them. And I work a lot with young black people and I'm not black, and that is always something I keep in mind. But I think to be able to have a clinical practice and to be able to say, I think I'm serving the community in which I live is so meaningful and so wonderful, it's something that I think we should be really going for.
In terms of pearls around what we talk about in that teaching and what I think are really helpful and this is something that I talk about with learners as well. Racism exists and it exists in the lives of our patients. And I think we have to acknowledge that. And we have to create a space clinically where people are willing to talk to us about the experiences that they have. And that sometimes means asking them directly. And sometimes that just means signaling to someone through your language and your way of hearing them that you are willing to hear all of their stories and all of who they are. And as you go on, as you do this work, you will figure out which one works best. The other thing that I think about quite often in my patient population is the interactions with the police. So, you know, it's always a consideration when you work with young, racialized people, how you get someone to hospital. And I in two or three years have called the police on a patient once or twice. And I work with a very acute young population that are frequently in crisis because we know the risks that come with that and we know the calculation that comes with interacting with the police for our clients. And so I think that's really important for people to think about when they're working with racialized populations.
And the other thing I would say is just being mindful of the fact that racialized people, but particularly black and indigenous people, come to the mental health system expecting that we don't understand them, expecting that they will not be cared for. Having had many times bad experiences, either having had their experiences dismissed or being reacted to out of fear and aggression. We just saw a presentation about the disproportionate use of restraints at CAMH on black populations and black patients and that is sort of consistent with what we see clinically. So when you're seeing a person who is a racialized person being mindful of how they might have experienced multiple systems, including the mental health system, and that's not about you, that's nothing to do with you, that just people come with their baggage and we're willing to acknowledge their baggage about their personal experience, their trauma, all of this. We have to also acknowledge the baggage that comes with being a person that is racialized in our society.
Saadia Sediqzadah: I wonder, Amy, what advice he would give not only to learners, but also existing staff psychiatrists, or any other mental health professionals listening, how to foster making space about speaking about racism within the clinical interaction. Do you have any practical tips for listeners where this might be a very new concept for them?
Amy Gajaria: I think, number one, it comes from learning to cultivate a nonjudgmental stance towards yourself. Usually when people get into trouble is when they feel like they have to be perfect. They want the checklist, give me the checklist, tell me exactly what to say so I never make a mistake and I'm good and I put it on my checklist and I move on. And I understand where that comes from because there's a lot of anxiety, especially if you're not a racialized person, for talking about these issues because you're always afraid of getting it wrong. And so I think the message is you will get it wrong. We all get it wrong. I get it wrong. I'm learning. It's about practicing talking about race outside of your clinical encounters. Practicing saying the word black, saying the word racism, like say it, you know, so you don't trip over it when you talk to people. Engage with art or movies or books that are created by people of colour so that you're just immersed in it and you're not it's an alien experience. And be willing to make mistakes and apologize for them. And your goal if you come to your, and this is what I always talk about, you come to your encounter with kindness and openness and genuine curiosity and acknowledge that you don't know everything, that you will make mistakes just like you do in all the other parts of medicine. You know, like you do in other parts of a psychiatric interview, this is the same, and you just have to practice and you have to acknowledge that you are not going to be perfect.
David Gratzer: So thinking about a patient encounter that you may have had, what was what was it one such encounter where you think you learned something important?
Amy Gajaria: I had a young person early on when I started at SAPACCY who had a psychotic disorder and it was early on in my kind of working primarily with this population. And I remember she said, like she said to me, I came because she was having a challenging experience with another service and felt they didn't see her as a person. That's what I remember she said to me and I said, let's try it again, because I really think this service is going to be the right one for you versus like my clinic. And we're sitting down with her and her mom and her mom looked at me and said, and you care. Like this is different. You see me as a person. And you see my kid as a person. And you're not just like I'm not just a client here and I want to see you for mental health care. And I think we can all do that, you know, we get in our boxes, we get in our spaces, we get in our ways of being physicians, and we forget that sometimes what someone needs is to be seen as a person and to be seen as a person that is cared for.
Saadia Sediqzadah: And just to add to that, I think one way to help facilitate that, just like Amy said, you know, reading books, consuming art, consuming different sources of knowledge when it comes to different cultures, different ethnicities, different races, et cetera, is something that has always been something I've been curious about, motivated about, always wanted to learn about. And, you know, what a wonderful place to do that. And other than being born and raised here in Toronto. Right. The most diverse city on this planet. And I feel like having all of that knowledge and background, and by no means am I an expert, but having that knowledge and that background allows me to be able to drop a couple of comments, make a couple of jokes, add a few, sort of cultural references that make that patient look at me twice and go, how did you know that? You know, about rice and peas and you know about, you know, that particular song in my culture or how did you know about this like, very small, like little known language that's a minority language in my culture or my country? You know, so little comments like that and little jokes like that can they're really, really tiny and yet so incredibly significant around fostering a safe space where one can you know, when you're entering an appointment, especially for a lot of racialized people, you kind of have your back straight and there can be anxiety as Amy said, lots of baggage that can come into the interaction. And I can actually see people sort of relax when that when that joke hits right. Or that comment hits right. And realize, oh, OK, this doctor is a lot different from some of the other doctors I've had in the past.
I know a lot of people who may not be racialized, who very much are motivated and want to be allies in the space, can sometimes feel powerless or feel very behind or feel that they don't have the expertise to be able to engage. But I feel like, as Amy said, you got to start somewhere. You got to put in the work. And I don't think it takes a lot of work to watch some shows, some movies, to read some books to talk to people, befriend people of different cultural background, racial backgrounds. And it does come with time. But I think it is totally doable as long as it comes from a place of humility and of genuine interest and motivation, because I really do feel it has a huge impact on patient care and on that therapeutic bond and therapeutic alliance.
Amy Gajaria: And I think I'll jump in just to say the thing I always say to my learners when they come to work with teenagers, don't just try to learn the references and see them because the teens will smell that out and they will destroy you.
It's more about authenticity, right? It's more about you engaging authentically with material and being yourself authentically in an encounter that I think is important. And in terms of things I really like, you know, there's certain shows and things that I always recommend. Black-ish is great. Also McKayla Cole did a beautiful short series called I May Destroy You, which was about her experience of sexual assault. And the beautiful thing about that series is that she's a black young woman and she created that whole thing. She wrote it. She directed it. It's her baby. And that is what's so important. If you're going to engage with art and with … make sure that by people of colour and it's authentically about their experience. That will teach you so much more than if you just see a show that has a black person in it. That's not the same thing. And the only thing I'll say is if you look at your friend group people you spend time with and you're in Toronto and you're not spending time with a diverse group, maybe just figure out why that is. Maybe that's something maybe change that. And if you look at your Netflix queue and its only things created by white people and its only content that has exclusively white people in it, maybe that's a suggestion. If you're authors that you read are only white, maybe you need to shake it up a bit.
Saadia Sediqzadah: And actually, on that note, Amy, I think, you know, we kind of nerd out over books that we enjoy that are particularly relevant for this topic. So maybe this is a good segue way for us to talk about or suggest some books and resources.
I know a book that both you and I have discussed and I think is really powerful and has one like so many awards and accolades in 2020 is The Skin We're In by Desmond Cole. I particularly recommend this book because I find a lot of the literature and books that we read come from the United States, which, don't get me wrong, I think is really important, but we don't have as many resources in Canada and especially Toronto-specific. So Desmond Cole's book is wonderful, particularly because he has one chapter dedicated to, for example, racism within the education system focusing on the Peel district school board. He also has an entire chapter dedicated to the Toronto Police Service and the racism that has been documented that exists there. So for me, The Skin We're In is really, I think, a must read for not only psychiatrists, but health care providers in general. What about you, Amy? Do have any suggestions?
Amy Gajaria: Yeah. So a book that would be Seven Fallen Feathers by Tanya Talaga. Super relevant set in the deaths of seven young people in Thunder Bay. Shows, Pose, which is on FX. It's about the ballroom scene in New York and it has a huge cast of trans, black and Latinx folks. Really amazing show. And another thing that I really like is, you know, this is like not retro for me because I actually watched Fresh Prince when I was on, the Fresh Prince of Bel-Air is on Netflix now. But they have this clip where Will gets pulled over and Uncle Phil explains to him, like they have a conversation what it means to be a black man who was pulled over. That shows from a long time ago. That is from like many years ago and that conversation is still happening now. So I think it's important not just to do it now, but to think about what happened in the past.
Saadia Sediqzadah: Yeah, totally agree. And I think another book that comes highly recommended is Medical Apartheid by Harriet A. Washington. I actually haven't started this yet, but Auntie Donna, Donna Alexander mailed me a copy of the book, so I'm very excited to read it. And it's about, you know, it says under the title, The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. And I think this book is particularly important and relevant for me to read as an M.D., because especially when, you know, David you had introduced the podcast today talking about the fact that black people are disproportionately affected by COVID, and there's a lot of conversation around black and other racialized communities around vaccine hesitancy. And I worry that blame is pinned on these communities, that it is their fault or they're doing something wrong or having hesitancy around vaccinations. But that's why I think it's particularly important to know our histories in medicine and why certain communities would mistrust the medical system, because there's a really dark past, including in psychiatry, the way that our systems have treated and mistreated black, indigenous and other people of colour.
David Gratzer: Both of you raised really important points and made important comments. One final question then. What makes you hopeful for the future?
Amy Gajaria: I think this is so good that we're together in this conversation because people like Saadia make me hopeful for the future and she keeps me excited, you know. I've been doing I've been doing anti-racism work and social justice work for a very - I'm not that old - but I've been doing it since I was very young. And sometimes that can make you feel hopeless and it can make you feel like nothing's going to change and it can make you really cynical. And then you need really awesome, optimistic, I guess new staff, previously trainee's, to give you hope for the future and to tell you things could be different. And we can build a community and we can see a different kind of mental health care system.
David Gratzer: And on that cautiously optimistic note, I'll thank both of you for your time and perhaps you'll consider coming back to another Quick Takes and so we can continue this very important conversation.
Amy and Saadia: Thank you so much.
[Outro:] Quick Takes is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at porticonetwork.ca/web/podcasts. If you like what we're doing here, please subscribe.
Until next time.
About this episode's guests:
Dr. Amy Gajaria (@AmyGajaria), is a Child and Adolescent Psychiatrist at the Centre for Addiction and Mental Health and an Assistant Professor in the Department of Psychiatry at the University of Toronto. She is the Inaugural Associate Director, EDI, Education and Training, for the department of Psychiatry at the University of Toronto and an O'Brien Scholar with the Child and Youth Mental Health Collaborative. Dr. Gajaria's clinical, research, and education interests are in equitable access to mental health care for diverse populations.
Dr. Saadia Sediqzadah (@Saadia_Sediq), is a psychiatrist and clinician-investigator in the Department of Psychiatry at St. Michael's Hospital and Inner City Health Associates. In the Department of Psychiatry at the University of Toronto, she is the Co-Lead of the Underserved/Marginalized Selective and Curriculum, which provides selective opportunities in and teaching about the intersection between structural determinants of health and mental health care for psychiatry residents.
Resources suggested by this episode’s guests:
- The Skin We're In: A Year of Black Resistance and Power, Desmond Cole
- Seven Fallen Feathers: Racism, Death, and Hard Truths in a Northern City, Tanya Talaga
- Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, Harriet A. Washington
- Between the World and Me, Ta-Nehesi Coates
- Why Are All the Black Kids Sitting Together in the Cafeteria?: And Other Conversations About Race, Beverly Daniel Tatum
- Afrocentricity: The Theory of Social Change, Molefi Kete Asante
Television and film:
Hardeman, Rachel R., Eduardo M. Medina, and Katy B. Kozhimannil. "Structural Racism and Supporting Black Lives-The Role of Health Professionals." The New England journal of Medicine 375.22 (2016): 2113-2115.
Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 2015; 10: e0138511
Jones, Shawn C. T, Anderson, Riana Elyse, Gaskin-Wasson, Ashly Louise, Sawyer, Broderick A, Applewhite, Kimberly & Metzger, Isha W. (2020). From "crib to coffin": Navigating coping from racism-related stress throughout the lifespan of Black Americans. American Journal of Orthopsychiatry, 90, 267-282. https://doi.org/10.1037/ort0000430
Fante-Coleman, T., Jackson-Best, F. (2020) Barriers and Facilitators to Accessing Mental Healthcare for Black children & Youth: A Scoping Review. Toronto: Pathways to Care Project