Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice.

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

Addressing Gendered Racism Against Black Girls Using a Strengths-Based Empowerment-Intersectional Framework for Sexual Health and Substance Use Prevention Programming.

Although Black girls use substances at lower rates than boys and girls from various other racial groups, they tend to have worse health outcomes associated with substance use that can also impact their sexual health. The association between substance use and sexual risk behaviors is usually attributed to lack of access to quality health care and lack of culturally specific prevention programming and treatment options tailored to this group. Accordingly, the theoretical frameworks for health promotion for Black girls often focus on addressing deficits, ignoring the powerful and intersecting social forces that can impact identity, agency, and behavioral options. Key among these forces is gendered racism. We propose a strengths-based conceptual framework to address and challenge gendered racism as a critical foundation for promoting health and wellbeing for Black girls. Our approach integrates Intersectionality Theory and Empowerment Theory, with psychological and intrapersonal empowerment identified as critical mediators of behavior and health outcomes, supported by protective factors of positive racial identity and gendered racial socialization. This framework has been developed with and for Black girls but can be adapted for health promotion efforts with other minoritized groups.

Sociopolitical control as a mediator between ethnic identity and social support on 30-day drug use among black girls.

While Black girls have lower rates of drug use, they face worse health and wellbeing consequences associated with drug use. Understanding which strengths-based factors serve as buffers to limit adverse outcomes related to drug use among Black girls is essential for prevention. This study investigated the mediating role of sociopolitical control on drug use among Black girls (n = 340). Using path analysis, models were tested to include the variables of interest. Sociopolitical control (e.g. leadership competency and policy control) significantly mediated the relationship between ethnic identity and social support on drug use. Implications from this study may consider bolstering empowerment-based strategies in drug use prevention for Black girls.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors.

WHAT IS KNOWN ON THE SUBJECT?: The impacts of racism on health are well documented and are greater for mental than for general health. Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings. AIM/QUESTION: We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff. METHODS: We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework. RESULTS: We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants. IMPLICATIONS FOR PRACTICE: Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

How Biased and Carceral Responses to Persons With Mental Illness in Acute Medical Care Settings Constitute Iatrogenic Harms.

Recognizing their roles in iatrogenesis requires clinicians and professions to take responsibility for attitudes and policies that harm patients and waste resources. A striking, neglected set of examples of iatrogenic harm involves persons with severe mental illness (SMI) who seek inpatient medical care. This article describes how medicine, despite spending billions each year trying to respond to acute physical medical needs of persons with SMI, participates in carceral policies and practices that fail to prioritize continuity of care. This article also details clinicians' and professions' responsibilities to mitigate their roles in iatrogenic harm incursion by practicing antiracist, evidence-based, collaborative care to motivate equity, reduce waste, and improve outcomes, especially in crisis responses to patients experiencing acute exacerbations of SMI in inpatient medical care settings.

Destigmatizing perceptions about Black adolescent depression: randomized controlled trial of brief social contact-based video interventions.

OBJECTIVE: To test the utility of brief social contact-based video interventions of a Black adolescent girl to reduce stigmatized attitudes and increase help-seeking intentions around adolescent depression. METHODS: We conducted a randomized controlled trial (RCT) with 14- to18-year-old healthy volunteers drawn from the general US population. We enrolled participants through a crowdsourcing platform (n = 1,093) and randomly assigned participants to one of three video conditions (117 s each): depressed (DEP); depressed, adjusted to aspects unique to being a Black adolescent girl (including experienced or internalized racism; ADJ); and control (CONT). The primary outcome was the Depression Stigma Scale (DSS); secondary outcomes were the General Health-Seeking Questionnaire (GHSQ), and thermometers for Black and white race perception "warmth". RESULTS: Following the intervention, the DSS changed from baseline across the three conditions (p < .001). ADJ outperformed both DEP (p = .031) and CONT (p < .001). A race-by-intervention interaction (p < .001) revealed different response profiles between Black (ADJ = DEP = CONT; p = .726) and non-Black participants (ADJ > DEP > CONT; p < .001). DEP and ADJ both resulted in higher treatment-seeking intentions for both the emotional problems and the suicidal thought subscales of the GHSQ. We found a race-by-intervention interaction (p = .01) for the Black thermometer, which revealed a significant 2° increase in warmth among white (p < .001), but not Black, viewers (p = .06). CONCLUSIONS: On a short-term basis, brief social contact-based videos proved effective among adolescents in reducing depression-related stigma, increasing help-seeking intentions, and providing an "empathic foothold" in the lives of racially stigmatized groups. Even as the enduring effects of these interventions remain to be determined, the deployment on social media of short videos opens new opportunities to reach a large number of at-risk youth."

Editorial: Black Adolescent Suicide in America: Insights From a Large Epidemiological Study.

As we sat down to review Sheftall et al.,1 we came across a chilling report in the venerable New York Times: "US suicides declined overall in 2020 but may have risen among people of color." The synchronicity would have been noteworthy, had the 2 reports not been so tragic. The pathos of the newspaper story was how painfully familiar it was, how heartbreakingly unsurprising, how sadly it rang true. This issue of the Journal includes the largest epidemiological study on Black adolescent suicide published to date. The article by Sheftall et al.1 provides reliable, granular, and actionable information about this major public health challenge.

Moving Beyond Implicit Bias in Antiracist Academic Medicine Initiatives.

The concept of implicit bias has arguably laid the groundwork for uncomfortable discussions surrounding race in academic medicine, but its effectiveness in changing racist behavior and systems remains unclear. Terms like implicit bias, while perhaps more palatable than other concepts to some, may result in confusion and divert time from meaningful reconceptualization and creation of effective antiracism initiatives. This Invited Commentary contends that the term implicit bias is inadequate for addressing racism because it is too broad; does not necessarily lead to a change in racist behaviors; assumes that racism is unconscious, aggressor-centered, and individual-focused; and implies that everyone suffers equally in a racist system. The authors illustrate why terms like implicit bias are inadequate in combatting racism in medicine and suggest alternate terminology to use while engaging in antiracism work in academic medicine.

Community Reintegration During COVID-19 for Patients in Long-Term Inpatient and Residential Psychiatric Settings.

COVID-19 has devastated communities worldwide, and individuals with serious mental illness often experience poorer outcomes. The literature on psychiatric hospitals has mostly focused on controlling viral spread, and scant scholarship discusses the transition of patients with serious mental illness from the hospital back to their communities. This column proposes principles for developing safe discharge policies and identifies barriers patients face when infection prevention and recovery goals conflict.

Supporting Clinician-Scientist Development in Child Psychiatry: A Four-Domain Model for Individual or Programmatic Self-Reflection.

Background: The Albert J. Solnit Integrated Training Program (AJSP) is a novel educational initiative designed to prepare physician-scientists for independent careers in the investigation and treatment of childhood psychiatric disorders. Methods: We conducted a qualitative study to explore the impact and active components of the AJSP through hour-long individual interviews of its enrollees and graduates. We were specifically interested in identifying individual or programmatic traits for success that could be replicated elsewhere. As components of our theoretical framework, we used sources on Strength, Weakness, Opportunity, and Threat (SWOT) Analysis as applied to healthcare, and on mentorship and career development as pertaining to child and adolescent psychiatry (CAP). Results: Thirty-four individuals matriculated into the AJSP between 2004 and 2020, 33 (97%) of whom participated. Through iterative thematic analysis, we developed a model consisting of quadrants resulting from the intersection of a developmental perspective (spanning professional or personal spheres) and a reflective direction (with outward- or inward-facing vantage points). The model can be of practical utility through putative questions that trainees/program leaders could ask themselves by using the four domains as points of departure: (I) Individual: "Is becoming a clinician-scientist right for me?"/"What traits are we looking for in prospective applicants?"; (II) Program: "Is this the right program for me?"/"What is the right balance between structure and freedom for trainees to thrive in?"; (III) Mentorship: "What is the right number and constellation of mentors for me?"/"How can we optimize our experience and backgrounds toward the benefit of our trainees?"; and (IV) Charting Course: "Who do I want to become?"/"How can we help our charges embrace, find, or reconnect with their true vocation?" Conclusion: Our analytic approach can help identify, refine, and replicate programs that are urgently needed to increase the workforce of clinician-scientists dedicated to improving the well-being and mental health of children and families. The model we describe can be fruitfully applied to the self-reflection by individuals or program leaders. Although based on a single program with very specific goals, the model could also be applied to other training initiatives within psychiatry-and beyond.

A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings.

Medical rapid response teams, now ubiquitous throughout hospitals, were designed to identify and proactively treat early warning signs of acute medical decompensation. Behavioral emergencies-including clinical psychiatric emergencies, coping/stress reactions, and iatrogenic injuries-are not responded to with the same vigor. At worst, behavioral crises are treated as unarmed security threats. Limited or inappropriate responses to such crises can lead to suboptimal outcomes on numerous levels, especially avoidable harm to patients and frontline clinicians. Widespread implementation of behavioral emergency response teams for patient-centered behavioral interventions has been impeded by a pervasive perception that these endeavors are medically unnecessary and optional. This article calls for a paradigm shift in responding to behavioral emergencies by arguing that security-driven risk management practices during behavioral emergencies are incompatible with fundamental medical and ethics principles.

The Face of Medicine Is Not My Face But, It Should Be.

The "face of medicine" is a term commonly used to describe the leaders and decision-makers of medicine. Medical ethics often discuss past historical atrocities committed by the "face of medicine," such as the American eugenics movement and medical experimentation. However, a great irony persists: the "faces of medicine" do not resemble the faces of the oppressed populations. Nevertheless, the discussion of white supremacy and systemic racism, structures which fueled historical medical atrocities, is often omitted. This reflection discusses the need for education, conversation, and action surrounding these topics to adequately combat racial and ethnic health disparities. We also argue that the decision-makers of medicine should be a diverse group of stakeholders, thereby representative of and personally invested in a diverse group of populations.