The USA

Abstract

As resident and attending psychiatrists, our role is to evaluate and treat people who require hospitalisation for acute psychiatric conditions. Our primary goal is to provide these individuals with a safe space to heal, and to offer treatment that can promote recovery. Although this is achieved for most patients in the psychiatric unit, not all are afforded such a sanctuary. Recently, a young man, Mr X, opened our eyes to the mistreatment that Black men can face within the psychiatric hospital setting. Mr X, unlike most patients we care for, was escorted, handcuffed, into the inpatient psychiatry unit by police officers. Earlier that morning, Mr X had been pulled over at a routine traffic stop and charged with possession of marijuana. In the context of the possibility that this charge might threaten his employment, Mr X told the officers he would rather die than lose his job. The police responded by charging Mr X with resisting arrest, placing him on involuntary psychiatric hold for danger to self, and transferring him to the inpatient psychiatric unit. We were alerted to Mr X's arrival at the unit by an urgent page requesting immediate evaluation of a patient who was not cooperating with staff. We expected to find an agitated patient; instead, we saw a tearful man at the far end of the room, with at least ten staff members guarding the exit. With reassurance, Mr X engaged with us and shared his story. He had served in the military and, like so many Black veterans, had a long-standing history of being vilified and persecuted by the very country he risked his life for. His sacrifices had apparently been quickly forgotten on his return from war. The story is all too familiar: one of many individuals who struggle to find employment, find themselves frequently targeted by the police, and wrestle with symptoms of depression and post-traumatic stress daily. After a prolonged period of unemployment, Mr X left his hometown in search of a new start. He stated that he was not suicidal; his main concern was potential loss of employment. We agreed that Mr X did not require inpatient hospitalisation, but that discharge with outpatient follow-up was appropriate. However, despite our efforts to reassure our colleagues, he was, in our absence, seen again by the police, and was prescribed and given intramuscular medication. In the following months, as our nation wrestled with questions around social justice and equality, we reflected on the many facets of this case and how it affected us. Our initial reaction was sadness. Later, our feelings evolved to include frustration at how Mr X's hospitalisation had been transformed into yet another tool for oppression. From the police, who initiated his hold and handcuffed transport, to the involuntary medications he received, Mr X was silenced, stripped of his rights, and further marginalised under the auspices of receiving care. Although we would like to believe that hospitals are somehow shielded from such mistreatment, Mr X showed us that the walls of inpatient psychiatry hospitals are easily penetrated by the racial injustices that flood this nation. Our experience with Mr X has motivated us to explore systemic racial injustices and scrutinise practices within psychiatry that have been unquestioned for so long. We have since been working to increase implicit bias training, promote diversity amongst our health-care teams, and establish several improvement projects dedicated to reducing the degree to which racial biases influence our clinical judgment. One of our primary goals is to reduce the use of restraints and emergency intramuscular medications and ensure patients of colour are not targeted for these last-resort measures. Although these are small steps towards addressing the larger issue of systemic racism within this country, we are hopeful that even these small changes will help us to protect some of our most vulnerable patients. The racial wounds in this nation are deep, but we can all make a difference, however small or insignificant it may seem, to participate in its healing. The patient has been anonymised, and details of the case altered to preserve confidentiality.