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To start a conversation about race, you need to know the lingo. We interview psychiatrist Kali Cyrus on internalized racism, microaggressions, implicit bias, and more.

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Published On: 05/09/2022

Duration: 15 minutes, 33 seconds

Related Article: “Racism and Psychiatry,” The Carlat Psychiatry Report, May 2022

Chris Aiken, MD, Kellie Newsome, PMHNP, and Kali Cyrus, MD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Transcript:

All psychiatrists need to know how to talk about race and its effects on mental health. And to talk, you need to know the language. Today, we get an update from Kali Cyrus. 

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

From anti-maskers to pro-vaxxers, the woke to the Q-anon truthers, it can seem like the events of the last two years have only driven the wedge that divides us deeper. But there were other stirrings during the pandemic. Stigma about mental illness has gone down, as the lockdown brought depressive symptoms a little closer to home for us all. Marginalized communities that have shied away from mental health treatment – fearing it will only further marginalize them – are coming to see us, and they are speaking up – both to their clinicians, their community, and to the world at large about the effects of centuries of oppression. 

 In this month’s issue psychiatrist and physician-activist Kali Cyrus gave us a crash course on race and psychiatry, and she reminds us that psychiatry – and medicine in general – has not always been kind to people on the margins – people who are not White, who are not cisgender, who are not able bodied or native English speakers. And she gives tips on everything from how to arrange your waiting room to how to open up a discussion about race to better understand your patient’s experience. Today, a few highlights from that interview.

CHRIS AIKEN: Let’s imagine a psychiatrist who fell asleep in 1993 and has just woken up to 2022. What do they need to know about race?

CYRUS: I would say that if you fell asleep in 1993 what you need to know is that you’re gonna have to learn enough to talk about it or find a way to learn how to talk about it. 

I think the thing that has changed the most drastically and probably the quickest in the past and I’m gonna credit (and this is one of the few things that I credit Donald Trump for) and it’s for bringing I think some dynamics to the forefront that a lot of people were thinking about, even if I don’t necessarily agree with them, about race and difference, although I think he went a little bit too far, not to get political. But I think it’s something that everyone wants to talk about with everything that’s happening in the news nationally and internationally. How many sort of protests have we seen around Black Lives Matter issues, not just in the United States but in Paris and other countries. 

And right now we are seeing a lot of Black people especially and people who weren’t normally seeking therapy and medication who are talking about their mental health for the first time and are actually seeking treatment. And just because of the mismatch in supply of providers who might look like some of these people of color, you have to be able to talk about race right now. 

I think I would also say don’t worry. I mean worry, do you work, but you are not going to be able to do it perfectly and the right way all the time, you just have to be willing to bring it up, and I think that’s the first step and probably the hardest to overcome is just knowing that you’re gonna have to talk about it.

CHRIS AIKEN: To talk about it you need language. And there’s a lot of words out there we need to know.  To start with, what is internalized racism?

CYRUS: Yeah, this is one of the most insidious forms, at least in the way I think about it. Internalized racism is essentially accepting those negative messages that you might hear about your identity. So I’m using internalized racism, but it can be ageism, it can be sexism, it can be any of these –isms that are directed toward your identity, but essentially you believe that those negative messages are true. An example for me of internalized racism has probably been one of the most recent layers of work I’ve done is when I find myself afraid, when I’m judging other Black people for things that I’m doing because I’ve accepted some sort of notion that they shouldn’t be doing this thing. And so it’s almost like a self-hatred that can take varying levels of intensity, you know like feeling embarrassed or feeling ashamed or feeling angry. And another saying that might demonstrate this is – a colleague I used to work with used to say this all the time – “An example of the White man’s ice is cooler.” So if you are a Black person going to buy ice from different stores and you see one that’s owned by a Black person and you see one that’s owned by a White person, you’re gonna go to the store that’s owned by the White person because you think their ice is cooler when ice is just ice like it doesn’t make a different. And I think that’s a perfect example of the internalized messages that we can take on and start to denigrate people who look like us and most importantly us as part of that group.

CHRIS AIKEN: How does internalized racism come out in patients you see?

CYRUS: Yeah. I see a lot of the theme of “lesser than.” So automatically thinking that in most spaces, ones where you’re probably being evaluated so probably at work is most often when I hear that you feel “lesser than.” You’re very afraid to say something that you might be perceived as less intelligent. You are overworking because you are afraid of being perceived as less driven. And I see this also in dating. You are being perceived as being less attractive or less desirable depending on what city you live in. 

You know there are a lot of fears and insecurities that are driving your interactions with people who don’t look like you who have power. And then I think what also starts to happen is that you may start judging people who look like you who are not behaving in those moments because you think that this is the right way that you are supposed to behave. 

But I think most of what I see is the response right now to being…It’s almost like a mass anxiety is the way that I see it with my patients and it’s in general some form of uneasiness, almost worry about being in a context that is primarily White where they are outnumbered, which is why I’ve seen a lot of my clients who have stopped going to work or have been enjoying the working from home lifestyle who really retreated from certain groups of people who they may have been closer with you know like college friends that may have all looked a certain way to maybe inquiring about maybe why they’re more connected to their family or a group of people who look like them who they weren’t so close with in college. Or you know some folks are just isolating a little bit more in general depending on where they live and are just of like angry and taking it out on themselves in general because you know you can’t turn that hate and that dislike outward so the other place for it to go is back inside of yourself, so a lot of sort of self-loathing that I’m seeing in my patients right now.

CHRIS AIKEN: I’m thinking of some other words to clarify: Interpersonal racism, and a related one, microaggressions.

CYRUS: So interpersonal racism is generally just between two people or between folks who are interacting with each other. So it might be when you might say something that is offensive to somebody of a different race or you might look over them in terms of a promotion or you might neglect them. I think neglect and omission is one that particularly hurts because it’s not like an overt like you know that it happened, it’s just like do you even matter?

And this is where microaggressions come in I think in the interpersonal realm and have earned a lot more popularity because microaggressions are sometimes so slight. And you know the other person is for the most part not doing or saying something intentionally, you know like not calling on you in class or not talking about people who look like you in concept. You go home and no one else has really noticed that but you, and you’re still thinking about it. You’re still spending all that time trying to figure out if this thing was directed toward you. Should you be feeling how you feel? Are you overreacting? Is your reality true? And I think that “Is your reality true?” is another one of these like I said my clients are feeling less than. I get a lot of, “Is my reality actually true right now that this is serious and that this is happening?” Because I think that so often there’s been a tendency to kind of just like you have to brush things off as a person who generally is a minority in any context to sort of be able to be in a group of folks who have a particular culture. And now we are seeing people who are not brushing it off and are actually recognizing what may be happening for the first time in their world like actually letting it penetrate their psyche, which is why I think we’re having a lot of anxiety and potentially people have been referring to it as a little “t” trauma. 

And probably why you see all of these fights that have racism including in the DSM is because once you’re aware of dynamics that are happening they are ever present and it’s hard to ignore them or at least to recognize and process them at a level that doesn’t disrupt your entire day. And so I think interpersonally you know one of the hardest things because you are usually looking at a person and the weight of that comment represents sometimes the history of a bunch of other comments or things that have been said to you. And it doesn’t necessarily mean that this person who is saying or doing this thing does this everywhere or is a bad person, but in that moment what they’re saying may hurt you which is where this intention versus impact comes from. And it’s sometimes just really hard to see the impact and separate it from the intention of the person because it’s coming out of their mouth. 

So I like to think of this a lot about how we think about when we have conflicts in general and we try to tell people you know to separate the comment from the actual person itself, but it’s really hard to do when that person doesn’t look like you or have the background that you’re from and you are thinking they don’t understand what it’s like to be in your shoes, and they probably don’t. But like all of that is just like wrapped into one comment and how are you supposed to process that and move on with feeling emotionally safe in the space when something is said that may be micro but is still contributing to like a lifetime of hurt that you may be experiencing.

CHRIS AIKEN: It sounds like people have been denying the effects of the microaggressions on themselves, denying their own reality, and now that the conversation about race has opened up more in the public sphere the lid is coming off.

CYRUS: Yeah, yeah, I think that’s the case. So much like a lot of self-awareness, I suppose there’s a spectrum of people who’ve always noticed it who call it out and do something about it. Then you have folks who may notice it but don’t do much about it and write it off, rationalize it. And then you have folks that don’t really recognize it because for whatever reason they either have never been made aware or they’re doing it because their psyche can’t take it. 

And what I think right now is that we have more of a societal recognition that this stuff is happening plus we’re talking about it, and I think that folks are more aware of this thing happening in their life and being confronted with having to do or say something about it or not. You know I’ve been thinking about this construct a lot when I’m talking to my patients who’ve undergone some form of usually complex trauma and it’s still in their body, but they experience it in different places but just don’t attach it to whatever that memory is. They might have a fight or flight type of response and rationalize it away, but for whatever reasons can’t go back to whatever that stressor is that might be causing them to react in a certain kind of way because it’s too painful to. 

And so I’ve had a lot of patients for the first time who are coming and talking about – and this is maybe in my over-50 patients – talking about experiences around racism that they’ve experienced that they haven’t been able to talk about before.

CHRIS AIKEN: Okay.

CYRUS: Yeah, yeah. In a way that’s like “I can’t believe I never talked about this when I know that it’s been happening now for probably some years.” So it’s interesting I think how like what’s going on in the mainstream culture and talking about this kind of stuff and what its impact is on people who have kept this kind of stuff dormant.

CHRIS AIKEN: Are microaggressions a kind of trauma?

CYRUS: No, no, but I like to caution folks that I think you know the definition of microaggressions are…it’s hard to say what’s micro or not. Like when I’m called “sir” in public or on the phone is that “micro” to me, or if I were a transwoman and someone called me sir, like how much would that hurt. So I think there’s a difference depending on sort of what lens, who’s calling you what or what that aggression is. But microaggressions are not forms of trauma the way that I think about it, but I think of them as still little tiny re-openings of wounds…

KELLIE NEWSOME: Kali Cyrus is an Assistant professor in the Department of Psychiatry at the Johns Hopkins School of Medicine in Baltimore Maryland. She maintains a private practice in Washington, DC and is a frequent commentator on CNN, NPR, and MSNBC. You can find her online at www.kalidcmd.com.

And now for the word of the day…. Biweekly

CHRIS AIKEN: This word “biweekly” has always confused me, and now that I’ve looked it up in Merriam-Webster I understand why. Biweekly can mean every 2 weeks, or twice a week, so if you are writing for a prescription to take every 2 weeks don’t use this word. The proper pharmaceutical notation is q2wk. And on that note, we have good news and bad news for you. Kellie and I will be taking our show biweekly – as in every other week – but the podcast as a whole is growing to the other kind of biweekly – with episodes twice a week.

KELLIE NEWSOME: The family of Carlat Journals has grown in recent years – it now includes Child, Addictions, Hospital Psychiatry, and a soon-to-be-released Geriatric edition. And with four editors on board we are able to bring you more episodes. You’ll still hear from Dr. Aiken and myself every other Monday, and we look forward to meeting you again on May 16th where we’ll cover 7 reasons to use tricyclics.

Do you have thoughts about the changes to the podcast? We want to hear from you – send your feedback to asktheeditor@thecarlatreport.com. As always, follow the link in the show notes to earn CME for this episode and thank you for helping us stay free of commercial support.