* * *
While race had been an important issue for me throughout medical school and my internship year, I wasn’t sure what to expect as I began my psychiatric training. I soon discovered that, there too, race was often a factor in the hospital and clinic. Psychiatry, like other areas of medicine, operates on a two-tiered system of public versus private care. In many ways, however, the distinctions are more blatant. Those with private health insurance, or who have the ability to pay out-of-pocket, have access to private facilities and providers, whereas those who don’t or can’t are relegated to a public system that has come under ever-deepening budget cuts.
As a resident, I worked in both settings and saw the disparities play out on a daily basis. A typical case might involve a young woman who’d come to the emergency room following an overdose on prescription pills. After doing the initial medical and psychiatric evaluation, the next and most important detail was to determine her insurance status. This single factor would determine whether she went to our inpatient unit or one of several private hospitals in the area where there would be other depressed and anxious patients like her and she could get individualized treatment, or whether she was shipped to a state hospital, where she would be surrounded by aggressively psychotic, manic, and antisocial personality disorder patients. Invariably, it seemed, the private patient would be white, the public one black.
The contrast was most overt with substance abuse treatment. Much of our inpatient psychiatry work during the first two years of residency training involved people with alcohol and drug problems. In Durham and its surrounding areas, cocaine and its cheaper derivative, crack, remained the street drug of choice well into the 2000s. In local public settings, the usual protocol was to admit a patient for four to seven days for alcohol detox and two to three days for cocaine withdrawal (if accompanied by suicidal thoughts). The patient would then be discharged to outpatient treatment. Occasionally, a person might be accepted to an off-site residential program (fourteen to twenty-eight days), but that typically required them to have established outpatient care first and to have remained alcohol- and drug-free before they could be enrolled.
All too often, patients struggled under this system. While rotating at the state hospital, I saw Steve, a mechanic in his early forties who’d been abusing cocaine for almost two years, having started shortly after his wife and young daughter were killed in a car accident. His supervisor had recently confronted him about his drug use and threatened to fire him if he didn’t seek treatment. Without health insurance to cover the costs of private office care and a three-month wait to be seen at the county clinic, Steve came directly to our hospital. Because the alcohol and drug detox unit was full, he was sent to the general admissions wing, where he was surrounded by patients like Lonnie who had severe mental problems.
Steve had arrived at the hospital on a Friday evening after work. Unbeknownst to him, that was the worst possible time. All hospitals operate with skeleton crews on weekends, but this tradition was more pronounced at the state psychiatric facility. There, one on-call weekend doctor at any given time covered the entire hospital of several hundred patients. Out of necessity, this psychiatrist saw only the patients who were having crises. After meeting one of my harried colleagues for a brief assessment when he first arrived, Steve didn’t see a physician or social worker again until Monday.
By the time I met Steve as his assigned doctor, he’d been in the hospital for about sixty hours. With my supervisor beside me, we went through the usual psychiatric interview, asking about mood, anxiety, and psychotic symptoms along with assessing for any suicidal or homicidal thoughts or impulses. Steve’s problems were basically limited to his cocaine addiction. We recommended grief counseling to help him cope better with the loss of his wife and daughter, but that was something that would be done on an outpatient basis. “We’re planning to discharge you tomorrow,” my supervisor said, after we reviewed with Steve his treatment options.
“But I came here for help,” he protested. “This is the first time I’ve seen a doctor or therapist since I’ve been up on this floor.”
Medically speaking, the purpose of detox was to prevent medical complications and monitor for suicidal behavior. Steve had stable vital signs and denied suicidal thoughts, so he technically didn’t need any sort of treatment to address these specific criteria. My supervisor and I glanced at each other. She was in her late fifties and had worked at the hospital for many years. She was sympathetic to Steve’s plight and his apparent sincerity.
“Before we came and talked to you,” she began, “we tried to see if the detox unit would accept you as a transfer, but they declined since you’ve completed the majority of your detox here without any problems.”
“But I think it would have helped to be around other addicts instead of here,” Steve said, looking over his shoulder, where a woman paced the hall cursing to herself. “Most of the people here, you know, you can’t really talk to them. They got even worse problems than I do. And now you’re already telling me I have to leave?”
He told us his boss had given him a month to get treatment. Like many other people with substance abuse problems, he’d come to the hospital seeking a jump start toward a clean life. Spending three days around psychotic patients hadn’t been much help. Compared to many of the drug-abusing patients who came to the state and VA hospitals, Steve had several factors in his favor—stable job, no criminal record, no history of failed treatments or misuse of the medical system—that made him a good candidate to succeed in a counseling-based inpatient program. But the next available opening was more than three months away.
The next day Steve was scheduled for discharge. The social worker responsible for arranging aftercare told Steve our plan. “We’ve gotten you an appointment for next Friday. That was the earliest that we could get you.”
“That’s ten days away,” he said, his dreadlocks flopping as he shook his head. “I mean, I’m not mad at you guys. I know you’ve done the best you can. It’s just not what I expected.”
He was right: We had done the best we could with the resources available, but that didn’t make us feel better. He genuinely wanted to get better, and we offered little help. Earlier that year, I spent a month at a private inpatient rehab facility not far away and saw the contrast. The patients had the same problems—addiction to alcohol, cocaine, heroin, and prescription pain medications—yet the approach was vastly different. Instead of planning their client’s discharges the moment they arrived, this facility saw itself as providing real treatment.
The program consisted of several daily group therapy meetings along with individual sessions at least twice each week. Family involvement was a crucial component of treatment. The patients had a variety of constructive ways to spend their down time. While it’s true that some in the public system succeeded in staying off drugs and some in private programs failed, it was hard to imagine that this more comprehensive treatment did not give patients a better chance at success. The private facility claimed that the majority of their clients remained clean after three years; in contrast, at the public facilities, most of the people whom I saw with drug problems never made it more than a year without relapsing.
During my time working at the private facility, over a hundred patients passed through, but just one was black. In contrast, blacks routinely made up more than 50 percent of the people seeking drug treatment at the public facilities where I worked. There was no reason to think that overt racism was behind these numbers. Instead, as is often the case in medicine, the disparities were more socioeconomic than racial. But the economic disparity largely played out along racial lines.
As I had several times earlier in my medical training, I found myself questioning where I fit in this scenario. Certainly I owed it to all the patients I saw to be as competent and compassionate as I could. But as a black doctor, now training to be a psychiatrist, did I owe black patients something more beyond my clinical expertise? Was it my role to try and help fix these disp
arities?
The more I thought about it, the more discouraged I became. These problems were far beyond the scope of a single doctor. And in some ways, they seemed even worse in psychiatry. I’d found the specialty that seemed the best fit, but race was complicating things once again. Not until an encounter in my final year of training did I begin to see a more hopeful possibility.
* * *
I was a few months into the last year of my psychiatry residency when I met Diane, a woman in her mid-twenties who referred herself to our outpatient clinic. She was a graduate student at Duke. Aside from this information, I knew nothing about her as I prepared to greet her. Unlike most patients I saw at the clinic, she had no paper trail of prior visits, nor were there any notes from other physicians in our hospital database; she was a virtual blank slate.
This abruptly changed once I saw her. She was black, her fair complexion and wavy hair suggested perhaps a biracial background. Immediately, I suspected that her presence on my schedule was no coincidence. Recent experiences had sensitized me to believe that someone had manipulated her assignment. Black students were a distinct minority across Duke’s schools. So were black psychiatrists. What were the chances that we’d been paired up randomly?
I was always one of two or three black psychiatry residents at Duke, and the only black man in any class during my entire residency. Just 3 percent of all psychiatrists in America at the time were black, so my experience reflected a national reality. In contrast, Durham had a population more than 40 percent black; the percentage of patients who came to the psychiatry resident clinic who were black was at least that high.
As a result, in the months leading up to my final year of training, senior residents or other psychiatrists leaving this clinic often asked me to take over the care of their black clients. Some said it was the patient’s request, while others decided that I would fit well with their patients. Initially, I felt obligated to accept these referrals, as these same-identity requests happened to other doctors too: a woman abused in childhood or raped as an adult who wanted a female doctor, for instance, or a Hispanic patient wanting a Spanish-speaking physician. But we had several female staff to share the load, and the number of Hispanic clients in our clinic was small. With nearly half the patients black, and since I was the only black provider for much of that year, the numbers simply didn’t add up. Further, I knew that simply being black gave me no special qualification to treat black people. Sometimes a same-race pairing made perfect sense, but other times they were off the mark.
At the beginning of that year, a faculty psychiatrist had assigned me the case of a frustrated black woman trying to cope with life as a single mother, thinking that because the woman and I were both black, I might be able to get further with her care than the previous resident had. The woman worked as a bus driver. She had two children from different relationships. Her daughter was a high school junior on track for college while her son was in danger of failing out of school. We had little in common. I’d been raised in a two-parent home, was married, and had no children. My supervisor, also a mother, connected to the woman on a level that I couldn’t and ultimately took over the case herself. Motherhood, not race, had been the crucial link.
Another time, a graduating senior resident sent to me an anxious middle-aged black man who struggled to find a compatible same-sex partner while feeling ostracized by the homophobia from his conservative family. While I’d moved past much of my earlier homophobia, it was still challenging to apply the skills of psychotherapy toward this case, as it involved discussing the intimate details of his sexual life. Although I put more effort into our sessions than with any other patient that year, I sensed that I was never as helpful to him as the previous doctor had been. During that year, the patient, frustrated by his lack of progress toward feeling better, relapsed on alcohol, something that he had managed to abstain from during the two years he saw the other resident.
With these experiences in my head as I led Diane to my office, I cynically wondered whether the clinic’s latest effort at racial profiling would be shortsighted too.
“So what brings you here?” I asked after we both sat down.
“I’m feeling overwhelmed,” she said, crossing and uncrossing her legs a few times.
She started by telling me that she was a graduate student and that she felt uncertain about her career path. I felt myself relax. So many of the men and women I saw had problems—bitter divorces, partner infidelity, drug abuse, troublemaking children—for which I had no personal frame of reference. Here I was on familiar ground. I assumed we’d explore the pros and cons of her current path and assess what she wanted from her career and her life, something that I had done myself and talked over with colleagues since college.
“I’m not sure if North Carolina is the right place for me either,” she continued. She described growing up in a predominately white neighborhood and attending white schools in suburban Massachusetts. She’d attended a liberal arts college in New York and was having a difficult transition to life in what she saw as a more racially segregated South. Although our backgrounds were different, again, I could relate to her perspective. Finally, I thought to myself, here is a clinic patient I might be able to help simply by talking with them through the lens of my own experience.
I asked her the usual inventory of questions about depression, anxiety, and other psychiatric conditions. She described how she isolated herself, slept poorly, felt tired, and enjoyed little. She seemed quite depressed, certainly enough to warrant some form of treatment. “How long have you been feeling this way?” I asked.
“For a while,” she said, her eyes drifting to the narrow, rectangular window behind me. “It probably started when Mom got sick almost a year and a half ago. It’s just gotten progressively worse.”
Diane explained that her mother had been diagnosed with breast cancer and had undergone surgery, chemotherapy, and radiation. Although her mom was currently healthy, I figured that this had probably factored into her ambivalence about living in North Carolina. I was about to inquire about this when Diane abruptly changed the direction of our session.
“My dad is an awful person,” she said, her eyes focusing on me.
I sensed that this was what she really came to talk about. I shifted in my seat. “How so?”
“He’s a terrible human being. I’ve never liked him.”
Diane went on to talk about how her dad had cheated on her mother and emotionally abused the entire family as far back as she could remember. She said that his parents were disappointed that he’d married a white woman and that while she was growing up, it felt like he was taking out their disapproval on her and her mother.
Diane’s racial dilemma came into focus. While she identified with her white mother and hated her black father, to the outside world, Diane’s light-brown skin, full lips, and other features signaled that she was black. She could not, like some biracial and other multiracial people, pass for white. I was getting the clear sense that her problems were more complicated than simply not liking graduate school or living in Durham.
“Have you ever had mental health treatment before?” I asked.
“In college, I went through a down period my sophomore year. I saw someone in the student health clinic and he prescribed Paxil. I took it for a few weeks and felt even worse. I don’t want to do that again. That’s why I didn’t go through the student clinic this time around.”
I’d entered psychiatry with a biomedical slant; my favorite rotation during residency was the hospital consult service where I evaluated medically complex patients and considered medication actions, side effects, and drug interactions. My first thought was that Diane probably needed to try a different antidepressant medicine, perhaps one less sedating than Paxil. When I hinted at this possibility, she made it clear that she didn’t want to take any pills.
That left counseling, or psychotherapy, as the mental health community refers to it. Despite the interchangeable use of these terms by the lay pu
blic, I’d picked up on the distinction pretty quickly. Counseling could be done by almost anyone—a pastor, a teacher, a coach, a family doctor—whereas psychotherapy was the domain of psychiatrists, psychologists, and specially trained social workers. In other words, counseling was the cheap watch you bought at Walmart; psychotherapy was the timepiece sold at a jewelry store. A person like Diane—intellectual, cosmopolitan, conflicted—would come to a therapist expecting to develop a better understanding of herself. At that nascent stage of my psychiatric career, I certainly didn’t see myself as skilled in that way.
As if my limitations weren’t enough, Diane imposed her own upon me. “I don’t know if you can help me,” she said.
“What do you mean?” I asked, worrying that my inexperience had shone through so soon.
“Please don’t take offense,” she began, looking away. “But I don’t trust black men. They scare me. Especially when they are bigger or darker-skinned like you.”
I sat speechless as Diane talked. This seemed like the worst match imaginable.
She said that her father had a dark complexion and stood a broad-shouldered, thick-chested six foot two. Diane had taken after her mother and was five-one and little more than a hundred pounds. My instinct was to take offense that by virtue of my appearance, she had lumped me with a person whose actions sounded despicable. But another thought entered my mind. This sounded like textbook transference, a psychological term for when patients project feelings and emotions about an important person in their early life (like a parent) onto their therapist. Until then, I had been somewhat dismissive of the psychotherapy glossary, but with Diane, the concept of transference finally made sense to me. I could see why a man who reminded her of her father would make her afraid. But where was I supposed to go with this knowledge?
Black Man in a White Coat Page 20
