The Crypto-Apartheid of Race, Class, and Safety Arbitration on the Inpatient Psychiatric Unit

Some months ago, we admitted Mr. A, a Black man who had a history of trauma, cannabis use, schizophrenia, and multiple previous hospitalizations, on our inpatient psychiatric unit. As had been well described by his outpatient team, he had previously been evicted from his home and incarcerated after violent behavior provoked by hallucinations and chronic paranoid misattributions. However, just before admission to our unit, his behavior was limited to agitation without violence. Accordingly, the police had brought him to our clinic’s emergency department instead of jail. When calm, Mr. A had insight into his schizophrenia, and he denied having violent ideation or intent. However, his psychosis was alarmingly brittle: within hours, he would again hear distressing voices and become agitated to the point of assaulting another patient as well as more than one staff member. We struggled to balance reducing his agitation with the need to minimize adverse effects of antipsychotic medications, including extrapyramidal symptoms, oversedation, and peripheral edema. His family told us how, as his psychosis became more severe, they had become unable to care for him.

After nearly 4 weeks of inpatient treatment, despite multiple medication trials resulting in a regimen of dual antipsychotic medications and multiple adjunctive medications, Mr. A’s psychosis had only tenuously improved. Moreover, because of his paranoia and (as we suspected) his frustration with the ongoing hospitalization, he had additional episodes of assaultive behavior. The unit staff raised increasing concerns about the danger he posed. After many multidisciplinary team discussions, our unit chief eventually decided that Mr. A’s psychosis was too severe and dangerous for protracted treatment in our facility and that we therefore should not extend his involuntary hold to a temporary conservatorship. We speculated whether he might eventually be better served in a forensic setting that could ensure his and others’ safety while also providing treatment and maximizing his dignity, without excessive seclusion or restraint (1). Coincidentally, Mr. A managed to maintain a more moderate level of paranoia and less agitation for several consecutive days. As a result, he prevailed in a probable cause hearing and was discharged back to his apartment.

Several weeks later, we admitted Mr. B, who had a history of cannabis use and severe schizoaffective disorder and was similar in age to Mr. A. Mr. B also had been brought in by the police, and his psychosis was similarly brittle in that he, too, could rapidly transition from calmness and some degree of insight to dramatic agitation. He had severely assaulted someone during a previous inpatient admission. Notably, unlike Mr. A, Mr. B was White and had a well-resourced family who was deeply involved in his care. Mr. B was hospitalized for several months, involving extensive laboratory testing and treatment trials, and eventually he was discharged to the care of his family. No matter how unpredictable or hazardous his agitation, there was no discussion of whether his psychosis was too severe for ongoing treatment in our unit.

ENACTMENT OF CRYPTO-APARTHEID IN PSYCHIATRY

We are profoundly uncomfortable with our differential treatment of these two patients with ostensibly similar psychopathologies and with how we perpetuated race and class disparities even as we condemned them. These two cases from an acute psychiatric setting illustrate how we psychiatrists enact a crypto-apartheid: a concealed system of racial and class discrimination. Our clinical decision making repeatedly privileges those who already carry more privilege, while effectively abandoning less-privileged patients, furthering their symptomatic decline or even predisposing them to subsequent incarceration. This discrimination both informs and is masked by our treatment and dispositional decisions and is further concealed by both our espoused criticism of centuries of structural racism and classism and our expressed desire to transcend this injustice.

Our clinical decision making is influenced by each care setting’s specific cultural norms, as well as external pressures such as the COVID-19 pandemic. Until the pandemic, our academic inpatient unit treated mostly patients with health insurance. Many patients were admitted voluntarily, and many had family members involved in their care. Prepandemic, we infrequently admitted patients with the highest severity of disorganization or agitation. Uninsured or underinsured (i.e., with Medicaid) patients were routinely transferred from our emergency department to the county hospital’s inpatient psychiatric unit, where the inpatient population skews heavily toward patients with a confluence of socioeconomic disadvantage, substance use, and chronic psychosis or affective disturbance. Nearly all hospitalizations in this county unit are involuntary, and many patients are admitted with extremely dysfunctional behaviors.

During September 2019–March 2021, of 1,034 inpatient admissions to the county unit, 31% (N=316) of the patients were White, 23% (N=237) were Black, 18% (N=181) were Latinx, 17% (N=171) were Asian, and 13% (N=129) were of other or unreported race-ethnicities (personal e-mail communication, Lee E., Sept. 10, 2021). In contrast, during 2019–2020, of 931 admissions to our unit, 51% (N=476) of the admitted patients were White, only 10% (N=92) were Black, 10% (N=100) were Latinx, and 16% (N=147) were Asian (personal e-mail communication, Wang M., Aug. 31, 2021). Solely on the basis of the county unit’s familiarity with treating and arranging disposition for patients with severe psychotic agitation, that unit was arguably a safer and more equitable setting for treating both Mr. A and Mr. B than our unit. If we also consider the difference in racial demographic characteristics of the patients between our unit and the county unit, would Mr. A’s identity as a Black male with psychotic agitation and socioeconomic disadvantage have made him better suited to the county unit’s culture?

When interfacility transfers were reduced during the pandemic, our unit admitted more uninsured or underinsured patients, including Mr. A. We suspect that the combination of his aggressiveness, maleness, and Blackness was less unit-syntonic and less well tolerated by our unit’s culture. For example, on one day during his hospitalization, Mr. A noticed that a non-Black patient had become verbally agitated and that the staff’s response was to redirect and calm her by talking to her. Mr. A complained about how if he yelled, he would get an injection. Based on Mr. A’s history of violence in the community and on our unit, the severity and brittleness of his psychosis, and his muscular habitus, we repeatedly rationalized that his risk for committing violence was in fact the highest of anyone on the unit at that time and that his shouting was far more likely to signal physical hazard than the other patient’s shouting. However, Mr. A’s comment also did force us to acknowledge that because of our own implicit biases and internalized anti-Black racism, we were likely to view his Black maleness and his psychotic aggression as being more threatening than aggression from a non-Black individual (2, 3).

Furthermore, the same social injustice that directly disadvantaged Mr. A had most likely contributed to his family’s being more fragmented and having fewer socioeconomic resources (4), resulting in less ability to advocate for his care. Conversely, although Mr. B’s habitus and behaviors represented a similarly high risk for violence, his race and class were more syntonic with the unit and so too was the advocacy of his well-resourced family. His identity was overall more familiar to us, and so our implicit biases may have made us more likely to separate his identity from his psychotic agitation, enough to overcome the system’s pressure to minimize a patient’s length of stay. In the end, partly because of his racial and class identity, Mr. B elicited considerably more care from us.

THE COMBINED ROLE OF DYSFUNCTIONAL SETTINGS AND BIASED CLINICIANS IN DISPOSITIONAL INEQUITY

On any given day, the decision of whether a patient such as Mr. A ends up in jail or a hospital is often determined by law enforcement (5, 6). However, after the patient is brought to the hospital on a psychiatric hold, we psychiatrists determine when the patient will again move within the dysfunctional network of community, inpatient, and correctional settings. For so many patients, it is only a matter of time before they again encounter the police. In fact, in Mr. A’s calm moments we talked with him about how, as a Black man with severe mental illness, he was deeply afraid not just of the threatening voices (hallucinations) that he heard, but also of the police. (This was not delusional ideation: from 2013 to 2017, the San Francisco Bay Area ranked second in the nation for Black-White inequity in fatal police violence [7]).

Perhaps we thought that by treating Mr. A as an inpatient, we were providing him some protection from that unsafe, unjust world. Perhaps we even thought that by acknowledging to him the unjustness of the outside world, we were demonstrating that we were not racist. Here, again, was the insidiousness of our crypto-apartheid. We did not fully recognize or acknowledge that we held decision-making power over his body in a treatment setting where a patient with similar illness, but of a different race and class, would likely be treated differently. Mr. A’s aggression on our inpatient unit may in fact have been driven by a combination of his psychosis, his history of trauma (including from anti-Black racism), and his fear of being harmed in a highly restrictive environment (3) where he was minoritized and viewed as a threat. In contrast, Mr. B did not carry the same history of racial trauma nor the fear that he would be harmed because of being perceived as a violent Black man.

Through our risk assessments, we function not just as arbiters of public safety but also of milieu safety. Mr. A was discharged after his immediate risk for harm to staff and patients was assessed as outweighing his immediate risk to the community and with a mitigating factor, that is, ongoing engagement with his outpatient (intensive case management) team. Dispositional decisions based on risk assessment can be highly subjective and, unsurprisingly, discriminatory. Mr. A’s safety in the community was directly tied not just to his own violence risk but also to his risk as a Black man for experiencing violence from the community. However, this elevated risk for experienced violence is not accounted for in risk assessment for the purpose of disposition. Discharging Mr. A exposed his community to the ongoing hazard he seemed to pose, and vice versa, but we had also decided that the alternative—conservatorship and a months-long hospitalization while awaiting placement—was untenable for him and involved predictably high risk to others on our unit. Therefore, the summed cost of Mr. A’s ongoing hospitalization was deemed too great for us to bear, despite our knowledge that he likely would face rehospitalization, reincarceration, injury, or even death. Indeed, a few months after his discharge, Mr. A was again incarcerated, and the jail then became his treatment setting for many more months.

ADDRESSING CRYPTO-APARTHEID IN PSYCHIATRIC SETTINGS

Our professional obligation to each patient involves recognizing social determinants of health, which includes acknowledging how crypto-apartheid is a significant determinant of our patient’s care and outcomes. Meaningful intervention in such determinants is generally relegated to the sphere of professional aspiration (8). However, as psychiatrists we need to decide whether we accept our complicity in this system wherein we are obligated to act as arbiters of safety and surrogates of the criminal justice system, many of our sickest patients will get sicker, and we experience moral distress. There are no easy solutions, although we should attempt to bridge the gulf between the actual and the aspirational. With this in mind, we outline several potential interventions in Table 1 (9, 10).

CONCLUSIONS

We entered the field of psychiatry with ideals of how we would deeply understand our patients, manage their illnesses, and help them live more meaningful and satisfying lives. When working in the inpatient unit of a top-tier academic institution, we carry optimism and sometimes arrogance about our ability to treat the sickest of patients with care that is patient centered, evidence based, multimodal, and even antiracist. Yet we are forced to acknowledge that working as a psychiatrist confers power in a world where patients such as Mr. A are a feared minority within a larger system that betrays our personal ideals. The most impactful decisions we make for certain patients may be orthogonal or even antithetical to relieving their suffering. If we do not acknowledge our own role in perpetuating the systemic racism and classism that our patients face, we will end up treating them as liabilities, rather than as humans in need of care.