The Case for Psychiatric Reparations

If conversations around racism are difficult, the particular topic of reparations is difficult in the extreme. Some of the difficulty lies in how reparations are defined. The Oxford English Dictionary, for example, defines the term as “the making of amends for a wrong one has done, by paying money to or otherwise helping those who have been wronged.” In other words, how much money is enough, and what else can help?

For instance, as an “otherwise” form of help, does affirmative action qualify as reparations? Affirmative action has been used for the past half century to encourage the success of African Americans in particular.² It is a political policy designed to make amends for their underrepresentation in workplaces, contracts, and education admissions.³ Over the years, affirmative action expanded to cover many kinds of differences in a commitment to diversity. That diversity could include severely ill psychiatric patients who encountered stigma and other obstacles to recovery. The policy has also helped White women, perhaps the most out of any groups.⁴ However, it is currently of concern for its use as a means of discriminating against Asian American college applicants. Along with the dramatic success of Asian Americans in admission to and performance in college, a form of backlash has emerged, such as the claim that Harvard has recently been manipulating their admissions process against Asian Americans.⁴

On June 17, 2021, President Biden signed the Juneteenth National Independence Day Act into law, making June 19th a federal holiday commemorating emancipation. Of course, it does not contain any particular financial reparations, but it may provide a measure of moral and psychological reparations. It will update our Declaration of Independence, commemorated on July 4th, because that declaration was not fully inclusive of African Americans or women. Nationally celebrating July 4th alone may be an example of unintentional hidden structural racism; Juneteenth can chip away at that. What a formal societal step forward this is from June 19, 1865, when General Granger arrived in Galveston to notify slaves that the Civil War was over and that they were free—of course, this came more than 2 years after President Abraham Lincoln signed the Emancipation Proclamation.

From the psychiatric perspective, making amends would refer to supporting the mental health of the victims in any way possible, including the provision of physical and mental health care. Health, education, and child development services would therefore need improvement. Moreover, making amends seems to overlap or follow forgiveness, a psychological process that can help both the perpetrator and the victim. A clear example of that might be the man-made traumas of posttraumatic stress disorder, for which the perpetrator(s) made enough amends to help the victim, say, in a sexual abuse case, and the victim conveyed some forgiveness.

In the United States, the societal discussion about reparations seems rightly focused on African Americans. However, as with affirmative action, it can pertain to other races, cultural groups, or populations across the globe. In the United States, there are groups that could convincingly claim they have been historically wronged by our government, including Native Americans, who have been wronged since the arrival of Europeans, as well as Japanese Americans, who were interned during World War II. Chinese Americans, who were not properly treated in the latter half of the 1800s, and Jews, many of whom were denied entry during the Holocaust, might also have a case. Not only have these groups suffered historical wrongs, they are still experiencing wrongs, as conveyed in the current discrimination that African Americans, Native Americans, Asian Americans, and Jewish Americans face. Resistance to reparations is common and may reflect the reluctance to accept practical responsibility for something in the past, as well as to avoid feeling worthy of blame and shame.

It seems psychiatry rarely addresses reparations. In fact, it was not mentioned in the recent apology for racism actions offered by the American Psychiatric Association. However, the psychoanalyst Melanie Klein mentioned reparations about a century ago, describing it as instrumental to the early developmental process.⁵ Infants could even unwittingly provide psychological reparations to the mother when they soften their inevitable angry outbursts with ensuing smiles of satisfaction.⁶ By extrapolation, reparations can be applied in later life from small gestures up to systematic amends.

This article will try to make amends for the psychiatric neglect, lack of education, and limited activism on racism and its danger to public mental health.⁷ It is also an actionable one-year follow-up to Psychiatric Times^TM’ 2020 article on dismantling racism.⁸

African American Reparations - Rahn Bailey, MD

Reparations for the damage of slavery began at the end of the Civil War in 1865 with General William Tecumseh Sherman’s order to redistribute acres of land—known as the mythical 40 acres and a mule—to newly freed African American families. However, President Andrew Johnson overturned this order. Nothing more happened for 100 years. Recent efforts have been stopped and started, and have often been polarizing. Although our country’s founding principles of equality, opportunity, and freedom have been eloquently promulgated, they are applied in a markedly different way for people, especially African Americans.⁹

More than 4 centuries of harm has resulted in structural racism, institutional racism in organizations, and conscious or unconscious individual racism in America. With intergenerational transmission of trauma, fueled by epigenetic vulnerability and recurrent triggers of historical and current trauma, the collective and individual psychiatric damage must be significant.

There is a wide divide between White and African Americans in terms of health, success, and prosperity.¹⁰ A small number of African Americans have achieved great success in the United States, mostly in the public eye of entertainment, sports, and government (eg, President Barack Obama). This fact has often been used as a counterargument to the disparities. Of course, these successes are the exception, not the rule.

The financial aspect of reparations tends to be the most controversial. Some scholars have devised a figure for the current descendants of slavery and ensuing discrimination. One example is the 1973 rough price tag, which was determined by multiplying the number of African Americans in the population by the difference in White and Black per capita income.¹¹ However, reparations do not solely, or mainly, need to be in the form of monetary compensations.

A variation on financial reparations has emerged in Evanston, Illinois––the first city in the United States to approve reparations for Black residents.¹² The plan is to use tax money from recreational marijuana sales to award $25,000 for home repairs, down payments on property, and interest or late penalties on property in the city. Eligible individuals include those who lived in or are a descendant of a Black individual who lived in Evanston between 1919 and 1969, who suffered discrimination as a result of housing policies. This plan fails to account for psychological amends, and some Black leaders are critical, mostly because they were not part of the decision-making process. They further see it as more of a housing plan than reparations.

In psychiatry, specifically, the need for reparations can be demonstrated in academic psychiatry.¹³ Some progress has been made in this area, with African American female psychiatrists serving in leadership roles. However, those roles seem to come too often with inadequate funding and power, which in turn contributes to limited success and substantial stress for these leaders.

This is a clear example in which reparations funding and adequate authority could lead to more opportunities that would ripple out to other faculty, the education of future psychiatrists, and improved patient care for diverse populations.

“Without internal growth, we are encumbered with the destructiveness of projecting our own faults upon others and doomed to an unlimited appetite for revenge.”

Indigenous (Native) Americans Reparations - Andrew McLean, MD, MPH

Indigenous Americans, including American Indians and Alaska Natives, have been wronged by government and institutional colonialism. These wrongs include broken treaties and forced migrations to land that was often unsuitable for habitation or development.

A century ago, our own profession sanctioned Indian insane asylums, where individuals would be committed with such dubious disorders as horse-stealing mania.¹⁴ So-called Indian Residential Schools were built under the guise of providing education, and discouraged or banned Native culture and language. Inevitably, historical traumas remain interwoven with individual traumas, although they can vary among the 574 federally recognized tribes. More loss and trauma have occurred more recently, as Indigenous Americans have been hospitalized with COVID-19 at 5 times the rate of White Americans.¹⁵ The mental health of Indigenous Americans has suffered for decades, and the population has a high rate of incarceration. The marginalization (geographically, socially, or otherwise) of any group allows discrimination to flourish, which has been the case for Indigenous Americans.

Occasionally, reparations have been given in the form of land, cash, tax relief, and other measures, which include those taken by the Indian Claims Commission of 1946 and the Alaska Native Claims Settlement Act of 1971. Former senators Sam Brownback, JD, and Byron Dorgan, MBA, proposed a stand-alone Native American Apology Resolution in Congress in 2009, but that effort failed. Instead, in what felt like a rather disingenuous approach, an unheralded Congressional apology was tucked away on page 45 of an unrelated military spending bill, with legalese indicating that it was not meant to support any claims against the government.¹⁶ President Obama, however, publicly acknowledged the apology.

Some governments and institutions have committed to partnering with Indigenous Peoples, engaging in positive movement. For almost 50 years, the University of North Dakota has ensured that roughly 10% of its medical school admissions are comprised of American Indian/Alaska Native individuals. The university has also developed the first Indigenous Health PhD program in the world.¹⁷

Even when financial reparations are provided, they may not change cultural narratives and mindsets, as transgressions can still be denied. For Indigenous Americans, telling, hearing, and acknowledging the truth has yet to occur. The fact that many tribes have leveraged their sovereignty to develop robust, Native-owned businesses and cultural programs does not pardon institutions from the responsibility of reparations.

Japanese American Reparations - Thomas Okamoto, MD

Calls for reparations often refer to the Japanese American World War II internment and its redress movement, which culminated in the Civil Liberties Act of 1987.¹⁸ After an 18-year process filled with factious differences of opinion, the fact-finding commission found no basis for what it called “pressing public necessity,” and that “race prejudice, war hysteria, and a failure of political leadership” had led to President Franklin D. Roosevelt’s Executive Order 9066. Beginning in 1990, each surviving Japanese American citizen was awarded $20,000 in compensation.

Despite its apparent success, many Japanese Americans were left bitter and frustrated. They viewed Japanese American legislators, attorneys, and others working within the system as accommodating the government’s institutional racism. Collective efforts supported the negotiations for eventual reparations, but they did not stop hate-inspired crimes against surviving internees and their descendants. The efforts did not erase lost generational wealth, or the continued emotional pain. In other words, the financial reparations did not transform racism against Japanese Americans.

Psychiatry can direct the discussion on reparations toward the intrapsychic world. Psychiatrists can see othering and the process of racism as regressive expressions of unconscious defenses, including splitting and projections. These necessary early functions in development promote a successful negotiation of our own good and bad internal world.

Perhaps the most healing part of the Civil Liberties Act of 1987 was not the restitution, but the validation of injustice and the promotion of community grieving. In recorded public testimonies, survivors and their descendants heard internees verbalize the descriptions of their experiences for the first time, including shared loss and pain.¹⁹ This process reawakened painful memories that had been suppressed for decades. In a culture braced by gaman (perseverance with dignity) and shikata ga nai (it cannot be helped), the testimonies initiated the sharing of grief, thereby beginning the intrapsychic healing for this trauma.

Climate Reparations - H. Steven Moffic, MD

In these interconnected global times, a new conception applies to the current climate crisis.

The instability of our climate has caused harm in various countries and sometimes simultaneously around the world. For instance, the cold and snow unexpectedly hit Texas in February 2021 and also caused canals to freeze in Amsterdam.

Although there are calls for the development of transformational resilience and mitigation in at-risk communities, there may not be funds to do so in poor communities.²⁰ Hence, some individuals become climate refugees, with all the mixed and ambivalent responses of potential host countries.

Climate reparations could provide amends for both past climate destruction as well as unborn future generations. Even with reduced carbon emissions, climate damage will continue for decades. The question of reparations is more challenging. In addition to the guilt of corporations—some of whom have hidden the risk and abuses for decades—and governments, how much is each individual to blame? A systemic approach to redistributing resources may be the solution.²¹ Perhaps countries and corporations with the most carbon pollution could contribute to international reparative funds to even out inequities in resilience capability. Such a comprehensive past, present, and future approach may also help to reduce undue anticipatory anxiety and pretraumatic stress in the most at-risk populations.

Recommendations

Although reparations are usually thought of in terms of financial amends to large populations and systems, they can be gestures provided on a spectrum from the small to the global. Given the ubiquity of microaggressions toward Black Americans and others, a smile, an apology, and a change in behavior by the perpetrator can have everyday psychological reparative repercussions.

However, in terms of our society, making amends is urgent. Why? Throughout history, epidemics have tended to intensify social inequities, and we are in a pandemic.²²

Psychological reparations clearly make a difference and can be put into motion quickly if psychiatric systems recognize the need to do so. One example would be assessing and responding to disparities in patient care and staff composition.

It could be argued that psychological reparations are the essence of any kind of reparations. Financial reparations, besides any needed practical repercussions, can increase feelings of self-worth because the individual and group are deemed worthy of the cost.¹ On the other hand, financial reparations alone can feel tainted, like a buyout resulting from guilt. Moreover, financial reparations may be time limited, whereas self-worth is likely to be more deeply satisfying and transmittable to others.

In psychiatry, we have most control over psychological reparations. As is done for any patient care issue and disaster response, a tentative standardization of practicalities needs to be established. For starters, we need a psychiatric reparations history (Table 1). This history can be applied to any given individual and any given system. After obtaining the history, interventions are necessary and possible (Table 2). For instance, the German government continued its reparations to Holocaust survivors by providing $135 million to help them get to COVID-19 vaccination sites around the world. This is an example of addressing trauma triggers by providing medical and psychological relief.

Without internal growth, we are encumbered with the destructiveness of projecting our own faults upon others and doomed to an unlimited appetite for revenge and retaliation, rather than acknowledging the common bond of mutual inner struggle toward loving the other. Successful psychological reparations require both community and intrapsychic reconciliation, beyond splitting and projection, entitlement, and retaliation. The process will require transformative leadership, provided by leaders from the wronged group. Finding commonality and diverse allyship is necessary for the healing of past trauma and for positive movement.

Psychological and other reparations do not need to be a zero-sum game in which one side wins and the other side loses. That outcome would inevitably cause psychological harm for some, with benefits for others. In reparation, along with truth and reconciliation, all can win and feel better about themselves. African, Indigenous, and Asian Americans, as well as climate refugees, will contribute more to our country and the world if they are valued appropriately. The health and success of all populations is paramount to the global success of maintaining a healthy planet and reducing the damage of climate instability.

Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. He serves on the Editorial Board of Psychiatric Times^TM. Dr Bailey serves as assistant dean of clinical education at Charles R. Drew University of Medicine and Science in Los Angeles, California, and Chief Medical Officer at Kedren Health Systems Inc in Los Angeles. Dr McLean is a clinical professor and Chair of the Department of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences in Grand Forks. Dr Okamoto is a psychiatry specialist in Santa Ana, California.

References

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