Racism in psychiatry and the case of presentism

Abstract

Acknowledging the impact of imperialist and colonialist attitudes on the development of psychiatry allows for the recovery of the work of practitioners whose contribution may have been overlooked, as well as recognising racist attitudes in predominant thinking. These combined approaches aid in the construction of a more complete critical history.

The ‘recovery’ of the achievements of Juliano Moreira, discussed in the article by Almeida-Filho and Schwarcz,¹ can be conceived of as an attempt to decolonise, that is, to look at the impact of the hegemony of colonialist power structures on the Global South. Moreira, a 19th-century African-Brazilian psychiatrist, is regarded as one of the most influential figures in Brazilian psychiatry. Notable achievements include his use of psychoanalysis in the teaching of medicine, and his debunking of racist theories to support certain claims in medicine, a preoccupation stemming from his doctoral thesis.

A similar case can be made for Frantz Fanon, the 20th-century Martinique-born philosopher and psychiatrist, whose special interest in the psychopathological effects of colonialism on colonised people was borne out of his own experience as a member of a racialised minority, and for which he is regarded as a key figure within the history of cultural psychiatry. While Fanon's philosophical theories were known in the anglophone world, his work as a psychiatrist has been overlooked until recently (see Laubscher et al² and Gibson and Beneduce³) and this can also be described with recourse to decolonising.

Context is key to acknowledging the achievements of both Moreira and Fanon and what they underwent. Constrained by their racialised minority identity status, each of them developed their contributions to scholarship against a backdrop of structural and institutional racism. By tackling prevailing racialised (and racist) views, they not only helped the oppressed but also shone a light on the biases of medical thinking of their day. Moreira was working just ten years after the abolition of slavery in Brazil; Fanon, during the Algerian War of Independence. The ‘recovery’ of their work is necessary in addressing the marginalisation of minority groups within the histories of psychiatry or medicine at large – but their contributions should be appraised more widely.

The ‘context is key’ argument can also be applied to the instances of commentators and their contributions that are morally dubious because of their espousal of racist – more broadly, offensive – views. Emil Kraepelin is a case in point. Described by many as the founder of modern scientific psychiatry, his theories strongly influenced psychiatry at the start of the 20th century. However, by the same token he was also a proponent of eugenics, manifested in antisemitism, and was antithetical to homosexuality. This raises the issue put by Michael Shepherd, of how are we to look at the ‘Two faces of Emil Kraepelin’,⁴ knowing what we do of his perspectives. There are many other leading historical figures whose work has been challenged because of their ideological views. The larger question is whether this should change the way we should engage with their work.

There are various responses to this. Presentism involves thinking about history from an exclusively present-day understanding and does not account for historical understanding. Within current-day thinking racist attitudes are not socially acceptable but they were in the past. To judge the past by today's standards would be to take a presentist stance. In addition, if we are to do this it means that we are penalising individuals for upholding commonly held views at the time. To adopt such a position runs the risk of forfeiting the edifying features of works marked as potentially problematic and could also result in the withdrawal of the scholarship or contributions of individuals who have held racist or other morally dubious views in the past. A more compelling position is to contextualise the view within sociocultural attitudes of the time, which itself does not mitigate current or subsequent perspectives on the offence but enables a fair assessment of the contributions of the individual to their field, psychiatry or otherwise.

Another argument is that we cannot purge history. The past is inextricably linked with the present and future and to sidestep it whether through erasure or minimisation is not helpful in the advancement of knowledge. What needs to be done is to learn from it in the development of more inclusive ways of thinking, and the production of newer, more multi-layered inclusive histories. It is this syncretic approach that brings about real learning. Without learning from the lessons of the past, we cannot reflect on and make substantial changes. We see this in psychiatry. Kraepelin's cross-cultural comparative work is fundamentally important in the development of cultural psychiatry in the West, which was further developed by figures in cultural psychiatry sans Social Darwinism (see Kirmayer⁵).

The issue of racism and discrimination raised by both Almeida-Filho and Schwarcz¹ and Tyrer⁶ (in his commentary) is vital within psychiatry because, as Tyrer reminds us, ‘psychiatry, its practitioners and its patients have long be[en] a subject of stigma and prejudice’ (p.1). This reinforces the need, key to the enterprise of psychiatry, to be critically reflective about one's biases to engender the most positive therapeutic environment. A progressive way forward, in my opinion, would be further engagement with White privilege. The general lack of nuanced understanding about what this entails leads to unhelpful accusations about cultural oversensitivity to racism – the view of ‘reading’ racism everywhere, and reading everything through a racialised lens. This is erroneous and unhelpful. White privilege involves reflection upon and accountability for the privilege that one may have by virtue, but not exclusively, of being White, cismale, heteronormative and so on. More importantly, though, is the need to position oneself in recognition of points of privilege and deprivilege, the action of which will refine psychiatry further.