The Holmes Report looked at racial, social, and economic biases in psychoanalysis. Beverly Stoute, MD, shares the findings.

Publication Date: 07/29/2024

Duration: 22 minutes, 11 seconds

CHRIS AIKEN: A new generation of psychoanalysts are picking up on something that Freud let drop, giving greater weight to how outside influences shape our internal world.  Today, we talk with Beverly Stoute, MD about how all this is reshaping the way that psychoanalysis views race.

KELLIE NEWSOME: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of The Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. Psychiatrists have taken many roads to find the cause of mental symptoms for psychoanalysis. Traditionally, they look to the internal world of defenses and drives to find those causes. But that view is starting to shift. Maybe it started in 1988, when the American Psychoanalytic Association opened its doors to non-medical professionals, allowing social workers to train as psychoanalysts. Or maybe it goes back even further, to an overlooked aspect of Freud’s original discovery.

You can never be an expert in psychoanalysis if you talk about blackness. Even though I say the core of psychoanalysis is blackness, Sigmund Freud was a negro in Europe. 

Freud grew up in virulently racist Vienna.

And he actually specifically talks about the outsider status, giving you a different view of the culture that you're living in.  

Freud understood that poverty and racism can profoundly affect a person's well-being. And he said, I never expected to go so far because of the poverty and conditions of my youth. Now, poverty is a condition, so what other conditions might he have been alluding to? He was in some way intimidated to name Antisemitism. 

[Credit: Black Psychoanalysts Speak, featuring Annie Lee Jones, PhD, Dorothy Holmes, PhD, and Michael Moskowitz, MD]

CHRIS AIKEN: In the wake of the George Floyd murder, the psychoanalytic association decided to look inward, into itself. At how the structure of its own organization maintains the status quo of privilege and prejudice. Today, Dr. Beverly Stoute shares the findings.

We’ve inserted clips from the documentary Black Psychoanalysts Speak, which you can watch in full at YouTube. That last clip featured – in order – Drs. Annie Lee Jones, Dorothy Holmes, and Michael Moskowitz. So, the Psychoanalytic Association wanted to turn the microscope on itself. And what did you find there when you, when you looked into the organization? 

BEVERLY STOUTE: When we did the study, we thought we wanted to just look at all aspects of psychoanalytic training from literally the time you get put in an admission application through recruitment, education, training, and you know, the psychoanalytic model also has personal analyses and supervision. If we looked at all aspects of training, could we make some suppositions and recommendations about how systemic racism affected every level? We wanted to think about also career development, both who stayed and who actually stayed in the field to practice as analysts. And we also wanted to look at how we taught, because the other issue is, is that I think there's a lot that we can offer, about how to look at these issues in psychotherapy and in groups to help people. So, we wanted to get a window into all of those and then we wanted to find out if there are issues around race, how are they, how are they experienced and how they process. Realize this was in 2020 when the world was going crazy. And so we thought, well, let's see how all of this is experienced in analytic institutes. The first thing that was really kind of so powerful was that faculty in Canada, that's all categorically agreed that we were not addressing race, racism, or aspects of white supremacy in the curriculum. And that was related to a lack of knowledge that people had on how to even address racial incidents, institute life, and how to even practice. And that's really powerful that everyone agreed on that. Then I think if we go through the findings in the long run, you'll see how they can impact clinical skills. 

The next thing that we found that the candidates felt clearly that they were not being taught and how to use racial analysis and psychoanalytic treatments. And they felt really that had to change in the curriculum. The curriculum we found often had token lectures or, token courses, but they were optional and not always required. And they were, however, generally not integrated throughout the curriculum. So, for example, we know a lot about ethnicity and racial identity and racial socialization-which is my area of scholarly interest-but we don't really teach about how that affects development at all, for the most part, like those areas of interest. The candidates were clear that they weren't being taught how to use this in their treatments. They found that even though people could choose supervisors, that there was a notable minority of candidates that said that race and ethnicity were not being considered, so, they weren't given the option to say maybe that white my banner or my supervisor experience. So, because you can imagine the supervisor has to be both sensitive to these issues and someone you feel might be able to understand them. Candidates also felt that, and this is, I think, a categorical thing that's beyond analysis. Candidates felt that they were actually more comfortable talking about race and racial issues than the faculty. And this perception was printed out, as you can imagine, upon people of color. So, in the study, the number of people of color is so small. So, we didn't stratify it according to ethnicities. Our goal was to maintain anonymity in the study. So, we categorized the demographic identifier as either white or BIPOC (Black Indigenous People Of Color) although that's an imperfect system. It was sort of what we did now to keep the aggregate group. 

Psychoanalysis by definition is something that thrives in otherness, difference. It understands being the outside, its roots are firmly. You know, you think of Vienna in the 20s and 30s, you couldn't have been more outsider than if you were a Jew then, and that's the, the midwife, the social midwife of this, and yet here we are in 2014, and Blacks in Psychoanalytic Institutes are a rounding error. So, what's that about?

[Credit: Jama Adams, PhD, from Black Psychoanalysts Speak]

BEVERLY STOUTE: We found that the faculties in American Psychoanalytic Association-affiliated institutes were less comfortable discussing issues of race than faculty in independent societies. Which is interesting. And if you know, we can't go into it, but a little bit about the field of psychoanalysis is that ABPSA, as we call it, is the mainstream, most traditional organization and the largest. And there are many institutes who, as you can imagine, because of the history of psychoanalysis, have a wider population. So, for a long time, you had to be an MD to be an analyst. Now that's not true. So, you have many institutes who broke away, and their flexibility and openness to different ways of thinking historically was wider. 

There's some tensions within psychoanalysis as a result of that. One sphere of it welcomes that outsider status and very much is skeptical of the larger system that gives rise to racism, anti semitist behavior, et cetera, and interrogates that quite rigorously. Another strain seeks to be respectable. They want to be scientific, they want to be accepted, they want to be taken seriously. And unfortunately, that strain has grown a lot in the United States.

When psychoanalysis came to the United States and got controlled by the medical establishment, I think that had a tremendously conservative influence, terrible conservative influence on the development of the profession.

[Credit: Jama Adams, PhD, and Richard Reichbart, PhD, from Black Psychoanalysts Speak]

BEVERLY STOUTE: We found also that a few side issues that may not be mainly related to race, but were important. We found that the coverage and curricula of intersectional issues altogether, so we include ethnicity, physical ability, um, religious affiliation, intersectionality, gender, and socioeconomic status, overall everyone felt that was not covered enough. Not just race. And then last, we also found the candidates. I'm going to go back to what the candidates pointed out- and because this is a barrier, while race is a barrier, there are many barriers, the candidates felt that the challenges of the financial factors of analytic training in today's world, socioeconomic factors, and the workload of the cases of how often you needed to see a case, and family responsibilities were not appreciated adequately, in their opinion, by faculty. And that has to do with then, Who can you recruit? Who will stay? And who will graduate? And who will become? And that's superseded race. 

I'm a project kid. I grew up in the grant houses. So, I guess people would say I'm from the hood. I got into this business because I wanted to work with underserved populations. The other people in the class, their patients were often very different from mine, which is okay. But I didn't necessarily feel that there was an interest in being open about the kind of patients that I worked with. So, I think there is this, you know, perception that certain people are the people that you want to work with and anybody else, you know, you don't want to work with because somehow they can't be analyzed. They can't be, you know, reflective. And I don't think that's true. 

[Credit: Janice Bennett, PhD, Black Psychoanalysts Speak]

BEVERLY STOUTE: The last set of things we saw was that when you draw attention to race, candidates and faculty felt that when issues came up in institutes, they were not adequately dealt with. And BIPOC and white psychoanalytic candidates had similar perceptions, and I'll say that again. So, BIPOC faculty and candidates and white candidates had similar perceptions of racism and white supremacy in institutes and had experienced it differently from white faculty's perception, which is interesting if you think maybe it's partly generational? In that older ways of psychoanalytic thinking position race outside the psyche and the social not relevant. And so, if, before we invoke racism, we can say that those older faculty members trained at a time when psychoanalysis didn't think this way.

CHRIS AIKEN: Is it true that a newer generation is thinking more broadly about societal forces on the psyche?

BEVERLY STOUTE: I think so, and that's probably not only an evolution in the analytic literature, but I think it's the times we live in. I think most universities will say that the younger generation is more audacious with their wanting to look at it, and the rest of us have to keep up, okay? The part of the study that was so much, more powerful than we anticipated was that the perception of racial incidences in institutes became a whole area of the study itself. And the reason why that mattered so much is that the perception of microaggressions and racial incidents not only did BIPOC candidates and faculty thought they were more impactful than white faculty, but it also led people to drop out of training. And white faculty and the general establishment had under appreciated that was such a significant factor. This is in line with the history of psychoanalysis in that there are many black psychoanalysts, even though they're a handful, most of them left institutes and did not stay. If we understand that, then we can begin to find ways of looking at the structure of what training is, and change that, both recruit more people to make it hospitable, because by learning, we had an arm of the study where we had people who were outside analytic institutes, who were psychodynamically trained clinicians. And we wanted to find out why they didn't come into institutes. And one of the things that we learned was that the perception people had of psychoanalysis mattered. It was even stronger for BIPOC clinicians that the perception was that psychoanalysis didn't look at these issues. And that's a negative factor if you want to recruit more people of color or more diverse populations into psychoanalysis. I feel hopeful because I think there is a lot we can do. It's like one thing that we did discover is that even though people agreed that racial enactments were really difficult for organizations and a good portion of the report comes up with a psychoanalytic formulation of how to think about it. Everybody wanted change. Everybody said we should, you know, we sure don't know what to do, but everybody wanted help with it because it was such a problem. One of the things we say in the report is these issues are inevitable, and we have to accept that, and that change requires commitment to it, and that most of these incidents occur in public, but people realize the other thing was that a lot of times things are avoided out of fear. And this is something we can do something about. We can make, for example, wholesale changes and looking at the way we recruit and our admissions processes. We discovered that word of mouth is the way people get to their institutes, not like really marketing. So, if you have a population that's primarily white and used to be mostly male, then if social networks are the way you get there, you're only going to replicate your same social network. Right? So, we can change that and begin to look at how do you recruit from a wider database. So, there are lots of really practical recommendations. Another thing is, well, the procedures for progression are largely subjective for a lot of places, and candidates wanted objective criteria. Tell me exactly what I need to do, you know, in my evaluation, I want really clear competencies that I'm supposed to get, because the less we have objective criteria, what, the more there's bias. The other thing too that we found out was that people were not comfortable, even though BIPOC faculty were less comfortable having to bring up issues of enactments, they did it more often. And that if we could help people with A, what happens and come up with policies and procedures in the institutes, it would give people a place to go and a structure within which to operate. And then we have to do wholesale reorientation of the curricula. The curriculum have to begin to realize that people want this kind of education and that it has to be integrated throughout. If you're really going to make a difference; and the other thing is that psychoanalysis not only has to make a philosophical shift. It has to make a philosophical shift that realize, yes, social and culture and ethnicity matter, and we can't ignore it. It has to make the shift that we can't only be individuals if we're going to function as social creatures. We have to understand how groups work. A group has not been a part of psychoanalytic education. If we're going to look at racial inequities, we certainly need to understand how groups work. No one said, "Hey, we've never had one", you know, so it was pervasive. So, if that's the case and they're inevitable, then we've got to look at it. We live in a society now that we could argue that these kinds of incidences occur repeatedly. So, we have to train people to understand that like it's a whole literature on the psychodynamics of racism and how racial enactments play out. We can help people understand how do you navigate these kinds of conflicts in the room? You can't just assign the readings. And then when people come in upset, not deal with it, you can do that. We can train faculty, faculty should have CME in this, like anything else and not diversity training courses. They're not very useful, to just tell people things that they don't know. You need an experiential process oriented component of learning about this because you have to learn it within yourself before you can then work with patients and just think of people became more aware of it. It would mean that the kind of care we provide is different. It would mean we'd be able to begin to see what we're actually doing and how different we are with different people. We would begin to see well gee how come I made the recommendation and said that person may be suitable for psychotherapy and that one for medicine and I didn't think "hey What are my selection criteria?" They're based on biases. I've had many candidates, for example, i'm a child analyst and there are woefully few child psychoanalysts in the country. And I've had candidates tell me well, they told me that this wasn't a suitable analytic case. Why? Well, they came from a poor family and they probably won't prioritize the treatment. I just look up people will do what you help them understand is necessary and especially if it's in service of the child, but that's based on the idea that there was a time when it was taught that black people didn't have an unconscious and we weren't suitable candidates for analysis. Those are old perspectives that we can change. So, in the report, we talk about how do we educate people and begin to look at it. And I also think that some of what we've learned from this can also be transported into psychiatric thinking. Sort of in a lot of my writings, the cases that I've used, I talk about how in psychiatric hospitals, psychiatric treatments that these things impair the ability to provide treatment. And I think there are lots of education that we could do in training programs in health care in general to help improve working with people across different ethnicities. Because we know that a poor match with interracial treatments or intercultural treatments has a higher likelihood of falling apart if the clinician is not attuned to how those issues might play into the treatment. And psychiatry residencies that try to teach you about these issues are not without problem either. I've consulted to psychiatric programs where they try to teach and these things blow up, and when in the classroom somebody makes a remark, you know, at once, when a young man who was feeling in the middle of the pandemic, sort of like everybody was coming at white people, quote-unquote, he was very disparaging towards a young woman in the room. And the instructor didn't know how to handle it, and it became this huge, horrific thing for the whole class, where he would yell and attack her. That's an enactment, but we could have helped them. If the instructor knew how to cultivate, let's back up and see what you're thinking. That you're reacting that way and knew how to manage those kinds of activations of racial identity and racial threat in the classroom, then it could have been an entirely different experience for that group. Martin Luther King wrote in his last book before he died, Where Do We Go From Here: Chaos or Community, racial understanding is not something we find it's something we must create. Racism traumatizes all of us, not just one of us. And if we can find a way to help people with that pain, then maybe we can make some real difference in the world. And so that's my hopefulness about it, even though when we started, you know, I said it took a lot longer than we thought to finish the study. And so I'm very hopeful and I felt very privileged to be a part of this study and this process.

CHRIS AIKEN: Let’s pause for a preview of the CME quiz for this episode – earn your CME through the link in the show notes.

1. Which aspect of psychoanalytic training perpetuates a lack of diversity in the profession?

A. The requirement that psychoanalysts have a medical degree (MD or DO)

B. Word-of-mouth recruiting

C. Lack of racial quotas

D. Cultural bias in the admissions exams

Beverly Stoute is a supervising analyst and adjunct professor of the Emory University School of Medicine and child supervising analyst at The New York Psychoanalytic Institute. She is the co-editor with Michael Slevin of the 2023 book, The Trauma of Racism: Lessons from the Therapeutic Encounter. She co-chaired the Holmes Commission on Racial Equality in American Psychoanalysis along with Drs. Dorothy Holmes, PhD, the eponymous chair, and co-chairs Anton Hart, PhD, and Dionne Powell, MD.

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