Am J Psychiatry 137:6, June 1980 679

Measuring Racial Bias in Inpatient Treatment

BY JOSEPH A. FLAHERTY, M.D., AND ROBERT MEAGHER, PH.D.

RACIAL DIFFERENCES VERSUS RACIAL BIAS

In a retrospective chart audit of66 black and36 white
male schizophrenic inpatients, the authorsfound that
Investigators and authors have focused on both ra-
black patients spent less time in the hospital, obtained
cial differences and racial bias. Racial differences have
a lowerprivilege level, were given more p.r.n.
been measured in terms of prevalence of various types
medications, and were less likely to receive recreation
of psychopathology and differential treatment re-
therapy and occupational therapy. Seclusion and
sponses; racial bias has been viewed from the per-
restraints were more likely to be used with black
spective of its influence on psychiatric diagnosis and
patients. The authors ruled out the possibility of more
treatment. These separate areas are often confounded;
severe pathology in the black patients by global rating
whenever psychological or treatment differences be-
ofan additional 15 white and 15 black patients.
tween races are found, one must consider racial bias as
Concluding that there was racial bias, they attribute it
a possible reason.
to subtle stereotyping and the staffs greater
familiarity with white patients; they suggest increased Racial Differences
recruitment ofblack professionals and the inclusion of
blacks in each treatment team. Blacks have been described as more disturbed than
whites according to type of diagnosis given (2), per-
sonality inventory scores (3-5), and behavioral obser-
T he degree of concern about the effects of race on vation. Although
psychopathology
each of these
may itself be subject
means of measuring
to bias, one
psychiatric treatment has varied over the last dec-
ade. With the community movement of the l960s and cannot exclude the possibility of the existence of real
the concurrent increase in the numbers of black pro- psychological differences between races.
fessionals and black patients, the issue of race gener- There have been few studies aimed at measuring dii-
ated considerable attention and literature. In more re- ferential responses to psychiatric treatment. Although
cent years race as well as other social variables have there is some evidence that blacks respond less favor-
received relatively less attention in the literature in ably to psychiatric hospitalization (6), these studies
comparison to other important emergent issues such have concentrated on release rates and early changes
as psychobiology, psychopharmacology, and health in symptoms and not on longer outcome. One study (7)
care delivery. In December 1970 the American Journal found that although blacks appeared more disturbed
of Psychiatry devoted a special section to racism in on initial rating scales and MMPIs, they had different
which Sabshin and associates (1) recommended that adaptive styles during hospitalization and were not sig-
this issue be kept alive, partly through communication nificantly different from whites at the time of discharge
in the Journal and Psychiatric News. and at 18-month follow-up.

Racial Bias

Racism has been described as ‘a set of attitudes

‘ to-
wards and modes of treatment of members of one so-
cietal group that are related to a perceived group,
Presented at the 132nd annual meeting of the American Psychiat-
ric Association, Chicago, Ill. , May 12-18, 1979. Received May 14, rather than individual, identifying characteristics” (8).
1979; revised Dec. 3, 1979; accepted Jan. 9, 1980. There is some bias in the commonly held assump-
From the Department of Psychiatry, Abraham Lincoln School of tion that blacks are not amenable to intensive psycho-
Medicine, University of Illinois College of Medicine, Chicago, Ill.
therapies and that they will drop out of treatment pre-
(both authors), and the West Side Veterans Administration Hospi-
tal, Chicago, Ill. (Dr. Meagher). maturely. Although one study (9) has shown a higher
Address reprint requests to Dr. Flaherty, University of Illinois drop-out rate for blacks, this rate is lower when blacks
College of Medicine, 192 South Wood St., Chicago, Ill. 60612. are referred for intensive psychotherapy (10). Yam-
This work was done in part through support from the West Side
Veterans Administration Hospital.
amoto (11) found that blacks, along with Mexicans and
Copyright © 1980 American Psychiatric Association 0002-953X1 Orientals, were more often referred for medication fol-
80/06/0679/04/$00.50. low-up only or never seen after the initial interview;
 680 RACIAL BIAS IN INPATIENT TREATMENT Am J Psychiatry 137:6, June 1980

they were seldom referred to individual or group psy- black staff knew more about black patients and re-
chotherapy. Cited as a reason that might explain sources in the community for the eventual referral of
blacks’ high drop-out rate was the degree of comfort these patients; this was just the reverse for the white
and perceived understanding that a black patient expe- staff.
riences with a white therapist.
Formal Study Methods
We believe that an inpatient unit may be a good
place to assess possible racial bias. The inpatient are- We performed a retrospective audit of the charts of
na, because of its fishbowl-like exposure and the re- 101 schizophrenic patients consecutively admitted
quired interracial communal living, is a place where over six months; there were 66 black and 35 white pa-
the issue of racial bias cannot be ignored. The task of tients. Schizophrenia was chosen because of the large
living and working together in harmony is an important numbers of patients with this diagnosis and the high
one for psychiatric patients and staff. degree of reliability in diagnoses (a recent hospital au-
dit showed no deficiencies in diagnosing schizophre-
nia). Also, we felt it was desirable to exclude one van-
METHOD able, diagnosis, in the measurement of bias. The retro-
spective chart audit approach was to used to control
Setting
for the possibility that patient treatment differences
The clinical setting consisted of a 45-bed all-male might be a function of the mere fact that differences
unit in a general teaching hospital. Staff consisted of 4 were being studied.
psychiatrists, 1 psychiatric resident, 2 social workers, Data were collected on those treatment variables we
I psychologist, and a nursing staff of 25. Patients and felt would indicate racial bias if significant differences
staff were divided into 4 treatment teams. A previous between races were found. We measured the use of
survey (12) of patients’ characteristics on this unit re- p.r.n. tranquilization, seclusion, and restraints; the or-
vealed the following: the average age was 34, the aver- dering of occupational and recreational therapy; and
age length of stay was 31 days, 60% of the diagnoses the level of privilege (on a scale of 1 to 4) over time.
included psychosis (75% of the psychoses were schiz- We felt that bias would be indicated by more restrict-
ophrenia), 10% of the population was employed, and ive measures and fewer privileges being applied to one
90% of the patients fit into Hollingshead and Redlich’s race. We also measured length of stay because we hy-
classes IV and V. The professional staff was almost pothesized that this public hospital system “allowed”
exclusively white, with the exception of I psychiatric certain patients to stay longer because of personal
resident and an occasional medical student. The ma- preference. We also collected data on patient charac-
jority of the nurses’ aides were black. teristics that might provide plausible alternative ex-
planations for racial differences in the treatment van-
ables and should be examined before conclusions
Initial Survey
about racial bias could be drawn. Of the 66 black pa-
One ofus (J.A.F.) designed a small survey as an mi- tients, 60 were unemployed, 1 1 were married, 8 were
tial assessment of racial bias on the inpatient unit. He divorced, 46 were single, and the marital status of 1
timed the number of minutes spent discussing black was unknown. Of the 36 whites, 35 were unemployed,
and white patients by each of 3 treatment teams. Each 7 were married, 3 were divorced, 24 were single, and
team systematically reviewed the treatment plans and the marital status of 2 was unknown. The average age
progress of each patient weekly. Two of the teams ofthe blacks was 32.2 years; ofwhites, 36.7. The aver-
were all white, and the third team had 3 black and 2 age number of previous admissions was 3. 12 for
white members. The author did this minute counting in blacks, 3.14 for whites.
an unobtrusive way, although he was aware that his The Brief Psychiatric Rating Scale (14) was com-
presence in the meeting was a contamination. pleted on a different sample of 30 newly admitted
The results of this survey were impressive: the two schizophrenic patients, 15 black and 15 white, by ra-
all-white teams spent an average of 5.0 minutes dis- ters blind to the purpose of the assessment. This was
cussing each of 54 black patients over the three meet- done in an attempt to see if there were gross dif-
ings and an average of 7.0 minutes discussing 40 white ferences in presenting symptomatology that might ac-
patients. The team with 3 black and 2 white members count for any black/white differences in treatment
spent an average of 13.5 minutes discussing each of its variables.
15 black patients and an average of 9.9 minutes dis-
cussing its 12 white patients. According to a sign test
(13) the difference was significant (p<05). Although RESULTS
we hesitate to draw conclusions from such an informal
survey, the tendency for white staff to prefer talking Separate one-way analyses of variance were calcu-
about white patients and black staff to prefer black pa- lated for each of the staff treatment and patient charac-
tients is striking. One possible explanation is that the teristic variables, using race as the independent vari-
Am J Psychiatry 137:6, June 1980 JOSEPH A. FLAHERTY AND ROBERT MEAGHER 681

able. The mean number of days spent in the hospital and age were ruled out in the analysis of matched sub-
was 29.09 for blacks, 48.60 for whites (p<.OOl). The groups. Because of the retrospective design of the
mean number of days on which p.r.n. medication was study socioeconomic status was not available and
ordered was 6.71 for blacks, 3.58 for whites (p<.05); could not be controlled. Although we have data that
seclusion and restraints were ordered for blacks on indicate socioeconomic homogeneity in our general
78% of the days they were hospitalized; for whites, population (12), this factor cannot absolutely be ruled
46% (p<.05). At discharge blacks had reached a mean out as a cause of different treatment in this sample.
privilege level of 2.64; whites, 3.08 (p<.05). Recrea- Several specific treatment differences need further
tional therapy was ordered for 47% of blacks and 78% analysis. The most striking finding was blacks’ shorter
of whites; occupational therapy was ordered for 47% length of stay. Based on our initial premise, that staff
of blacks and 75% of whites. Furthermore, blacks allow favored patients to stay longer, this is an in-
more often left the hospital ‘‘against medical advice” dication of bias. There are, however, other ex-
(18% of blacks versus 5% of whites), whereas whites planations for this shorter length of stay. Perhaps
more often were “absent without leave” (9% versus blacks have, as stereotypes suggest, a more chaotic
4%). social and family life and real-life events (e.g. , death of
The Brief Psychiatric Rating Scale (14) scores for a friend, need to pick up public aid checks, etc.) bring
the separate sample of 15 black and 15 white con- about premature discharge. It is also possible that
secutively admitted patients were added for each pa- black patients have less practice or ability to postpone
tient. Total symptom scores were considered a rough gratification, prompting discharge as soon as the most
estimate of the number and severity of presenting distressing symptoms abate. Another possibility is that
symptoms. There were no differences in either central white staff feel more comfortable working with white
tendency or distribution of scores between the 2 patients; they know more about community resources
groups. Although these ratings apply to a different (e.g. , half-way houses) for these patients and therefore
sample from the large group used in the study, we feel spend more time and care in discharge plans, thus in-
confident in asserting that there were no measurable creasing the length of stay. Also, the ward atmosphere
differences in global pathology between the black and created by a white staff may make life uncomfortable
white patients. for a patient from another culture, thus prompting
Since there was a trend for the two groups to differ early discharge.
in age (p<.10), a subsample of 36 black patients, The greater use of p.r.n. medication, seclusion, and
matched with 36 white patients in employment status, restraints for black patients may also indicate bias. It
marital status, and age, was selected from the pool of is possible that another variable such as greater size or
66 black patients. The pattern of differences between strength of the patient was the determining factor in
the 2 groups was an exact parallel, with blacks staying the use of these measures and that these features were
a shorter time and receiving less recreational and oc- more common in blacks. We speculate that this was
cupational therapy (p< .05). There was a trend (p< .10) not the case but that the stereotype of the black male
for blacks to be given more p.r.n. medication, to have made the staiffeel and act as if blacks were more dan-
p.r.n. medications ordered more frequently, to have a gerous, prompting more restrictive measures. The dii-
lower privilege level at the time of discharge, and for ference in privilege level at the time of discharge can
the type of discharge to be different, with black pa- largely be explained by the greater length of stay of
tients more often leaving against medical advice, white patients: the longer any patient is in the hospital
whites, absent without leave. the more likely he is to receive a higher privilege level.
Probably the clearest measure of staff bias in this
study is the difference in rate of ordering recreational
DISCUSSION and occupational therapy. Although physicians report
that they order these therapies routinely unless a pa-
It seems clear that there are significant differences in tient is too dangerous or psychotic to participate, it is a
the treatment of the two racial groups. It is now neces- striking fact that they are more ‘routinely”
‘ ordered
sary to examine these differences to see if explanations for white patients. It is possible that white patients are
can be found other than racial bias. The first possibility more aggressive in asking the physician to order these
is that treatment differences may reflect more severe measures, but we feel the differences were due to bias.
disturbances or psychopathology in the black group. Based on these measured treatment differences we
Although the separate sample did not indicate dif- conclude that there is some indication of racial bias.
ferences in global psychopathology, it is possible that a Our experience with the staff indicates that this bias is
more extensive set of scales, examined separately not due to hostility or contempt for black patients but
rather than globally, might yield consistent dif- from subtle stereotyping and greater familiarity with
ferences. and preference for white patients. Feedback of the re-
The groups did not differ in chronicity or marital sults of our data to the staff was met by an openness to
status, and trend differences (p<.10) in employment consider racial bias as a possible explanation. The staff
682 RACIAL BIAS IN INPATIENT TREATMENT Am J Psychiatry 137:6, June 1980

also considered measures to reduce bias; issues such phrenia ratings. J Nerv Ment Dis 153:343-350, 1971
as increasing the recruitment of black professionals as 3. Dreger RM, Miller KS: Comparative psychological studies of
Negroes and whites in the United States, 1956-1965. Psychol
well as the use of black trainees were discussed. Pro- Bull, Sept Supplement, 1968, pp 1-58
viding a few black professionals or trainees to each 4. Fisher J: Negroes and whites and rates of mental illness: recon-
team was seen as a key measure needed to increase the sideration of a myth. Psychiatry 32:428-446, 1969
5. Fabrega H, Swartz JB, Wallace CA: Ethnic differences in psy-
sensitivity of the white staff toward blacks as well as
chopathology. Arch Gen Psychiatry 19:218-226, 1968
improve the quality of discharge planning for this 6. Singer B: Some implications of differential treatment of Negro
group. We felt that the staff feedback was a useful and and white patients. Soc Sci Med 1:77-83, 1967
necessary part of our evaluation project. 7. Genthner RW, Graham JR: Effects of short-term public psychi-
atric hospitalization for both black and white patients. J Consult
We appreciate that our approach to measuring racial Clin Psychol 44:118-124, 1976
bias is somewhat crude but feel it was a useful begin- 8. Jonas 5: Health, health care, and racism. Hospitals, Feb 16,
ning. More refined measurements of treatment 1974, pp 72-74
9. Rosenthal D, Frank JB: The future of psychiatric clinic out-
coupled with in-depth studies of staff, patient, and sys-
patients assigned to psychotherapy. J Nerv Ment Dis 127:330-
tem attitudes and perceptions would be helpful. We 343, 1958
felt that the willingness of an institution to allow such 10. Lief HJ, Lief VF, Warren CO: Low dropout rate in psychiatric
research is probably itseif a measure of its sensitivity clinic. Arch Gen Psychiatry 5:200-211, 1961
II. Yamamoto J, James QC, Pally N: Cultural problems in psychi-
and concern for the issues of bias. atric treatment. Arch Gen Psychiatry 19:45-59, 1968
12. Verinis JS: The evaluation of a short-term psychiatric hospital-
ization program. VA Newsletter for Research in Mental Health
REFERENCES and Behavioral Science, Aug 1976, pp 1-3
13. Wallis WA, Roberts HV: Statistics: A New Approach. Glencoe,
1. Sabshin M, Diesenhaus H, Wilkerson R: Dimensions of institu- Ill, Free Press, 1956
tional racism in psychiatry. Am J Psychiatry 127:787-793, 1970 14. Overall JE, Gorham D: The Brief Psychiatric Rating Scale. Psy-
2. Allon R: Sex, race, social class and process-reactive schizo- chol Rep 10:799-812, 1962