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Social justice entails equal access to liberties, rights, and opportunities, as well as care for the least advantaged members of society. The paradigm-shifting new book Social (In)Justice and Mental Health addresses the ways in which society's failure to deliver on that humane ideal harms people with mental illness. The editors, at the forefront of the effort to make psychiatry responsive to critiques of institutional racism, argue that in the United States, a perfect storm of unfair and unjust policies and practices, bolstered by deep-seated beliefs about the inferiority of some groups, has led to a small number of people having tremendous advantages, freedoms, and opportunities, while a growing number are denied those liberties and rights. Mental health clinicians bear a special responsibility to be aware of these structural inequities, to question their own biases, to intervene on behalf of patients and their families, and to advocate for mental health equity. To that end, the book provides a framework for thinking about why these inequities exist and persist and provides clinicians with a road map to address these inequalities as they relate to racism, the criminal justice system, and other systems and diagnoses.
The book is hands-on, with topics mental
health clinicians will find timely and relevant:
• The role of social injustice and specific diagnoses and conditions,
including substance use disorders, schizophrenia, personality disorders, and
child trauma, is covered. For example, research has shown that white
psychiatrists are more likely to over diagnose schizophrenia in Black
patients, and this diagnostic bias may partly account for Black men being
involuntarily committed to mental institutions in higher numbers.
• The
authors advocate for research that prioritizes the needs of participants and
communities, rather than the needs of institutions, and focuses on
structural, not individual-level, differences.
• Accompaniment, an
important strategy for infusing social justice into clinical practice, is
described and modeled. This process of radical empathy—of trying to minimize
power dynamics in clinical relationships by listening, witnessing, and
advocating with patients—is critically important in confronting mental
health inequities.
• The inadequacy of current medical and mental
health education and training in countering the powerful forces of social
injustice in mental health is discussed in detail. The authors emphasize
that change requires adopting an active practice of self-study and
self-reflection, and accordingly, a list of self-study resources, consisting
of books, documentaries, podcasts, and TED talks, is provided to further the
reader's knowledge and awareness.
• Of further assistance are the
chapter-ending "Questions for Self-Reflection," which challenge mental
health clinicians to examine their own attitudes and preconceived ideas
about race, poverty, disabilities, and privilege.
Social (In)Justice and Mental Health addresses the context in which mental health care is delivered, strategies for raising consciousness in the mental health profession, and ways to improve treatment while redressing injustice. Clinicians owe it to themselves, their patients, and their profession to read—and heed—this important work.
Like the rest of American culture, psychiatry is
at a
crossroads with respect to race and racism and
its treatment of black,
indigenous, and people of
color (BIPOC). The American Psychiatric
Association (APA) recently apologized for psychiatry's role
in
historical direct and indirect acts of racism. In
its apology, the APA
wrote that "early psychiatric
practices laid the groundwork for the
inequities in
clinical treatment that have historically
limited
quality access to psychiatric care for BIPOC The
APA
apologizes for our contributions to the structural racism in our nation and
pledges to enact
corresponding anti-racist practices."1
Psychiatry's
reckoning with its own racist past is
overdue, but what exactly should
the path forward
look like? After all, it is easy to decry some of
the
overtly racist theories of someone like Benjamin Rush
(whose
image graced the APA's logo until 2015), but it
is quite another to
systematically explore and expose
the myriad less visible and less overt
ways that racism is infused throughout mental health care.
Enter the new
volume edited by Drs Ruth Shim
and Sarah Vinson entitled Social
(In)Justice and
Mental Health, a book whose timing could not be
more
perfect. In this multiauthored volume Shim and
Vinson thoughtfully and
comprehensively investigate
the systemic inequities and racist
structures that
permeate mental health care in the United States
and
that cause—and exacerbate—health disparities and
generally worse
outcomes for BIPOC.
Social (In)Justice and Mental Health
looks
beneath the surface of mental health care and
offers the most
extensive excavation and critique of
the pervasive racism throughout
mental health
that we have read. Shim and Vinson describe the
myriad
ways in which the mental health field has
not only failed to see racism
in its various forms
but has also actually contributed to
racial
disparities. These authors tell their readers that
they want
"to make the invisible visible" and,
indeed, they do just that.
From
its outset, this volume puts standard mental health practice on notice. Shim
and Vinson, who
authored or co-authored a majority of the
chapters
in this multiauthored book, state that they hold the
mental
health field in high esteem and "it is for this
reason that [they]
insist on viewing the field with an
unflinchingly critical eye." No
matter their personal
feelings about issues of social justice and race,
the
authors note that the book is "informed by data
rather than by
sentiment."
The authors address the question of whether or
not
mental health care workers ought to care about
social injustice. After
all, the argument goes,
shouldn't mental health providers confine
their
view toward conditions like major depression or
posttraumatic
stress disorder or anxiety and not
delve into larger societal questions?
Why should
clinicians look at social conditions and determinants of
health when those factors were not the
focus of our training?
Shim
and Vinson are unequivocal in their answer
to this question. Their
position—as is ours—is that
health is more than medicine, and clinical
care is
ultimately one small aspect of what factors into
one's
health. One's social environment, political
context, and socioeconomic
status all play significant roles as well. And racism, as a system
that
distributes unequal access to resources, power, and privilege based
on a social construct called race, is a
major social determinant of
mental health. As the
authors write, "As health care workers, it's
impossible for us to divorce our work from the relentless
societal
challenges our patients face. We have to
expand our field of
intervention beyond the consultation room." Moreover, they add, "The failure
to
consider how race and culture intersect class, gender, and
socioeconomic issues and how these influences shape diagnostic assessment,
treatment, and
health outcomes is yet another example of
how
structural racism is built into mental health care."
As seasoned
clinicians who have worked extensively
in public settings with many
BIPOC patients, we
have seen more times than we can count the
ways
in which our patients have suffered from a confluence of factors
extending far beyond our clinics.
As such we couldn't agree more with
Shim and
Vincent on this observation.
But it is not only social
forces at large that can
oppress our patients and cause or contribute to
illness. The system of mental health care itself can be
and often is
oppressive and part of the problem. As
Shim and Vinson assert, our
profession is "shaped
and practiced in the context of oppression, (and)
also
plays a major role in perpetuating and
sustaining
inequity."
How does our field do this? To start, racial
concerns, including overt racism at times, were written into the mental
health system in various ways
—including diagnoses replete with biases
and
assumptions regarding race—that are largely
invisible to us now.
Social (In)Justice and Mental
Health makes clear that considering a
diagnosis
apart from the historical, social, and
political
considerations that all factor in to how an individual
presents to us in any given moment is
dangerous (because it can support
and lend credence to what might be racist), naive, and ultimately racist if
it ends up bolstering racist attitudes and institutions.
Understanding
the racist forces at work within
mental health care in the past enables
new
ways of addressing current implications and
identified barriers,
including how schizophrenia is
more frequently diagnosed among BIPOC,
racial
bias and stereotyping of BIPOC when diagnosing
substance use
and personality disorders, and
why BIPOC are disproportionately jailed
and
imprisoned in the United States, just to name a
few. We need to
hold society and the mental
health system accountable for health
disparities
and shift toward practices and policies that result
in
fair and equitable mental health care for
everyone.
The book is
divided into 4 parts. The first part
addresses some theoretical concerns
about social
injustice. The second section addresses systems
and
structures that affect mental health. The third
section addresses the
ways in which social injustices factor into a number of specific
psychiatric
diagnoses, and the final section focuses on how to
move
forward to try to effect real change. With
chapters dedicated to federal
policies, mental
health, the carceral system (the authors are
correct
to refuse to use the term "criminal justice system"
since so
much of that system is unjust toward
BIPOC), and public health, this
multidisciplinary
work marks a seminal contribution that will
pave
the way for further advances in research, theory,
and practice.
The book is also meant to cause
readers to introspect and consider their
own
thoughts and actions in their daily lives. Along
these lines, at
the end of each chapter the authors
include "Questions for
Self-Reflection" to help
probe and prod readers to look within and to
take
action.
This volume has a number of significant
strengths:
It is very well written, comprehensive in
scope, loaded with compelling
data, and, as noted
above, it is beyond timely. Readers will learn
the
realities of the mental health system and delve into
thoughtful
and expansive chapters that promote
both awareness and equity. The data
cited in this
volume and the argument that it makes are
so
compelling that, once you finish the book, you will
be hard
pressed to look at mental health care in the
same way. And not just
mental health care—Social
(In)Justice and Mental Health makes it
difficult to
look at everyday life in the United States in the
same
way as before.
Social (In)Justice and Mental Health is an overt
call
to action, including looking beyond the walls of
our clinics and
hospitals. As the authors write, "Our
level of engagement in advocacy as
mental health
professionals often falls short. As clinicians, we
are
charged with supporting patients' progress toward
recovery even
when much of what makes them sick
or well cannot be addressed by our
staying in our
proverbial lane." We couldn't agree more. In the end, you
can't read
Social (In)Justice and Mental Health and not feel
moved
to act. And by the way, you need to read
this book.
— Candy Smith, PhD, and J. Wesley Boyd, MD, PhD
Ruth S. Shim, M.D., M.P.H. is Luke and Grace Kim Professor in Cultural Psychiatry and Professor, Department of Psychiatry and Behavioral Sciences, at the University of California, Davis, in Sacramento, California.
Sarah Y. Vinson, M.D. is Founder and Principal Consultant of Lorio Forensics and Associate Professor of Psychiatry and Pediatrics at Morehouse School of Medicine in Atlanta, Georgia.
Contributors
Foreword
Preface
Part I.
Foundations of Social Injustice
Chapter 1. Social (In)Justice
and Mental Health
Chapter 2. Social Injustice and the Social
Determinants of Mental Health
Chapter 3. Social Injustice and Mental
Health Inequities
Chapter 4. Social Injustice and Structural
Racism
Part II. Systems and Structures
Chapter 5. Social
Injustice and the Schooling System
Chapter 6. Social Injustice and the
Child Welfare System
Chapter 7. Social Injustice and Urban
Development
Chapter 8. Social Injustice and the Carceral
System
Chapter 9. Social Injustice and the Health Care
System
Part III. Diagnoses and Conditions
Chapter 10.
Social Injustice and Substance Use Disorders
Chapter 11. Social
Injustice and Schizophrenia
Chapter 12. Social Injustice and Personality
Disorders
Chapter 13. Social Injustice and Child Trauma
Part IV.
Achieving Mental Health Equity
Chapter 14. Social Justice and
Mental Health System Reform
Chapter 15. Social Justice and
Advocacy
Chapter 16. Social Justice and Mental Health: A Call to
Action
Index