Social (In)Justice and Mental Health

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 * Journal of Psychiatric Practi