Alleviating the Mental Health Burden of Structural Discrimination and Hate Crimes: The Role of Psychiatrists
Publication: American Journal of Psychiatry
Case 1: Post-Orlando Trauma
An African American psychiatrist has been working with a middle-aged gay black man over 2 years to treat depression and anxiety after a severe traumatic brain injury for which he receives Social Security Disability Insurance payments. Over the past 4 months, the patient’s mood and anxiety have worsened, and the patient feels that his life lacks value as he watches videos of the deaths of Mike Brown and Alton Sterling at the hands of police officers. He fears that his sexual preference puts him in danger as he watches interviews in the aftermath of the Orlando gay nightclub shooting. Recent increases in violence against ethnic, racial, and sexual minorities seem to validate his fears that this experience will not end. He feels unsafe outside his home, feeling more vulnerable to hate speech and hate crimes than at any time in memory. As his anxiety and mood worsen, the psychiatrist wonders how to help, because he shares many of his patient’s concerns and feels helpless because he cannot shelter his patient from the trauma that comes with being both a black person and gay male in a marginalizing national climate.
Case 2: Immigrants’ Anxieties
A Colombian-born Spanish-speaking psychiatrist notices heightened uncertainty and anxiety among both patients and staff in the urban public mental health clinic in which she works. The clinic serves primarily first-generation non-English-speaking patients, many of them undocumented immigrants. Patients who had been psychiatrically stable for years are decompensating, yet they are avoiding hospitalization because they do not feel safe in public institutions because of news reports of changes in immigration law. Colleagues at other public clinics serving immigrants are reporting steep declines in their census, and staff members in her clinic are receiving questions from their patients every day about the legal complexities of their immigration cases, which they are unable to answer. They find, too, that some patients are being taken advantage of by con artists claiming to be immigration lawyers, and others are desperately preparing wills and custody arrangements for their children who were born in the United States, fearing that they will be deported without warning, based on sensationalist local Spanish and Chinese television shows that provide inaccurate information. The psychiatrist attempts to garner accurate information about immigration law enforcement and a list of legal resources in the neighborhood but is told by a senior psychiatrist colleague “not to get mixed up in those issues” and to “just take care of your clinical work.”
Case 3: Marked for Religious Violence
A Sikh psychiatrist gets reports that suicides among Sikhs have increased over the past year, related to anti-Muslim violence directed at (non-Muslim) Sikhs wearing turbans. In her clinic, Muslim and African American patients report escalating religious and racial profiling in public spaces. In her Gurdwara (Sikh house of worship), she hears of families that are disintegrating as a result of anxiety among parents, sales of family businesses in neighborhoods that have become unbearably hostile, and back-migration of elder members to India. Sikh community members draw comparisons between current religious violence in the United States and the long history of oppression and beheadings of Sikhs in India. Fearing violence against her elementary school–age son, the psychiatrist wonders if she should cut his hair so that he will not be bullied by classmates, but she hesitates given that his uncut hair is a valued link to his heritage and his community’s beliefs. She and her husband talk about leaving the United States, even though she was born here and is a U.S. citizen. She laments, “I feel it’s not my own country.”
Recently in the United States we have seen a string of widely publicized deaths of young African Americans at the hands of police, as well as increasing reports of public harassment and violence on the basis of race, gender, religion, sexual orientation, and immigration status. In the month following the 2016 U.S. presidential election, the Southern Poverty Law Center reported over 1,000 bias-related incidents, including over 300 anti-immigrant hate incidents, over 200 anti-black hate incidents, over 100 anti-Muslim hate incidents, and over 100 anti-LGBT (lesbian, gay, bisexual, transgender) hate incidents (1). At national meetings and on online forums, members of professional groups dedicated to promoting mental health equity, including the American Psychiatric Association’s Council on Minority Affairs and the American Association for Community Psychiatry, report heightened fear among patients from targeted groups, including young children who worry about the safety of their parents and caretakers. The relationship between systemic discrimination and mental health outcomes has been established by research findings of elevated cortisol and blunted stress response in targeted populations, as well as elevated rates of emotional dysregulation, anxiety and depression, sleep disturbance, and substance use (2, 3).
It is timely to reflect on how we as psychiatrists should respond to the influence of targeted violence on our patients and on our communities.
This atmosphere of anxiety and mistrust is harmful to mental health in our communities. Publicized incidents of violence, discrimination, and deportation within hospitals, social service agencies, schools, and the justice system threaten our capacity to develop a therapeutic alliance with people in need of support and threaten our ability to advocate for people in emotional and mental distress. We need to bring our expertise to bear in a time of insecurity about civil rights and protections to help ameliorate the community and institutional dynamics that foster insecurity and its detrimental effects on mental health.
Without intervention, we may encounter increased mistrust among patients on the basis of race, gender, ethnicity, religion, sexual orientation, and migration status. For example, African Americans and recent immigrants report that they hesitate to seek health care, given their historical experience with substandard care, unethical human experimentation, and disproportionate reporting of patients to agencies such as Child Protective Services and Immigration and Customs Enforcement (4, 5). African Americans, Latinos, and Native Americans may experience mental health services as entwined with law enforcement, given that the nation’s largest provider of mental health care is now the jail and prison system, and that members of these groups are two to six times as likely to be incarcerated (6).
Our patients and members of our communities may also be traumatized and retraumatized by the graphic media coverage of police shootings, hate crimes, white supremacist groups, and aggression toward women. Such imagery affects viewers of all ages, including young people who are learning to navigate schools, clinics, and systems of public safety. In this atmosphere of anxiety and mistrust, what can we do as psychiatrists?
We can first educate ourselves and our colleagues about the mental health impact of targeted violence and discrimination and the ways that our actions are implicated in alleviating or exacerbating their impact. Targeted violence and discrimination further compound the marginalization of groups that already have histories of interpersonal and institutional violence (such as unethical clinical experimentation, forced sterilization, disproportionate law enforcement) as well as mental health stigma and limited access to mental health care. Reviews of the literature on the impact of discrimination on health have identified significant mental health effects of at least three types of racism: internalized racism (the incorporation of racist attitudes, beliefs, or ideologies into one’s worldview), interpersonal racism (interactions between individuals), and systemic, institutional, or structural racism (for example, exercised through control of and access to labor, material, and symbolic resources within a society) (7).
Approaches that help health care providers recognize and counter internalized and interpersonal discrimination in their clinical practice include cultural safety, developed in the context of health services for indigenous people (Maori) in New Zealand, in which practitioners examine their own cultural identities and attitudes in order to create an environment that is spiritually, socially, emotionally, and physically safe for people from other cultural backgrounds and affirms their identity and their needs. In New Zealand, this also required increasing Maori community control of clinical institutions (8). In addition, cultural humility encourages practitioners’ self-reflection, co-learning with patients, and collaboration with community organizations in order to enhance patient and community participation in care (9); and narrative humility encourages practitioners to attend carefully to their patients’ stories, to evaluate their own role in those stories—their expectations of, responsibilities to, and identifications with patients’ stories (10, 11). These approaches help clinical practitioners consider the social and historical context of systemic discrimination in marginalized communities and address power imbalances between health practitioners and patients in clinical practice.
The second is to provide trauma-informed care (12). Trauma-informed care recognizes that a high percentage of patients in mental health and addiction treatment settings have experienced interpersonal trauma, and it responds with the conscious provision of safe environments (13). Practitioners and clinics that are unaware of patients’ histories of trauma risk retraumatizing patients by inadvertently reenacting abuses of power based on the race, ethnicity, gender, sexual orientation, religious background, and socioeconomic status of the patient. Many systems of care regularly screen patients for depression using validated instruments (14). We suggest expansion of this model to add trauma and posttraumatic stress disorder screening instruments (such as the PTSD Checklist–Civilian Version [15]), especially for systems of care that primarily serve racial/ethnic, sexual, or religious minority populations, and that such screening be followed by appropriate mental health support.
The third is to address the systemic and institutional nature of racism and other biases that have a negative impact on health (16). Institutional discrimination, caused by systemic practices, regulations, and policies rather than individual bias, such as disproportionate law enforcement in nonwhite neighborhoods and targeted deployment of Immigration and Customs Enforcement agents in poor neighborhoods, requires intervention above the level of individual patient care. One way to counteract the negative effects of institutional discrimination is to build trust and foster collaboration between mental health clinics and communities. This requires that mental health professionals learn about the neighborhoods from which their patients come and to partner with community leaders and organizations, including those in non-health sectors (e.g., schools, housing agencies, and faith-based organizations), to plan local events (17). For example, after the September 11, 2001, terrorist attacks, successful mental health interventions in New York City brought neighborhood residents, the staff of local schools, and community-based organizations together for group discussions and creative arts events that promoted collective recovery (18). Other forms of community engagement involve the employment of community health workers, such as peers—people with lived experience with psychiatric diagnoses from cultural/racial/ethnic backgrounds and neighborhoods similar to those of patients (19).
The fourth way that psychiatrists can counteract institutional discrimination is through collaboration with relevant non-health sector agencies, such as housing agencies, schools, and law enforcement, and with policy makers. One example is medical-legal partnerships between clinical and legal professionals (20) that use legal means to prevent unlawful eviction of decompensating psychiatric patients or to enforce landlord compliance with health codes, such as those governing lead removal. Another example is From Punishment to Public Health, a multidisciplinary group in New York City that includes clinical practitioners and public health researchers who work with New York City police to redirect symptomatic people in subways from arrest to mental health care, and which prepares physicians to testify to policy makers regarding the health impact of laws such as mandatory minimum drug sentences (21).
Structural competency integrates the approaches listed above by training clinical practitioners to engage with community organizations, non-health sectors, and policy makers (22). It involves 1) recognizing and naming the institutional forces that shape clinical interactions; 2) rearticulating “cultural” presentations in structural terms (e.g., nutritional choices as limited by “food deserts” in poor neighborhoods rather than by cultural tradition); 3) observing and practicing structural interventions as clinicians (such as collaborating to form mental health support groups in churches and community organizations and advocating for mental health–promoting policies); and 4) developing structural humility—the ability to collaborate with community members and members of other disciplines who have complementary expertise, while recognizing that institutional change is incremental and requires patience. Structural competency responds to the call that clinical trainees are making for intervention against institutional discrimination, as reflected in the medical student–initiated group White Coats for Black Lives (23).
Despite its utility to clinical practitioners, however, the concepts of structural racism and institutional discrimination, which have origins in social science and legal scholarship, rarely enter into the broader clinical mental health discourse. In our own review of clinical journals indexed in PubMed over the past 40 years, we found just over two dozen articles about the impact of structural racism on mental health (24–50), the majority (67%) of which were published in the past decade (see the online supplement ). Almost 30% of these articles were published by investigators outside the United States, predominantly in Germany and the United Kingdom (26, 32–34, 37, 44–46). Only five of the articles offer systemic solutions to overcoming structural racism (24, 29, 35, 47, 48). The proposed systemic solutions emphasize having members of these minority populations provide mental health care to their community and the need to empower providers with the responsibility of identifying and dismantling discriminatory practices (24, 29, 35). To introduce the concept of institutional discrimination to practitioners, it is critical that papers on this topic be published in leading clinical journals.
Discussion
To return to the case vignettes, we found that the psychiatrists involved in each of the cases ultimately found ways to intervene at structural levels. The psychiatrist caring for the black gay man whose symptoms of anxiety and depression steadily worsened as he saw televised violence in Orlando and elsewhere connected the patient to the National Black Justice Coalition, an organization dedicated to empowering and protecting the rights of black lesbian, gay, bisexual, transgender, queer (LGBTQ) community members. This motivated the patient to look for ways to demonstrate, which led to his participation in a protest. At the local level, the psychiatrist helped the patient find support groups at The Center, an LGBTQ community center in the patient’s city that had groups specifically addressing the needs and concerns of members of color. To better identify, understand, and support the problems unique to the patient, the psychiatrist familiarized himself with the Association of LGBTQ Psychiatrists, which provides resources and information relevant to the care of LGBTQ members. Other resources and advocacy groups include the Trevor Project, which operates a suicide prevention hotline for LGBTQ youth, the Human Rights Campaign of the Historically Black Colleges and Universities Program, which develops LGBTQ students of color to become agents of change on their respective campuses, and Lighthouse (www.lighthouse.lgbt) which aids in finding LGBTQ health providers for patients.
The psychiatrist working in the clinic with undocumented patients partnered with a legal defense group to host informational sessions on immigration law and legal aid, as well as guidelines for clinical staff to refer patients with immigration questions to local legal aid offices. She and colleagues organized a series of stress-reduction workshops for patients, called “Todos Somos Bienvenidos/All Welcome Here,” featuring yoga, nutrition information, and discussion groups. In addition, her clinic is now offering a therapy group in Spanish specifically for undocumented immigrants that not only provides psychosocial support but also offers information about social and legal resources for undocumented immigrants and solicits feedback from participants about additional offerings that the clinic should have for those without documentation.
The psychiatrist who experienced the impact of anti-Sikh and anti-Muslim violence on her community convinced her local Sikh Coalition to participate in interfaith marches against religious violence, women’s discussion forums on religion, and educational outreach to local elementary schools involving a turban coloring activity, teaching students to play Sikh music, and offering lessons on the history of Sikhs in India and the United States. Using personal experiences of discrimination to fuel local activism and foster inclusion could be encouraged as a healthy defense mechanism for minority and immigrant psychiatrists (51).
Additional resources for psychiatrists who strive to ameliorate the impact of institutional discrimination and violence on their patients include the Substance Abuse and Mental Health Services Administration’s guide to trauma-informed care (www.samhsa.gov/nctic/trauma-interventions), and the American Psychiatric Association is preparing a tool kit for mental health practitioners that provides tailored guides for addressing distress in members of specific targeted groups, including black, Latino, Native American, Asian, LGBTQ, Muslim, Jewish, and women patients. In addition, articles written by and for psychiatrists on structural competency provide approaches for and examples of interventions to reduce institutional discrimination (52–54). These resources are designed to help psychiatrists promote collective recovery among their patients and in their communities in an era of major structural challenges to our nation’s mental health.
Acknowledgments
The authors acknowledge the support and contributions of Dr. Maria Oquendo, Dr. Puneet Sahota, and Dr. Pamela Montano.
Supplementary Material
File (appi.ajp.2018.17080891.ds001.pdf)
- View/Download
- 105.98 KB
References
1.
Southern Poverty Law Center: Update: 1,094 bias-related incidents in the month following the election. SPL Hatewatch, Dec 16, 2017. https://www.splcenter.org/hatewatch/2016/12/16/update-1094-bias-related-incidents-month-following-election
2.
Williams DR, Medlock MM: Health effects of dramatic societal events: ramifications of the recent presidential election. N Engl J Med 2017; 376:2295–2299
3.
Bailey ZD, Krieger N, Agénor M, et al: Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453–1463
4.
Rhodes SD, Mann L, Simán FM, et al: The impact of local immigration enforcement policies on the health of immigrant Hispanics/Latinos in the United States. Am J Public Health 2015; 105:329–337
5.
Roberts D: Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century. New York, New Press, 2011
6.
Nellis A: The color of justice: racial and ethnic disparity in state prisons. Washington, DC, Sentencing Project, June 2016
7.
Paradies Y, Ben J, Denson N, et al: Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 2015; 10:e0138511
8.
Williams R: Cultural safety: what does it mean for our work practice? Aust N Z J Public Health 1999; 23:213–214
9.
Tervalon M, Murray-García J: Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved 1998; 9:117–125
10.
DasGupta S: Narrative humility. Lancet 2008; 371:980–981
11.
Tsevat RK, Sinha AA, Gutierrez KJ, et al: Bringing home the health humanities: narrative humility, structural competency, and engaged pedagogy. Acad Med 2015; 90:1462–1465
12.
Harris M, Fallot RD: Envisioning a trauma‐informed service system: a vital paradigm shift. New Dir Ment Health Serv 2001; 89:3–22
13.
Substance Abuse and Mental Health Services Administration (SAMHSA): Trauma-Informed Approach and Trauma-Specific Interventions. 2015. https://www.samhsa.gov/nctic/trauma-interventions
14.
Unützer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836–2845
15.
Weathers F, Litz B, Herman D, et al: The PTSD Checklist–Civilian Version (PCL-C). Boston, National Center for PTSD, 1994
16.
Hardeman RR, Medina EM, Kozhimannil KB: Structural racism and supporting black lives: the role of health professionals. N Engl J Med 2016; 375:2113–2115
17.
Hankerson SH, Weissman MM: Church-based health programs for mental disorders among African Americans: a review. Psychiatr Serv 2012; 63:243–249
18.
Saul J: Collective Trauma, Collective Healing: Promoting Community Resilience in the Aftermath of Disaster. New York, Routledge, 2013
19.
Colliver V: Mentors reduce return trips for mental health patients. San Francisco Chronicle, June 5, 2016
20.
Zuckerman B, Sandel M, Lawton E, et al: Medical-legal partnerships: transforming health care. Lancet 2008; 372:1615–1617
21.
From Punishment to Public Health: Capabilities for a New Ecology of Justice. New York, John Jay College of Criminal Justice, 2017
22.
Metzl JM, Hansen H: Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med 2014; 103:126–133
23.
White Coats for Black Lives (WC4BL) National Working Group: #BlackLivesMatter: physicians must stand for racial justice. AMA J Ethics 2015; 17:978–982
24.
Sabshin M, Diesenhaus H, Wilkerson R: Dimensions of institutional racism in psychiatry. Am J Psychiatry 1970; 127:787–793
25.
Acevedo-Garcia D, Rosenfeld LE, Hardy E, et al: Future directions in research on institutional and interpersonal discrimination and children’s health. Am J Public Health 2013; 103:1754–1763
26.
Bennewith O, Amos T, Lewis G, et al: Ethnicity and coercion among involuntarily detained psychiatric in-patients. Br J Psychiatry 2010; 196:75–76
27.
Cheng ZH, Tu M-C, Li VA, et al: Experiences of social and structural forms of stigma among Chinese immigrant consumers with psychosis. J Immigr Minor Health 2015; 17:1723–1731
28.
Earnshaw VA, Rosenthal L, Carroll-Scott A, et al: Everyday discrimination and physical health: exploring mental health processes. J Health Psychol 2016; 21:2218–2228
29.
Ellis WA: A case study of institutional racism. J Natl Med Assoc 1975; 67:158–161
30.
Fox K, Hinton WL, Levkoff S: Take up the caregiver’s burden: stories of care for urban African American elders with dementia. Cult Med Psychiatry 1999; 23:501–529
31.
Friedman SR, Tempalski B, Brady JE, et al: Income inequality, drug-related arrests, and the health of people who inject drugs: reflections on seventeen years of research. Int J Drug Policy 2016; 32:11–16
32.
Green G, Bradby H, Chan A, et al: Is the English National Health Service meeting the needs of mentally distressed Chinese women? J Health Serv Res Policy 2002; 7:216–221
33.
Gustafsson PE, Linander I, Mosquera PA: Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in northern Sweden. Int J Equity Health 2017; 16:22
34.
Hancock C: It is time institutional racism, chaotic inner city mental health services, and child cruelty were all brought out into the open. Nurs Stand 1999; 13:26
35.
Hatzenbuehler ML: Advancing research on structural stigma and sexual orientation disparities in mental health among youth. J Clin Child Adolesc Psychol 2017; 46:463–475
36.
Hatzenbuehler ML, McLaughlin KA, Keyes KM, et al: The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health 2010; 100:452–459
37.
McKenzie K, Bhui K: Institutional racism in mental health care. BMJ 2007; 334:649–650
38.
Mendez DD, Hogan VK, Culhane JF: Stress during pregnancy: the role of institutional racism. Stress Health 2013; 29:266–274
39.
Metzl JM, Petty J: Integrating and assessing structural competency in an innovative prehealth curriculum at Vanderbilt University. Acad Med 2017; 92:354–359
40.
Metzl JM, Roberts DE: Structural competency meets structural racism: race, politics, and the structure of medical knowledge. Virtual Mentor 2014; 16:674–690
41.
Morales A: Institutional racism in mental health and criminal justice. Soc Casework 1978; 59:387–395
42.
Oldenburg CE, Perez-Brumer AG, Hatzenbuehler ML, et al: State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States. AIDS 2015; 29:837–845
43.
Pachankis JE, Eldahan AI, Golub SA: New to New York: ecological and psychological predictors of health among recently arrived young adult gay and bisexual urban migrants. Ann Behav Med 2016; 50:692–703
44.
Pachankis JE, Hatzenbuehler ML, Mirandola M, et al: The geography of sexual orientation: structural stigma and sexual attraction, behavior, and identity among men who have sex with men across 38 European countries. Arch Sex Behav 2017; 46:1491–1502
45.
Swartz L: The politics of black patients’ identity: ward-rounds on the “black side” of a South African psychiatric hospital. Cult Med Psychiatry 1991; 15:217–244
46.
Thackwell N, Swartz L, Dlamini S, et al: Race trouble: experiences of black medical specialist trainees in South Africa. BMC Int Health Hum Rights 2016; 16:31
47.
Wade JC: Institutional racism: an analysis of the mental health system. Am J Orthopsychiatry 1993; 63:536–544
48.
Williams DR, Mohammed SA: Racism and health II: a needed research agenda for effective interventions. Am Behav Sci 2013; 57:1200–1226
49.
Williams DR, Mohammed SA: Racism and health I: pathways and scientific evidence. Am Behav Sci 2013; 57:1152–1173
50.
Yang LH, Chen FP, Sia KJ, et al: “What matters most”: a cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma. Soc Sci Med 2014; 103:84–93
51.
Mangurian C, Lee CM, Rodriguez C: Contributions of immigrants to the field of US psychiatry. Lancet Psychiatry 2017; 4:584–585
52.
Metzl JM, Hansen H: Structural competency and psychiatry. JAMA Psychiatry 2018; 75:115–116
53.
Hansen H, Braslow J, Rohrbaugh RM: From cultural to structural competency: training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiatry 2018; 75:117–118
54.
Kirmayer LJ, Kronick R, Rousseau C: Advocacy as key to structural competency in psychiatry. JAMA Psychiatry 2018; 75:119–120
Information & Authors
Information
Published In
History
Received: 17 August 2017
Revision received: 20 April 2018
Accepted: 30 April 2018
Published online: 1 October 2018
Published in print: October 01, 2018
Keywords
Authors
Funding Information
National Institute on Drug Abuse10.13039/100000026: DA032674
National Institute of Mental Health10.13039/100000025: MH093689
Robert Wood Johnson Foundation10.13039/100000867
National Institute of Diabetes and Digestive and Kidney Diseases10.13039/100000062: DK092924
Dr. Hansen was supported by a NIDA Career Development Award (K01DA032674) and a Robert Wood Johnson Foundation Health Policy Investigator Award. Dr. Mangurian was supported by an NIMH Career Development Award (K23MH093689).The authors report no financial relationships with commercial interests.Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).