Front Matter

Contributors

Foreword

Prologue

Preface

Part I

FOUNDATIONS OF SOCIAL INJUSTICE

1 Social (In)Justice and Mental Health

Ruth S. Shim, M.D., M.P.H.

Sarah Y. Vinson, M.D.

2 Social Injustice and the Social Determinants of Mental Health

Ruth S. Shim, M.D., M.P.H.

Michael T. Compton, M.D., M.P.H.

3 Social Injustice and Mental Health Inequities

Sonya M. Shadravan, M.D.

Nicolás E. Barceló, M.D.

4 Social Injustice and Structural Racism

Matthew L. Edwards, M.D.

Samuel Ricardo Saenz, M.D., M.P.H.

Roy Collins, M.D., M.P.H.

Belinda Bandstra, M.D., M.A.

Part II

SYSTEMS AND STRUCTURES

5 Social Injustice and the Schooling System

Tiffani Marie, Ph.D.

Brennin Y. Brown, M.D.

6 Social Injustice and the Child Welfare System

Melissa D. Carter, J.D.

Courtney L. McMickens, M.D., M.P.H., M.H.S.

7 Social Injustice and Urban Development

Jacob Michael Izenberg, M.D.

Mindy Thompson Fullilove, M.D.

8 Social Injustice and the Carceral System

LeRoy E. Reese, Ph.D.

Seyi O. Amosu, Ph.D.

Sarah Y. Vinson, M.D.

9 Social Injustice and the Health Care System

Michelle Ko, M.D., Ph.D.

Angie Lisbeth Cruz, M.H.S.

Janet R. Cummings, Ph.D.

Part III

DIAGNOSES AND CONDITIONS

10 Social Injustice and Substance Use Disorders

Jessica Isom, M.D., M.P.H.

Sonya M. Shadravan, M.D.

Melvin Wilson, M.B.A., L.C.S.W.

11 Social Injustice and Schizophrenia

Khalima A. Bolden, Ph.D.

Poh Choo How, M.D., Ph.D.

Swati Rao, M.D.

Deidre M. Anglin, Ph.D.

12 Social Injustice and Personality Disorders

David Freedman, Ph.D.

George W. Woods, M.D., LFAPA

13 Social Injustice and Child Trauma

Walter E. Wilson Jr., M.D., M.H.A.

Nicole Cotton, M.D.

Sarah Y. Vinson, M.D.

Part IV

ACHIEVING MENTAL HEALTH EQUITY

14 Social Justice and Mental Health System Reform

Phillip Murray, M.D., M.P.H.

Ruth S. Shim, M.D., M.P.H.

15 Social Justice and Advocacy

Kali D. Cyrus, M.D., M.P.H.

Sarah Y. Vinson, M.D.

16 Social Justice and Mental Health: A Call to Action

Sarah Y. Vinson, M.D.

Ruth S. Shim, M.D., M.P.H.

Index

Postdoctoral Fellow, Counseling Center, Georgia State University, Atlanta, Georgia

Associate Professor of Clinical Psychology, Department of Psychology, Graduate Center, City College of the City University of New York, New York, New York

Assistant Director of Residency Training and Clinical Associate Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Postdoctoral Felllow, National Clinician Scholars Program, University of California, Los Angeles, Los Angeles, California

Licensed Clinical Psychologist, Assistant Director of Clinical Training, Davis Medical Center Early Psychosis Program, University of California, Davis, Sacramento, California

Psychiatry Resident, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio

Clinical Professor of Law and Executive Director of the Barton Child Law and Policy Center, Emory Law School, Atlanta, Georgia

Resident, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Professor of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York

Assistant Professor of Psychiatry, Morehouse School of Medicine, Atlanta, Georgia

Ph.D. student, Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia

Associate Professor, Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia

Assistant Professor, Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, Maryland

Chief Resident, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Senior Research Consultant, International Academy of Law and Mental Health, New York, New York

Professor of Urban Policy and Health, Milano School of Public Policy, Management, and Environment, The New School, New York, New York

Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, California

Attending Psychiatrist, Codman Square Health Center, Boston, Massachusetts

Clinical Assistant Professor, Department of Psychiatry, University of California, San Francisco, San Francisco, California

Assistant Professor, Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, Davis, California

Postdoctoral Fellow, Community Responsive Education, San Francisco, California

Psychiatrist, Cityblock Health, Inc., Brooklyn, New York

Assistant Professor of Psychiatry, Atrium Health, Charlotte, North Carolina

Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, California

Associate Professor of Community Health and Preventive Medicine, Kennedy Satcher Center for Mental Health Equity, Morehouse School of Medicine, Atlanta, Georgia

Resident, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California

Clinical and Forensic Psychiatrist, Office of Diversion and Reentry, Los Angeles, California

Luke and Grace Kim Professor in Cultural Psychiatry and Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, California

Founder and Principal Consultant, Lorio Forensics; Associate Professor of Psychiatry and Pediatrics, Morehouse School of Medicine, Atlanta, Georgia

Senior Policy Consultant, Social Justice and Human Rights, National Association of Social Workers, Washington, DC

Child and Adolescent Psychiatry Fellow, Vanderbilt University Medical Center, Nashville, Tennessee

University of California–Berkeley School of Law, Berkeley, California

I am a general pediatrician, not a mental health specialist. So why am I writing the foreword to a book about mental health and not children’s health? In part because I am head of the Robert Wood Johnson Foundation, and our focus is on health equity. Also because the issues of social injustice are relevant to all areas of health. I’ve been taking care of children for more than 30 years, always in the setting of community clinics, providing services for children on Medicaid or without any health insurance at all. Over the course of my career, my perspective on health and my role as a physician has changed dramatically. Early on, I focused primarily on the list of items I was expected to cover at each well-child check: nutritional assessment, developmental assessment, various types of screening, and, of course, immunizations. I knew the guidelines from the American Academy of Pediatrics and the Centers for Disease Control and Prevention inside and out. My questions focused on teaching parents and children about health and healthy behaviors.

“Where does your baby sleep? It is important to put your baby on his back to sleep. That can reduce the chances of sudden infant death syndrome.”

“What are you feeding your baby? Breastfeeding is best.”

“What does she like to drink? Sugar-sweetened beverages are empty calories.”

“How many hours is he sleeping? Sleep is critical. “

“How much screen time does she get? The Academy recommends no more than 2 hours per day.”

“Let’s talk about physical exercise. The CDC recommends 1 hour a day. How many hours does your child get?”

I’d march through the questions, document the answers in the electronic medical record, and order age-appropriate tests and vaccinations. Mission accomplished. Yet something about these interactions felt unsettling. So many of my patients and their families were struggling, and the issues that concerned them were not always physical ailments. Instead, the issues were the broader challenges in their lives. I was their doctor, but I wasn’t dealing with the full picture of their well-being.

When I began working at the Robert Wood Johnson Foundation, I learned much more about the deeply rooted structural barriers that were impacting my patients’ physical and mental health. And I had to ask myself a difficult question: Was the way I was delivering care part of the problem? The painful answer was “yes.” I had to take a hard look at the assumptions and biases I was carrying into the clinic with me. I had to slow down. Ask more, and different, questions. And really listen. Then my understanding started to change.

I remember a conversation with a grandmother in Harlem. She was caring for her two grandsons, ages 9 and 11. I asked about physical activity, and she told me that her kids got only about 30 minutes of exercise twice a week, in school. I started to tell her about the CDC guidelines, and she stopped me. “I know that,” she said. “But it’s not safe for them to be outside playing in our neighborhood.”

There was another conversation with a mother whose toddler son had asthma. We had been trying different approaches with medications, but he still kept ending up in the emergency department. Her son was allergic to dust mites, and as we continued to talk, I learned they lived in an apartment plagued with them. She had asked her landlord repeatedly to do a deep clean and make the place safe. But he was unwilling, and she didn’t have the resources to do it herself or to move.

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. To have care about the conditions of the communities in which our patients live. And we have to weigh the impact that unfair policies have on their opportunity to thrive. Otherwise, we’re not getting to the heart of the matter; we’re just nibbling around the edges, and our treatment plans will continue to fall short.

I live in Princeton, New Jersey. It’s the town I grew up in, and it is also the home of the Robert Wood Johnson Foundation, where I work. Life expectancy for a child born in this largely white, affluent community is 87 years. It has some of the best schools in the nation, secure neighborhoods, and ample green space for outdoor activities. I volunteer in a medical clinic just 14 miles away, in Trenton, New Jersey. These two cities are in the same county, but they might as well be on different planets. Trenton is not affluent, the population is mostly Black, and the life expectancy for a child born near the medical clinic is 73 years. That’s a difference of 14 years in 14 miles. I think about that every time I make the drive. The families who live in Trenton and Princeton all care about their health and well-being. They have the same dreams and aspirations for their children. They work hard and strive to prosper. So how is it that one community can provide so much opportunity for health, while another just down the road makes it so much harder?

We like to think of America as the land of opportunity, but that opportunity isn’t distributed fairly, and that is why social justice is a health issue. Access to jobs that pay a living wage is a health issue. Transportation is a health issue. Our nation’s long history of racism and intentional segregation is a health issue. And the ongoing legacy of prejudicial policies that have kept families of color from building generational wealth is a health issue.

This book, Social (In)Justice and Mental Health, stresses the indisputable connection between equity and well-being. The authors recount how racism and other forms of injustice have contaminated the mental health profession, from the biased development of criteria for various diagnoses to the inequitable ways that patients are treated. The authors argue strongly and convincingly for a new approach to mental health care—one that acknowledges social injustice as a root cause of mental suffering. And most important, they offer individuals in the profession a path toward positive change.

I’m writing this foreword in the year 2020, when the critical need for structural change throughout every segment of our health care system has been laid bare. The unprecedented confluence of a viral pandemic, economic devastation, and a nationwide antiracism movement this year has revealed profoundly devastating fissures in our society, with Black, Latinx, and Indigenous people suffering and dying from illness, police violence, and racism at rates that surpass their proportion of the population.

How will historians record the reckonings of 2020? What will they write about our responses? Will they say we recognized the connections between social justice and health? Will they say we consciously worked to dismantle unjust systems?

The authors of this book believe positive change is truly possible, and that is what makes their insights so powerful. What could our nation look like if every health care provider embraced working toward social justice as a fundamental part of their profession? I’d like to think historians will point to 2020 as a true inflection point in America’s road toward health equity and social justice. This book is an important part of that journey. And for those of you in the field of mental health, you can start by turning the page.

Our first round of edits for this book took place on a work retreat in San Miguel de Allende, a city in central Mexico named for General Ignacio Allende, a prominent figure in Mexico’s War of Independence. The city is famous for its well-preserved colonial and Spanish architecture, so on one of our breaks, we took a guided Tacos and Tequila tour through the rolling cobblestone streets, around the tree-lined town square, and under the twinkling string lights. Despite San Miguel’s namesake, the tour guide, a friendly Latinx man in his early twenties, defaulted to telling the city’s story from the perspective of the Spanish conquerors rather than that of the oppressed Indigenous people or the victorious revolutionaries. After a few tequila stops and our repeated nudges to share the landmarks’ real stories, he opened up not only about injustice in San Miguel de Allende but also about his personal experiences of injustice in the United States.

Although born in Mexico, he came to the U.S. with his family when he was very young. He grew up in Florida and Georgia and stayed clear of the authorities—until he was flagged as undocumented during a minor traffic stop. Unsure of whether he qualified for the Development, Relief, and Education for Alien Minors (DREAM) Act, and without the money for an immigration attorney, he had never pursued that path before his arrest. He was incarcerated immediately. The funds his family scraped together to pay an attorney were pocketed by the officer of the court who did nothing to help him.

After being jailed for over a year, our affable tour guide was deported—away from his family of origin—and returned to an unknown and unfamiliar country. Although he had some extended family in Mexico, the loss of his home and the trauma of his incarceration led to despair and self-medication with crystal methamphetamine. He spoke of his path to recovery and his family’s reality in the United States; how fear of deportation and mistreatment by those in authority relegated his loved ones to going straight from work or school to home; how their lives were defined by work, constricted by the need to lay low, and shaped by fear of detention and deportation. He openly shared that despite his path and the uphill battle he faced after his forced relocation to Mexico, he was happier now because he felt mentally freed. As two so-called experts, we were humbled by what our guide taught us about the power of perspective. We left San Miguel de Allende with a renewed appreciation for the humanity of the people we often overlook and for the direct impact that society’s choices have on the mental well-being of these individuals.

Our last round of edits for this book took place on our home soil as we, two Black women in opposite corners of the United States (California and Georgia), watched the most dramatic manifestations of the devaluations of Black lives in our lifetimes. Coronavirus disease 2019 (COVID-19), with its first U.S. case in northern California, laid bare the deadly implications of chronic, intergenerational health, employment, and socioeconomic racial inequities, exacting an age-adjusted death rate for Black people at 3.6 times that for white people. Meanwhile, the shooting death of Ahmaud Arbery in Georgia bubbled beneath the national consciousness until the nation watched George Floyd die with a police officer’s knee on his neck. The two men’s names became part of a tragic trio, also including that of first responder Breonna Taylor, who was killed by police while asleep in her home, bound together in protest chants of “Say Their Names.” The killing of George Floyd broadcast to a world slowed by COVID-19, imprinting on the American psyche the words first made famous by another unarmed Black man killed by police, Eric Garner: “I can’t breathe.”

COVID-19 is literally taking people’s breath away. So, too, is the killing of unarmed Black people. Injustice and oppression take lives. And they shape them. An understanding of social injustice must inform every aspect of how we think about mental health and substance use disorders, their diagnosis, and their treatment. We edited and finalized this book in equal measure tired, afraid—and resolute. We are frankly fed up with every system, including our own, that perpetuates rather than fights injustice. We humbly hope that Social (In)Justice and Mental Health becomes part of the arsenal for mental health professionals who understand that without justice there can be no peace.

For the two of us, psychiatry is not merely a chosen specialty, a career, or even a profession—it is a calling. We are privileged and grateful to contribute in some small part to the dynamic, multifaceted, exciting field of mental health—a field in which relationships change lives. For two Black women psychiatrists in an occupation in which only 2% are Black, this privilege is even more profound. We hold the mental health profession in high esteem. We know how much it matters to our colleagues, our patients, and our larger society.

It is for this reason that we insist on viewing the field with an unflinchingly critical eye. It is for this reason that this book’s content is informed by data rather than by sentiment. And it is for this reason that we concluded that this book could not be named Social Justice and Mental Health as we had originally planned. In compiling this book, the recurring theme throughout the research, editing, and revision process was one not of justice but of injustice. While it is true that inequities in mental health are complex, are deeply entrenched, and have multiple drivers, it is also true that society’s pervasive injustices permeate our field, our diagnoses, and our systems. Our profession, shaped and practiced in the context of oppression, also plays a major role in perpetuating and sustaining inequity. Our relentless focus on individual pathology relegates social injustices to the periphery of our diagnostic formulations. However, on the basis of society’s declining mental health status and consistently poor outcomes for many, our current approach has not been effective.

The authors of this book endeavor to introduce many readers to the concept of social justice and the outsized, but often ignored, role that social injustice plays in the identification, diagnosis, and management of mental illnesses and substance use disorders. Social injustice sustains mental health disparities and inequities, leads to reliably poor outcomes for highly treatable illnesses, and limits the potential for recovery.

Many great minds have attempted to solve the issue of mental health disparities in the United States. Highly intelligent, multidisciplinary teams of experts have come together to examine the literature, determining that patient-, provider-, and systems-level factors lead to disparities in health outcomes. Professionals in the mental health field have attempted to tackle this problem head-on, with significant focus on trying to address what can be more readily changed: patient- and provider-level factors. These efforts have led to training mental health professionals to be culturally competent, educating patients to reduce their stigma about mental illnesses, and encouraging patients to access care. There has been significant progress in these areas, yet mental health disparities and inequities persist. As professionals and as a society, we have neglected to tackle systems-level barriers with the same fervor and intensity as patient- and provider-level factors. It is time to examine the structures and systems that are driving mental health disparities and inequities.

This book is divided into four parts. In Part I, we define the foundational elements and theories of social injustice. In Part II, we describe the role of systems and structures and how they interact with mental health. In Part III, we discuss specific mental health conditions and diagnoses, reanalyzed through a social justice lens. Finally, Part IV is a guide on how to take action to achieve mental health equity. Of note, the various categorizations for people used in this book are reflective of contemporary academic and journalistic practice and the publisher’s conventions. However, they do not necessarily reflect how members of these groups would categorize themselves. Furthermore, these categories are neither static nor precise. With time, and as a more representative group of those being defined become definers, it is anticipated that understanding will evolve and, in turn, so will the terminology for these categorizations.

We anticipate that this book will affect readers in different ways. Some of you have been on the front lines and in the trenches, doing the hard work for quite some time. You have championed issues of social justice throughout your careers and have dared to speak out against injustice, many times at risk to your own professional aspirations. You have inspired us to continue when things became difficult. We are honored to be members of this shared, supportive, and courageous community. Consider this book our thank you note for your work—we acknowledge the sacrifices you have made to advance mental health equity and we hope this book provides you with a scholarly resource to help support your ongoing efforts.

Some readers will find aspects of this book challenging because of their personal, lived experiences (past and present) with structural violence and social injustice. For these readers, we hope that our attempts to shine a light on a neglected area in mental health do not lead to vicarious harm. Please prioritize your well-being with multiple check-ins and a focus on self-care as you read this book.

Other readers of this book will struggle with the content. These are difficult and uncomfortable topics. The discussion of these issues stirs up many emotions, including sadness, guilt, anger, fear, and resentment. You may perceive us to be accusing you of some of the behaviors described in the book, including racism, classism, sexism, ableism, homophobia, transphobia, xenophobia, and others. You may perceive us—especially as two Black women psychiatrists—as having a specific political agenda and lacking in objectivity. We have faced harsh, irrational, and even racist criticism before. But the issues delineated in this book are not going away. As mental health professionals, we have a responsibility to face, explore, and examine complicated emotions—in our patients and in ourselves. Complex emotions may arise for those who have never considered these topics before, for those who have considered them with alternative theoretical frames from those contained herein, and even for those who have been championing these issues for decades. If you happen to notice some of these negative emotions rising in you, please take a moment to stop, take a deep breath, and practice self-reflection. Be willing to sit with and explore the emotion for a bit. It is an opportunity for growth.

Often, as mental health professionals who support patients in confronting hard truths about their past, themselves, and their relationships with others, we tell our patients that they may feel worse before they feel better. This is because we know that confrontation, while necessary for healing, is hard. We know that uncomfortable truths that are tucked neatly away and compartmentalized impair functioning. As mental health professionals, we acknowledge that therapy is challenging, but we insist that it is worth it because the process will leave our patients more insightful and better able to build the lives they desire.

To our valued colleagues, for many of you, this content will be similarly challenging. Confronting hard truths about our profession’s past and present, while demanding, is needed for us to do this vitally necessary work. In the words of James Baldwin, “Ignorance, allied with power, is the most ferocious enemy justice can have.” As mental health professionals, we enjoy many forms of privilege—our income, education, and titles, to name a few. Our work and our approach can shape life trajectories. Our assessments, diagnoses, treatments, and administrative choices hold power. For far too long, we have wielded this power ignorant to the oppressive context that weighs on the backs of our patients’ lives. Our ability to heal has been impaired.

So, in recognition that the content will be challenging for some because it contradicts current beliefs, we offer a few guidelines for how to go about reading this book. First and foremost, please consider reading with an open mind and an open heart. Consider the personal perspectives and the lifetime of experiences that you bring to your profession. And consider—as difficult as it may be—that the frame of your worldview may be flawed because these structural inequities are so ingrained in our society that they have essentially been rendered invisible. With this book, we aim to make the invisible visible. However, there must be an openness to receiving this information in order to see that which is not readily apparent and that is in conflict with what you sincerely believe to be true.

We encourage all who engage with this book to do so at a slow pace. As we have discussed, the content requires self-reflection, and progress from self-reflection takes time and effort. Our expert authors have taken great pains to make the content as readable, scholarly, and thoroughly honest as possible. By design, the chapters are relatively short so that a chapter can be read in one sitting, followed by ample time to reflect on the reading. To help guide your reading, we have included three self-reflection questions at the end of each chapter. Take the time to consider them. To that end, it might be helpful to read this book with other people and to dialogue about the content with other mental health professionals who both share and disagree with your perspectives.

We are indebted to our chapter authors, who contributed to this work beyond measure with their perspectives, their expertise, and their fearlessness in expressing truth, anchored in deeply intellectual thought. Additionally, this work could not have been accomplished without the loving support of our families and friends, the guidance and wisdom of our mentors, and the energy and creativity of our students and trainees. But most importantly, this book would not exist if not for our many patients, past and present, who have taught us so much about dignity, resilience, and courage in the face of insurmountable obstacles in their lives. They are our inspiration and the reason why we cannot fail in our task.

As the editors of this book, and more importantly, as your colleagues who are privileged to do this work, we have prioritized the examination of hard truths about our practice, our profession, and our society over the employment of euphemisms or strategic omissions in the hopes of striking a more optimistic tone. Rather, this book’s critical and, at times, righteously angry tone is rooted in something much more important: the optimistic belief that all of us hold untapped potential to advance mental health equity and the genuine hope that, collectively, we can make meaningful progress toward this goal.