Chapter 1. Social (In)Justice and Mental Health

Extensive debate about the meaning and intent of the term social justice persists, despite its having deep roots in contemporary philosophy. Like many things that are associated with politics, the definition and use of the term have been distorted and misrepresented over time. On a basic level, however, the concept is quite simple. American philosopher John Rawls (2003) defined social justice as “assuring the protection of equal access to liberties, rights, and opportunities, as well as taking care of the least advantaged members of society” (Robinson 2010, p. 79). When stated this way, the principles of social justice seem like values that everyone can support.

Yet in some circles, social justice has a bad reputation. The term social justice warrior, added to the Oxford English Dictionary in 2015, is used pejoratively to describe people who espouse values of feminism, civil rights, and social progressivism. Recently, physicians and others have expressed criticism of the growing role of social justice in medicine, as exemplified by a high-profile op-ed published in the Wall Street Journal (Goldfarb 2019). Doctors and other health professionals have been encouraged to “stay in their lane.” Despite this criticism, social justice is still considered to be the moral foundation of public health. In fact, the American Public Health Association (2020) asserts that structured inequities “sap our potential to become the healthiest nation.”

This book, however, is not about social justice. This book is about social injustice. The United States does not assure “the protection of equal access to liberties, rights, and opportunities” to everyone and does not excel in “taking care of the least advantaged members of society,” to use the words of Rawls (2003). 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 in the United States having tremendous advantages, freedoms, and opportunities, while a growing number of people in the United States are denied liberties, human rights, and opportunities. As a society, we have received—sometimes covertly, sometimes overtly—inadequate explanations as to why this is the case. We are taught to believe in the “American Dream”—that all Americans have the opportunity to succeed if they have enough drive and ingenuity. This dream was founded on the concept of a meritocracy that espouses talent and drive as more important than money and class. However, the American Dream was founded on a lie, one that elevated white men above (and at the expense of) all other groups and ensured that they had the most advantages, liberties, rights, and opportunities. This belief in the superiority of white men when compared with other groups has invaded every aspect of American society, including medicine. In fact, this belief has infected the way we think about, diagnose, and treat mental illnesses.

As the authors explore in this book, our frames for determining what is normal and what is psychopathology are specifically filtered through a lens that has been distorted by social injustice. Why else do we so easily blame individuals for the challenges that they face in trying to live healthy, productive lives? And why else do we focus so singularly on the role of personal responsibility and free will in the pursuit of health?

Social injustice drives both mental illnesses and mental health inequities. Therefore, any discussion of either topic is incomplete without a deeper examination of the connection between social injustice and mental health. Where people live, work, and play has implications for how they think, feel, and behave, and these aspects of people’s lives are influenced, at times even dictated, by social injustice. The varied forms of oppression that groups experience are mentally toxic forces and, when they are perpetuated by societal systems, are profoundly harmful. Every major U.S. system has been created and reformed in the context of social injustice and has, in turn, produced inequitable outcomes. The mental health system is no exception. Mental health professionals may not have personally borne the weight of these forces or may have been privileged to advance in their professions in spite of them. As a result, despite the ubiquity of its manifestations, social injustice is frequently glossed over or rationalized away by many mental health professionals.

Progress in medicine and mental health has led to the understanding that nature versus nurture is a false dichotomy and that it is the interaction of the two that produces health or illness. The next step is to understand the scope of the nurture component. Family dynamics are important but so too are the dynamics of the larger society. Far beyond the cradle to the grave, the interplay of injustice and biological risk starts prenatally and extends through generations. It is no wonder that this results in mental illnesses that manifest differently and at disparate frequencies in oppressed people.

Instructional methods, theoretical paradigms, assessment approaches, and service delivery methods have not resulted in equitable outcomes for two primary reasons:

Our methods, paradigms, approaches, and services are contaminated. To understand individual patients, we as mental health professionals must deepen our understanding of broader society. We must question not only how it has shaped our patients’ personal experiences but also its influence on our professional perspectives and practices.

In the 1990s, the United States entered the “decade of the brain.” Amazing neuroscience advances were made in mental health—especially in understanding that mental illnesses are brain diseases. More recently, a push to integrate neuroscience into training and clinical practice has taken hold (Arbuckle et al. 2017). However, the initial formulations of the biopsychosocial model do not discount the role of the social environment in the shaping and development of healthy brains and in the creation of mental illness. In some ways, in shifting to a neuroscience frame, we as mental health professionals have forgotten the important role of social factors in the development of disease. If we discount the role of social factors in the development of mental illness, then we also discount the social determinants of mental health—the main cause of mental health inequities. It is impossible to even begin to explain the deep inequities in the United States as they relate to mental health outcomes without a fundamental understanding of the role that social injustice plays in the development and shaping of disease. Neuroscience is not irrelevant, but its contributions to social determinants of mental health and mental health inequities are minimal. Attempts to contemplate inequities through the lens of neuroscience lead us at best to consider the importance of epigenetics and at worst to advance a type of biological determinism that implies that different outcomes in populations are the result of underlying biological differences (Graves 2015).

Unfortunately, medicine has long erred on the side of biological determinism and a belief in the inherent inferiority of some groups. In a letter to a colleague in 1931, pathologist and oncologist Cornelius Rhoads described his Puerto Rican patients as

Rhoads went on to have an illustrious career in medicine and was featured on the cover of Time magazine. When the letter was first discovered in 1932, and again later, when the American Association for Cancer Research stripped his name from a prestigious award, Rhoads had several defenders within the medical profession who asserted that the letter was a joke and “intended as a confidential note” (Rosenthal 2003). The fact that Rhoads was allowed to continue and have an illustrious career reflects the way medicine has repeatedly conferred advantages and benefits to some people even when doing so is in direct conflict with the well-being and safety of others.

Several concepts—oppression, implicit bias, privilege, othering, and intersectionality—require a basic level of understanding for readers to engage effectively with the work described in this book. As accomplished and smart professionals, we often feel we have a clear grasp of these concepts, but they are not routinely taught in standard medical educational paths. Thus, we define these important concepts so readers have a more universal comprehension of what is meant when the terms are used throughout the book.

Curiously, many Americans consider themselves to have expertise in issues of race and power, although they may have little by way of training, formal education, or self-study to support this belief. The authors of this book draw from an extensive body of research on social justice, including sociology, anthropology, critical ethnic studies, disability studies, Chicana/Chicano studies, Asian American studies, Black studies, American studies, Indigenous studies, gender studies, queer studies, critical race theory, liberation theology, and environmental studies, among others. The authors build on this immense foundation of scholarly thought because it is quite difficult to come to reasoned, scientifically accurate conclusions without the benefit of this prior knowledge. However, attempts to apply this foundation to the field of medicine and mental health has proven to be challenging in execution because most health professions educators do not have extensive knowledge in these disciplines.

The writer Chimamanda Ngozi Adichie (2009) talks about “the danger of a single story,” in which power can allow people to tell one, limiting story about other groups of people. Indeed, in A History of Psychiatry, historian Edward Shorter (1997) paints an image of mental illness deeply influenced by European and white American ideals and thoughts in which Sigmund Freud and proponents of biological theories reign supreme. The result is a single story of the triumphs, successes, and occasionally failures of psychiatry—without an understanding of how bias, oppression, and structural forces intersect to create a skewed vision of mental health and illnesses in this country. If we neglect to understand the fullness of history, we miss an entire critical perspective, and we are then led to erroneous conclusions about the origins of disease. How can we tell the history of psychiatry without considering the impact of psychiatrist Frantz Fanon? How can we come to understand identity development without reflecting on the work of psychologist Mamie Clark? How can we contemplate teaching about culture and mental health without examining the writings of educator Paulo Freire? And how can we think about adverse childhood experiences without considering historical trauma as conceptualized by social worker Maria Yellow Horse Brave Heart? The single story we have been told is wholly inadequate, and as Toni Morrison said, “It limits knowledge.”

There are some limitations to consider when contemplating the impact of social injustice on mental health. At a cursory glance, it may appear that we are attempting in this book to deemphasize biology and genetics. However, that is not our intention. Biology and genetics indeed play a role in the development of and outcomes associated with substance use disorders and other mental illnesses. It may seem that by choosing to focus on the social determinants of mental health, we are not acknowledging this role. Rather, we posit that the role of biology and genetics is relevant but not as infinitely relevant as we have been led to believe. According to studies of premature death rates (one of the best indicators of population health available), genetics contributes to about 30% of premature death; however, 70% of the determinants of premature death are attributable to environmental factors, behavioral patterns, social circumstances, and access to health care (McGinnis et al. 2002). These social determinants make up the majority of reasons for premature death, and they are intimately shaped by social injustice.

Another limitation of considering mental health inequities through a social justice frame is that it tends to minimize the importance of free will and personal responsibility. These are deeply held American ideals, and, yes, the choices we make contribute to the outcomes and differences in our health. However, the exercising of free will is constrained by oppression, structural discrimination, and social injustice. The statement “the choices we make are shaped by the choices we have” rings true here (California Newsreel 2008). Social injustice limits options and choices, effectively making personal responsibility less personal. Not everyone has the same options; some choose what they perceive to be the best choice from a range of disadvantageous choices.

The path to a mentally healthy society goes through justice. Just as mental health professionals must learn patients’ history and functional impairments to effectively treat their symptoms, we also must learn (or, more accurately, relearn) our society’s history and structural injustices to effectively transform its systems. Even with time and great effort, some inequities may persist. Substantial progress toward mental health equity will not come overnight, and it will not come without struggle. In the absence of knowledge about social injustice, it is certain that mental health equity will not come at all.