My colleague at Baylor College of Medicine Candy Smith and I co-authored a book review of Social (In)Justice and Mental Health by psychiatrists Ruth Shim and Sarah Vinson for the Journal of Psychiatric Practice. You can find the first page of our review here, but see below for full text.
In our review Dr. Smith and I write: “In this multi-authored volume Shim and Vinson thoughtfully and comprehensively investigate the systemic inequities and racist structures that permeate mental health care in the US and that cause—and exacerbate– health disparities and generally worse outcomes for black, indigenous, and people of color.”
Shim and Vinson ask, “Why should clinicians look at social conditions and determinants of health when those factors were not the focus of our training?” and they are unequivocal in their answer. Their response—with which I completely agree—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 socio-economic 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.
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. How does our field do this? In fact, it does so in a myriad of ways, and if you want to explore them read their book to find out.
Near the end of our review Dr. Smith and I write, “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.”
See below for more.
BOOK REVIEW–JOURNAL OF PSYCHIATRIC PRACTICE
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 Psychiatry 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.”(https://www.psychiatry.org/newsroom/apa-apology-for-its-support-of-structural-racism-in-psychiatry)
Psychiatry’s reckoning is 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 up 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 multi-authored volume Shim and Vinson thoughtfully and comprehensively investigate the systemic inequities and racist structures that permeate mental health care in the US 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 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 multi-authored book, state that they hold mental health 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 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 PTSD 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 socio-economic 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, 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), naïve, 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 disproportionately are jailed and imprisoned in the US, 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 factors into a number of specific psychiatric diagnoses, and the last section is a section on how to move forward to try to effect real change. With chapters dedicated 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, there are questions at the end of each chapter called “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 this volume cites 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 the same. And not just mental health care: Social (In)Justice and Mental Health makes it difficult to look at everyday life in the US the same 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.
Recommended Readership: Social (In)Justice is an invaluable resource for all clinicians, educators, researchers, and persons in training who aspire toward equitable, just, culturally responsible, and affirming best practices in mental health care.
Overall Grading: \ ««««« = outstanding (5 stars)
Reviewers: Candy Smith PhD and J. Wesley Boyd, MD, PhD. Michael E. DeBakey VA Medical Center and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX