October 9, 2021
By Beshaun Davis
The specter of racism looms over the mental healthcare industry and affects the lives of patients in pervasive and insidious ways (Mensah, Ogbu-Nwobodo, & Shim, 2020; Shim, 2021). While renewed awareness of the impact of racism in its most violent forms, due to the murder of George Floyd, has led to many incremental policy changes and self-evaluations, little has been written about ways to best change practices to minimize the impact of racism on engagement in early intervention services. Many have called for the overarching goal of an anti-racist framework but translating this goal to everyday practice remains elusive for many in clinical practice. To minimize the impact of structural, institutional, and interpersonal racism, a basic understanding of the ways that racism impacts the etiology and prognoses of Black, Indigenous, and People of Color (BIPOC) is needed.
Fortunately, the work of Anglin and colleagues offers a comprehensive review of the impact of racism on social determinants of health well before clients even step foot in a clinic (2020). The review offers a useful model that details the foundational impact of structural racism on the etiology and course of psychosis within the context of the racially stratified social structure of the United States. Within this framework, structural racism is the bedrock of a myriad of disparities which lead to the development and maintenance of psychotic symptoms such as the experience of collective trauma in the form of police shootings and heightened police surveillance, everyday discrimination, neighborhood disadvantage, and individual-level social disadvantage. These factors lead to increased stress and a variety of downstream neurobiological consequences such as increased genetic vulnerability for psychosis, heightened stress responses, and perinatal consequences. A similar review focused on the impact of racism for racially minoritized communities in the UK called for the acknowledgement and intervention on the interrelated factors of interpersonal, institutional, and structural racism experienced by BIPOC (Nazroo, Bhui, & Rhodes., 2020).The key takeaway from these reports is that addressing racism cannot be predicated on the interpersonal/individual level interventions. Rather, large-scale systemic change must occur at the structural and institutional level if we can hope to make a dent in disparities in outcome.
So, Where do We go from Here? What does this mean for everyday clinical practice, when even the most well-meaning and socially aware clinicians can still make decisions that reflect institutional and interpersonal biases? The first fact to consider is that simply being aware of these inequities is not enough. If it were, we would not be writing the same articles for the past 50 years. At the individual level reflecting on the structural inequities affecting client participation and engagement such as where clinics are located, access to transportation, and now, in light of the global COVID pandemic, access to telemedicine resources and coming up with flexible and individualized approaches to circumvent these is of the utmost importance. Next, engaging at the institutional level and evaluating things such as perceptions of client risk, diagnostic bias, prescription decisions, presence of translators, and decisions related to involuntary hospitalization is warranted. Additionally, surveying the diversity of your clinical team is a vastly underappreciated and simple solution to increasing BIPOC client willingness to engage. Making efforts not only to recruit, but to retain BIPOC staff is critical. Lastly, providing culturally sensitive care and practicing cultural humility (i.e., acknowledgement of one’s cultural blind spots) can better meet the needs of minoritized communities. On Track New York (OnTrack NY, 2021) has created a useful guide to providing culturally sensitive care in early intervention services. This guide spans various aspects of care including spirituality, culture, language barriers, working with gender and sexual minorities, and youth culture. Though a definitive approach for addressing racism and structural inequity has not been investigated formally, these resources provide a useful jumping off point to guide clinical practice.
Dr. Davis completed his doctoral studies at Indiana University Purdue University Indianapolis, where he gained experience in clinical interventions focused on bolstering metacognition across the psychosis-spectrum. During graduate study, Dr. Davis became interested in the role of clinical insight in personal recovery from psychosis. This led him to complete a meta-analysis focused on the impact of clinic insight on quality of life. Following his graduate work, he completed his predoctoral internship at Vanderbilt University Medical Center in their early psychosis track, gaining experience in coordinated specialty care, inpatient assessment, neuropsychology, and forensic assessments for individuals experiencing psychosis. This led him to pursue a postdoctoral fellowship at the Massachusetts Psychosis Network for Early Treatment or MAPNET, a technical assistance center for early psychosis programs across the state of Massachusetts housed within Harvard Medical School. Dr. Davis’ current research interests focus on investigating real world adaptations to gold standard interventions for people experiencing early psychosis. He has a specific focus on pathways to care and treatment disengagement for people of color living with psychosis.
You can follow Dr Davis @DrBeshaun
1. Anglin, D. M., Ereshefsky, S., Klaunig, M. J., Bridgwater, M. A., Niendam, T. A., Ellman, L. M., … & van der Ven, E. (2021). From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States. American Journal of Psychiatry, appi-ajp.
2. Shim, R. S. (2021). Dismantling structural racism in psychiatry: a path to mental health equity. American Journal of Psychiatry, 178(7), 592-598.
3. Mensah, M., Ogbu-Nwobodo, L., & Shim, R. S. (2021). Racism and mental health equity: history repeating itself. Psychiatric services, appi-ps.
4. Nazroo, J. Y., Bhui, K. S., & Rhodes, J. (2020). Where next for understanding race/ethnic inequalities in severe mental illness? Structural, interpersonal and institutional racism. Sociology of health & illness, 42(2), 262-276.
5. About ontrackny. OnTrackNY. (n.d.). Retrieved September 14, 2021, from https://ontrackny.org/.
This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.