What Is the Psychiatrist’s Role in Addressing Mental Health Inequities?

“When day comes, we ask ourselves where can we find light in this never-ending shade?

The loss we carry, a sea we must wade.

We’ve braved the belly of the beast.

We’ve learned that quiet isn’t always peace,

And the norms and notions of what “just” is isn’t always justice.

And yet, the dawn is ours before we knew it.

Somehow we do it.

Somehow we’ve weathered and witnessed

A nation that isn’t broken, but simply unfinished.

—Amanda Gorman, “The Hill We Climb”

The year 2020 was indeed a transformative one for America. The COVID-19 pandemic’s physical and mental assaults, increased focus on racial injustice in response to highly publicized Black Americans’ deaths at the hands of police, and a uniquely polarizing presidential election by a deeply divided populace culminated in an overt attack on American democracy. As experts in human behavior and psychopathology, psychiatrists struggled to make meaning and provide context for these major events, not only within our clinical encounters, but also within our own professional circles.

Psychiatry’s previous attempts to understand major shifts in the psyche of our society have frequently failed to consider the role of social injustice. Although some psychiatrists are primarily focused on social justice issues, the topic can be met with a high level of skepticism and pushback by others. As we endeavor to provide the highest quality of assessment, diagnosis, treatment, and management of mental health and substance use disorders, we have often been guilty of a major omission: that inequitable mental health outcomes are by design—and caused by the systematic and structural oppression of certain groups.

Many of us are aware that mental health inequities exist. For example, Black people are more likely to be diagnosed with schizophrenia than a mood disorder compared with White people. Indigenous people are more likely to be diagnosed with alcohol use disorder than White people. Transgender youth have higher rates of suicide attempts than cisgender youth. Women have higher rates of depression and posttraumatic stress disorder than men. Black and Latinx people are less likely to receive treatment for serious mental illnesses and substance use disorders than White people. The list goes on and on.

As psychiatrists, we have increased our understanding of the role of the social determinants of mental health in contributing to these poor outcomes and inequities. We have begun to understand that intervening at the level of the risk factor is insufficient for true healing, as social determinants of mental health (for example, adverse early life experiences, discrimination, poverty, unemployment, lack of access to health care, and food insecurity) set the context that creates and perpetuates the risk factors that lead to mental illnesses and substance use disorders. However, as we begin to consider the role of social injustice in the creation of poor mental health, we come to understand that intervening at the level of the social determinants is also insufficient, as the underlying context that creates social determinants is social injustice itself or the unfair and unjust distribution of opportunities and advantages in society.

This unfair and unjust distribution of opportunities is entrenched by public policies, or the laws we pass as a society, and social norms, the core beliefs that we have about people in society. In the United States, we have many negative social norms about the worthiness, goodness, or deservingness of Black people, Latinx people, Indigenous people, Asian people, poor people, people with disabilities, LGBTQ people, Muslim people, Jewish people, women, people with mental illnesses and substance use disorders, or any groups that do not fit the primary group that has been most elevated and advantaged in our society—White men. As a result, we have passed laws and created public policies that align with these beliefs and that also benefit the perpetuation of the existing hierarchy. Psychiatry is no different, as we have built the very structures and lens by which we identify and assess what is pathology and what is normal behavior through this same frame.

This may seem overwhelming, even bleak, but there is hope. With an increased understanding of how social injustice perpetuates mental health inequities, psychiatrists can begin to take an active role in the process of dismantling these toxic structures. So, precisely how can psychiatrists begin to take action?

First, psychiatrists must dedicate themselves to increased awareness of social injustice. Second, they must reflect both on their internal states and on their practice settings and radically examine their role in the maintenance of social injustice.

We have much work to do on this issue. In a recent survey conducted by APA’s Task Force on Addressing Structural Racism Throughout Psychiatry, in response to the question, “What are the top three ways that institutional racism is reflected in APA as an organization?,” the second most common response was “None,” meaning that a significant number of psychiatrists in APA do not see institutional racism as an issue. How, then, do these psychiatrists accurately and empathically assess, diagnose, and treat patients for whom institutional racism is a defining element of their existence? The likely answer is simple yet alarming: They probably do not.

As James Baldwin wrote in his 1972 book, No Name in the Street, “It is certain, in any case, that ignorance, allied with power, is the most ferocious enemy justice can have.” Psychiatrists must take an active role in educating themselves on social justice issues, which are not traditionally covered in medical school, residency, or continuing education programs. Knowledge must then be paired with action: advocacy for patient care, clinic procedures, and public policies that counter social injustice across a variety of settings. Policies impact private practice, group practices, large clinics, and health systems. Psychiatrists must work with diverse stakeholders to examine these policies through a mental health and a social justice lens, supporting change that helps people with mental illness and substance use disorders who have traditionally been oppressed and marginalized.

Finally, psychiatrists must speak out against injustice and oppression as expressed by our social norms. Our voices have power and privilege, and far too often, we use our singular voice for personal gain or our collective professional voices to maintain our own power and privilege. However, our role as those who purport to champion mental health demands that we use our voice on behalf of those who are systematically silenced, understanding that oppression is a critical public mental health problem that cannot be avoided or ignored. Admittedly, advancing social justice is not easy, but it is psychiatry’s unfinished work. ■