This post continues our new blog series on poverty. As our nation reflects on its progress in fighting poverty over the last 50 years, this blog series will highlight how psychology can contribute further to this discussion.
By Eric Greene, PhD (Clinical Psychologist)
I would like to address the inherent racism, classism and oppressive dynamics which fill our mental health care system. I would like to highlight three problems and proceed to illustrate these problems by way of a case study.
- Psychiatrists, psychologists and other mental health workers are complicit in further oppressing disenfranchised populations by making patients think their illness is a result of a biological or genetic dysfunction (i.e., the medical model). This turns their patients’ attention away from their oppressive environment and creates stigma.
- Medication can be used as an oppressive tool which can lead to iatrogenic (i.e. illnesses created from the treatment) illnesses.
- Structural racism is embedded in psychological diagnosis, testing and treatment.
These critiques are illustrated in the following case study, a boy with whom I worked. His name and identifying information have been changed to protect the rights of the patient.
Case Study Disclaimer: The names and any recognizable information have been changed to protect the privacy and confidentiality of those involved.
John was an eight year old, African American boy. He had steady eye contact, spoke well, and had normal thoughts. He was dressed appropriately, had normal gait and had above average IQ.
He was referred for treatment by his school for aggression, being unable to focus, for declining grades and impulsivity. This was the second school he had attended in the past two years; he was expelled from the first.
His family life was very difficult. Approximately one year earlier, His father had been sentenced to prison for 10 years for selling drugs, and his mother worked several jobs to keep him and his sister supported. John’s maternal grandmother also provided support.
At my treatment facility, John was first sent to the psychiatrist and was prescribed Adderall for his diagnosed Attention Deficit Hyperactivity Disorder (ADHD), and Aripiprazole (Abilify) for his Oppositional Defiant Disorder (ODD). The treating psychiatrist told John’s mother and grandmother that John suffered from a chemical imbalance, and the medication would correct it. It would help to calm him down, make him less aggressive, and improve his grades. Abilify is an atypical antipsychotic used, originally, to treat schizophrenia. Among the side-effects are headaches, anxiety, insomnia and weight gain—all of which John developed over the course of his treatment. Because he had trouble sleeping (which was not a presenting problem) he was treated with a sleeping aid called Trazadone at a low dose.
He was sent to me to begin individual therapy which he attended regularly two times per week for eight months. The treatment was very difficult. He was an animated (and angry), young boy who was in a lot of pain, desperate for more attention and to have a regular adult figure in his life. His mother was too busy working and struggling with her own illness (i.e., depression) to give her son the attention he needed. His grandmother, while providing support, could not be the primary adult in his life. He was skeptical of getting too close to me, for fear, rightly so, that I would not be there in the long run in his life.
Our work together consisted of talk therapy, play therapy and art therapy. It was evident very quickly that John desperately missed his father, who he loved very much, and that for John, his father’s incarceration was very traumatic. Many of his symptoms resembled PTSD and depression more than ADHD or ODD. As the months passed and the medication became effective, John became more quiet and subdued, and he gained weight. However, he was acting out less in school and at home. His grades remained relatively the same, but he was able to sit still.
John’s mother revealed that she had beaten him physically. She reported feeling stressed out and having a very short fuse when it came to John’s difficulties at school and talking back. She felt very guilty about it, and said that she did not know what came over her sometimes; life seemed too difficult, and she often felt hopeless. On one occasion, she strapped him up in a closet and beat him with a belt, yelling racial slurs at him. It seemed, that the intergenerational transfer of trauma, and the inner city neighborhood in which they lived, created an internalized situation of the slavery their ancestors had experienced. The demonstrated behavior suggests an intergenerational transmission of violence which extends back multiple generations.
During my meetings with the psychiatrist, we would discuss John’s case. Often he would describe John’s situation as hopeless, and the only help that John could get was the miracle of medicine. Further, racist and classist statements flew around the room, the worst of which was from one white, male psychiatrist: “We should just drop a bomb on this whole community and end their suffering. They are evil and broken, they can’t help themselves, all they do is act like wild animals, and there is no way to help them.”
Protesting such racist statements was not effective. No matter how I approached the staff or the administration regarding many of the racist and classist statements and attitudes, nothing changed.
A sense of hopelessness set in me. It was a very dark period in my training as a psychologist. I realized that structural racism has led to a mental health care system that has both given up on and antagonized the poor and the marginalized.
Stories like Johnny’s are all too common within marginalized and disenfranchised populations. However, the origin of one’s illness is not always a biological or intrapsychic one; it is oftentimes a social or environmental one (Arrendondo, Tovar-Blank & Parham, 2008). The longstanding tradition of over-medicating and turning patients’ attention inward to focus on the biological or psychological origins of their suffering, runs the risk of oppressing patients further by denying the effects of their social context.
Structural racism and classism require structural change. Focusing on the multiculturalism, empathy, understanding the ‘other’, identifying microaggressions, and empowerment are all helpful to create greater awareness and consciousness of the problems we face. However, ideological changes are more likely to happen by means of a radical confrontation with a racist and classist system. For example, many mental health workers are joining forces with public policy initiatives to help create structural change.
Eric Greene, PhD, is a clinical psychologist in Los Angeles, CA. He has been working in the mental health field for 10 years in various organizations. He has worked in a hospice center, a juvenile detention center, a private practice, an intensive outpatient psychiatric clinic and others. He wrote his dissertation on the social sources of psychopathology.
Arredondo, P., Tovar-Blank, Z. G., & Parham, T. A. (2008). Challenges and promises of becoming a culturally competent counselor in a sociopolitical era of change and empowerment. Journal of Counseling & Development, 86(3), 261-268.
Leary, J. D. (2005). Post traumatic slave syndrome: America’s legacy of enduring injury and healing. Vallejo, CA: Uptone Press.
Mullan-Gonzalez, J. (2012). Slavery and the intergenerational transmission of trauma in inner city African American male youth: a model program- from the cotton fields to the concrete jungle. (Unpublished doctoral dissertation). California Institute of Integral Studies. California.
Reid, O. G., Mims, S. & Higginbottom, L. (2004). Post traumatic slavery disorder. (n.p.): Conquering Books.
 For a detailed analysis of the intergenerational transfer of trauma within the African American community, see Mullan-Gonzalez (2012); Leary (2005); and Reid, Mims, & Higginbottom (2004).
Image source: iStockPhoto
It never fails to appall me to see that discrimination still transcends historical and cultural barriers to affect individuals today, especially in the health care system. It’s ironic because I’d expect medically trained professionals to remain more objective in their diagnoses, approaching patients with grounded knowledge rather than personal antagonism. It’s equally dismal to think about the “intergenerational transfer of trauma” that John’s mother exhibited toward her son – beating him seemed to have been a response entrenched in her behavior from her own experience that stemmed from the iniquities of the past. However, I feel that the racism and classicism that was present in John’s case demonstrates only partially the structural change that is needed in health care today. In order to tackle the problem of racism in mental health care, would you agree that it is first necessary to resolve the issue of the difficulty in receiving quality care that many mentally ill face? Neglect seems to be the central issue that affects the American mental health care system today as budget cuts eliminate so many of the nation’s available psychiatric hospital beds. The increasingly apparent fact is that there doesn’t currently seem to be enough resources allotted for treating the mentally ill – in fact, in recent years, states have made budget cuts of $4 billion in mental health funding, according to an article I read in TIME by Maia Szalavitz, a neuroscience journalist – and the question is, why is this happening? Why are mental illness treated any differently than physical ones?
In fact, faced with the prospect of not receiving any treatment at all, or receiving hasty and inaccurate diagnoses and subsequently being inundated with ineffective medication as John did, people take drastic measures so that they could force their way into being noticed by the system and obtaining proper attention. Liz Szabo wrote an article in USA Today that highlighted this negligence with Keren Kelley, who suffered from chronic depression and had to resort to swallowing pills to force the system into admitting her. In other cases, parents feel helpless when they cannot present a convincing amount of evidence to admit their children, and some even release custody of their children so that the state might offer them a greater chance at receiving help. Then there are the cases in which children can no longer qualify for involuntary treatment – if they are no longer under the jurisdiction of their parents, and refuse treatment when it’s obvious that they need it, what policy should be adopted for these high-risk-of-violence individuals? Is increased funding really the only way to improve the present system, or would you suggest other approaches to reforming the inefficiency in treating the mentally ill?
Hi Rachelle, you have touched upon so many issues that our current mental health institution struggles with. Thank you for your thoughtful and well articulated response to my post.
I think finances are important, but I do not think that institutionalized racism and classism would be confronted and changed because more money is funneled into our mental health system. Granted, bringing back psychiatric hospitals would increase the number of spaces and locations where persons who suffer from mental illness could find respite, thus diminishing the over-crowded nature of community clinics, but this is no guarantee that racism and classism would be changed. One wonders if the mental health community would broaden the definitions of mental illness so to fill the increased number of hospitals and clinics. Perhaps there would be profit in that process. A good parallel is the criminal justice system. More locations of institutionalization does not necessitate a diminishing of racism. In some ways it makes it worse. Now we have more places to keep persons of color confined and hidden from mainstream eyes. Also, filling prisons with inmates is profitable, so could filling psychiatric wards with patients.
Neglect is something our institution faces, but the neglect itself is political in that the impoverished and the minorities are the ones neglected.
The bigger problem for me is that the disenfranchised and marginalized are part of a social and political dynamic, not a psychological one. WIth increased impoverishment, an increase in racism, there is an increase in stress and an increase in mental illness. When a marginalized or disenfranchised person goes to a mental health clinic for help and are overmedicated or told to focus on themselves, they are further oppressed by the greater political dynamic. In short, the problem is not in them, its in the system, and mental health institutions become more of a form of social control than a place for psychological healing.
I think a good starting is to become as educated as possible about how classism and racism permeate all aspects of culture, even places such as mental health institutions which claim to be locations of healing. I think that we need people to speak up, to join organizations and create social policies.