Mental Health Mosaics
Mental Health Mosaics
Racism and Mental Health
Racism directly affects people's mental health, and there's racism within mental health systems. During this episode we explore these issues through poetry with M.C. MoHagani Magnetek as she shares her lived experiences. We'll also discuss ways to make mental health systems more equitable and more effective through an interview with professor and psychiatrist Ruth Shim.
Learn more about all of these issues on our website mentalhealthmosaics.org.
Racism and Mental Health
[00:00:00] Anne: Welcome to Mental Health Mosaics, an exploration of mental health from Out North, which is located on the unceded traditional lands of the Dena'ina People in Anchorage, Alaska. I'm Anne Hillman.
On this episode we're talking about racism and mental health, both racism within mental health systems and how racism in general affects mental health. We're talking about really painful stuff, like police brutality and misdiagnosis, so please care for yourself. Later in the episode, we'll also get into ways to shift the mental health system to start to solve the problems with psychiatrist and professor Dr. Ruth Shim.
We're starting this episode with another poem from M.C. MoHagani Magnetek, an African-American transwoman poet and activist, that speaks directly to police brutality, white supremacy, and pain. She puts all of these issues into context of her lived experience with mental health issues. Here's MoHagani:
[00:00:57] MoHagani: The title of this poem is “No Justice, George, No Peace Breonna,” clearly written in 2020.
Where are you now that George Floyd has died? Are you down and ready to ride? Take no more with your last breath? Let the system burn ‘till there’s, nothing left, but the hardcore reality that Black lives matter. Water cooler convo field with chatter, calling into question your humanity, like a grudge Corona, got a grip on sanity.
Got folks, sick, tired, hot bothered, and sad. Everybody. And their mama all pissed off and mad about a Black woman shot and killed in her own house. Don't act like you don't know Breonna Taylor's who I'm talking about. So, yeah, don't worry about that. Bucket of water. Remember the centuries of genocide and slaughter superiority complex can be unlearned.
And so what the roof is on fire, let it burn, give them, give them no choice, but to listen and respect our voice, get your hands out my pocket. No means no, we said stop it. Murderers getting paid on administrative leave promoted for using their needs to choke hope out of the people. All lives matter. Come on, man?
That shit ain't equal. Tell me what's making a difference supposed to look like. Match struck fireworks in broad daylight. No longer satiated refuse to be placated until the killing of our people ceases. If there's no justice for George and Breonna, there will be no peace.
[00:02:56] Anne: When we were talking about this episode of Mosaics and we're talking about, you know, mental health and oppression, like what made you think this poem? What about this poem made you associate it with mental health?
[00:03:09] MoHagani: Right. Well, you know, I think this, this episode's not just oppression, but we're talking about white supremacy.
We're talking about, um, structural institutionalized systemic internalized racism. There is, um, there's oppression and there is class issues, you know, police brutality, some serious things going on, right. But we must talk about these things and they like greatly affect every aspect of our lives. Racism and white supremacy are so invasive and not just how our lives access to healthcare, access to wealth access to, you know, to housing and, and, you know, treated fair fairly in the courts, but it impedes on our, on our own lives, you know? When you go home and like, you know, you're trying to mind your business, you know, just, just chilling, but you gotta, you know, watch, you know, catch the news clip or whatever, you know, now they got, what 11 white jurors and one, one Black juror on Ahmaud Arbery’s case, what's that about? Right. And I want to say, you know, attitudes have changed, maybe won't be so bad, but no, clearly there's a problem there, like what does that say? That message.
So it's just like hard, you know, you know, you can't like just come home and take racism off of you. Right. You just, you just can't go home and get rid of white supremacy because there's no food in the refrigerator. You know why you don't have any food? Is it? It's not always from my lack of trying.
It's the fact that, well, you can't get a job because they're not hiring Negroes today. Period. And that's that. And, and so, and this is like one hurdle after another one challenge after another, it impedes on our, on our personal relationships and the way we interact with one another, especially when we think about and talk about internalized racism, right?
So in, in, in this poem, I talked about superiority complex can't be unlearned. Well, just as, you know, European white Americans have been able to adopt this attitude that this superiority over people, you know, um, as people of color have often like, you know, internalized racism where we’re like inferior. Another word that I don't use, I don't use, but I can't say it is minority, right? There's nothing minor about me. Period. End of discussion on that. But, but to say that, that I’m minor I'm internalizing, it's like, I'm less than, and, and I'm not. So, and that plays into it, right. Internalized racism can, you know, make me like straighten my hair, perm my hair when my hair is like naturally curly, right? It’s kinky and stuff.
Internalized racism's like you see it in, in like many, uh, on a continent Africa, you go on African stores. I haven't seen here in, here in Anchorage. Yes, I have. I've seen them every place I've gone and gone to African stores to get traditional African food has always skin lightener there on the shelf somewhere, you know?
Right. So, you know, to lighten our skin to, to, to be more passable and, and you know, things, or one of the things that I remember, like learning, too, is like how you gonna interact with the police? Don't look them in the eye, you know, it'll say, cause you don't want to be confrontational, you know? And at one point in time in American history, you know, it's like if I'm walking down the street and there's some good, you know, old white folks walking, I had to like, you know, step off to the side and let them have the sidewalk that does what the days he was living in, you know, when we talk about segregation.
I'm not that old, I'll be 46 in January. I am. I am that old, right? I am that old, because I had my grandmother, I had my parents' memories and their experiences, how my grandmother's memories that I know of, right? Maybe things will start getting out of reach when I no longer have people like that to connect it, but then I still have the history books.
And I love history. So for me to like, you know, read about the past, I'm like experiencing this thing now.
[00:07:22] Anne: I mean, you tied directly to what Meda was talking about in the last episode where she was talking about how history reverberates through, and you're not disconnected in your, even if it's not in your living memory, it's still connected to you and the people around you.
[00:07:37] MoHagani: Totally, totally, totally. Like, you know, when, uh, what was it 2013? When I was like, you know, being discriminated against for using the ladies room at Humpy’s downtown. And, um, when I finally like, like left there and I was on my way home, I was like crying. I was like, how can this be? I've never been told where I can not go into.
I was never, I had never been discriminated against. I said, why is that? You know, it says, because like my ancestors, my African, African-American ancestors, like, you know, from. 1954 Plessy vs Board of Education, you know, the sixties and seventies, civil rights, man, you know, laid it all out on, on the line, just so I'm not like, you know, segregated against, you know, discriminated against, I can be in public situations.
You and I can use the same, like, ladies room, you know what I mean? Um, I can do those places. I had never, like, interacted, had to experience that type of discrimination in my lifetime. Now maybe, you know what I'm saying, job application or something like this that wasn't like overtly but then we, now we talking about this covert racism can, all those things factor into it.
Yeah. And you know, some things, some days I'd be like, wow, when I see the things that's happening in our world, right.
And I was like, man, this is like this, this post-George Floyd murder life is actually pretty good. You know, it's, it's sad that he had to, you know, he had to die. Breonna Taylor had to die, but there are things that are changing in our society, in our culture, in our attitudes and our mindsets. For the better.
[00:09:16] Anne: And you feel like that's holding true a year and a half later?
[00:09:19] MoHagani: Yeah. Yeah. I, I still think so. It's not just a trend, you know, trends, you know, cause like last time, you know, summer 2020 was nice. Nice. I didn't have to open any doors. You know what I'm saying? White folks would just like step out of the way, like, you know, hold the door open for me, you know, just to go into the, to the, to the grocery store.
I definitely see it a lot more in, uh, in the nonprofit world, in the arts world, there's, you know, more push to, you know, to, to get Black artists out there. It's more push for, you know, recognizing, uh, indigenous people and POCs.
You know, w we'll see, but I think the whole nation burning, the whole world burning, you know, summer 2020, like it really, really changed some things for us. So, but yeah, it's more, it's always more work to go.
You know, one more thing I say about racism that's important, too, is that it's a weapon that any, anyone can pick up and use at any given time. White folks do not have the monopoly on racism. Do not own a monopoly on racism. And I was like golly. I get into with some old Black folks, my friends and everything. They'd be like telling some old racist jokes about Chinese people or Japanese people. It's like, no, that's not cool, period.
Under no circumstances, we just, because we've internalized racism, we experience oppression don't mean you gotta turn around and treat other people like crap, period. Don't do it. You know? So those are the conversations that need to be had too. ‘Cause we, none of us are absolved from using this, you know.
Me personally, I've given it to characters in my stories, you know, it's like, I feel like saying some racist stuff, so I'm gonna put it on the character, like get it on out there for me, you know? But those attitudes are real and they’re genuine. And within our own cultures and language, we all have these very derogatory terms and names for other people, other cultures that they may not ever hear or know, because this is our own life language system. The only internal codes that we using, you know, da da da da, to speak ill about other folks.
But white folks don’t have the monopoly on racism and people need to learn to deal with that.
Um, but yeah, so, you know, in, in this piece, I've just like, you know, asking this question, where are we, where are we now?
You know, George Floyd has died as murder. Like what are we going to do next? You know, are you ready to, to like go and affect change in community, you know, help other people, uh, make our culture better, you know, community better by having these hard conversations on race in America, the hard conversations on, colonization, you know, don't, don't really want to talk about that.
But yeah, racism and white supremacy. It's a beast.
[00:12:11] Anne: Have you experienced that like in your treatment for, for mental illness? Have you experienced, like within the mental health system, people being white supremacists or being racist or just pushing ideas on you?
[00:12:30] MoHagani: Yeah. I mean, definitely received some stuff from, from, uh, patients that I was hospitalized with. You know, that's what, the thing that we, you know, we talk about mental, uh, health and being hospitalized. Oftentimes we talk about what it's like, you know, with the doctors and nurses and have been treated certain kinds of ways with them based on.
Um, and I that's it's, it's, it's difficult for me to say. Um, why people are discriminating against me sometimes. I dunno if it is because of race or because of gender, sometimes it's both. And, but I know it when I felt it, and I've had experienced quite a bit, a bit of that. Um, and I've been in a lot of different hospitals and, you know, Staten Island, um, Atlanta, Georgia, here in Anchorage, and I've been to every one but API.
You know, and so, uh, and I've been treated like, you know, sometimes in very, uh, disrespectful ways, neglectful ways, um, just this dismiss. Right? And like I remember this time where I had, um, a manic episode, I was, I was suicidal after being, um, kind of like, you know, just, just, I don't know what to say.
I, I want to say it was an attack was too strong, but this white man, basically, like he asked me was a woman or a man. And I says like, I have a dress on, I have these nails and have this lipstick on. I had black lipstick on that day and he grabs my head and he twists my head. So I can't tell your lipstick take apart from your face because you're Black, you know?
And then as I was moving away, he, you know, moves to like lifted up, my dress. And so when I called Alaska State Troopers about it, this was like 2017 around Labor Day. And. You know, and, and, you know, in, in when I call the trooper, it was like, yeah, I'm a look, you know, go, go, go check this out. Now my license has been changed, you know, to reflect that I'm female, my name is legally changed and everything.
So the officer was like, yeah, you know? Yes, ma'am. So he goes and talk to the other people to get their side of the story. So, but when he comes back and he's talking to me, he's like, misgendering me, what? You know, he's talking to me and it doesn't tell him. He says, well, this is a, it's a non-reportable crime.
Like what's a non-reportable crime. Basically, you're telling me what happened to me, a Black woman is not worth filling in some funky boxes. What happened to me wasn't worth that.
So when I'm and I'm hospitalized, you know, and I'm telling, you know, the, uh, the doctors and the nurses and the counselors, my experience of how, like, you know, this manic attack, this, this, this psychotic episode, this suicidal ideation stems from, you know, how I was treated, you know, racially discriminate against at Humpy’s racially attacked by, by, by this man here that, that plays into why I'm there in the hospital. Can they empathize with that? No, well, we don't know what to say, but you should definitely try this medication. See how you feel tomorrow. You know, that's just what it leads to. Cause you know, many of these doctors and physicians are not people of color, so they don't know what these experiences are like, you know, and how it actually factors into, uh, depression and, and, uh, and, and, and mania and panic and anxiety attacks, you know?
So yeah, that's like, you know, a major part, but I guess I started to say too, one of the things that they'll talk about is when you are hospitalized, you also are in there with other people who are, you know, going through some things.
However, they may have mental health issues, but they're still bringing themselves there. They’re still bringing their racist ideas. They still bring their transphobic ideas to the group, their homophobic ideas to the group, to the meetings, to the setting. And it's been taught, you know what I'm saying? It's like, yeah, you know, the counselors do the work in like setting these ground rules and stuff, but every now and then someone breaks these rules and says something very hurtful to another person. You know, why are you, why are you trying to get care and treatment? I just want to get, well, I don't want to have to, like, deal with no racism and transphobic stuff right now. You know, like, can I just be, you know, a patient?
But yeah, that's, that's my poem in the essence though, to, to, to speak to that. And to talk about, um, you know, specifically this one speaks to, you know, the deaths of Breonna Taylor and George Floyd. We’re talking about police brutality here. We talk about systems and we talking about like over four or 500 years of this captivity, like. And it's, it's, it's living with memory, you know what I'm saying? My great-grandma, grandmother, grandparents can, can tell me what it was like, you know, growing up as children and sharecropping that's, you know, it's not that far away.
MUSIC TRANSITION
That was MoHagani Magnetek talking about poetry, racism, and mental health. MoHagani's experiences are unfortunately not unique. Discrimination has a direct effect on mental health and there is discrimination and racism within the mental health system. To put MoHagani's experiences in a larger perspective I reached out to Dr. Ruth Shim, a Black psychiatrist who is working to fix these problems.
[00:18:12] Ruth: My name is Ruth Shim and I am a psychiatrist. Um, my official titles right now are that I am the Luke and Grace Kim professor in cultural psychiatry at the University of California, Davis, in the department of psychiatry and behavioral sciences. I'm also the associate Dean of diverse and inclusive education in the school of medicine at the University of California, Davis. Um, and so those are the, that's my day job. That's what I've been working on for the last couple of years. And, um, yeah, and I've been a psychiatrist for about, um, going on nearing, nearing 20 years now.
The work that I do is, has been really rewarding and, and I've managed to see a lot of, kind of the field of mental health. I see a lot of, um, what's wrong with, with mental health that particularly in this country, and that has led to me, um, trying to come up with solutions for how to fix some of the problems and the system as it relates to mental health.
[00:19:19] Anne: I really appreciate that about your work, that you're not just like, this is wrong and this is wrong, but this is where we go from here.
[00:19:26] Ruth: Yeah.
[00:19:27] Anne: How did you end up in psychiatry to begin with?
[00:19:31] Ruth: You know, it's interesting. I, for whatever reason, since I was really young, have always been interested in mental health and psychiatry, and I have no idea why, but I always tell people when I was like 10 or 11, I would read a Time Magazine articles about people with mental illnesses and I was always like, I remember there was a fascinating article in Time about, um, clozapine one of the, uh, drugs that treats schizophrenia and I read it cover to cover. And I found it so interesting and I was really young. And so I don't know where that interest comes from, but his, it has always been there for some reason.
Um, you know, as I have gotten older, um, clearly I've encountered lots of family members and friends that have struggled with mental health problems and substance use disorders. And so that kind of increased my interest, um, especially, um, the fact that. Uh, how those illnesses in my family and friends, how they were kind of not discussed all the time, how, how people kind of avoided the topic, uh and so that really led me to, to kind of strongly want to do something in the mental health world. Uh, I majored in psychology when I was in college and wanting to be a physician and decided to go to medical school and started out medical school, pretty certain that I was going to do psychiatry. And then, and then, um, somewhere in the middle of medical school started thinking that, um, Well, I had a lot of stigma about being a psychiatrist and the idea that people don't always view psychiatrists as like real doctors.
Um, and, and this idea that I was, you know, spending all this time and work to become this physician and to get this MD degree. And then, you know, to have people not know that I was an MD, I was like, can I spend the whole rest of my life? Um, having people not know that about me, like, you know, I'm, I'm working so hard.
Like I kind of want people to know like my efforts. And then, and then I did my psychiatry rotations as part of my medical school. Um, and I liked everything that I did in, in medicine, but I loved psychiatry. My psychiatry rotation. It was, it was just like the only rotation where I would wake up in the morning, like fully excited to, to just be at work and be interacting with patients.
And so I realized I needed to, um, not worry about any of those other concerns and just follow my passion.
ANNE: What do you think it was about being, like doing psychiatry that really just resonated with you?
Uh, I think that, um, It it's it's it's just to turn that question a little bit, you know, I, I think that people have a really strong perception of what a psychiatrist is.
There's like a, uh, an image of a psychiatrist and often it is like an older white man on a couch, um, you know, talking to a patient in, in his office. Um, and, and that is kind of the image of what a psychiatrist is. And I, um, you know, I, I just felt like there was more, um, there, there is more for what psychiatry should be.
And so I was kind of drawn to the idea that, that I wanted to change the perception of, of psychiatry and I wanted to change, um, how people view that field. Um, and, and really, because I think I was seeing so much, um, mental health problems everywhere, you know, like everyone is dealing with mental health problems.
Everyone is dealing with substance use disorders. This is, like, pervasive. And, and I didn't feel, I felt like the, the images of what a psychiatrist was were so removed from the day-to-day reality of what regular people are dealing with. And, and I really wanted to kind of think about how can we make this more accessible for people.
So that, that's one of the reasons I went into psychiatry because I wanted people to kind of look at me and say, oh, this is somebody that I could, um, go and see and talk to about my mental health problems. And maybe it's not like super expensive and maybe it's not so hard to access services. And maybe it's more about like trying to solve regular everyday problems that people have as, as it relates to mental health.
[00:24:02] Anne: I like your vision of what psychiatry could be.
[00:24:06] Ruth: Yeah. We're not there yet. We're not there yet, but I, I'm really encouraged because there's a lot of young people coming into the field that feel just like me and a lot of people that, um, have, have looked at the problems that we see in our society, the ways that so many people are having, um, uh, mental health issues, uh, and that they're not being addressed.
And, and how it's an equity issue in particular, how certain populations have less access to mental health services and substance use services and how, um, just the very nature of being oppressed and marginalized in society leads to, um, mental health problems, um, just by navigating the world when you're being discriminated against or when racism occurs.
And there are more and more people going into the field of psychiatry now that understand those things really clearly when that was never something that was highlighted, um, in traditional psychiatry training. So I'm really excited and hopeful for the future because I do think the field and the face of psychiatry is changing.
[00:25:16] Anne: That's really exciting to hear, because I mean, I fully admit that I come into it with the same biases of thinking, you know, you picture the New Yorker cartoon, and yeah, I don't view that as helpful. Whereas, like I talked to all these peer support specialists who have lived it, you know, and I'm like, oh yeah, you're the one I want to talk to.
[00:25:37] Ruth: Exactly. And that's the thing, you know, the, the other, um, perception that old perception of psychiatry is pretty elitist. Um, it's this idea that only certain people have expertise and everybody else should not be involved in the care or management of people with mental health issues. And so there is no space in that old model for peer specialists.
There's no space for psychologists. There's no space for social workers. And a large number of psychiatrists are still kind of like fighting. Fighting, um, other fields around prescribing rights, um, as if this is like the most critical issue that we have in the field of mental health. It's, you know, people do not access are not able to access mental health services.
And so if there are models that are trying to increase access, I, I don't understand why we spend so much time arguing and kind of excluding people from providing services and providing support, which is what many psychiatrists, uh, do. At least many psychiatrists of old do. And I, and I do I, again, one point out that I do think that coming into the field now and moving us in a new direction, there's a much more inclusive model for how psychiatry should be provided. There's much more thought that it should be done in teams, not this individual provider sitting on his couch, waiting for people to come in the office, but that teams, including peer specialists and psychologists and social workers and all number of people, work together to provide more population level care to people with mental health problems.
[00:27:18] Anne: That's, it's exciting to hear that you see that evolution happening.
Um, so let's take a step back and talk about where we were before we could talk about where we're going.
Um, I was, I was interested in talking to you because you were so open about talking about the inequities in mental health care, um, and how we got there. And I was wondering if, if you could talk about that place.
[00:27:45] Ruth: Yeah. So the reason that I'm so interested in inequities is because w the same as we talked about before, like the training that I got, and I got a great psychiatry training, and I had a great track psychiatry training experience, but that training involved, um, you know, providing the evidence-based treatments that we learn about to different populations. And I trained at Emory university. And one of the interesting things about Emory in Atlanta is that the training sites, there's two separate training sites. One site is at Emory University hospital, which is located distinctly in the suburbs of Atlanta, in the richest part of Atlanta.
Um, and then the other training site is Grady Memorial hospital, which is the poorest parts located in, in the city and downtown Atlanta in the poorest part of the city. And so you had these two sites and residents and trainees would rotate at both of these sites. And, um, what I started noticing kind of very early on in my training is that I'm the same provider. Um, and yet, and I'm doing the same thing. So I'm providing the exact same treatments and I'm talking to people exactly the same way and I'm prescribing the exact same, um, recommendations. And we're doing all of the same things around caring for these patients. But the outcomes for the people at Emory University hospital were completely different from the outcomes of people at Grady Memorial hospital.
And the difference was people for instance, with depression, when we, uh, when I would see them at Emory University hospital, I would treat them and we would prescribe medications and we would do therapy and they would get better. And then I would rotate at Grady Memorial hospital and do the exact same thing and they would not get better.
And, and I couldn't. I, I couldn't fundamentally understand, or I wanted to understand, what is happening here. Again, I'm, I'm no different, um, and the environments are different, but like, it's this, as, as many people have started, have posited, is there something about the population? Is there something intrinsic about the people at Grady Memorial hospital versus the people at Emory University hospital?
I couldn't figure it out. And one of the things that I remember thinking is the old models of, of education have really highlighted that those differences are the result of, um, biological or genetic differences between races and ethnicities or these differences are the result of cultural differences between, uh, racial and ethnic groups.
And none of that really made sense to me. And so that really started me on a journey where I started to understand that it's, it has very little to do with any of those things, and it has everything to do with the environment, um, with what we call the social determinants of health. Um, those factors where we live, learn, work and play that impact our health.
That these are the reasons why you see these huge differences and just the very, um, act of living in a neighborhood that is well-funded and well resourced versus living in a neighborhood that is underfunded. And under-resourced that those things can lead more significantly to differences in mental health outcomes.
Um, and those are the, and that's where we have to focus our interventions.
[00:31:24] Anne: So that seems completely logical to me. So why was that ever in question? Like why was that not ever just…
[00:31:36] Ruth: I take it, it's a great question. And, um, I think it's because, um, the people that have spent time in the field, um, did not have the experience of what it's like to be in a neighborhood to grow up in a neighborhood that is under-resourced and underfunded, um, or they didn't have the experience of, um, encountering, um, and, and interacting with people outside of that clinical environment, interacting with people that are from those under-resourced, um, and under funded neighborhoods.
And then, you know, there is this, this big, um, elephant in the room, which is structural racism, and it is so pervasive, this idea that our institutions have been built and created and, and have been, um, set up to advantage certain populations and certain racial and ethnic groups and disadvantage others.
And so that frame, um, medicine and psychiatry has operated in that frame since the beginning of time. Um, and so we, we have passed those values on, um, the idea that we look at a, um, an illness or we look at a condition and we say, um, that, that, that group has that condition because that group makes different choices, makes worse choices about their health or that group has that condition because that group, um, has a higher genetic predisposition to have this particular diagnosis or this particular problem, or, you know, even things like, uh, the, the belief that certain populations are more prone to use certain drugs um, uh, when, when that's, that's not been proven in any sort of way. So we've got all of these ideas and, and with that structurally racist frame that we all marinate in, in society, it's very easy to kind of err on the side of thinking that these differences have nothing to do with the social determinants and have everything to do with people's personal choices and individual decisions that they make.
[00:33:49] Anne: I feel like that's, that's a common, though less common than it used to be, story that's often told in Alaska, especially about Alaska Native people and, you know, indigenous people are more prone to being alcoholics when it's just…
[00:34:05] Ruth: That is one of, exactly, indigenous people and alcoholism is probably one of the most pervasive examples of mental health inequities um, in which many studies have been done, looking at genetic predisposition, um, to try and find the gene that exists among indigenous populations. So the gene that exists in Alaska Native populations that predicts higher rates of alcoholism with no understanding or consideration for the historical trauma that has been visited upon in indigenous populations since the founding of this country.
And the idea that, that historical trauma, that trauma, um, may in fact lead to, uh, through historical, um. uh., epigenetics may lead to gene changes, but really it is an environmental and a structural impact that leads to, um, uh, coping or a self-medication, um, through alcohol that is really driving this. And yet people want to say that this is some sort of biological or genetic, um, influence, or that again, Alaska Native populations, indigenous populations are somehow just, they like alcohol better, or they, or they make bad choices about, uh, about substances so they, they choose to use alcohol more, um, than other populations. And none of that is really accurate, but it has been very pervasive in, in our society.
[00:35:42] Anne: I have no medical doctors in my family who have told me these things when I first moved to Alaska and I was like, oh, they must know. I was like, okay.
And then you get up here and you start learning the true history. And it's like, oh, Everything, everything I've been taught is wrong. Are there, that's the most pervasive damaging lie? Are there other pervasive, um, assumptions made about Black populations are made about other, um, other cultural groups that pervade psychiatry that you're working to abolish?
[00:36:18] Ruth: Absolutely. And I think one of the clearest examples is, um, is thinking about schizophrenia and, um, the, the ways that we think about schizophrenia as it relates to Black people. Um, and so Jonathan, the author and psychiatrist, Jonathan Metzl wrote an incredible book on this called The Protest Psychosis: How Schizophrenia Became a Black Disease, and he really highlights how, um, in, in, around the 1960s, as we started to see the rise of the civil rights movement, the very definition of schizophrenia was kind of altered from this disease that mostly affected white women who were, um, not operating in their, um, uh, appropriate gender roles. So they weren't taking care of their households appropriately and they weren't cleaning and cooking, um, as much as they should have been and they would find themselves diagnosed with schizophrenia prior to the 1960s.
And then with the rise of the civil rights movement, um, you saw a shift and a definition of, uh, a type of psychosis called the protest psychosis where, um, schizophrenia was kind of reformed by psychiatry into this condition that was, um, that people were considered to be aggressive and hostile and violent and paranoid.
And, and that, um, really took off in the 60s and was really associated very particularly with Black, um, Black people and particularly Black men. Um, and so the very act of championing civil rights or the very act of trying to fight against, uh, oppression was mislabeled, um, in the minds of many white psychiatrists was mislabeled as a psychotic illness.
Um, and, and, and it's, it's really complicated because it's not even that it wasn't that there were, uh, there weren't some, there wasn't psychosis happening. So in some of those populations, there was a psychosis happening because stress induces psychosis. And so, um, those men and women that were fighting for civil rights were under higher levels of higher rates of stress and so they were in fact maybe some of them were having psychotic symptoms at times. But not because of the context by which it was defined and not because of the act itself of, of, of protesting and fighting for civil rights.
So what, what we saw in that time was really an erasure of context, a lack of understanding of how, um, the history, the socio-historical context by which somebody operates in, um, dictates their behavior and how behavior is, natural and normal behavior could be, pathologized to, to be seen as something, especially if you come from a place where you don't understand that context.
That behavior could be pathologized and, and, and attributed again, the hostility, the aggression. And, and so that happened in the sixties. And again, documented really well in the, in the book The Protests Psychosis, but that happened in the 60s. But what we have here in modern times, which has been really well studied by many researchers and could, including Steve Strakowski is that we see inequities in all sorts of outcomes, as it relates to, um, people of color and Black people and schizophrenia.
So Black people are more likely to be diagnosed with schizophrenia than with a mood disorder, like bipolar disorder or depression compared to white people. And, um, they're, they're, they're misdiagnosed, so they may have bipolar disorder and they're misdiagnosed as schizophrenia.
[00:40:08] Anne: Can you help me, um, I guess, understand the differences between these two diagnoses and kind of, yeah, understand the differences in why it matters if you're given one, versus the other, like with one student
[00:40:21] Ruth: matters a lot because of treatment options. And so when you have a mood condition, the treatment is a mood disorder. The treatment is often very different from a primary psychotic disorder.
And so, um, if you don't, if you're misdiagnosing the condition, you're often then providing the wrong treatment. Um, and so if somebody is not getting the most effective treatment for their condition, then they're not going to improve. And so, so what you see is in this particular population, a misdiagnosis followed by then, um, not the right, uh, management of symptoms, so a lack of improvement and then, um, you see these populations having again, worse outcomes.
So, so if you have misdiagnosed Black people, um, at higher rates, then those people do not recover completely from their illnesses. And then we look at like rates of, of, um, treatment responsiveness. And we say this particular population does not respond as well to this particular medicine or this particular therapy when really what it came down to was that the diagnosis was wrong in the first place.
Um, but even beyond making a mistake in the diagnosis, um, we also see things like, again, associated with this, this conceptualization of aggression, we see things like Black people are more likely to be put in seclusion and restraints. Um, when they go to the hospital for emergency psychiatric care, they're more likely so they're more likely to be seen as hostile and aggressive. They're more likely to be given, um, antipsychotic medications against their will to manage their behavior. Um, and they're more likely to be given higher doses of those antipsychotic medications. So, so the management, uh, in addition to the misdiagnosis, the management in crisis situations is, is more harmful.
Um, and like a very clear example I can give you is from my personal, um, clinical experience I've had, um, there, there are many different medications that you can use to treat psychotic symptoms. But one of the medications, an older medicine haloperidol is a medication that back in the 60s, um, when they were, uh, very strongly associating Black people with aggression and psychosis and schizophrenia, um, there were ads that you started to see, um, pop up in, um, psychiatric journals, which showed like a threatening aggressive Black man, um, and, and the, the headline on that ad the tagline on that ad set aggressive belligerent cooperation begins with Haldol. Um, and so what you've seen over time is that that particular medication somehow became associated in the minds of psychiatrists with that direct marketing with, oh, this is the medication you use when some, when a Black person presents with schizophrenia and is aggressive.
And so that marketing was very effective because, um, last year, one of my patients had to go into the hospital. Um, and I have, I have him on an antipsychotic medication and he was doing reasonably well, but then he had a, uh, a decline in his functioning. Um, and he went into the hospital and, um, he was hospitalized in a psychiatric facility.
And the first thing that the inpatient psychiatrist did was remove him from his medicine and start him on Haldol. And I thought to myself, why, why would, would that be the choice, the first choice, you know, and I, I certainly don't want to imply, um, that, that this, this inpatient psychiatrist was racist. Um, but I, but I also think there was a clear connection there because there is this connection in this drug that this drug works in this particular population.
It would be fine if that was a one-off thing, but a year later, uh, another patient of mine who is a Black woman, also went into the hospital because she had a decline in her functioning and she was taken off of her medication and put on Haldol. Now that being said, I have several white patients that when they go into the hospital, they are not put on Haldol.
So, so even today we see these inequities kind of, uh, and, and, and, you know, it's complicated because it's not like Haldol is a terrible medication. Um, but it has side effects and it has, and there are things to be considered, and it's not first-line anymore, really all the time for like ongoing outpatient management of schizophrenia.
And yet the only times that I've seen inpatient doctors prescribe that medication, um, to my patients is when they are, um, deemed to be aggressive or threatening or are, or when they're Black.
[00:45:28] Anne: Wow. Even today, it's like, it's not surprising and yet it's still
[00:45:35] Ruth: shocking. Even, even when it's not surprising, it's still shocking.
Anne: Yeah. Yeah. That's a really good distinction.
[00:45:46] Anne: So looking beyond like, these are heinous things to happen to individuals, but when you're treating individuals are not just looking at an individual, you've got a whole family and a whole community. How, how did these, um, how do these beliefs then spiral out wider into communities?
[00:46:08] Ruth: Um, I think that, I think that we, part of what happens is, as, so we, we are not, we are, we, human beings are not islands. And so we do not operate, um, independently. We operate within our family units. We operate within, um, our communities. Um, and I think that when one person has a negative interaction with the mental health um, system that scars families and communities.
Um, and, and, and again, um, so, so we know that, and I know from personal experience, you know, if you experienced discrimination, if you experienced mistreatment, when you go for, uh, services or care somewhere, um, I have never returned to a restaurant that I ate at where I felt I was discriminated against.
I've never once been like, okay, I'll go back there because it was probably a one-time. I always think I have choices, I have options, and I don't need to go to that restaurant again. Um, and so for mental health care, it's a little bit different. Um, people go and they're mistreated and they may be discriminated against in healthcare settings, um, and they then have very limited options about like, how, how do they re interface with that, um, with that setting. And so the damage that can be done, the damage that's done to one person, um, then ripples through that family. And so I spend a lot of time interacting clinically with family members who have been traumatized by watching their loved ones, be harmed, um, in seeking care, or be made to feel less than, or be, or be discriminated against in their pursuit of mental health care at maybe some of the worst times in that family's life when, when someone is in crisis and they need help and they're made to feel less than, and they're made to feel, um, not important and not valuable. Um, and so that then is, causes a ripple effect and then the whole family, um, and the whole community tends to kind of turn away from seeking those services.
And so that's when you end up with this narrative that certain populations, certain racial and ethnic groups, Black and Latinx populations, for example, indigenous populations that they, um, have so much stigma that they don't want to interact with the mental health system. And I'm not saying that stigma doesn't exist and I'm certainly not saying, um, no, there is no stigma, but I actually don't think that the driving factor in minoritized populations or populations that have traditionally been oppressed, I don't think it's actually stigma.
I think it's a very reasonable response to a system that has been harming individuals and a desire not to willingly interface with a system that has, that treats you like you're not worthy or is more likely to put you in seclusion and restraints when you go for crisis help. You know, I think that it's a very reasonable thing, not to want to interact with that system.
So it's not a stigma problem, as much as it's, uh, a general reasonable response to a trauma being elicited on you. And so then the, the, it's really important because the intervention is very different. So many times people say, oh, there's stigma in these particular populations. So we have to educate people on how important it is for them to seek mental health services and how important, and that is not where the emphasis needs to be.
The emphasis needs to be on us, improving the mental health system and to be providing, um, culturally humble services and structurally competent and structurally humble services that values and appreciates people and makes them feel, um, important and, and cared for. Um, and if we fix the system to be more trustworthy, then people will engage with the system more.
So it's not about educating. Um, it's not about educating certain populations and say, oh, you know, come, come to our health care system. If the onus is on the providers and the people in the healthcare system to make it a better place for people to enter.
[00:50:35] Anne: And you, you've done some work trying, like, talking about specific ways that could happen. What are specific ways? Like what, how can we make the mental health care treatment system actually responsive to people in a more inclusive? Not my, I hate the word inclusive,
[00:50:53] Ruth: I like the word inclusive.
[00:50:58] Anne: I think, I feel like I've encountered, oftentimes people are like, oh, let's make it inclusive, but they don't really,
[00:51:04] Ruth: there is no action following the inclusivity. Yeah, I hear you.
[00:51:09] Anne: So that's, I guess that's what I mean, like how do we make it like actually inclusive and mean it?
[00:51:16] Ruth: So I, I feel, I think there's many ways and I, um, but I, but I think that the lack of inclusivity and real action behind that inclusivity has to do mostly with power and power dynamics and who has power and who doesn't.
And so if we start to kind of like tease that apart, we see systems that are designed, um, to make it clear when people interface with those systems, that the people who have power are powerful, um, and that the people who don't are made to feel less than. And so then the work becomes unraveling that hierarchy that we have created within our mental health systems.
And that can happen on multiple levels. But I think the quickest way, the quickest way to get there is to have the people working in that system, be the very people, be the very people who are actively, um, from those communities and members of those communities.
That's when workforce diversity becomes most important because, um, because that is not the traditional ways that mental health clinics are designed. the mental health clinics do not traditionally reflect the demographics of the population that they're serving.
And so it, it really does. So it's not just a matter of, um, of, of creating a more diverse workforce. It's truly having the people that work in that particular mental health setting be from the very community that they're serving and look, and be those members of that community. And this is one of the reasons why I am so kind of supportive of the idea of peer specialists, because it is, it is, that is the very function of, of a peer specialist to be a person from the community who has lived experience, who knows exactly what it feels like to go through this situation and to be able to provide that care and support.
And that is the fastest way that we will make the settings, um, we, we will redesign these settings so that people can come in and feel valued and feel important because they are the setting. They are the people that are in that setting. And so that's the work that we have to do. Um, and that involves across all levels, um, aggressively diversifying the workforce.
Um, and we talk about workforce shortages and all of that, but I think we need more psychiatrists of color. We need more psychiatrists from oppressed and marginalized backgrounds. We need more sociologists and social workers and psychologists and peer specialists from, from all sorts of backgrounds.
Um, and that is the way that we, um, change, change the system and, and truly build an inclusive, um, mental health system.
[00:54:16] Anne: I'd like to delve a little bit more into, um, you kinda touched on people's lived experience and bringing that in and, and social determinants of health. Um, I'd love to kind of talk more about what can be done or what you're advocating people within the mental health field to do to really account for all of these other factors that influence our mental health, as opposed to just seeing a therapist or a psychiatrist.
[00:54:47] Ruth: I think one of the best ways that people can start to take action is by increasing awareness.
Um, and, and so I think that the mental health field, as it's kind of currently structured, spends a lot of time thinking about the individual patient that sits in front of, comes to the office and sits down in front of them. Um, and does an assessment that again, doesn't have all of the context in place and particularly the context that I think most providers miss when they do an evaluation on a, on a client or a person with a mental health problem is that they're missing the structural components.
They're missing that understanding of how those social determinants are interacting directly with that individual. So they're not understanding how, um, access to healthy foods or how poverty or how adverse childhood experiences or how homelessness or housing instability, um, they're not always understanding, uh, or how discrimination and racism and sexism, how they're not always understanding how those things show up in people's lives and they're not searching for it.
They're not asking questions about that. So they're not asking people about their identities. They're not trying to understand like who this person is and how the external world, um, has, has interacted with that person and who they are and who their identity is. Um, and I think that, uh, if, if we, as providers don't do that work, um, we're, we're dropping the ball on, on taking care of whole people and moving them towards health and wellness.
So, so the, the key, um, and the first step is recognizing that when somebody comes and sits in front of you, um, for an evaluation or for help, and, uh, in managing their mental health, that they're not just some diagnosis or they're not just some condition, but they are like a whole person who brings multiple identities and multiple, um, beliefs and, and, and multiple cultural, um, cultural identities to, to who they are and that, and that the job of the provider is to understand better that person's story and how they interact with the world and how the world interacts with that person.
So some people talk about this in the concept of structural competence. And this is again, um, Jonathan Metzl and Helena Hansen. This is work by Jonathan Metzl and Helena Hansen, um, to think about how we talk about cultural competence. We, we, we talk about how it's important to understand that there are lots of different cultures and understand the groups, um, that different cultures have different values.
But part of what structural competency is saying is we have to better understand how all of those social determinants show up in people's lives. And we have to be better at identifying those social determinants and asking people about those social determinants and thinking about that context.
[00:58:05] Anne: So to put this into terms that aren't using, like structural competency or social determinants, like basically helping providers, but potentially also helping individuals understand like all of the different factors that are happening around them and how that influences them from the stress of not having enough food to the stress of being discriminated against to the stress of having to navigate complicated systems that weren't built for you to navigate.
[00:58:39] Ruth: Exactly. Exactly.
[00:58:43] Anne: Making sure that I could explain this the way it's supposed to be. Explain it's it's
[00:58:46] Ruth: You explained it beautifully. And I think, um, that, that that's the key is, is that's not the model by which most psychiatrists are trained. Psychiatrists are trained to say, what are your symptoms? Um, you know, how much have you, you know, what's your appetite been like?
So like ask about appetite because appetite is a symptom of depression and poor appetite is a symptom of depression. Um, so ask if your appetite has changed, but not ask how, how, how easily can you access food? How easily can you access healthy foods? Um, do you have food insecurity?
And so there's like a number of the symptoms. So, uh, lack of sleep is, um, another symptom of depression. And so we ask those questions, how's your sleep, but we don't ask, um, is there like noise in your neighborhood that prevents you from sleeping? Is there, um, you know, are you witnessing violence or are you experiencing things that are interfering with your sleep that aren't just, I have this symptom of, of insomnia.
So it's really about it's, it's about going deeper and understanding how those environmental factors really do, um, come into play when, and we are social beings that interact with our environment. It seems pretty obvious, right?
Like we should be assessing how people interact with their environments and what's in those environments. Um, and that is just as critical as just understanding and ticking off the symptoms of certain disorders and conditions.
[01:00:19] Anne: This is going to sound like, like a really basic question, but I would love it if you could talk about, even just really quickly, like how discrimination directly affects mental health. Um, just so that people like grasp that.
[01:00:34] Ruth: Yeah. That's not a basic question at all. Um, uh, it's, it's a great, it's a great question. When, um, when I was working on, um, the book, the book, I edited, The Social Determinants of Mental Health, we were, um, trying to gather all those determinants and look at their impact on mental health outcomes. And there was this really fascinating pattern that we were just, uh, noticing when we were writing that book because we looked at things like discrimination, we looked at housing, we looked at food, we looked at adverse childhood experiences and there wasn't a lot of data out there at the time. And one of the things we noticed is that there was, um, a lot of data that showed, um, for almost all of those social determinants, there was a lot of data that showed, uh, that people, um, have significant physical health problems associated with things like adverse childhood experiences and housing instability and food insecurity.
Um, and there was less data to support that there were mental health impacts. We found them, but they were harder to find. And it was like that for all of the social determinants except discrimination. So for discrimination, there was not a lot of evidence to show that discrimination directly led to poor physical health, but there was an abundance of information and lots of data that showed that discrimination leads to poor mental health outcomes.
And specifically, certain diagnoses are directly correlated with being perceived as being discriminated against. So you actually don't even have to have been actively discriminated against. You, just as an individual, have to feel as if you were discriminated against. And that would lead to an increased risk of a number of mental health conditions, including major depressive disorder, alcohol use disorder, post-traumatic stress disorder, more days of having psychological distress, um, all of those illnesses, um, and all of those mental health conditions are tied directly to the experience of perceiving that you are discriminated against.
And so there's a direct line there. And again, it's really powerful because, um, that data is, is really robust data that we have on this. So absolutely discrimination leads to poor mental health and leads to poor mental health outcomes. And we have really strong data that scientists have been working on for, for decades now that that says that pretty definitively.
[01:03:15] Anne: And so the solution for that is?
[01:03:21] Ruth: Less discrimination. Less discrimination, I think is the key. How do we eliminate discrimination? Um, and, and so, you know, that, that leads a lot of people to say, okay, that's where we have to do implicit bias training. And I do think implicit bias training is one piece, but, but I also, again, I'm back to at least, you know, we can't solve discrimination in the world, you know, like that's too big of a, uh, a thing to address, but we can at least minimize the discrimination that people experience accessing healthcare.
Um, and there is, you know, um, David Williams is a researcher on, on racism and discrimination and health, and he created an everyday discrimination scale. And this is like a scale that asks people how they've been discriminated against in, in, in their lives. And this is where a lot of that data comes from that shows that if you score higher on that everyday discrimination scale, you have a greater likelihood of developing, um, a number of mental health conditions.
And, and one of the things that, uh, happened is that that everyday discrimination scale was adapted for health care settings. And so the same questions are now asked, has a nurse or doctor ever made you feel, um, that you were less than, or talk to you? Like you were, um, not important or, you know, made you feel like you were stupid.
Like those questions, um, that were part of the regular scale have now been adapted for the healthcare setting. So we can't fix all of the ills of society, but we could at least eliminate the discrimination that people experience when they go to seek health care and the discrimination that they experience when they get mental health care services.
And, and again, one of the quickest ways we can do that is by diversifying the workforce, by making sure that there are more people from those same identities providing care, because it's less likely that somebody is going to be discriminated against, by someone from the same group or category that they are in.
[01:05:25] Anne: Anything else you'd like to add before you run to your next meeting?
[01:05:29] Ruth: No, I just thank you so much for the time. It's been great to talk to you.
[01:05:33] Anne: Likewise. Thank you so much for your time.
That was Dr. Ruth Shim talking about racism and mental health. As Dr. Shim said, there are ways to make the mental health system more equitable. Part of that starts with diversifying the workforce and valuing the skills and life experiences that peer navigators bring to the table. Providers also need to consider all of the different aspects of life that influence our mental health, like the resources we have access to and the environment we live in.
During the next full episode of Mental Health Mosaics we'll delve more deeply into another issue that influences our mental health -- our sense of identity. You can find more resources related to all of these issues as well as poetry and art on our website, mental health mosaics -dot- org. If you enjoyed today's episode, help others find it by rating the podcast on any and all podcast platforms.
Today's episode was edited by Susy Buchanan with audio editing by Dave Waldron. Our theme music is by Aria Philips. I'm the show's host and producer. We received funding from the Alaska Center for Excellence in Journalism, the Alaska Mental Health Trust Authority, and the Alaska State Council for the Arts.
Thank you for listening!