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The Impact of Race and Racism on Mental Health Outcomes

Achieving positive mental health outcomes in the context of race and racism begins with awareness and action. Clinicians are motivated to relieve negative symptoms and support wellbeing; however, their work rarely promotes anti-racist values such as Learning from History; Sharing Culture; Developing Leadership; Analyzing Power; Networking, Maintaining Accountability; Gatekeeping; Organizing, and Undoing Internalized Racial Oppression. The contributing authors to this article focus our attention on the multiple realities for people who seek help. We become aware of the myriad of ways to create an anti-racist environment and the actions necessary to reach that goal.

Armed with research findings that illustrate “the over-diagnosis, misdiagnosis and under-diagnosis of mental disorders in people of color,” Ben Kohl provides the broader context and helps us define a model of anti-racist clinical practice. He argues that if the intent is to improve mental health outcomes, anti-racist principles must be integrated with clinical treatment. His insights remind us, that our clinical work does not have to contribute to racial oppression, and sets the stage for learning how to better serve people of color. He asserts, “We must not only meet clients where they are but listen and create opportunities for them to tell us where we are.”

In “They Spoke about the Things that bothered them,” Milta Vega-Cordova invites us to listen to the dialogues of several women who participated in a long-term research group that focused on the disparities in women’s physical and mental health in several communities in the Bronx, New York. We learn from the women’s narratives about the blatant aggressions and micro-aggressions they experienced from systems that claimed to help them. They tell of the careless assumptions made by mental hygiene professionals that caused them further hardships. When the dialogue ends, many of us wonder how we may have unknowingly contributed to the racial oppression of our clients.

Kimberley Richards’ contribution, “Community Sage,” helps us to see how a wise woman guided her family, her community and local institutions to health by using anti-racist principles. Looking through a different lens, we see community leaders like Ma Richards, as true organizers, a traditional/non professionalized clinician, and a natural leader.

What Does Anti-Racist Clinical Practice Look Like?

Clinical social workers treat the mental, behavioral and emotional disorders of individuals, families and groups using numerous modalities and theoretical orientations. Most of us are trained to assess the biopsychosocial needs of individuals and provide interventions that embrace a person-in-environment perspective. While clinical treatment can ameliorate symptoms and empower clients to manage mental illness, it often has little to do with an essential anti-racist principle: organizing.  Mental health and sociological outcomes, such as the misdiagnosis of people of color and disproportional representation of children of color in foster care, reflect the need to integrate anti-racist organizing principles with clinical practice.

As the Antiracist Alliance gained momentum in New York City and increasing numbers of social work practitioners and educators attended the Undoing Racism workshop many of us struggled with how to integrate what we were learning into clinical practice.  The workshops resonated with our values, renewed and deepened our awareness of the impact of the race construct on our lives, and began to change the language we used to understand our profession.  We also began to understand the limitations of the treatment models we subscribed to and how the service delivery systems we worked for often perpetuated systemic racism.  As we recognized our role as gatekeepers and endeavored to increase our accountability in dismantling the race construct, we were challenged to integrate the skills and tools we used in our profession with the call to organize.

One place to begin is in organizing our educational and training structures to teach racial self-awareness before cultural knowledge.  Our field has done a remarkable job in identifying norms and values that need to be understood in order to engage assess and treat people from specific ethnic and marginalized groups.  However, without an awareness of how practitioners’ social identity group memberships impact the dynamics of helping relationships, culturally specific knowledge is less likely to have traction in clinical practice. Research I conducted at the Jewish Board of Family and Children’s Services associated significantly higher multicultural knowledge scores with clinicians who had attained a threshold of racial self-awareness.  This suggests that clinicians who understand this county’s race-based power arrangement are more likely to seek out and integrate culturally specific knowledge needed for effective practice.

An important caveat is that racial self-awareness (and this was especially true for white practitioners in the sample) leveled off and even decreased over time, unless clinicians had been involved in further training or projects with outcomes related to dismantling racism. This finding emphasizes the importance of understanding antiracism as an ongoing process with the need for regular “tune-ups.”

Even when clinicians have a healthy level of racial self-awareness and are knowledgeable of the backgrounds and lived-experiences of the people they are helping, consumers of mental health services still need to be engaged in a therapeutic relationship before they can be accurately diagnosed and successfully treated.  When clinicians are able to integrate an understanding of the race construct into their practice many clients will more freely relate their problems of living and current attempts to solve them. How do we organize clinical practice to more effectively engage consumers?

One way to begin is by analyzing how power is reified in our clinical settings. The magazines and art in our waiting rooms, questions on our client satisfaction surveys, and level of consumer involvement on our advisory committees are necessary, but not sufficient ways to value community participation and flatten hierarchy in service delivery. Antiracist clinical practice must also embrace who and how we hire and the resources we assign to supervision. We need to invest in ongoing training not just to serve the community, but whenever possible to be trained by the community. In the clinical hour as in the management of our programs we must not only meet the clients where they are, but listen and create opportunities for them to tell us where they think we are. The following narratives give us important insights into how to do this.

They Spoke About Things that Bothered Them

These narratives from women using mental health services shared incidents that made them feel shame, less than and abused… At times, there were deafening silences in our meetings and at other times overwhelming, unstoppable laughter shook the room. The women that joined us were the leaders, the strong advocates, the victims and the survivors of what we saw as the disparities in women’s health and mental health services. Because of what they experienced, they came together to help us create something “different.” For six years we heard their stories and worked together to build a strong net that would work for them. In the end we developed a national model, “Community Centers of Excellence in Women’s Health”, that was funded by the Department of Health and Human Services’ Office of Women’s Health.

The following are a sampling of the narratives that helped shape health and mental health services that were accountable to a community struggling with racial oppression.

“I have to go to the clinic every couple of weeks. They say I am high risk because of the diabetes and because of the depression. I have my mother to take care of. Sometimes I just can’t make it. The clinic is always so crowded and I have to wait all day to see someone. It never is the same the person. Sometimes I just leave, cause I have to go to make sure my eats. She forgets sometimes. They called me “non-compliant.”

We were determined not to impose institutional “gate keeping” or demonstrate the lack of respect for cultural values that this narrative highlights.

“…They don’t know us. They come here to learn on us. I know me and what and who I am. I go to the doctor for the pressure. I eat the low salt and take the pills, but they don’t know a pill for the other things that make the pressure. I have two boys, 30 and 32. They were raised right. I know them but others don’t know them. They just see two black boys, so I worry because things can happen. We know and we have to deal …”

We understood the lessons from history. Women of color are anxious about the safety of their sons from their infancy through their sons’ adulthood. Mothers worry, “will my obviously Latino or African American son survive the day.” Racial stress is a constant in the lives of people of color and has a negative impact their health and mental health outcomes. We accounted for this reality and incorporated stress reduction measures into treatment plans.

“… talking about the doctors. One time, I had a doctor tell me that I had an infection, because I had too many sexual partners. My husband was real mad, me too. He finally said that is not true. It could have gotten crazy. I have the diabetes and get infections when my sugar is high sometimes…”

Misdiagnoses based on racial stereotypes by poorly informed providers add to the community’s mistrust of institutions; ultimately compromising positive treatment outcomes. We were committed to undoing internalized racial oppression and were keenly aware when even our own acts of internalized racial superiority surfaced.

“… my mom is in the hospital and was on dialysis and had a heart attack. She was in a lot of pain in her legs when the doctor finally came. He was mad. I guess we woken him up or something. He said, “do you think Medicaid patients get the same treatment here as the patients on the other side?” I told the nurse and the big doctor (Attending), but I knew the other doctor was right. My mother was always scared at the hospital and didn’t want me to talk too much. She was scared they wouldn’t help her if I did.”

In each of these stories the proverbial “elephant in the room,” racism, colored the lives of each of the women and their outcomes. The project ended after six years. Many of the women returned to doing what they always did, and others courageously maneuvered the systems that served them and their communities. We never asked them if we could be there, but when we left, they thanked us. They taught us well that undoing racism had to be a fundamental part of treatment for people of color to achieve healthy living.

Community Sage

Every village or community has leaders, sages, wise men and women providing wisdom and guidance to its members. One such community sage is Martha Reen Alfred Richards. She was the wife of the late Henry W. Richards Sr., is mother of five children, grandmother of eight and great-grandmother of four.

Mrs. Richards began counseling and monitoring the human development of her customers in her beauty shop. Many represented three or four generations of a family, which allowed her to observe patterns, behaviors, and correction/treatment efforts for more than forty years. At the same time the Richards family not only parented their own children, but many others who were not related by blood, but circumstance.

Faced with her son’s drug addiction and the pregnancy of her teenage daughter, Mrs. Richards was able to reflect on the challenges faced by others while mapping out a treatment plan for her own children and family. She became the lead therapist and service provider for her own children and in doing so formally began her role as Community Sage.

Mrs. Richards saw the new baby as gift to the family versus the sole responsibility of her daughter. This family ownership enabled the teen mother to graduate high school attend college and earn a doctoral degree. When Mrs. Richards saw her son’s behaviors change from being a very trustworthy person to someone who broke commitments and lied, she knew something more was going on than alcohol and marijuana. Ultimately her son was placed in an inpatient treatment facility.

Affected by her son’s addiction and the drug epidemic consuming the community, Mrs. Richards organized a neighborhood block club. The Club grew into the Southwest Gardens Economic Development Corporation, providing comprehensive services to the community, and she would go on the establish UNITY House in 1989.

Her early work with UNITY House residents established a personal relationship that transformed how the professionalized mental health providers worked with residents at Unity House. She did not define the men in recovery by their addictions or their pathology, but viewed them as whole with aspirations and gifts. Thus, she worked with them from a place of humanity and not pathology. This produced results and provided a difference paradigm for professional mental health providers who were 99% white with pre-conceived notions about African Americans, and poor whites. In the twenty years that Unity House operated, over 1000 men resided there. More than 50% remained drug free and stayed involved in community work. Although subsequently closed due to funding, the impact of Unity House continues to be felt in the community.

Mrs. Richards exemplifies the principles of a community sage. She is one who uplifts individuals and collectives while being venerable, uplifted by individuals and collectives in return. She is one who serves and leads with an understanding of racism, history, culture, while being a gatekeeper committed to developing leadership and accountability. She believes in people and in the community from a place that speaks life into situations and moves as if it is already so.

Andrea Harnett-Robinson, ACSW, LCSW, is President, Harnett-Robinson Consulting. Kimberley Richards, EdD, is Regional Organizer/Core Trainer, The People’s Institute for Survival and Beyond. Milta Vega-Cardona, MS, is an Organizer and Trainer, People’s Institute for Survival and Beyond. Ben Kohl, PhD, LCSW-C, is Director of Mid Shore Programs, Eastern Shore Psychological Services.

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