Social (In)justice and Mental Health

The editors rightly warn prospective readers--mental health professionals with a background of privilege--that reading this book will be disturbing and challenging. If only by implicitly accepting the status quo, professionals unwittingly participate in perpetuating an unjust and inequitable system. Many recognize the social determinants of mental illness--blatantly clear in the mid-twentieth century--but fail to connect these determinants with systemic social injustice. The editors have done a masterful job with this volume: It is carefully constructed and the many authors seem to speak with one voice; it is a consistently clear voice. This is not a polemic; it is a scholarly and solidly researched description of many facets of social injustice as they adversely affect mental health and mental healthcare. It is a plea for advocacy. The authors speak best for themselves:"In the United States, the term health care system is widely understood to be a misnomer.The name implies the provision or maintenance of health, but providers and policies focus on the provision of clinical services. Likewise, care suggests that these services involve meeting the needs of patients, but services are more often centered on the arrangements of providers. Last, system implies an organized, cohesive, and connected structure, rather than the public-private patchwork of health system conglomerates, hospitals, clinics, private offices, and payers that is characteristic of health care in the United States today....We define health care system as the amalgamation of providers of clinical and social goods and services and the attendant payment and policies that support the continued operation of these providers" (p. 126).Childhood trauma is a sadly telling example. "Just as childhood dysfunction cannot be understood apart from the context of family violence and neglect, family dysfunction cannot be understood apart from the context of societal violence and neglect" (p. 190). For example, extensive research on "adverse childhood experiences" (e.g., abuse, neglect, parental substance abuse or mental illness) shows that an accumulation of such experiences is associated with ill health--physical and mental. But the authors point out that this research "does not take into account community violence, structural trauma, racial trauma, or the severity and chronicity of trauma....No consideration is given to societal drivers of parental dysfunction" (pp. 193-194). Critiquing psychiatric diagnoses and treatment of individuals that fail to take the social-political context into account, the authors conclude, "Aided and abetted by the field of psychiatry, our broader society has, quite effectively, achieved a comfortable distance form the issue of children's chronic victimization. However, comfort and distance are luxuries that these children do not have" (p. 204).Two more quotes from concluding chapters will suffice for this short review: "The current U.S. mental health care system is a reflection of a society that has not, to this point, placed value on the importance of preventing mental illness, promoting mental health, or reducing mental health inequities" (p. 221). Lastly, from the editors, Sarah Vinson and Ruth Shim: "This book is about the injustice inherent in society's stacked odds--their drivers, their design, and their detrimental impact on society's mental health. It details how social injustice--rather than individuals or cultural factors--is the antagonist in the narrative of the struggle for mental health equity" (p. 239).Although the book applies to all professional mental health disciplines, psychiatry plays a leading role in the plot. In addition to the editors and authors, I think the publisher also deserves credit in disseminating this vital knowledge: American Psychiatric Association Publishing.