Miraj U. Desai, PhD
Assistant Professor
Department of Psychiatry
Yale University
The American Psychological Association’s new apology and resolutions concerning psychology’s long-standing support of racism and inequity are long overdue. Expansive in scope, the resolutions touch on every sphere of psychology, from education and practice to science and service delivery. And yet, despite now seeking to challenge racism and bias at all levels—structural, institutional, interpersonal, and internalized—the broader field may be only beginning to scratch the surface of the first two domains, on which research and understanding remains limited.
When one does look more closely at these systemic inequities within, for instance, mental health organizations, the problem may prove to be more deeply embedded than imagined. It can even undermine the efforts of well-attuned, culturally responsive care providers. Why? Because the inequities may be bound up with implicit policies and procedures that appear in nearly every clinic. Put simply: What if what the mental health system requires of people to obtain care is the same thing that drives some clients away, including and especially clients of color? This is precisely what we found to be the case after conducting years of research within mental health organizations.
In a study described in a recent edition of the American Psychologist, we interviewed service providers regarding their work with Latinx and Asian clients in the context of person-centered care, and discovered via qualitative analyses that—despite an important explicit emphasis on staff centering their work around persons’ values and goals—there remained an implicit organizational bias against clients who did not fit the system’s hidden requirements and expectations. These included implicit expectations for clients to be verbal, to admit a problem or illness, to accept predefined services, to be proactive, and to focus on the self. Clients that did not adhere to these norms—which have been modeled, in large part, on Euro-American culture—were at risk of reaching roadblocks in receiving care. These structural requirements, found in clinics all over the country, may thus set up invisible walls for those who do not readily fit the taken-for-granted expectations of mental health treatment culture.
In fact, these norms were not just reflective of the organizational culture but became bound up with what the organization needed to remain financially and administratively efficient. Nearly all mental health systems, for instance, depend bureaucratically on there being a problem definition, a service, and using speech to conduct this work—without these there would likely be no system at all. In brief, the very ways in which the system is designed to operate—what it requires of all those who enter it—may be key parts of what leads to cultural, racial, ethnic, and other forms of inequity and exclusion. Incongruous or “inefficient” clients would simply cost more to accommodate in terms of time, personnel, and resources. But the real cost-based question is: Who has the system been designed for, and at what cost? This problem is deeply institutional, inter-institutional, and pervasive, as implicit organizational biases such as these are likely found in all major American institutions, as the APA resolutions suggest.
Collective problems benefit from collective responses. What we hope may be an outgrowth of this study is encouraging more collective awareness and action, within and outside of clinics, regarding transforming the hidden dimensions of organizational life that threaten to disrupt the work of diversity, equity, and healing. This is something that should concern us all, as it can undermine even the most innovative practice, provider, or program. As we said in closing: “The central message suggested by this study is to consider removing, rather than building, yet another new wall” (p. 88). Overall, we hope that this framework can help provide a concrete way to begin tackling the longstanding problems of institutional inequity.
Reference:
Desai, M.U., Paranamana, N., Restrepo-Toro, M., O’Connell, M., Davidson, L., & Stanhope, V. (2021). Implicit organizational bias: Mental health treatment culture and norms as barriers to engaging with diversity. American Psychologist, 76(1), 78-90. https://doi.org/10.1037/amp0000621
Further Reading:
Desai, M.U. (2018). Travel and movement in clinical psychology: The world outside the clinic. London: Palgrave Macmillan.
Desai, M.U., Wertz, F.J., Davidson, L., & Karasz, A. (2018). An investigation of experiences diagnosed as depression in primary care—from the perspective of the diagnosed. Qualitative Psychology, 6, 268-279. http://dx.doi.org/10.1037/qup0000129
Desai, M.U. (2021). Of signs, symptoms, and stereotypes: Fanon, institutional racism, and institutional subjectivity. In N.C. Gibson (Ed.), Fanon Today: The revolt and reason of the wretched of the earth. (pp. 249-269). Montreal: Daraja Press.
Desai, M.U., Bellamy, C., Guy, K., Costa, M., O’Connell, M.J., & Davidson, L. (2019). “If you want to know about the book, ask the author”: Enhancing community engagement through participatory research in clinical mental health settings. Behavioral Medicine, 45, 177-187. http://dx.doi.org/10.1080/08964289.2019.1587589
Laubscher, L., Hook, D., & Desai, M.U. (Eds.). (2022). Fanon, phenomenology, and psychology. New York: Routledge.