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A Rationale for an Anti-Racist Entry Point to Anti-Oppressive Social Work in Mental Health Services

By

Charmaine C. Williams, Ph.D.
Faculty of Social Work
University of Toronto, Canada

 

 

Abstract

Anti-oppressive social work must address equity and social justice issues across a wide range of social difference. Practitioners and theorists often struggle to negotiate the multiple forms of oppression that operate simultaneously in a given practice context. This paper attempts to engage with that challenge by building a rationale for anti-oppressive action in the mental health care system to be focused on anti-racist change. It demonstrates that an achievable goal for social work is to be able to articulate and substantiate claims that systemic oppression affects service delivery, and has particular consequences for specific populations.

Introduction

One of the challenges in anti-oppressive practice is addressing the multiple ways in which oppression affects the lives of individuals. Although it is easiest to conceptualize the “isms” through single axes of sexism, racism, heterosexism, classism and other categories of discrimination, we are well aware that lived experience involves simultaneous activation of privilege and disadvantage in multiple areas. The promise of anti-oppressive practice is that it prioritizes considerations of equity and social justice across a wide range of social difference. Yet advocates of this perspective seem reluctant or unable to discuss ways in which decisions can be made about focusing on specific categories of oppression as an entry point to engagement with the issues. Valiant attempts to construct theoretical models that focus on non-specific ideas of difference and diversity avoid the potential controversy of creating a contentious “hierarchy of oppressions”, but ultimately hinder attempts to develop a coherent strategy for systemic intervention. Small overall gains may be made in several areas, but at the expense of substantive progress in addressing specifically identified problems (Dei, 1996; Williams, 1999).

This paper aims to provide an example of how a rationale can be built for selecting a specific entry point for anti-oppressive action in a given practice area. The discussion is derived from the process of developing educational programming for cultural competence in an addiction and mental health care setting in Toronto Canada. It is hoped that this paper will contribute to a literature that can share and develop ideas about how to integrate anti-oppressive principles into practice. Ultimately, both clients and practitioners gain if social workers increase their proficiency in negotiating multiple forms of oppression.

Race, Ethnicity and Mental Health Services

As Pinderhughes (1989) asserts, culture determines the perspective that people bring to their problems, the way in which problems are expressed, their preferences for treatment, and their preferences for treatment providers. Cultural variation in these areas is often understood to refer to ethnic differences. It is important, however, to not overlook that cultural differences can arise from the common socialization and collective experiences of groups that are defined in other ways. Accordingly, cultural competence in mental health services needs to address a wide range of perspectives that people can bring to the experience of illness, treatment and healing. Yet, as will be demonstrated, there is a particular need to focus on the implications of racial and ethnic difference in the mental health care system.

In Canada, research evidence indicates clearly that there are specific problems with providing mental health services to ethnoracial and ethnocultural groups. Since the publication of the report After the Door Has Opened: Mental Health Issues Affecting Immigrants and Refugees in Canada (Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees, 1988), there have been several policy documents reinforcing that ethnoracial and ethnocultural groups in Canada are marginalized in the mental health care system (for example, see Barwick & Campbell, 1993; Metropolitan Toronto District Health Council, 1992; Ontario Ministry of Health, 1992; Ontario Ministry of Health, 1995; Reitz, 1995). The substantial documentation of system inequities that affect ethnoracial and ethnocultural groups points to the need to prioritize race and ethnicity in the discussion of increasing the accessibility of mental health care. Yet, the current arrangement of services and service provision reflects an indifference to the impact that culture (ethnicity, language and race) has in these areas. Apathy in the system translates into the absence of strategies and that communicate the importance and relevance of integrating relevant cultural issues in the provision of mental health care. Studies in the multicultural environments of Canada, the United States and Britain are probably most able to shed light on the issues that effect service provision in Ontario. A striking finding in this body of work is that the consequences of indifference to culture seem to be most pronounced for racial minority individuals and communities. Although both ethnocultural and ethnoracial minorities are disadvantaged by systems that exalt Euro-American standards, people of colour are less able to benefit from the reservoir of privilege that exists for White people and those that can approximate their standards. Cultural practices, language, physical appearance, and social segregation all create barriers between racial minorities and the dominant group that make it more difficult for people of colour to participate in mainstream environments (deAnda, 1984). Consequently, racial minorities are highly affected by problems of systemic oppression in the mainstream mental health care system.

Systemic Racism in the Mental Health Care System

Many people acknowledge that racism influences systems in our society. Mental health care services, which function as part of those systems, are affected by racist ideology as well. However, articulating the rationale for anti-racist action in the system is often met with demands for “evidence”. It has become popular for people to speak of racism (and other types of oppression) as if they are historical artefacts that have little bearing on present realities. Fortunately, researchers concerned with the experience of racial and ethnic minorities in the health care system have investigated these issues and provided evidence of inequities. This evidence can be assembled to present a coherent picture of marginalization and disadvantage in the system that arises from systemic racism. Mechanisms of systemic racism in mental health care include at least the four following processes:

Racial and ethnic minorities do not receive care. Many ethnic and racial minority people never access mental health care. They are unaware of services, or they “fall through the gaps”, receiving attention for legal, financial, and vocational problems while mental health problems are prolonged and unaddressed (Beiser, Gill, & Edwards, 1993a; Boyer, Ku, & Shakir, 1997; Lin, Inui, Kleinman, & Womack, 1982; Lin & Lin, 1978; Morales, 1978; Pham, 1986). Service providers are implicated in this lack of service as they fail to respond to appeals for help from racial minority communities (Beiser, Johnson, & Turner, 1993b; Morley, Wykes, & MacCarthy, 1991). A persistent disengagement between service providers and ethnoracial and ethnocultural communities has prevented both sides from gaining an understanding of when help is needed and how it should be provided. This disengagement extends to agencies and policymakers who do not make an effort to establish forums and networks that would make it possible to integrate the needs and concerns of ethnoracial and ethnocultural communities into their strategies. Therefore, for many reasons, the people of many ethnoracial and ethnocultural groups do not have the same opportunity to receive care from the mental health care system as do people from mainstream groups.

Racial and ethnic minorities receive inadequate care. Several research studies document that racial minority clients receive less service than other clients do. They often seek help, but withdraw from mental health and social services after initial contacts (Ali, 1997; Armstrong, Ishiki, & Heiman, 1984; Beiser et al., 1993a; Ontario Ministry of Health, 1995; Reitz, 1995; Ridley, 1989). Carillo (1999) suggests that during these first contacts, clinicians’ failure to communicate in ways that can lead to shared understanding problems is a significant barrier to minority groups receiving care. This important opportunity to establish a therapeutic or working alliance is often jeapordized by experiences of racism or ethnocentrism (Brantley, 1983; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998). It is further jeapordized by the experience of disrespectful treatment from individual service providers (Foster, 1998). Attempting to increase the cultural competence of the system by providing information to service providers about various racial and ethnic groups has been a mixed success. Misinformation and stereotypes can be used to justify diminished services to ethnoracial and ethnocultural groups, on the basis of presumed incompatibility with cultural practices (Akerlund & Cheung, 2000; Cameron & Wycoff, 1998; Rogler, Malgady, van Ryn & Burke, 2000; Yan & Lam, 2000). Therefore, there are ethnoracial and ethnocultural clients who are seeking help from the mental health care system, but ultimately do not receive full assistance.

Racial and ethnic minorities receive improper and inappropriate care. People who are ethnic and racial minorities are more likely to be the recipients of improper treatment in the mental health care system. Research from the United States that compares the experience of racial minority Americans to the experience of White Americans in the mental health care system demonstrates that Blacks and Latinos are more likely to be misdiagnosed, more likely to be institutionalized and report more dissatisfaction with services (Malgady & Zayas, 2001; Ridley, Chih, & Olivera, 2000; Ridley, Mendoza, & Kanitz, 1994). There is a long legacy of stereotyping and misunderstanding leading to more negative evaluations of people of colour. Specific examples include assumptions of psychological and intellectual inferiority, presumptions of poor motivation and resistance, and lowered expectations for progress and recovery (Akerlund & Cheung, 2000; Draguns, 1989; Marquez, Taintor, & Schwartz, 1985; Sodowsky & Taffe, 1991; Wade, 1993; Zhang, Snowden, & Sue, 1998). Racial stereotyping has also been associated with inappropriate use of treatment (e.g., tranquilizing medications, restraints, containment) to deal with the presumption of danger from racial minority patients (Lewis, Croft-Jeffreys, & David, 1990; Littlewood & Lipsedge, 1981; Pipe, Bhat, Matthews, & Hampstead, 1991). In addition, service providers have started integrating interpreter services to provide care to people who do not speak English, but there is recognition that poor training for work with interpreters is contributing to misdiagnosis and errors in treatment (Malgady & Zayas, 2001; Sabin, 1975). In the context of ongoing experience of improper treatment in the mental health care system, it is not surprising that ethnoracial/ethnocultural communities have expressed mistrust of the system and may avoid seeking care (Dolan, Poley, Allen, & Norton, 1991; Owens, Harrison, & Boot, 1991; Schnittker, Freese, & Powell, 2000; Thomas, Stone, Osborn, Thomas, & Fisher, 1993).

Racial and ethnic minorities must assimilate to successfully receive care. Ethnoracial and ethnocultural clients seeking service are forced to assimilate to mainstream norms to negotiate the care system. The majority of North American health and social service organizations are staffed by service providers who speak English exclusively (Pugh, 1994). Accessing services requires either speaking English as a first language, or forsaking a preferred language to attempt communicating in English. Ethnocentric service provision is further demonstrated in value systems underlying interventions. For example, psychosocial models of care are infused with Western-based, individualistic standpoints that “pathologize” certain forms of family dynamics. Culturally appropriate use of boundaries or emotional expression are redefined as unhealthy. Interventions are offered without alternatives available that address the fact that many individuals and families living in North America subscribe to more collectivistic orientations and engender different norms for interaction (Carrillo et al., 1999; Husband, 2000; Yan & Lam, 2000). Because service delivery is based on a narrow, dominant perspective, success in the system depends on a client’s ability to meet a White, Eurocentric English-speaking standard. Furthermore, treatment success depends on orienting toward norms and expectations that can be unacceptable and inappropriate for people functioning outside of dominant identity groups. Consequently, the mental health care system is complicit in systemic efforts to assimilate ethnoracial and ethnocultural people toward dominant culture values and behaviours (Pina & Canty-Swapp, 1999; Sodowsky, Kuo-Jackson, & Loya, 1997; Sue et al., 1982).

The research describing these four areas of systemic marginalization forms an evidence base for demonstrating systemic racism in the mental health care system. Yet, a system that is so centred on the needs, knowledge and values of dominant identity groups is unlikely to confine its oppression to racial minorities. Furthermore, one cannot speak of racial disadvantage without also addressing how sexism, classism, and other types of discrimination influence the experiences of racial/ethnic minorities and others in the system. Multiple forms of discrimination operate simultaneously to maintain a secure position for a social, political and economic elite. Yet, as this brief discussion has demonstrated, there is a pattern of systemic racism in the mental health care system that is expressed through specific mistreatment and marginalization of people of colour. This is the evidence upon which one can rest the assertion that anti-oppressive action in the mental health care system needs to focus on anti-racism.

Anti-Racism, Anti-Oppression or Something Else?

Work has been done that establishes anti-racism is a necessary strategy for addressing the systemic oppression that affects the mental health care system. A similar process of documentation and assembling of evidence can provide the rationale for a different entry point for anti-oppressive work in another context. In addition, the evidence base must be scrutinized to identify where specific differences translate into specific disadvantages. Through this type of analysis, priorities for action can be established that may result in multi-pronged efforts that transform the system to redress inequities experienced across multiple identity categories. Racism clearly creates barriers to accessing and using mental health services, but sexism, classism, heterosexism and other types of discrimination may create similar barriers. They may also be associated with different, unique problems in other parts of the system. Assembling appropriate evidence will clarify this issue and define sites for appropriate, anti-oppressive action. Effective anti-oppressive social work depends on our value base being complemented by research to accumulate empirical evidence, and advocacy to present this evidence as the grounds for transforming an oppressive system. In the absence of evidence, it is too easy to dismiss anti-oppressive action as based only on ideology or goodwill. Initiatives that rest on the system’s capacity to act according to humanitarian values are quickly put aside when other agendas take priority. They are also easier to dismiss if there is a perception that they lack focus. Rather than shying away from identifying specific entry points for anti-oppressive practice, social workers can take on the challenge of articulating how these entry points can launch a cohesive, but multifaceted, program of social change.

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Charmaine Williams, PhD can be contacted via e-mail at: charmaine.williams@utoronto.ca

 

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