Changing the Conversation

I often write about relationships between providers and people they serve. It is very easy to look at services and write about what is wrong and what needs fixing. However, I do think that there are more respectful and caring providers and agency personnel than not.

As a young adult, I was homeless. I had been in and out of hospitals and was discouraged about my chances of being successful in therapy. My moods were all over the place, and I was having intrusive memories. I was trying very hard to find housing. I showed up for appointments. I was so scared and angry at the possibility of being turned down that my intolerance for disappointment was reflected in my attitude. I was anxious and certain that no one wanted to help. 

Research on “health care disparities,” the euphemism for unnecessary deaths and adverse outcomes among people from low socioeconomic groups and from communities of color, often attribute them to individual characteristics and structural barriers within mental health systems. Most often an individual’s use of services as well as the way services are arranged and delivered are cited as causes.

I want to begin by commenting on what is going wrong and then discuss what is hopeful in the provider-client relationship. Although research is taking place, there is little agreement about best practices and ethical standards in minority mental health care. The issues of staff bias, racism, institutional racism, prevailing practices, and methods of prioritizing who gets time and attention are omitted from the discussion. Also, questions of discrimination that stem from preconceived notions and racial profiling of African American people and/or questions of how stigma influences medical decisions are absent, if not actively avoided, in discussions of healthcare disparities.

Too often, trauma research focuses solely on impact on patients in health services—especially people who experience mental illness, trauma, substance use disorders, and homelessness. We need to expand the research questions to include the following: How does trauma impact physicians and what are the implications for their relationships with patients?

We know that healthcare disparities exist! Statistics can tell us where disparities are occurring, which providers have the worst outcomes, and what medical decisions are contributing to the problem.

Resolving healthcare disparities is hampered when we refuse to ask hard questions about conscious and unconscious bias among service providers and staff. For example, research on obesity has documented that physician attitudes greatly impact service use, quality, and outcomes. Studies on the impact of physician attitudes demonstrate that examining bias is critical for understanding how patients use services and how well they do.