Researchers Call for Structural Competency in Psychiatry

Structural competency in Psychiatry emphasizes the social factors shaping patient presentations and encourages physician advocacy

Zenobia Morrill
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A series of recent Viewpoint articles published in JAMA present a growing body of literature on “structural competency,” a framework for promoting social justice and advocacy in psychiatry. Researchers Helena Hansen, MD, PhD, Jonathan M. Metzl, MD, PhD, Joel Braslow, MD, PhD, and numerous others describe how an approach focused on structural competency serves as an in-depth way to address how systems and policies shape presentations and experiences of people diagnosed with mental illness.

“Structural competency calls on health care professionals to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases, and to mobilize for correction of inequalities as they manifest both in physician-patient interactions and beyond the clinic walls.”

Helena Hansen is a joint-appointed assistant professor of anthropology and psychiatry at New York University, and a research psychiatrist at the New York State Office of Mental Health’s Nathan Kline Institute.

Previous models in psychiatry have focused on ideas surrounding cultural competency. These frameworks have promoted the integration of culture into understandings of mental health and clinical case conceptualizations, yet they have been largely centered around shifting clinician-patient interactions to accommodate cultural factors. The structural competency model advances a bigger picture approach, addressing the ways that different systems, policies, and social forces influence health and healing.

“Whereas previous models such as cultural competency focus on identifying clinician bias and improving communication at moments of clinical encounter, structural competency encourages clinical practitioners to recognize how social, economic, and political conditions produce health inequalities in the first place.”

In this framework, mental distress is understood to be connected to social and economic oppression. The authors of the Viewpoint introduction, Dr. Metzl and Dr. Hansen, articulate numerous examples where social institutions and practices determine who is affected by certain forms of distress, such as the ways in which opioid dependence and other substance abuse issues are influenced by drug marketing strategies, regulations, and the attendance to the pain and suffering of dominant racial groups over minority communities.

Diagnosis and treatment of “mental disorders” vary across race, ethnicity, and social class, indicating the role of institutional practices indirectly. Incarceration, housing accommodations, lack of transportation, and other structural factors, concentrated in low-income communities and communities of color, provide additional, explicit examples of institutional influence. Finally, mounting evidence in epigenetics research suggests that social and institutional factors modify individual biologies, including intergenerational trends.

Physicians who note this connection between the social and individual may feel at a loss for how to provide appropriate care. One study found that 85% of clinicians agreed with the statement that “unmet social needs are leading directly to worse health for all Americans.” They further report feeling ill-prepared to meet patient social needs and provide the form of necessary care they deem to be fundamentally important.

Advocacy, therefore, becomes a fundamental part of the structural competence framework.  Clinicians are encouraged to expand notions of individual healing and work toward rectifying oppressive and inequitable social systems.

“Structural competency thus advocates deeper understandings of how institutional discrimination and its often invisible, systemic oppressions can produce racialized, gendered, and socioeconomic status–related ‘symptoms’ in clinical settings.”

The structural competence framework consists of a series of benchmark skills, including, but not limited to, the following:

  • Recognizing the structures that shape clinical interactions,” such as social conditions and institutional policies that shape patient presentation
  • Rearticulating ‘cultural’ formulations in structural terms,” by accounting for neighborhood and institutional factors
  • “Observing and enacting structural interventions” through community-based projects that address patient needs
  • Developing structural humility” through community and interdisciplinary collaboration alongside the reality that systemic change often requires long-term commitment resulting in progressive change

Metzl and Hansen conclude:

“Structural competency thus represents one evolving approach that enables clinical practitioners to bridge the microprocesses of their interactions with patients with the macroprocesses of population-level inequalities that often determine their patients’ mental health outcomes.”

 

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Metzl, J. M. & Hansen, H. (2017). Structural competency and psychiatry. JAMA Psychiatry. Published online December 20, 2017. doi:10.1001/jamapsychiatry.2017.3894 (Link)

9 COMMENTS

  1. What kind of a structure supports the myth of mental illness, the chemical imbalance hoax, or psychotropic drugging of innocent children, the homeless, and the elderly? The structure is a house of cards, or it is like the house of straw in the story of the three little pigs. There is no sense in trying to reform or rethink the structure that Whitaker has referred to as a rotten barrel. What ought one to do with a rotten barrel? Throw it out, and set the apples free.

      • I believe he at least only supports the non-coercive kind. In Anatomy of an Epidemic he argues that the “medicine” often provides temporary relief to both the patient and those around them. But the benefits are short term and rapidly wear off.

        I experienced short term benefits from stelazine then later zoloft. I don’t worship these drugs, the men who prescribed them, or the companies who concocted them.

        Why? They taught me I didn’t need to work on changing myself or improving my life; drugs could do it for me. They also helped me get sucked down the rabbit hole of “severe mental illness.”

  2. The white doctors are inappropriately force drugging the dark skinned patients, and the dark skinned doctors are inappropriately force drugging the white skinned patients. An example is my former force medicating, dark skinned doctor, who was finally arrested by the FBI, although I was never able to find a lawyer to sue him for the crimes and fraud he committed against me.

    https://www.enewspf.com/law-and-order/state-crime-reports/oak-brook-doctor-sentenced-two-years-prison-connection-kickback-scheme-sacred-heart-hospital/

    He was sentenced to a mere two years, for likely medically unnecessarily killing lots of patients, and in reality for defrauding our government out of lots of money.

    It seems we have a problem with lots of racist doctors, of all colors. Which is likely because the medical community, in general, has been given, and usurped, too much power. And, of course, all people with brains should know, “Power corrupts, and absolute power corrupts absolutely.”

    Today’s medical community’s right to force drug anyone they want, for any unethical reason, should be taken away. Such a “right” is being used for unethical reasons, like covering up rape of children and easily recognized iatrogenesis by incompetent doctors.

    The right to force psychiatric treatments onto others needs to be taken away from the entire medical industry. Since today’s medical doctors can’t handle this unjustly given power in an ethical manner, none of the doctors from any of the races.

    Today’s medical community has lost it’s mind, and its Way, due to being given unchecked power that they can’t handle.

  3. Sounds like some beginning awareness that something is wrong in the State of Denmark, which I guess is a good thing. I notice a couple of things – first, they’re still using “illness” language, like “symptoms,” to describe the effects of these institutions, continuing to allow and encourage victim-blaming. Second, it’s fascinating that of all the institutions listed, they fail to mention school and family, which are the institutions that most seriously affect young children and are the cause of a great deal of suffering regardless of race or gender. The other factors mentioned are, of course, very important issues that can’t be disregarded, but the specific failure to mention childrearing practices as a major contributor to what they call “mental illness” seems significant and suggests continuing energy to protect the parents and adults rearing children from accountability for their impact.

  4. I read this:

    “Recognizing the structures that shape clinical interactions,” such as social conditions and institutional policies that shape patient presentation
    “Rearticulating ‘cultural’ formulations in structural terms,” by accounting for neighborhood and institutional factors
    “Observing and enacting structural interventions” through community-based projects that address patient needs
    “Developing structural humility” through community and interdisciplinary collaboration alongside the reality that systemic change often requires long-term commitment resulting in progressive change”

    And then I read about this lot:

    http://baddoctordatabase.tumblr.com/search/psychiatrist

    Here is Wim Wenders talking about working with Michelangelo Antonioni on
    Par-delà les nuages:

    https://www.youtube.com/watch?v=87Vvyj1oXj4

    Actors like to perform with words:

    https://www.youtube.com/watch?v=8NZZxOJaV30&feature=youtu.be&t=414