Researchers Present Structural Competency Training Model for Psychiatrists

Researchers argue that a social determinants of health approach must be made central to psychiatry training


In a recent Viewpoint piece in JAMA Psychiatry, Helena Hansen MD, PhD., Joel Braslow, MD, PhD, and Robert M. Rohrbaugh, MD, present a structural competency-oriented psychiatry training model. This new approach aims to equip early psychiatrists with the knowledge and skills needed to understand and intervene in the systems that influence their patients’ distress.

“Psychiatrists in training launch their careers in a time of inequalities and structural barriers to their patients’ health,” the authors write. “These broader forces not only likely contribute to psychiatric disorders but also make living with these disorders significantly more difficult.”

Photo Credit: Community Healthcare Network, Flickr

The piece is one in a series on structural competency, covered recently in the MIA newsroom. Structural competency is an approach to psychiatry that moves beyond cultural competency, which focuses on the role of culture in mental illness and treatment, to examine systemic influences on mental health, such as policies and institutional practices that result in social groups’ differential access to education, housing, healthcare, and other resources.

Hansen, Braslow, and Rohrbaugh argue that emerging psychiatrists must receive substantial training in structural competency in order to practice ethically and effectively. This need is particularly pronounced now, they write, as the U.S. contends with a number of challenging systemic issues including a health care system in flux, a weakened social safety net, and a rise in racial, religious, and sexual-orientation-based discrimination and hate crimes.

They write that while psychiatry training has done a good job of integrating advances in neuroscience, it has failed to include teachings about the social determinants of health. And the latter, they argue, is equally critical to psychiatrists’ education. Furthermore, recent developments in neuroscience indicate that the biological and the social are interrelated.

“We must take the results from neuroscience that show the influence of social environment on biology and symptom expression (eg, in neuroplasticity and epigenetics) and then translate the findings from social science to intervene on the social environment,” Hansen and her co-authors write.

When psychiatrists do not have the skills needed to analyze structural factors and intervene at a systems-level, the authors write, not only are they unable to fully serve the needs of their patients, but they also burn out more quickly. Moreover, community mental health systems suffer from provider shortages as a result.

In response to these concerns, Hansen, Braslow, and Rohrbaugh, who all have social science backgrounds in addition to their medical training, have developed and implemented a “structural competency approach” to psychiatry education at their home institutions – NYU, UCLA, and Yale respectively. Their education model’s central tenets include conceptualizing patients’ illnesses through the lens of systemic conditions, taking steps to act on these conditions at institutional levels, and cultivating “community connectivity” and “structural humility” regarding the slow speed of systemic change.

Their various structural competency-focused curricula share the same guiding philosophy, rooted in the belief that structural competency training is central to becoming a psychiatrist, regardless of whether or not trainees ultimately go on to work in clinical settings.

The authors have designed training courses which are taught by cross-disciplinary faculty from a number of fields, such as anthropology, sociology, medical humanities, and health policy. The goal of these classes is to offer a depth of information about social contributors to mental health while also developing trainees’ ability to think critically. Course subjects include the role of race, gender, and socioeconomic status in diagnosis, treatment, and pharmaceutical marketing; the recovery movement; and the relationship between mass incarceration and mental health.

The curricula include activities designed to connect theory with practice, as well. One example of this is a “structural competency rotation” at NYU. As part of this rotation, psychiatry residents spend time working at a state mental health clinic where they receive mentoring from a “peer” who has “lived experience of severe psychiatric diagnosis.”

“Ultimately,” they write, “the goal is to inculcate an enduring habit of observing patients’ living conditions and continuously educating oneself about structural barriers to mental health.”

The authors have also incorporated an emphasis on research and advocacy into their curricula in order to instill a sense of hope in residents and build their institutional change-making skills. Related training activities include guidance in analyzing field notes with an eye to patients’ “structural vulnerabilities,” and a policy advocacy mentorship program, through which students participated in drafting mental health-related legislation.

In closing, the authors write:

“When we incorporate the principles of structural competency, psychiatry addresses the structural problems of communities that make people sick and keep them from getting well.”



Hansen, H., Braslow, J., & Rohrbaugh, R. M. (2017). From Cultural to Structural Competency—Training Psychiatry Residents to Act on Social Determinants of Health and Institutional Racism. JAMA psychiatry. (Link)

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Rebecca Troeger
MIA Research News Team: Rebecca Troeger is a doctoral student in the Counseling Psychology program at the University of Massachusetts Boston and has a Master’s degree in Psychology. Her work explores how Western psychology can move towards valuing other cultures' knowledge more deeply. She is also interested in the impact of social support and community life on mental health and anti-racism interventions.


  1. Psychiatry doesn’t need more training. It is dangerous and useless and needs to be abolished.
    Psychiatry is noted for making people sick/sicker and keeping them from getting well.
    We are talking about ppl that poison little kids with Ritalin, worsen outcomes in “schizophrenia” through long term prescription of antipsychotics, and shock ppl causing brain damage and trauma.
    They should be trained to clean up nuclear waste spills with tiny sponges.

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  2. “When we incorporate the principles of structural competency, psychiatry addresses the structural problems of communities that make people sick and keep them from getting well.” Yes, it’s long past due to stop blaming individuals’ brains, and start looking at our sick society.

    Especially given the apparent fact that we are currently living in a ‘Western civilization’ that will likely go down in history as one of the most disgusting ‘civilizations’ ever, largely because our society is currently ruled by “satanic pedophiles.”

    And many of us here on MiA do know that the primary function of today’s “mental health professionals” has been for decades, and still is, turning child abuse victims into the “mentally ill’ with the psychiatric drugs on a massive scale, even according to their own medical literature.

    It likely would be a good idea for the “mental health professionals” to some day garner insight into the reality that when they profiteer off of covering up child abuse on a massive scale, they are also functioning in a manner, as to aid and abet the child molesters.

    And this leads to a very sick society – a child rape and child trafficking run amok society, an appalling society in which to live, that understandably makes “people sick and keep[s] them from getting well.”

    I do so hope some day that the psychiatrists and psychologists will get out of the business of empowering the “satanic pedophiles,” by way of turning millions of child abuse victims into the “mentally ill” with the psychiatric drugs.

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  3. All this assumes that doctors, and particular psychiatrists are receiving an education in medical school. “Education” is the euphemistic term that is used to cover up the indoctrination that is really taking place. It is absurd to discuss the structural competency of a structure that is for all intents and purposes a house of cards. We might as well discuss the compassionate service of the Third Reich.

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  4. The failure to identify access to healthcare as a contributing factor to bad outcomes without simultaneously identifying the utter lack of choices and alternatives available in the healthcare system, even to privileged people with cadillac insurance makes this training program utterly disingenuous and useless. Rich white people get the same sh*tty treatment in the mental health system as disadvantaged people unless they luck into receiving genuine fully informed, non- coerced treatment up front.

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  5. In other words, the psychs are saying, “This is what we need to start doing….”…..
    Sorry, kids, but this is what the psychs SHOULD HAVE BEEN doing for the past few decades.
    Thank-you, Rebecca, for proving yet again what most of us here at MiA already know:
    (…even if some of us refuse to publically admit it….)….
    “Psychiatry is a pseudoscience, a drug racket, and a means of social control. It’s 21st Century Phrenology with potent neuro-toxins. The DSM is nothing more than a catalog of billing codes. Every diagnostic allegation in it is BOGUS, and was INVENTED to serve as excuses to $ELL DRUG$….

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  6. Shrinks and GP’s have NO BUSINESS putting their greedy hands into and scamming whatever tax dollars they don’t already pocket and waste on their corrupt discriminatory, pathologizing of life and social problems as if they were diseases.

    We need SOCIOLOGISTS, ethical psychologist and others who practice non-pathologizing trauma therapies to step up and do their jobs rather than sitting back and allowing these disease mongering thieves and liars to destroy any hope there is of salvaging the damage they have already done to the lives of millions, to the environment, to the social fabric and to the economy.

    These “mental health” mongers seeking to make everyone “sick” for their own personal benefit must be stopped.

    There are strong connections to the #METOO movement in terms of social abuse by the power abusing 1% forcing their will on women and the young. These groups continue to be used, abused, experimented on with impunity, defrauded of their “health” (psychiatry knows nothing about human health) silenced, shamed, blamed, insulted, betrayed and subjugated by a truly evil system run by truly dangerous people.

    We need to make, expand and disseminate those connections in a way that allows the reality that psychiatry is a the king pin of the sick systemic destroying the social fabric and now it is seeking to co-opt the SDOH too. DISCUSTING!!!!

    We need to form a logical alliance with the #METOO and other movements, in order to further break away from, expose the crimes of and refuse to support any further involvement of psychiatry (which is the key structural evil that needs to be abolished) rather than handing the keys to what is left of our social structure over to them to destroy.

    Psychiatry (GP’s) et al, have absolutely NO BUSINESS putting their corrupt, incompetent hands on the critical Social Determinants of Health. They are NOT sociologists and social problems are not imaginary diseases they should continue to be allowed to profit off, to the collective detriment of the world.

    The message to psychiatry and anyone supporting the medial model that medicalizes social problems, is get out and stay out, keep your dirty “sick care”, take your bags of blood money and leave the little you haven’t already stolen, so the rest of us can try to rebuild everything your toxic industry is killing. The nightmare of endless lies and abuse will never stop unless and until the fraud of psychiatry and its handmaiden of death, Allopathic “medicine” are abolished. Anyone supporting the fraudulent notion of “mental health” without scientific evidence, is equally guilty of the crimes against humanity. Refuse to support them in any respect.

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