Helena Hanson is professor and chair of translational social science and health equity and associate director for the Center for Social Medicine at UCLA. As a psychiatrist and anthropologist, she has spent much of her career researching how race, class, gender, and social determinants of health affect psychiatric diagnosis and treatment.
Growing up in 1970’s Oakland and Berkeley, California, Hansen witnessed the consequences of deinstitutionalization and mass incarceration policies firsthand. Losing family members to both the prison and mental health systems gave her a personal understanding of the social and structural failures she interrogates in her work today. She also draws on the principles she learned as a participant in AIDS-related activism to mobilize community organizations and champion mutual aid groups in combatting our current mental health crises.
In this interview, Hansen discusses how race and class affect psychiatric diagnoses and subsequent treatment, the moral implications of psychiatric diagnosis, structural competency, and more.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Richard Sears: First, will you tell us a bit about what brought you to your work? How did you end up interested in psychiatry and anthropology? More specifically, how did you end up looking at these questions about intersectionality and psychiatric diagnosis?
Helena Hansen: Since I’m speaking to a contributor to Mad in America, let’s start by saying that it’s probably because I was “mad,” as in angry.
My childhood was profoundly shaped by the mental health system in California. I grew up in the seventies in Oakland and Berkeley, California, at the height of deinstitutionalization. The mental hospitals were being closed with a verbalized motive of getting people out into the community and not confined in mental hospitals, but there was nothing on the other end, no community services, no supports. I remember on my way to school and back, there were a lot of people sleeping on the streets, and I had to find my way through a maze of people who clearly had just been totally abandoned.
The other part of that story is that mass incarceration was starting, and many people who otherwise might have been in the mental health care system were instead in the carceral system. It got personal in that three of my uncles were caught up in it. I grew up largely in the home of my grandparents. My mother was a single mother raising me in Oakland, and my grandparents had a cycle of my uncles in and out as they lost their own independent housing and had to move home. They struggled with drugs and what we might have called a psychiatric crisis. They were often brought home by the police, and they went in and out of jail.
One of them ended up dying in a mental hospital. He got one of the few remaining beds in California but probably was medicated with antipsychotics that ended up stopping his heart. Two of my uncles were arrested on drug charges. They were probably using drugs because of the mental distress that they were going through. It was a really hard time to be a black man in Oakland and Berkeley.
They were both involved in the civil rights movement and had experienced a lot of repression and oppression. So likely, as a result, they had issues that we could label with psychiatric diagnoses, basically distress. I think drug use was a way of coping for them. But, unfortunately, they ended up in the prison system with those struggles.
With the war on drugs came a lot of police surveillance and arrests. This is what I grew up with. I grew up in a home where my grandparents, my mother, and I were always in fear that we’d come home to a police car. There was a lot of anxiety, a lot of emotional distress.
When I got into medical school, it was on the heels of my own participation in AIDS activism. I graduated college in the early nineties, just as AIDS activism was really peaking. The thing that inspired me about AIDS activism was the grassroots nature of it. In a very creative way, the people directly affected by HIV were on the frontlines. They had a lot of success, making changes in public policy and medical practice and shifting what research and clinical care got funded.
That really inspired me. I think it was because I had seen the other end. I’d seen how horrible it can be to have no voice in the mental healthcare system, no voice in drug policy. So, inspired by AIDS activism, I decided to try to make the change from within medicine. I majored in biology, and it seemed like a natural step to get into medicine.
I wanted to study medicine with another kind of political consciousness that was deliberate from the beginning. That’s why I combined it with anthropology. I found that anthropology was a counter-cultural way of looking at questions of medical practice and the assumptions that psychiatrists and others brought to their work.
Sears: Can you talk a bit about how race, class, gender, etc., can affect psychiatric diagnosis?
Hansen: I’ll try to answer it from two different angles.
The first is a bit more intuitive. I was a psychiatry resident at NYU in 2005 and trained in Bellevue hospital, which was New York City’s largest public hospital. It takes people from all over the city and has historically been known for its psychiatric care. Many of the patients were on Medicaid or uninsured. We would get people from the homeless shelters. We would get people from low-income areas in the South Bronx, Harlem. We got new immigrants looking for mental health care. We got people from all over.
The very high-end New York University (NYU) Langone Hospital was just three blocks up the street. It accepts private insurance on the psychiatric unit. A lot of the patients we saw there were sons and daughters of psychiatrists, doctors, lawyers, celebrities, etc.
What really struck many of my classmates in our psychiatry training and me was the contrast between how we saw people treated at the exclusive NYU hospital and how we saw people treated at Bellevue. We saw people who would come in with very similar symptoms but get radically different diagnoses.
The reason for that radical difference was really the life circumstance and the goals of “care.” For example, somebody comes into Bellevue with mood symptoms, with hallucinations. Let’s say they’re coming from the homeless shelter or they’re unemployed or uninsured. We would really steer them towards a schizophrenia diagnosis.
At Bellevue, because it was so understaffed, a lot of times, what was used to treat schizophrenia would be highly sedating antipsychotics like Zyprexa. The purpose was to keep people quiet because we’re dealing with an overcrowded and understaffed ward. These medications come with some serious side effects (including weight gain, diabetes, and heart disease). Still, we used the diagnosis because it was easier for people to get Social Security if they had a schizophrenia diagnosis. It was well-intentioned.
Classism also likely played a role here because so many of us were worried for our safety. My classmates grew up in neighborhoods where they did not encounter black men as friends or as colleagues. And they saw them on TV as very violent individuals. This was, of course, part of the logic. We want to keep these large black men quiet. But some of it was well-intentioned to grant access to Social Security benefits. Otherwise, they don’t have anything to survive on once we discharge them. With the schizophrenia diagnosis, maybe they can qualify for what tiny amount of supportive housing there might be out there in New York.
Contrast that with Langone Hospital, where we’re confronted with the daughter of a fellow psychiatrist who might’ve been in graduate school, and we’re trying to get them back on track to have a professional career. You don’t want to give somebody like that a schizophrenia diagnosis. That’s not going to help them finish grad school or get a job so that a bipolar disorder diagnosis might be more appropriate. That’s thought of as somehow less severe, less threatening to a professional career. The medications we used were designed to keep them alert and enable them to finish their studies or succeed as professionals.
It was race and class reasoning; it’s not just out of the blue. It’s not like randomly doctors think, “oh, I hate black people.” It’s a part of an entire system in this country of race and class hierarchy. Medical care is just one little piece of that. Medical care is designed to keep people where they are in the hierarchy. That’s one version of the story.
There is a second way to look at this problem. Over the past decade, I’ve been studying the pharma industries and what I’ve come to call racial capitalism. Through interviews with people in different parts of the pharmaceutical industry—people who are doing the drug development, people who are visiting doctors and basically advertising their products through promotional dinners and gifts and things like that, people who are prescribing and people who are consuming—I’ve discovered that there’s a whole race and class logic to how the pharmaceutical industry is set up. For example, it’s entrenched in psychotropic medications like antipsychotics and antidepressants because these are considered “lifestyle drugs.”
There’s no explicit biomarker. You can’t do a blood test to decide if someone should get an antidepressant or an antipsychotic. It’s an expandable category, and you can designate who the people that should get these medications are, which means that it has been a gold mine for pharmaceutical industries.
Since the era of Prozac, pharma industries have really focused a lot on psychotropic drugs as a category because they’ve been extremely lucrative. The more they’ve been able to define emotional distress as a biologically treatable brain disorder, the more money they’ve made. Race and class logics are integral to that.
We have a system in our country of race and class apartheid regarding who has access to what kinds of medical care. We have a public and uninsured track, and then we have a privately insured track. So the pharma industries have been extremely deliberate about which drugs they are developing and marketing for which market. It’s very clear that at least two and probably more markets divide along these lines. Psychotropic drugs are right in the center of that.
I already mentioned the highly sedating antipsychotics that were used at Bellevue Hospital when I was training. The pharma industry is very savvy about this stuff, and they do it in ways implicit and secretive as well as explicit. They market drugs according to race and class strata, so you’re going to see a lot more of those heavily sedating antipsychotics in hospitals like Bellevue. You’re going to see drugs like Abilify, which don’t have all those side effects, being marketed to a white clientele in private hospitals.
I’ll give you another example. ADHD is a diagnosis that has been controversial because it’s a category that’s radically expanded over the past few decades, a lot of it thanks to pharmaceutical industry marketing in the United States. We prescribe 10 times as much medication for ADHD than many European countries that outlaw the kind of marketing and promotions that we have here. Stimulants have been shown to improve academic performance in children, whether or not they meet the criteria for ADHD diagnosis. So, what you see is a market segment for ADHD medication, stimulants in particular, among more affluent, largely white children.
On the other hand, children who meet the criteria for ADHD who are poor and largely black and brown overwhelmingly get prescribed off-label antipsychotics because they come to medical attention through teachers who feel that they need to be behaviorally controlled in the classroom. So there’s been a very deliberate marketing strategy underlying that as well. Teachers and parents in public schools are subject to a certain kind of marketing around medications. Then more affluent parents are subject to another kind of marketing around stimulants that improve educational outcomes.
I’ve discovered that race and class are absolutely baked into our pharmaceutical industries and mental health system. I do think the fact that “mental illness” is so politically marginalized makes it even easier for pharmaceutical industries to take advantage of healthcare systems and to be negligent about the implications of this stuff.
Sears: Are certain groups more at risk of misdiagnosis and mistreatment in psychiatry than others?
Hansen: I think the “mental health care system”—and I put that in quotes because it’s not a system to promote mental health—reflects the political disempowerment or impairment of the groups involved.
What my uncles experienced is just a reflection of where they stood in the political-economic hierarchy of society. I think that mental health care is like an index of where people are in the power hierarchy. I’m not going to say that wealthy people in this country necessarily have good mental health care. I think we’re in a system that is crazy-making for everyone.
An interesting study came out almost a decade ago by social epidemiologists Richard Wilkinson and Kate Pickett. They compare industrialized nations by health outcomes against measures of social inequality. What they find is that the more socially unequal the country, the worse the health outcomes.
For example, in the US, we have the worst distribution of income. We also always come out the worst in measures of mental and physical health. I want to emphasize that the severe inequalities we have in this country give us all bad physical and mental health outcomes. The same study found that the wealthiest people in industrialized nations in the most unequal countries (like the US) have worse life expectancies and worse mental health outcomes than the wealthiest people in more equal countries. The soundbite from the study was that inequalities are bad, even for the rich.
It’s well documented that poor, black, and brown people don’t get a treatment that follows professional society guidelines. They get a lot more in the way of dangerous over-sedating drugs and multiple drugs that interact, which reflects that the doctor hasn’t taken any time to think through the regimen or the side effects. They get restrained a lot more often.
I was describing the wards at Bellevue that were totally overcrowded and understaffed. You had frightened nurses and frightened floor attendants that were very quick to put people in four-point restraints or put them in a seclusion room. In contrast, in a better-funded ward, like up the street at the NYU hospital, you had staff trying to talk people down if they were having an emotional outburst. They had soothing music and calming rituals instead of four-point restraints.
These days what you’re seeing is both too much “care,” in the way of over-medicating people and over restraining people, as well as abandonment. Insurance companies will only pay for a few days of hospitalization. So what you get is people coming in serious crises, getting a bunch of strong antipsychotics to sedate them, getting into restraints, and then being released a few days later with no plans for housing support, no plans for social support, and no plans for continuity of care.
I don’t think the answer is more medications and more restraints. I think the answer is we must look at what kinds of community supports we have. We need a more equal distribution of resources and the things that would develop our communities economically. I’m not advocating for more restraints or more polypharmacy; I’m saying that we have really used “mental illness” as a way of abandoning a large swath of people who are largely poor. Remember, wealthy people don’t get the best mental health treatment in unequal countries either. I think the answer is that we need a better society.
There are ways forward, but one of the biggest challenges is the unraveling of the social fabric of our communities. Our communities have a lot of disorganization, and people are becoming socially isolated. Sociologists have documented that many signs of distress, including drug overdose, are directly linked to feelings of isolation and the disintegration of community organizations and sources of social support.
Instead of debating how we can get more medications to people, we need to debate how we can foster community, economic, and social development. How can we support social connections and supportive communities?
Sears: What can we do to start rebuilding our communities?
Hansen: Over the past decade, my colleagues and I have been building a movement that we call structural competency.
I think many of us have been exposed to the idea of cultural competency. The idea is that if we’re going to try to address differences in health outcomes and healthcare by race, class, etc., we need to pay attention to culture. That sounds good, but in practice, what it’s meant in medicine and psychiatry has been that we kind of blame the victim. We act as though the reason why the outcomes are so bad for poor people, for black and brown people, is their beliefs and behaviors. We really need to look at the economic decline and the accompanying social isolation and disintegration of community organizations and support.
We need to be looking not at the level of an individual patient’s beliefs and behaviors, but we need to look at what’s available in the community. Who can we partner with in these communities in community organizations, mutual aid organizations, etc.? Who can we partner with to support our patients? I’m using the language of patients because I work in a psychiatry department, but I realize that there’s a movement not to refer to people as patients. What can we do to help people in their communities? What about institutions that are relevant to people’s health outcomes, but aren’t really part of the healthcare system, like housing agencies, criminal legal systems, schools, and parks? How can we collaborate with them for health-promoting initiatives and public policies?
There are lots of things that psychiatrists and other clinical practitioners can do to promote health in these areas. It does involve a lot of collaboration because we don’t necessarily learn how to do community organizing in medical school and clinical training. Still, there’s a lot we can do if we partner with community organizers.
I’m inspired by the new generation of mental health practitioners because I see residents and interns, and trainees do things very differently. I’ll give you an example. A group of residents in New Haven at Yale that I’ve been working with have been partnering with urban farms. They’ve been partnering with organizations that assist undocumented migrants. They’ve been partnering with mutual aid organizations, including theater and arts organizations that have in them people with lived experience of serious mental health distress. They’re also working with policymakers. They hosted a series of conferences called Rebellious Psychiatry. They invited policymakers and started to think about how mental health practitioners can partner with people with lived experience to get better public policies in place. As a result, they managed to get some laws regarding affordable housing and supportive housing in Connecticut passed. I look to things like that as inspiration for how we can do our business differently.
We need to address the root of the problem. The root of the problem is not the beliefs and behaviors of individual patients. It is rather this pathogenic society with seriously oppressive public policies. The issues with affordable housing and bad economic policies have left people with insecure employment and no benefits. These people are stranded and hurting. One thing that we have that’s great in this country is a history of community and grassroots organizing and mutual aid. And again, I take my inspiration from the AIDS epidemic. AIDS activism achieved a whole lot.
Sears: A lot of moving parts there, but there are definitely things we can do, I think.
Hansen: Mad in America is no small part of it.
Sears: I agree. Can you talk to us about what patients or service users can do to protect themselves in these healthcare systems?
Hansen: I mentioned mutual aid, and some of these organizations are national in scope. Some are founded and run by people with lived experience.
One such organization is the Icarus Project. They have, for example, a guide to tapering off medications, which is something that psychiatrists are not trained to do. I’ve seen people from the Icarus Project bring this guide into their psychiatrists and teach their psychiatrists how to taper them off of certain medications that are problematic for them.
There’s a lot that mutual aid organizations can do to help people understand the problems they’re having with the mental health system differently and understand their rights and how to push back.
One of the huge problems with giving somebody a psychiatric diagnosis is that it automatically associates them with all of the stereotypes and all the baggage of images of people with psychiatric diagnoses over the past century. It really weighs people down. Not only does it objectively make it harder for them to get jobs and housing etc., but I think it also makes it harder for people to feel good about themselves, to have faith in themselves and their own internal compass.
One thing that’s great about mutual aid organizations is that when you’re with other people who’ve been through that, you begin to understand yourself not as a flawed individual but rather as somebody who’s felt the impact of an oppressive system. That makes all the difference in the world because it puts you in the position to fight back, to fight for your place at the table. That’s why I think mutual aid is so critical in all of this.
I have colleagues that are threatened by that. I know psychiatrists who will say, “Mutual aid organizations are antipsychiatry, they’re out to get me, and they’re run by people who are deluded, people who think they don’t have a problem and they don’t realize they need help.” I think that kind of defensiveness is a sign of the insecurity that we have in our field. I think it’s an unfortunate cop-out because we know that psychiatry as a field is not having the positive impact that it should.
We know there’s something wrong with the way we practice. If we could just be curious and if we could just learn from people with lived experience, we’d see that mutual aid is one of the most powerful things that people can seek out for themselves.
We’ve been encouraging people to seek out mutual aid organizations. We have encouraged them to question their diagnoses and really think carefully about what kinds of treatments seem to benefit them or not. I hope more of my colleagues do not react like they’re threatened and are much more curious and supportive.
Sears: How do issues of morality end up influencing psychiatric diagnosis?
Hansen: Psychiatric diagnoses can be weaponized against people and can take away their legitimacy as moral actors. So I think one of our most important jobs, if we’re going to advocate for a better approach to mental distress, is to provide the conditions for people to get their moral agency back. That’s really what I was talking about regarding trusting one’s own compass.
One of the first things a mainstream psychiatrist (the kind who might get defensive about mutual aid) might do is question the judgment of the person who is coming in distress. We use the term “insight.” If somebody is hospitalized, day by day, we must document in the patient chart how much insight they have about their mental illness. When somebody accepts our terms of their mental illness, then they have insight. That’s what we reward, and that’s when we can discharge them. I think it reflects the power inequalities involved and how we’ve misused psychiatric care to enforce power hierarchies. Therapeutically, it’s exactly the wrong approach.
What we want to do is help people to trust themselves because that’s part of the crisis that they may be having. Often, they’re trying to express a critical truth. I think the stereotype that the media and the public have is that if somebody is psychotic, it means they just have wildly crazy and unpredictable associations in their head that aren’t at all rooted in reality. I think that’s totally wrong.
If you spend enough time with people who have a psychotic episode, you realize that there is a coherence to the story they’re telling; there’s some truth there. If you spend enough time with them and if they spend enough time with themselves, they can get to that. It often has to do with trauma. It often has to do with a really horrifying experience they’ve had that they couldn’t resolve in another way—other than going to the kind of symbolic realm of psychosis—but there’s a truth there. I think the first thing to do is to acknowledge that truth.
Sears: You’ve written about “context-free neuroscience” in psychiatry. What do you mean by this?
Hansen: Psychiatrists would really love to see mental health treatment become applied neuroscience. They just want to boil everything down to the brain because that would give the field of psychiatry a lot more prestige. It would give it a veneer of scientific control. A lot of my colleagues think it would get rid of the stigma of psychiatric diagnosis. Now that is a delusion.
When my sociology colleagues actually research this, they find that people who believe in the brain disease model actually stigmatize people with psychiatric diagnoses more because they think, “Oh, it’s biological, It’s something that is hereditary that can’t be changed. I wouldn’t want my son or daughter marrying anybody with that diagnosis. I don’t want to move in next to them.”
It’s a fallacy, but many of my colleagues think if we could just boil it down to the brain, it’ll de-stigmatize mental illness because it’ll hold people blameless. It doesn’t necessarily hold them blameless, but it does take away their moral agency. It consigns people to a category where you just can’t expect them to participate in their own decision-making and so forth.
These days, we in psychiatry are beholden to this idea that neuroscience will produce magic bullet solutions on the molecular level and that we can identify everything in the brain. This ideology ends up reinforcing the same class and race hierarchies that we were discussing. It presents itself as neutral because you’re talking about a brain. It doesn’t matter where somebody lives. It doesn’t matter the color of their skin, what their job is. It’s just the brain. It shouldn’t matter where they live, what they do, who they are.
This kind of molecular universalism is expressed in the kinds of images put in psychiatric journals these days. You’ll see an image of a brain scan. That is the image of contemporary psychiatric research; it’s just the brain. It doesn’t matter who this person is.
What that ends up doing is completely distracting us as psychiatrists, policymakers, and consumers from all of the social determinants of health. We end up not asking questions like, why is it that certain groups suffer so much more than others? Why are certain groups so much more likely to get certain diagnoses? Why are they so much more likely to die prematurely with this diagnosis? It erases neighborhood conditions. It erases public policies. It erases race and class. It prevents asking about housing policy and how it relates to elevated mortality among people who have psychiatric diagnoses. What about drug war policies?
That’s what I mean by context-free neuroscience. I think that ideology, that kind of worship of the brain and molecular solutions, has worsened many of our mental health problems because it’s detracted from any kind of attention or investment in the social determinants.
Sears: Can you recall any significant pushback or criticism you’ve experienced due to your critical view of psychiatry? Is it ever tough to be a psychiatrist with a critical perspective?
Hansen: Thank you for that question. I feel very lucky. I think being an anthropologist has insulated me on the one hand. On the other hand, I don’t have the National Institute of Mental Health running after me trying to give me grants. I’ve gotten a little bit of money from the National Institute on Drug Abuse when I managed to disguise myself as somebody who could produce data supporting the benefits of buprenorphine and medication for opioid dependence. But I haven’t had a lot of NIH funding, and I certainly don’t get asked to serve as a division chief or chair or anything.
But there are these rare pockets where everybody’s running to me for help in addressing a crisis. I’ll give you an example. I (and colleagues like me) are typically pretty marginalized within psychiatry. Over the past year, we have seen huge inequalities in COVID deaths by race, and huge upticks in overdose deaths, particularly among black and brown people, but also many poor white people. There’s all this emphasis right now on racism, inequalities, and health. So, psychiatry departments and the American Psychiatric Association are scrambling to show that they’re attending to these issues. All of a sudden, I’m being invited to serve in many positions I wasn’t before.
This year has been an interesting experiment, and I think groups like Black Lives Matter had a lot to do with that. When you ratchet things up to a certain level of attention, then you can get an institutional response. I think that my fear is that this is just for show and that it’s temporary. Maybe as soon as the cameras are gone, we’re going to go back to ignoring social determinants.
That’s what my colleagues and I are trying to figure out: How can we keep the pressure on around social determinants of mental health and structural racism in mental health? How can we make sure that this continues and that it builds? I don’t have the answer to that, but I think it has something to do with organizing efforts like Mad in America to push back against the status quo.
MIA Reports are supported, in part, by a grant from the Open Society Foundations