Mental Health Care More System-Centered Than Person-Centered

A new qualitative study identifies how institutional interests in the mental health field dehumanize care for clients.

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In a new study, researchers from Yale studied how mental health organizations’ implemented (or failed to implement) person-centered care. They explored how institutional biases can systematically lead individuals to treat people as bureaucratic objects or “nonpersons.” Their observations provide essential information about why mental health organizations frequently fall short of providing person-centered care to a wide variety of clients.

The study authors, Miraj U. Desai, Nadika Paranamana, John F. Dovidio, Larry Davidson, and Victoria Stanhope, also forward suggestions for improving these institutions.

“Patient- and person-centered care, and related variants, are fast becoming a staple of health systems in North America and around the world. At stake in the initial formulations of these approaches in medical and healthcare settings was awareness—often born of the sociopolitical movements of ‘patients’ themselves—of how the person was getting lost in the predominant service focus on disease, deficit, and medicalization.”
“Movement away from paternalistic professional models toward shared decision-making, empowerment, and the whole person has gathered momentum, with wider system transformation efforts ensuing. Attempts to implement these strategies, however, still encounter professional and organizational resistance to reorienting care toward the person.”

As part of a larger study, the researchers explored structural dynamics impacting care for racially marginalized populations, specifically in two community mental health centers (CMHCs) receiving Medicaid and state funding. However, they acknowledge that narratives and suggestions from participants drove their interest in bureaucracy. CMHC institutions are particularly important as there are more than 2,500 of them in the United States. In addition, they are notably more available than other mental health resources to minoritized and stigmatized populations.

They conducted semi-structured, qualitative interviews with 12 mental health care providers. They used two types of analyses: one focused on identifying phenomena and the other exploring relations between psychological processes and real-world context. The process involved research team members analyzing each transcript line by line to create a one-page summary of ideas central to each provider’s narrative. The first author then identified themes from the one-page summaries. Validity checks in terms of the lived experiences of people of color generally were provided by Latinx and Asian research team members. Experiential validity checks were also conducted by practicing psychologists, physical health care practitioners, and people with lived experience of mental illness connected with the research group.

The main finding was that providers’ attempts to engage in person-centered care competed with institutional pressures towards system-centered care (centering the legal, financial, bureaucratic, or racist interests of the institution).

“Our findings reveal that provider efforts to center the person in community mental health services competed with pressures to characterize the person in the way the bureaucracy sees them as—for example, as an object, a number, paperwork, or a racialized caricature. The goal of person-centering thus competed against system-centering… We term these processes through which staff can be conditioned by systems and institutions to perceive and attribute objectifying meanings as ‘bureaucra-think’ and ‘bureaucra-seeing,’ respectively.”

The authors identified three main narrative themes in the results of their study: bureaucratic centering (4 sub-themes), racialized centering (4 sub-themes), and recentering the person (0 sub-themes). The following provides only a summary of the themes. However, more detail about each theme and sub-theme is provided in the original article.

Bureaucratic centering refers to “how a client could become viewed (a) as low in priority; (b) as bureaucratic objects such as agenda items, paperwork, or units of time; or (c) as culturally nondistinct—and (d) how the providers themselves could become disillusioned and/or needed to push back against this climate.” Desai and colleagues explain that in racialized centering, “racial stereotypes and profiles get concretized within and between institutions as reality; that is, how racialized descriptors can become the person [to the institution and providers], with negative implications within wider systems such as education and law.”

Recentering the person was summarized as “provider adoption, or readoption, of a humane, personalized perspective to care for the client,” which was sometimes in response to marginalizing bureaucratic processes and sometimes then here in philosophy that the provider already had.

Desai and colleagues identify their shift in the study’s focus on bureaucracy as a limitation and suggest the study is a starting point. They encourage more research to be done in varying mental health settings and across different populations but do not specify which populations were most missing from this investigation.

The authors state that “the initial focus of the study was Latinx and Asian persons, but it also included opportunities for providers to discuss persons from other groups (e.g., African American and American Indian clients) in the interviews.” However, they provide no rationale for why Black people were deprioritized when they are so prevalent in the studied settings or why First Nations people were deprioritized when they are so heavily erased. Furthermore, requiring providers to volunteer information about these two racialized populations while asking about others explicitly makes it challenging to know what essential themes might be missing and how these results generalize to interactions and understandings of Black and indigenous people.

Researchers from racial minority groups provided validity checks for the relevance of themes to “lived experience.” Still, this group also had no Black nor American Indian researchers despite the prevalence of Black research subjects (25% of interviewed providers).

This article has several implications for the broader context of mental health care. First, “There was a risk inherent in institutions and systems to condition dehumanized ways of perceiving minoritized clients (and, conceivably, many others)….”

Desai and colleagues describe an inherent risk of institutions dehumanizing clients, especially those with minority identities. Multiple bureaucratic and racialized profiles and meanings form inside the system of institutional life for providers, creating an impersonal “fog” of meanings that interfere with person-centered care.

“At stake in these clinical encounters were the ways in which meanings can become ascribed to clients by an institution, which can have little to do with the client’s own life and personhood… On one end of the spectrum lies the possibility of staff creatively navigating these meanings for their clients’ care, of pushing back, or even of vying for structural change. On the other end of the spectrum, however, is the possibility of staff drawing on these floating, institutional meanings to further their own bias or aggression toward people. In the middle, but no less disturbing, is the possibility of staff implicitly and unwittingly transmitting these ways of viewing–a constant risk within bureaucratic environments filled with procedures and paperwork.”

The authors label the process above as “person-centered.” They suggest that mental health institutions are also “system-centered,” making it likely for clients to be viewed as bureaucratized and racialized objects.

“If so, this moves us toward the disturbing possibility that systems have the capacity to see—and often in ways that remain hidden to human eyes. The staff member, in turn, may become an unwitting carrier of the system’s intentionality and meaning-making. The staff, as a whole, can become collective carriers, systematically enforcing a particular reality onto the person. The reality that gets produced may then be considered objective, rather than as skewed or biased.”

Desai and colleagues suggest an alternative to the stifling and dehumanizing processes that seems to be so common in these institutions:

“There was evidence that person-centeredness or, more specifically, attuned and aware clinicians could present a different vista wherein clients could breathe, move, and dream in a less stifling, stigmatizing environment. Yet although the findings suggest that these stances are possible, they also allude to the texture of what this work is up against to make that a reality.”

They suggest that accomplishing this requires not only being person-centered but actively being system-decentered system-wide and throughout multiple levels of an organization.

The authors clearly demonstrate that institutional systems make it difficult for clients to receive adequate care by influencing providers to treat their clients as nonhumans in addition to already present implicit biases that individual providers hold. Addressing this will require attention at multiple levels, including at the research level – prioritizing the humanity of those most frequently dehumanized by prioritizing their narratives and input in attempts to improve systems.

 

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Desai, M. U., Paranamana, N., Dovidio, J. F., Davidson, L., & Stanhope, V. (2022). System-Centered Care: How Bureaucracy and Racialization Decenter Attempts at Person-Centered Mental Health Care. Clinical Psychological Science, 0(0). https://doi.org/10.1177/21677026221133053(Link)

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Tsotso Ablorh
Tsotso Ablorh is a doctoral student in Clinical Psychology at the University of Massachusetts Boston. She primarily researches improvements to culturally relevant therapeutic methods based on the experiences and needs of marginalized peoples; including methods for training therapists, decreasing therapist cultural biases, and assessing the effectiveness of therapist training.

6 COMMENTS

  1. People don’t need a disease-centered, agenda-laden system. They need caring human beings without an agenda who know how to listen—something that used to be called a very good friend.

    Healing happens in understanding, NOT “diagnoses”.

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    • Definitely, it was my good friends who saved me from my former – distress caused by 9/11/2001 is distress caused by a “chemical imbalance in your brain” believing, all dreams are “psychosis” believing, gas lighting, Holy Spirit blaspheming, child abuse covering up, satanic, criminal, your entire life is “a credible fictional story” believing, depersonalizing, DSM “bible” thumping – “mental health” lunatics.

      Political and criminal abuse of psychology and psychiatry is, and has been, rampant in the US for decades, or longer. All people who don’t stand 100% in support of never ending wars and pedophiles are the sane people. Those who stand 100% in support of profiteering off of covering up rape of babies and the never ending wars – like my former “mental health” lunatics – are the insane, stupid, and delusional people.

      Ten years ago your DSM “bible” was debunked as scientifically “invalid.” How long will it take the DSM “bible” thumpers to realize that means you flush your “bible”? And get out of the pedophile aiding, abetting, and empowerment business, criminal “mental health professions,” who are still claiming to know nothing about the common adverse and withdrawal effects of their neurotoxins. What is “professional” about being ignorant and criminal, psychology and psychiatry?

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