“I work at a psychiatric clinic that serves marginalised families.” “Be careful! These people are dangerous!”—a conversation when I had with a peer that I could never forget. As I was writing this op-ed, I conditioned my prompts to see people’s reactions. When I changed the statement to “I work at a elite mental health clinic for children with learning disability.”, people’s reactions shifted drastically, “That is meaningful work, you are protecting the future of this nation.” In a convenient sample of 15 people in each condition (N=30), people homogeneously responded more positively when the prompt is framed as “elite”, and more aversively when the prompt is framed as “marginalised”. Why is this? Since when has getting ill and accessing service become an elitist construct?
To understand this issue we first need to break it down to two basic levels: 1) who are the “good patient”? And 2) how the marginalised population became victims of structural violence in clinical diagnostics?
In the world of clinical psychology, we strive to squeeze extensive phenomena, patterns, and behaviours into rigidly defined classifications and label them as “symptoms”, and lead to a diagnostic for a mental disorder. Stigmatisation in mental health is no longer something new, but while we are trying to de-stigmatise it for the “good patients”—those who demonstrate high compliance to clinicians’ orders, adhere to the protocols, and understand complex medical terms, as suggested by Dr. Joseph and Dohan (2009). These characteristics often come with people who are relatively well-educated, and from a middle to upper socioeconomic status (SES). Study shows providers are more reluctant when researching with patients who don’t possess such characteristics—who are disproportionally from low-SES or culturally marginalised background. I believe this fundamental bias is not rooted in the recruitment phase of clinical research, like Joseph and Dohan suggested, instead the bias is present at the most rudimentary stage—how we are associating and overgeneralising past observation to new situations. Healthcare professionals who work in underserved neighbourhood consistently stress their work is inherently challenging mainly because of low-SES population are “unpredictable” and “hard to work with”, said by an anonymous clinical service administrator with 20 years experience at a major NYC healthcare system. I firmly believe low-SES should not be weaponised or disguised as a label to justify discrimination against specific population. Identifying specific factors that’s keeping them from gaining characteristics that make them to be “good patients” and strategise ways to remove that barrier through targeted community intervention and dissemination of science to the needed population is essential. Behavioural psychology believes that people are born as a “blank slate” regardless of SES. Targeted educational intervention, like the Nurse Family Partnership (NFP), can be used to equip vulnerable population with traits that “good patients” possess.
After “abnormal behaviour” are classified into disorders, clinicians make diagnoses based on the peer-validated criteria and psychometric scales. The instruments of measurement, also known as measurement scales in psychometric testings, are designed to unbiasedly measure a patients’ cognition and behaviour, then comparing the score to the distribution of the demographic group (Ramsden, 2024). However, demographic that dominants the development of such clinical evaluation scales are people who are western, educated, industrialised, rich, and from democratic nations (Muthukrishna et al.), which is not representative of the population. Like prescribing medication for which is not formulated for certain population, using scales not developed for a certain demographic to make diagnoses is risky and problematic—with elevated risk of missed diagnoses or even misdiagnoses. Unfortunately, this issue is at a structural level that it is standard practice across the field, and it is violence against marginalised population because it violates their basic human rights to access appropriate care (Farmer et al., 2006).
Marginalised population generally faces three enduring challenges that have negative implications on their health outcomes—creations of margins, living between cultures, and creation of vulnerability (Baah et al., 2018). To better understand this issue in clinical practice, I have interviewed Dr. Sonel Rowley at Promise Clinic, Columbia Psychiatry—a clinic that provides free neuropsychological evaluations to low-SES families. She expresses that with multiple stressors on their lives, even when they got a comprehensive evaluation and diagnoses, it is challenging to follow clinician’s recommendations as many of their patients work multiple jobs and raise multiple children.
Luckily, this is a solvable problem and we know how to work towards the right direction. First of all, Dr. Rowley argues that education is key—for both clinicians and patients. The healthcare system should start to nurture interests and provide opportunities to undergraduate students, so that more students could potentially become clinicians, which leads to better representation of the US population, and consequently creates a better predisposition where ethnography methods and explanatory models to patient care can be more effectively implemented in clinical settings. We also call for research on better test development so that the norms are more representative of the population so that the scores are compared to the norm which reflects the patients’ demography. Finally, policy on easier access to neuropsychological evaluations and funding for education on mental health fields to support culturally and racially divers aspiring clinicians is imperative for a more equitable access to mental healthcare (Rowley, 2024).
Acknowledgements
I would like to express my gratitude to Dr. Rowley for generously sharing her insights on equity in mental health care and neuropsychological evaluation access. Her expertise and thoughtful guidance have been instrumental in deepening my understanding of the field through the lens of inclusivity and equity.
References
Baah, F. O., Teitelman, A. M., & Riegel, B. (2018). Marginalization:
Conceptualizing patient vulnerabilities in the framework of social determinants of health—An integrative review. Nursing Inquiry, 26(1). https://doi.org/10.1111/nin.12268
Farmer, P. E., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural violence and clinical medicine. PLoS Medicine, 3(10), e449. https://doi.org/10.1371/journal.pmed.0030449
Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. https://doi.org/10.1371/journal.pmed.0030294
Muthukrishna, M., Bell, A. V., Henrich, J., Curtin, C. M., Gedranovich, A., McInerney, J., & Thue, B. (2020). Beyond western, educated, industrial, rich, and democratic (WEIRD) psychology: Measuring and mapping scales of cultural and psychological distance. Psychological Science, 31(6), 678-701. https://doi.org/10.1177/0956797620916782