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From cultural to structural competency--training psychiatry residents to act on social determinants of health and institutional racism

H. Hansen, J. Braslow, R.M. Rohrbaugh
JAMA Psychiatry

Psychiatrists in training launch their careers in a time of inequalities and structural barriers to their patients’ health. Many believe that the uncertain funding and regulation of the US health care system and a frayed social safety net have led to a crisis in mental health care. The United States has fewer mental hospital beds per capita than almost all peer countries, while US suicide rates are at a historic high. Prisons and jails have become the largest provider of “care” of those with severe mental illness. Systemic violence and discrimination based on race, ethnicity, religion, sex, and sexual orientation have increased. These broader forces not only likely contribute to psychiatric disorders but also make living with these disorders significantly more difficult.

Over the last 50 years, psychiatric training and education have incorporated the revolution in the neurosciences. At the same time, psychiatric education has paid little attention to the powerful social determinants of mental health, which call on us to rigorously train our residents to understand and work at systems levels to eliminate the structural causes of illness. While cultural competency initiatives train residents in beliefs and behaviors of patient groups that experience health inequalities, cultural competency often falls short of systemic intervention. As a result, psychiatrists may not have the tools to improve their patients’ outcomes, which may lead to professional burnout, departure from clinical practice, and severe shortages of psychiatrists in the public sector.

As psychiatrists also trained in the social sciences, we have adopted what we call a structural competency approach.

 

Hansen H, Braslow J, Rohrbaugh RM. From cultural to structural competency-training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiatry. 2018;75(2):117-118. PMID: 29261827. DOI: 10.1001/jamapsychiatry.2017.3894.

 

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