Implicit bias in mental health professions including psychiatry and psychotherapy
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Abstract
Mental health professionals face a range of unique issues in the course of their work. One of these issues is the implicit bias. Professionals in the fields of psychiatry and psychotherapy that are the primary mental health care providers are not exempt from implicit bias. Implicit bias refers to the unconscious stereotypes and attitudes that cloud an individual’s decisions, actions and comprehension. Time and again, mental health professionals have been accused of letting implicit bias get in their way when dealing with mentally ill patients. In one case, a patient describes her experience of discrimination from her physician. She says that her doctor was all cheery and professional until she found out that the patient had an ACE score, after which she treated the said patient condescendingly. Yet, healthcare professionals are humans first and physicians second. They cannot fully take the blame for an unconscious inbuilt tendency. Though it is a subliminal reflex, being implicitly biased as a mental health professional is hazardous as it may cause the physician to invalidate patient’s experiences or lead to poor decision making on critical choices affecting the patient under the influence of these biases. The ripple effects of this practise are that clients end up receiving substandard healthcare, discrimination of some patients over others and the creation of an unhealthy relationship between patients and their doctors. This paper will argue that implicit bias in the mental health professions exists and its effects are widespread. The first step will be to evaluate the cases of implicit bias among physicians in the mental health field. Next, it will focus on implicit bias by psychiatrists and psychotherapists. Later on, it will evaluate the effects of implicit bias on the mental health patients and their families. Finally, it will argue why implicit bias in mental health is an ethical issue. Having proven the existence of negative bias in the mental health field, the paper will conclude that implicit bias does exist and is detrimental in this field.
Introduction
Implicit bias has plagued the medical profession since time immemorial, and emerging research has recently recognized it as one of the challenges facing healthcare practitioners. Human beings are built with the subliminal aptitude to form generalizations and conclusions concerning other people based on age, weight, ethnic status and other such factors. This subliminal aptitude is referred to as implicit bias. Scientifically, implicit biases are defined as “the unconscious and/or automatic mental associations made between the members of a social group (or individuals who share a particular characteristic) and one or more attributes (implicit stereotype) or a negative evaluation (implicit prejudice)” (Fitzgerald et al., 2019). Implicit bias can both be positive and negative, but negative implicit bias is more prevalent than the positive type. Studies have shown a strong correlation between implicit bias by healthcare professionals and patient-provider relations, patient health results, abidance to treatment and treatment decisions (Hall et al., 2015). According to recent statistics, no less than two-thirds of all health care providers perpetrate some form or other of implicit bias (Merino et al., 2018).
Further, people of color are more prone to suffer implicit bias from health professionals (Hall et al., 2015). Mental health professionals have not been excepted from the plague of implicit bias. The field of mental health is especially susceptible to the brunt of adverse effects of implicit bias since the diagnosis and treatment of mental health illnesses is heavily dependent on the circumspection of the mental health professional. Since the nature of mental health care is on one to one basis as opposed to the inter-professional team-based care in other areas of healthcare, it perhaps has a larger window for implicit bias that barricades some groups of people from accessing wholesome mental health services.
Implicit bias pervades the mental health system. Healthcare professionals display implicit biases in the same ways that the general population does. Emerging research has shown that gender, age, race/ethnicity, socioeconomic status (SES), mental illness, weight, disability, intravenous drug users, social circumstances, having AIDS and brain-injured patients who are viewed to have caused these injuries are some of the cases that trigger healthcare professionals to exhibit implicit biases to patients (Fitzgerald & Hurst, 2017). For instance, say, a black man from a rough neighbourhood reports to a hospital citing extreme feelings of anxiety, delusions, mental confusions and paranoia. Instead of using the DSM-5 diagnostic criteria to address these patients signs and symptoms, there is a high likelihood of the psychiatrist handling this patient will underdiagnose this patient. The latent influence of implicit bias may prompt the psychiatrist to ignore the man’s signs that point towards schizophrenia and instead assume that the patient is simply in trouble due to the susceptibility of his race to be involved in criminal activity and the type of neighbourhood he lives in. The psychiatrist may feel that s/he is professionally diagnosing the patient when unbeknownst to them, they have already judged the man based on the stereotypes associated with the man’s race and socioeconomic status and these stereotypes further led them to underdiagnose the patient.
Implicit bias is evident in the treatment regimens, and medical attention mental health professionals provide to their patients. A study has shown that mental health professionals with a positive implicit bias towards some patients (e.g. white, wealthy patients) often over-diagnosed these patients (Fitzgerald & Hurst, 2017). Further, studies have indicated the presence of subliminal bias in mental health providers during diagnosis, treatment recommendations, and the number of questions asked and tests ordered from the patients (Fitzgerald & Hurst, 2017). These results indicate that mental health practitioners tend to be more attentive when offering treatment to those patients to whom they have positive implicit bias, e.g. wealthy white patients but show lesser comparatively lower attention and care to other patients with qualities that induce stereotypes.
A majority of mental health providers manifest negative subliminal bias towards people with mental health. A survey to evaluate the attitudes of mental health providers towards mentally ill patients was conducted, in which 731 mental health services providers (psychiatrists, psychologists, therapists, case managers, nurses, managers and program directors) and members of the general populace participated (Meyer, 2014). The two groups were presented with a vignette that described people who had schizophrenia and untreated depression but were not informed of their diagnosis. The group were then questioned on how they would react when they learnt that the people with untreated depression and schizophrenia would be residing next door to them, marrying into the family, living in a home close by or participating in the job (Meyer, 2014). Both groups, the mental health professionals, were okay with interacting with those with depression, and both groups had reservations about interacting with the schizophrenic people (Meyer, 2014). Both groups were of the view that the people with schizophrenia were more likely to be violent; hence interacting with them would be potentially dangerous. Looking at the results of this survey, it is ironic that the professionals who have a complete experience with people with extensive expertise hold utterly negative perspectives their patients.
Further, more than a third of the mental health specialists stated that they would be unwilling to have a person with schizophrenia as a work colleague. The survey also revealed that professionals with more advanced degrees in the mental health field handled the mentally ill better than their counterparts with lesser education (Meyer, 2014). All these negative assumptions are as a result of the unconscious bias in these mental health specialists who are expected to treat the mentally ill better as they have a better understanding of these patients. It can also be concluded that professionals in this field are better equipped to handle patients when they have more advanced education.
Psychiatrists and psychotherapists, who are some of the primary care health professionals, are also influenced by latent bias when providing mental health care. One study in Poland revealed that psychiatrists manifested more negative bias towards schizophrenic and major depression patients as compared to the general population (Kopera et al., 2014). A recent study uncovered some grim statistics. The data used was the audio recordings of potential psychotherapy clients that revealed that middle-class white women were more likely to get a call back when booking a psychotherapy appointment as compared to working-class black men (Merino et al., 2018). Consequently, schizophrenic and major depression patients may receive substandard health care because of their psychiatrist’s view of them.
Lower quality of healthcare is one of the consequences of implicit bias of mental health providers. When the mental health provider has no control over their subliminal reaction towards a patient, then they will be less attentive to this patient’s unique needs (Fitzgerald & Hurst, 2017). For instance, a psychotherapist may fail to properly diagnose depression in a patient complaining about low moods for extended periods if the patient resides in a poor neighbourhood as they may subconsciously assume that the said patient is depressed because of his/her socioeconomic status. This patient will continue to suffer under the subliminal bias of their doctor, while another patient is getting proper treatment from the same doctor. This varied treatment of patients may result in disparities in the outcomes of treatment.
Moreover, low quality of treatment, especially in mental health, may produce permanent negative results. A patient suffering from significant depression may end up committing suicide or committing other atrocious acts like homicides. Poor quality treatment of mentally ill patients that is orchestrated by implicit bias is potentially life-threatening.
Negative implicit bias affects the patient’s satisfaction with the mental health care services they have received. Mental health specialists under the influence of implicit bias may dismiss a patient’s signs and symptoms through the various stereotypes they view the patient through. One study uncovered the dismal fact that black patients are overall the most dissatisfied patients and not just in mental health but in all other forms of healthcare (DeAngelis, 2019). These patients often rated the quality of the treatment services they received as poor. This open dissatisfaction also results in poor patient-provider relations. Indeed, a patient will not relate optimally with a physician who gives them poor healthcare services and appears dismissive of their frets. Absence of patient satisfaction and lack of a good rapport between the patient and their mental health provider may lead the patient to take on self-diagnosis and treatment measures which may or may not work, especially with mental illnesses, and these may end up worsening the patient’s mental situation even further.
Besides, most mental health conditions are long term, consequently necessitating long term treatment. Lack of cohesion between the health provider and the mentally ill patient may result in poor abidance and commitment of the patient to the long term treatment they need (Merino et al., 2018). Further, mentally ill patients usually suffer affronts from their mental health providers. All these combined factors may eventually cause these marginalized patients to opt to forego treatment, hence undermining long term treatment that would otherwise have been instrumental in aiding the patient to lead a stable, everyday life. The overall effect of the patient avoiding treatment may pan over the broader community with the eventual consequence of the creation and nurturing of social norms that shun mental health treatment. Therefore, implicit bias has the potential to foster negative attitudes towards mental health treatment in society.
Overdiagnosis, under-diagnosis and misdiagnosis of mental health conditions result from implicit bias from mental health providers. Positive implicit bias is when an individual receives preferential treatment because they are viewed as rational, reasonable and overall a good citizen, without any damaging underpinnings to tarnish their image. Negative implicit bias, on the other hand, is when an individual receives lousy treatment from the people around them because they possess a certain quality that is associated with something negative. In mental healthcare, a white person who shows up at a mental hospital is more likely to receive better treatment and attention from the hospital staff as compared to a man with a non-white ethnicity. While the white patient will get proper treatment and possibly get an overdiagnosis, the non-white patient will probably get limited medical attention, and his symptoms will not be taken with much seriousness. The base cause of this disparity is the patient’s skin color, one is white that grants them positive implicit bias, and the other is non-white and consequently suffers negative bias. The reality is that even healthcare professionals are not immune to racial prejudice, which in itself is a form of implicit bias. While this is not always the case, it is what happens in most cases.
Implicit bias in mental health indirectly plays a role in the propagation of crime. According to research, approximately 50% of incarcerated inmates suffer from one form or other of mental health illness (Merino et al., 2018). Most of the prison population are people who come from ‘rough’ neighbourhoods and who were subsequently written off by society. Some of these people may have tried to seek mental health help but were either dismissed based on their socioeconomic status or underdiagnosed by the care specialists they turned to. Also, it can be argued that the high rates of recidivism among former inmates are partly as a result of the discontinued mental health treatment once these people are incarcerated (Gonzalez & Connell, 2014). The prison mental health system fails to provide required mental health care to its inmates, perhaps because they see no purpose in continuing treatment to individuals deemed as social misfits.
Further, Implicit stereotyping sometimes results in the wrongful incarceration of individuals. Before a suspect receives their judgment, the judge may order that an individual be subjected to mental health examinations, carried out by mental health experts. Should these experts fail to detach themselves from implicit stereotyping, they may end up sending to jail individuals who need psychiatric treatment as opposed to disciplinary measures. Mental health specialists hold the life of the suspects and inmates in their hands.
While implicit bias is subliminal, it is still counted as an ethical and moral misappropriation. The Hippocratic Oath forbids physicians against nihilism, which in part means rejecting the moral principles. When the mental health practitioner takes the Hippocratic Oath, he/she has committed themselves to identify and aptly respond to the clinical needs of all their patients regardless of what shape, form or color they come in. It follows that they should, at all times, endeavour to make accurate judgments based on the needs of all their patients. Making a precise judgment concerning the needs of their patient is the best demonstration of ethics that a mental health practitioner can engage in throughout their career (Puddifoot, 2019). Based on this deduction, when mental health practitioners let bias, even subliminal bias, to influence them to treat some patients more favourably than others, it becomes a deviation from the moral standard set both by society and the Hippocratic Oath. In essence, favourable treatment of some patients over others is a gross disregard of work ethics.
Subliminal bias in mental health practitioners inflicts additional suffering to mentally ill patients. Mentally ill patients are already going through so much in their lives and cannot accommodate the stress caused by being discriminated against by people expected to care for them. This can be explained in the following analogy. Under the crushing pressure of social stigma towards mentally ill persons, the mentally ill individual gathers the bravado to finally address his/her problem by taking themselves to see the doctor. Only for the doctor to take a glance at them and decide that the individual does not know what they are talking about; that they are not sick, that they are just non-white, or economically unstable or other such generalizations. Every human being even when ill, mentally or otherwise, needs to feel that they are seen as a fellow human being first instead of being judged for their being non-white, homeless, from a rough neighbourhood to mention but a few stereotypes that they find themselves in and have no control over. Consequently, the ill individual will feel invisible and unrecognized when they fail to get the attention they need because of the stereotypes their caregivers use to judge them by. With an already fragile state of mind, the stereotyping and micro-aggression they suffer in the hands of their supposed caregivers causes them further suffering that only worsens their mental health.
Implicit bias can be deemed as unethical because it obstructs some individuals from accessing help. When mental specialists fail to take the signs and symptoms of some patients into full account due to their stereotypical views, they end up arriving at poor judgments during diagnosis. A patient with a chronic underlying mental illness ends up getting under-diagnosed and gets progressively worse. Had the physician identified and cast aside their negative biases, they would have facilitated quick recovery or management of the condition. It is unethical to withhold or act in a way that causes one to withhold help from a fellow human being.
All in all, implicit bias is a leading cause of inadequate healthcare provision for mentally ill patients. Implicit bias/stereotyping happens when a healthcare professional is unable to detach themselves from their subliminal biases when handling mentally ill patients. Unfortunately, healthcare professionals are just as biased as the average individual. These specialists marginalize their patients based on ethnicity/race, socioeconomic status, age, gender, weight and other such stereotypes. The effects of bias from these specialists are widespread and range from mild to severe. The impact of subliminal bias spread as far as the criminal justice system where mentally ill inmates are denied access to treatment as they are viewed as social misfits. Some of the adverse effects of these stereotypes include that misdiagnosis, under-diagnosis and general neglect from their health providers to mention but a few. Mental health providers who are incapable of accurately diagnosing and attending to the needs of their patients commit ethical misappropriation. From the arguments presented herein, mental health providers need to devise means through which they can abandon their innate tendency to stereotype their patients subconsciously.
References
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