Racial inequality negatively influences the lives of people of color in the United States. Although race refers to differential concentrations of specific genes, the impacts are confined to physical characteristics such as skin color, hair type, and eye color. Rather than designating meaningful biological categories, race is a social construct. Yet, where there are inevitable intersections with institutional structures and interpersonal health relationships, race and racism produce inequities.
Racism occurs within and permeates the overarching political, social, cultural, and economic systems of American society. It can take several forms: structural, institutional, interpersonal, and internalized. Institutional racism in the healthcare system yields adverse effects on the physical and mental health and well-being of racialized individuals and communities. These inequities are well documented.
Recommendations are offered for creating a fairer and more just healthcare system in America. Equality and equity in the country’s healthcare system will be achieved only if racism is challenged in all its forms.
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Institutional Racism and Effects on Health and Well-Being
Valire Carr Copeland, Betty Braxter, and Sandra Wexler
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Best Practices for Supporting Transgender Youth in Schools
Patrick Mulkern, August Wei, and Maggi Price
Transgender youth are those whose genders do not align with their sex assigned at birth. Transgender youth are increasingly visible and frequently encounter discrimination and a lack of understanding from others, especially at school. As a result, they experience profound mental health challenges, with one in five transgender youth attempting suicide. However, such youth who are adequately supported do not experience serious mental health difficulties. Accordingly, promoting school support for transgender youth is critical. While school staff know how to help youth generally, many want more guidance on how to help transgender youth. However, few resources provide clear and actionable best practices for school staff to help transgender youth.
Best practices for supporting transgender youth in schools include verbal, behavioral, and visual skills that all school staff can use. Research shows that when these practices are used, transgender youth experience fewer mental health challenges, feel more connected to their school community, and do better academically.
There are at least 20 best practices for supporting transgender youth in schools supported by empirical and practice-based literature; they span four categories: (a) language to use and avoid, (b) coming out at school, (c) creating a supportive school environment, and (d) preventing and intervening in bullying. Examples include sharing pronouns, advocating for, and sharing the location of gender-inclusive facilities, and intervening in gender-based bullying. School staff—including school social workers—can and should use this set of easy-to-implement, research-informed best practices to improve transgender youths’ mental health.
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Maternal Mental Health
Suresh Jungari
Maternal mental health (MMH) concerns encompass perinatal or postnatal fear of childbirth and any stress during pregnancy, childbirth, and the postpartum period. Maternal mental health issues have not received sufficient attention in research discourse, especially in low- and middle-income countries. The prevalence of maternal mental health problems ranges from 10% to 35% in both developed and developing countries. Individual, reproductive-related, and community-level factors contribute to increasing MMH concerns. Maternal mental health conditions may lead to compromised quality of life, delayed child development, loss of employment, and financial burdens. Routine maternal healthcare has been found to lack of integration of mental health aspects. Health systems should be equipped to address maternal mental health problems during routine maternal healthcare. More efforts are also needed in conducting research on varied dimensions of MMH.
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Special Education
Annahita Ball and Candra Skrzypek
The special education system in the United States serves youth with disabilities in the public schools. After decades of marginalization and oppression, federal and state policies established in the 1970s created a complex policy and service delivery system that serves more than 15% of youth in schools. Under federal law, disabled youths are entitled to a free and appropriate public education (FAPE) in the least restrictive setting. At the federal level, the Individuals with Disabilities Education Act (IDEA) is the guiding policy for special education. Under IDEA, key features of special education include the identification and evaluation of disabled youths, the least restrictive environment, Individualized Education Plans (IEP), procedural safeguards, and shared decision-making. To be eligible for services, a youth’s disability must directly and adversely impact their education as demonstrated by a comprehensive evaluation. Following the evaluation, a student will receive an educational placement in the least restrictive environment meaning the student must be included with students who are nondisabled to the maximum extent possible. The student will also receive an IEP, or a written document that specifies how the school or district will provide FAPE for the student as well as measurable annual goals. Students and their families should be involved throughout this process, and procedures are in place to ensure that any disputes are resolved.
Vast inequities and disproportionalities have been identified within the special education system. Specifically, inequity spans the identification, evaluation, and discipline of youths with disabilities. Some youths are overidentified in special education, while others are underidentified. Black, Native, and Hispanic youths are more likely to be identified for special education services and are more likely to be placed in restrictive and segregated settings. Disabled youths, especially racialized youths, are also at increased risk of exclusionary discipline (e.g., suspensions and expulsions). Policy changes identify and rectify disproportionality in special education. States and districts are required to report on disproportionality and those that have significant disproportionality by race or ethnicity must provide early intervening services to eliminate the disproportionality. Debate persists on whether the current special education system can truly be equitable though continued advocacy, policy changes, and innovation to ensure that special education practices meet the needs of all students.
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Critiques of Trauma-Informed Systems
Wendy Shaia, Temeka S. Bailey, Christopher Beegle, and Maura Tennor
Much of the trauma experienced by individuals, families, and communities, especially in historically marginalized areas, has been created by a series of social phenomena such as structural oppression, racism, and discrimination. Public-serving systems are uniquely positioned to counter the perpetuation of retraumatization that disproportionately impacts oppressed groups. Therefore, trauma-informed care (TIC) and trauma-responsive care (TRC) must evolve through the conscious application of an antiracist and antioppressive approach, thereby preventing the further harming of already marginalized groups. Macro accountability is established by analyzing power systems through a culturally responsive lens rather than blaming and pathologizing individuals impacted by historical and persistent racialized trauma. Applied to TIC and TRC, the SHARP framework renders more effective social work services at the personal and individual, professional and organizational, and political and societal levels more just and humane. A compare and contrast analysis of adverse childhood experience studies, summarizing TIC and TRC, and a case study of the application of the SHARP framework to human services work may shed light on guiding public-serving systems and promoting opportunities for posttraumatic growth and transformative change necessary for dismantling policies, protocols, and practices that increase vulnerability and long-term adverse outcomes in socially disadvantaged communities.
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Psychosocial Support in Emergency Settings
Maryanne Loughry
The integration of psychosocial support into emergency responses is a recent development. In the 1990s, the need to address the mental health and psychosocial well-being of individuals and communities affected by emergencies became clear following the breakup of the former Yugoslavia (1991–1992) and the Rwandan genocide (1994). Prior to this, mental health in emergencies was primarily addressed in clinical settings. However, the humanitarian field was divided between the medical sector, which asserted that psychiatric clinical intervention was best, and many nonmedical actors, who preferred a person-in-environment approach. The need for consensus resulted in the Inter-Agency Standing Committee (IASC) working group’s establishment of the framework of Mental Health and Psychosocial Support (MHPSS), which combined both approaches. The IASC Guidelines on MHPSS in Emergency Settings, published in 2007, are widely recognized as explaining how best to administer psychosocial support in emergencies. This ended decades of tension between mental health and psychosocial experts in emergency and humanitarian settings.
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Moral Injury in the Military
Lataya Hawkins
Moral injury has become a common term used to describe the complex symptoms experienced when there is a violation of one’s moral code. While the term is new, the concept of moral injury has been prevalent in human society since ancient times and conceivably since the beginning of humankind. It can be traced back to the Greco-Roman era when warriors shared intimate stories of their moral challenges on the battlefield. Moral injury has been extensively researched within the military population to describe the soul wound some service members carry because of war. It should not be confused with posttraumatic stress disorder (PTSD), the well-known mental health condition associated with veterans, however they can comorbidly exist with overlapping symptoms which therefore often makes it difficult to distinguish. What makes moral injury different from PTSD is that in many occurrences, it is the individual who commits a moral offense (versus mortal danger to self or others), and consequently must deal with aftermath of failing to be the moral (good) person they believed they were. Moral injury is important to understand conceptually and recognize clinically as it has been found to be closely associated with increased risk of suicide in service members and veterans.
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Disaster Mental Health
Leia Y. Saltzman, Regardt J. Ferreira, and Tonya C. Hansel
Disaster mental health refers to the provision of psychological and substance use services in environments coping with and recovering from disasters. In addition, disaster mental health refers to the study of the psychological and emotional impacts of disasters on individuals, families, and communities. Disasters—including climate-related, human-caused, biological, technological, and infrastructure failure—have documented impacts on the mental health of survivors. Disasters do not equitably impact individuals, families, and communities but rather may exacerbate existing disparities, worsening health and mental health outcomes and limiting access to mental health care. As societal and environmental factors continue to evolve, communities that previously were not impacted by disasters have begun to feel the effects. Simultaneously, communities that have previously been impacted by disasters are now facing recurring or compounding disaster experiences—for example, repeated wildfires, hurricanes, or flooding. The 2020 COVID-19 pandemic has also increased concerns about protracted and lengthy disaster experiences and the impact these events may have on new and/or worsening mental health symptoms. Social workers have a unique perspective that can contribute to the practice of disaster mental health with individuals, families and communities—from the provision of clinical services to policy and preparedness, to research. The system approach coupled with a strengthsbased perspective which is the hallmark of social work is imperative when working with individuals, families, and communities impacted by disasters and those who face mental health challenges in the wake of these experiences.
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Racism and Accountable Policing for Black Adults in the United States
Robert O. Motley Jr. and Christopher Baidoo
Racism is a public health concern for Black adults in the United States given its prevalence and association with adverse health outcomes for this population. The frequency of high-profile cases involving police use of gratuitous violence against Black adults has raised concerns regarding racially discriminatory law enforcement practices. In this article, racism is defined and a discussion is offered on its impact on the health and well-being of Black adults in the United States; the intersection of racism and policing; contemporary racialized policing practices; emerging evidence on prevalence rates for exposure (direct and indirect) to perceived racism-based police violence and associated mental and behavioral health outcomes; and police accountability through executive, legislative, legal, and other remedies.
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Dissociative Identity Disorder
Gregory L. Nooney
Individuals with the diagnosis of dissociative identity disorder (DID) developed a myriad of methods, including the creation of an intricate inner world of alternate identities, or alters, to creatively survive the devastating effects of early childhood trauma and attachment wounds. Unfortunately, a belief in its rarity even by mental health professionals, the perceived difficulty in diagnosing and treating dissociation, and a fear of the unknown have resulted in DID’s being underdiagnosed. The result has been that many with this condition have been ineffectively treated for co-occurring disorders and have been inaccurately perceived as resistive to treatment. Detailed methods of diagnosing DID, specific steps to help stabilize clients with DID, and in-depth trauma-specific protocols are summarized, along with ways to minimize the elevated risks of compassion fatigue and countertransference in working with this population.
