Institutional structures can help drive inequities, study says

By Andrew Cromarty
July 2nd, 2023
Miraj U. Desai, Ph.D.
Miraj U. Desai, Ph.D., assistant professor, Yale School of Medicine.

Person-centering may help counter trend

Organizational structures in mental health care may shape staff perceptions and behaviors in biased ways—usually unconsciously—according to a study published in “Clinical Psychological Science.”

The study, titled “System-Centered Care: How Bureaucracy and Racialization Decenter Attempts at Person-Centered Mental Health Care,” was headed by researchers Miraj U. Desai, Ph.D., Larry Davidson, Ph.D., APS Fellow John F. Dovidio (Yale University) Ph.D., Victoria Stanhope, Ph.D., (New York University), and Nadika Paranamana, Psy.D (University of Hartford).

“The paradox is that system-centering becomes implicit and explicit at the same time. It is implicit because it often occurs outside staff members’ awareness. It is explicit because it occurs right out in the open.” -- Miraj U. Desai, Ph.D., assistant professor, Yale School of Medicine

It was conducted through a series of interviews at community mental health centers with 12 providers who were receiving training on person-centered care planning. The study team included people of Asian, LatinX, and White backgrounds

The findings expose how institutional structures, including behavioral health organizations, can condition ways of perceiving clients as bureaucratic objects rather than people. Specifically, the research shows how racialized stereotypes and caricatures can enter inter-institutional functions and lead to discrimination embedded in standard operating procedures.

The researchers arrived at the startling revelation that institutions were capable of biased things normally attributed to individuals, such as perception, language, and intentionality.

“Psychology, particularly western psychology, has grown up as a field to focus primarily on individuals,” said Desai, assistant professor of psychiatry at Yale School of Medicine and lead author of the study. “But we are hoping this study helps people to see and think more structurally—how collective psychological processes are a major concern and help drive health and social inequities.”

What concerns the researchers most is how staff of mental health organization can become unwitting carriers of systemic agendas and intentionality. Through this process, which the authors refer to as “bureaucra-think,” practitioners perpetuate institutional biases simply by meeting their typical work requirements.

If institutions and systems lead care providers to view patients as non-people, then providers are unknowingly creating the conditions for widespread dehumanization.

Over time, bureaucra-think can lead to care becoming system-centered instead of patient-centered. Patient-centered care initiatives emerged as a way to refocus providers’ attention on the person rather than on the diseases and deficits.

“While this was a valuable shift in approach, our findings showed that this kind of person-centering can become derailed by system-centering, that is, a system’s preferences and ways of seeing,” said Desai. “The paradox is that system-centering becomes implicit and explicit at the same time. It is implicit because it often occurs outside staff members’ awareness. It is explicit because it occurs right out in the open.”

Highlighted in the study are the two primary ways in which patients might be perceived by institutions that reflect system-centering. The first is bureaucratic centering, which can lead to perceptions of patients as “one among many and easily forgotten,” “person as agenda item,” and “person as bureaucratically and culturally identical.”

The second is racialized centering, which includes perceptions such as “person as criminal,” “person as possible suspect,” and “person as racialized caricature or stereotype.”

In its conclusion, the study acknowledges that refocusing on person-centeredness with greater attunement and awareness of the unseen constraints of institutional processes may help counter system-centering trends. However, they caution that even if staff can re-engage their clients in this way, the institutions may still pressure them to view patients as objects because that is how institutions maintain operational efficiency.

A multilevel, system-wide approach is needed in order to achieve system-decentered care, according to Desai. One that would require the collective involvement of the community at all levels of operation, policy, and planning.

“Systems see; systems judge; and systems act,” said Desai. “There’s a haunting quality to this. We as a field may be just scratching the surface of what drives many of society’s greatest collective challenges.”

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