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SPECIAL REPORT: DIVERSITY

The August Special Report emphasizes the urgent need for action beyond diversity in psychiatry.

Far More Than Diversity: What the Field of Medicine Needs

Amanda Calhoun, MD, MPH

When Psychiatric Times invited me to chair its Diversity Special Report, I was pleased. But I was also at a loss for words. I called my dad, also a child psychiatrist: “What do you think I should say, Dad?”

“Diversity? Are they still talking about that? People were talking about that 200 years ago, when I was in medical school,” my dad said, chuckling.

His words encapsulated what I was feeling, and why, when I put my pen to paper, the words I kept writing felt empty. It was because it felt futile.

During my third year of residency, I did an OpEd Project fellowship. “Raise your hand if you think you are working on a forever problem,” the facilitator asked, straightening his glasses. “You know, a problem that will not be solved in our lifetimes.” I raised my hand.

The importance of diversity in psychiatry, and in medicine in general, cannot be overstated. But the percentage of Black physicians has barely budged—only by 4%—in the past 120 years. And of these current Black physicians, it is unknown how many of these are Black American Descendants of the Enslaved, like me and my dad. Who knows? Those numbers may have decreased. And that matters. Most demographic spreadsheets and checklists put all individuals racialized as Black in a box, regardless of whether they are immigrants who are unfamiliar with the unique impact of anti-Black racism on health, or whether they are Foundational Black Americans who have been in this country for generations and live that impact every day.

Like my dad said, we as a field are still talking about increasing diversity when we need far more than diversity, far more than mere representation. Black children are more likely to be physically restrained than white patients and more likely to be diagnosed with disruptive mood disorders than white children, which trickles down to poor diagnoses and inadequate medication regimens. The stress of everyday racism in Black individuals leads to a splintering effect of depressive and anxiety symptoms, even those akin to posttraumatic stress disorder. It leads to telomere shortening and diminished lifespans. Racism is killing Black people and wearing down on our mental health, so we need far more than diversity.

We need research funding that does not just highlight another devastating white-Black disparity but funds the implementation of antiracist initiatives that lead to better health outcomes in Black individuals and other marginalized groups. We need more funding for programs that will increase the pipeline of Black physicians, by funding their medical school and undergrad programs. We need hospital and academic institutions to listen to us when we talk about the impact of racism on our Black patients, instead of silencing us. We need media platforms to listen and amplify our voices.

This Special Report is just that, and I am thankful to Psychiatric Times for walking the walk, not just talking the talk, and for supporting my voice, as well as the voices of the authors included in this report.

Dr Calhoun is an adult/child psychiatry resident at the Yale Child Study Center at the Yale School of Medicine. She is an expert on the harms of medical racism and the mental health effects of anti-Black racism in children.

More Than Diverse: Race as an Insufficient Proxy of American Historic Lived Expertise

Carmen G. Black, MD, MHS

As an Ethnic Black American psychiatrist, I believe this famous quote by Albert Einstein can help American psychiatric clinicians navigate today’s rapidly changing landscape of diversity-based frameworks: “Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.” I interpret this saying to implore clinicians and academics to never stop critically interrogating extant health care knowledges and practices. As a compass to navigate these lines of questioning, Einstein instructs us to first learn from the past. History books and lecture halls are certainly one way of learning about health care’s inequitable past. Yet, worthwhile histories of American health care harm are not limited to the realm of secondhand academic knowledge or documented disparities. Rather, we can learn about the past directly from the individuals carrying firsthand, living perspectives of American history.

As a medical educator and originator of the sociohistorical justice (SHJ) framework, I have dedicated my career to helping health care systems, clinicians, and educators disaggregate and honor the individuals bearing historic lived expertise: knowledges born from direct and multigenerational experiences of enduring and overcoming American medicine’s storied past. Lived experts differ from academic experts in their epistemological approach to knowledge, which is the way that experts know what they know. Academics often assess knowledge credibility through normative metrics like seniority, publications, and degrees. In contrast, the epistemological credibility of lived and/or living experts is established through direct experience; they know what they know because they lived or are still living it for themselves.

Yet, knowledge construction is not a socially neutral process: Groups unequal in power also have unequal access to academic knowledge, like possessing enough resources to obtain a formal education or to become a credentialed educator themselves, especially one who is freely spoken within the academe.¹ Because knowledge is not neutral, lived experts frequently hold firsthand subjugated knowledges of how minoritized groups survive oppression, and these subjugated knowledges know the realities of social oppression in personalized ways that vicarious knowledge can never replicate or achieve.¹ Indeed, Patricia Hill Collins, PhD, once spoke of the epistemological advantages of lived experts: “Those individuals who have lived through the experiences about which they claim to be experts are more believable and credible than those who have merely read or thought about such experiences.”¹

Let us now return to the meaning contained within Einstein’s words of wisdom: Hope for the future begins with learning from the past. Despite the present controversy of diversity-based frameworks, we are still accountable to innovate knowledge that prevents future disparate outcomes. Moreover, according to Einstein, the knowledge required to truly understand today’s inequitable practices is largely rooted in the past. However, because experiencing health care inequity is a form of social minoritization in itself, only lived and living experts are epistemologically equipped to offer firsthand, subjugated knowledge of American medicine’s shortcomings.

Identifying Living Experts

Identifying living experts of present-day harm can be relatively straightforward, since they are alive to speak for themselves. In contrast, identifying living experts of American historical harm may sometimes seem impossible because many of history’s original victims are no longer alive. Indeed, many of the harmful historic acts that still detriment modern medicine’s functionality occurred many decades or centuries ago. For instance, historic acts of educational segregation, like the Flexner Report of 1910, generationally deprived educational opportunity to over 35,000 doctors to Black Americans with lineages established in the US by 1910, being Flexnerian-Deprived Black Americans (FDBAs).^2-4 Discrete acts of medical racism also directly contribute to historic Black Americans’ adaptive distrust of health care systems, like the medical exploitation of Black men during the Tuskegee syphilis study, whose public exposure in 1972 instilled so much rational avoidance of health care systems among Black men that it literally reduced their lifespan by 1.5 years.⁵ If the original living experts of historic harm are deceased, how, then, can we learn from lived experts with firsthand knowledge of American medical history?

Thankfully, living experts of American historical harm are all around us: They are individuals who inherited yesteryear’s subjugated knowledge from their elders as they transmitted their wisdom of surviving American health care’s oppression across generations through storytelling. Nonetheless, identifying living experts of American historical experiences is trickier than identifying living experts of present-day experiences, especially regarding historic acts of racism. This complexity arises because, due to the welcomed voluntary migration of diverse populations, Americans bearing a present-day racial identity do not automatically possess direct (vs vicarious) familial ties to a defined historic harm, even if that historic harm was executed along racial lines. Allow me to explain.

All Black Americans share a present-day racialization due to similar physical features, and most carry present-day lived expertise of American racism and historic lived expertise of colonization and/or race-based harm rooted to diverse national contexts across the wider African diaspora. Notwithstanding, Black Americans are not a historical monolith in their epistemological perspectives to timelines of American medical harm. To begin, FDBAs represent the 90% ethnic (historical) majority of Black Americans with ancestry originating within foundational American history, conceptually termed Ethnic Black Americans within the SHJ framework. The other 10% of Black Americans are non-FDBAs who do not possess familial ties throughout foundational American history due to voluntarily establishing their lineage within American society many centuries later, over half of whom arrived within the last 20 years.^3,4,6,7 Therefore, FDBA lineages are the historic living experts of the missing 35,000 Black doctors caused by 115 years of ongoing Flexnerian educational segregation.^3,4,7 FDBA lineages equally carry the historic lived expertise and subjugated knowledge of surviving every moment of American anti-Black racism since 1910, including Tuskegee, the American Civil Rights movement, and so much more. However, compared with prior decades, the representation of FDBA doctors has acutely declined, including by roughly 50% for FDBA men, despite institutional claims of accountability to their problematic history through diversity-based programs.⁴ Some medical school classes have no FDBA epistemological or living representation among their Black-identifying students at all. Historic lived expertise is misconceptualized and decentralized within present-focused, diversity frameworks, thereby limiting the infusion of historically corrective subjugated knowledge into the academe. The historical homogenization of distinct, contemporarily minoritized groups within prevailing frameworks sustains this inability to optimally learn from America’s past.^3,4,7

The diverse lived expertise of all individuals experiencing presently mediated discrimination must still be prioritized. Truly, in the spirit of Einstein’s guidance, he instructs us to “live for today,” and diversity frameworks shine in these present-focused subtypes of equity work. Yet, in addition to being inclusive of diverse living histories of worldwide experiences, if American health care institutions truly wish to “learn from yesterday,” they must specify and honor the historic lived experts bearing subjugated knowledges of surviving their own institutional harm.

Sociohistorical Justice Framework

Institutional historical accountability sometimes overlaps with modern-day notions of racial diversity. However, race is an insufficient proxy of subjugated knowledge born of American historic lived expertise: Race is a fluid construct that changes as the sociopolitical, geographic, and temporal context changes. Thus, the equity work of institutional historical accountability requires attunement to concepts stably anchored to place and time, for which the SHJ framework was crafted.^3,4,7 Socio honors the unique sociopolitical construction of discrimination within a defined geographic region and/or nation (including but transcending notions of race), and historical differentiates the temporal aspects of endured harm for contemporary minoritized persons (like ancestry, ethnicity, chronicity of endured harm within a given social context). SHJ is a 5-step, history-based equity framework that helps institutions build locally relevant, lineage-based, restorative equity endeavors in historically, racially, ethnically, and nationally diverse societies. SHJ achieves this goal by (1) naming a historic discriminatory act, (2) defining the geographic footprints and generational timelines of that historic harm, (3) interrogating the sociopolitical constructs that marked the original victims, (4) disaggregating present-day populations to identify the modern descendants of original victims bearing direct and continuous—not vicarious—historic harm, and (5) measuring success only by how precisely those modern descendants benefit from a given historic equity effort.³

SHJ provides institutions the vernacular and nuance required to respectfully disaggregate contemporary groups in relation to American history. SHJ’s insistence upon historic lived expertise by no means competes with diversity-based frameworks for present-day accountability or lived experiences. However, SHJ does assert the irreplicable epistemological strength of historic lived expertise at the helm of medical knowledge interrogation, production, and validation.

Concluding Thoughts

In hopes of building a brighter tomorrow, we must stand in solidarity as a unified—though historically distinct—contemporary body of clinicians, researchers, and educators to innovate solutions to today’s health care inequities. As we forge paths forward in this tumultuous climate of health equity, let us use these periods of critical self-reflection to center the recruitment, representation, and retention of historic lived experts within the epistemological construction of new health care knowledges.

Dr Black is an adult psychiatrist, associate professor at the University of Connecticut, and vice chair of education at the Institute of Living, one of the country’s oldest psychiatric hospitals.

References

1. Hill Collins P. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. 2nd ed. Routledge; 2000.

2. Campbell KM, Corral I, Infante Linares JL, Tumin D. Projected estimates of African American medical graduates of closed historically Black medical schools. JAMA Netw Open. 2020;3(8):e2015220.

3. Black C, Temple S, Acquaye A, et al. Sociohistorical justice: a corrective framework to mend the modern harms of medical history. Lancet Reg Health Am. 2024;38:100874.

4. Black C, Brinker M, Acquaye A, et al. Beyond race-based ideology in HPE equity attempts: a framework and vocabulary for sociohistorical justice. Teach Learn Med. Forthcoming 2025.

5. Alsan M, Wanamaker M. Tuskegee and the health of Black men. Q J Econ. 2017;133(1):407-455.

6. Tamir C, Anderson M. One-in-ten Black people living in the U.S. are immigrants. Pew Research Center. January 20, 2022. Accessed June 16, 2025. https://www.pewresearch.org/race-ethnicity/wp-content/uploads/sites/18/2022/01/RE_2022.01.20_Black-Immigrants_FINAL.pdf

7. Black C. How do we know what we know? centering lived experiences in health equity knowledges. Teach Learn Med. Forthcoming 2025.

Beyond Representation: Rethinking Emotional Asymmetry in Psychiatric Diversity Models

Christopher T. Fields, PhD

The psychiatric field has increasingly embraced diversity, equity, and inclusion (DEI) frameworks. From institutional pledges to workforce diversification to the inclusion of cultural factors in diagnostic manuals, progress has been made. But beneath this visible transformation lies an unspoken asymmetry: an imbalance in how emotional expression and affective labor are distributed, recognized, and pathologized across lines of race, power, and structural privilege. As DEI becomes increasingly procedural, it risks reinforcing rather than challenging the emotional hierarchies that define psychiatric engagement.

Emotional asymmetry refers to the unequal expectation and social tolerance of emotional expression based on positionality. In psychiatric settings, this means that structurally marginalized individuals are often expected to modulate or suppress legitimate affective responses. They are pressured to perform composure in the face of distress, or risk being labeled as “difficult,” “noncompliant,” or “borderline.” Meanwhile, individuals from structurally privileged groups are more readily granted emotional latitude. These asymmetries are not merely interpersonal dynamics; they are entrenched in diagnostic criteria, institutional culture, and broader societal narratives about who is allowed to be hurt and who must remain composed.

For instance, consider a Black patient who presents with symptoms of hypervigilance, mistrust, and emotional detachment following workplace discrimination. Without a structural lens, these symptoms may be pathologized as signs of a personality disorder or treatment resistance. But when viewed through the framework of racialized trauma and institutional betrayal,^1,2 they emerge as adaptive responses to chronic stressors. The risk of psychiatric misrecognition, in which structural injuries are interpreted as individual pathology, is amplified when clinicians lack training in the emotional dimensions of structural racism.

This pattern is particularly pronounced in therapeutic encounters where clinicians unconsciously expect racialized patients to minimize distress, avoid critique, and demonstrate gratitude for care. These expectations often go unspoken, yet they shape the transference and countertransference dynamics in subtle but profound ways. As Fanon observed, the psychological violence of racialization creates a double consciousness where marginalized individuals must constantly navigate both their internal experience and external expectations of emotional propriety.³ The asymmetry is also mirrored in institutional spaces where emotional restraint is demanded from staff of color, even in response to microaggressions or policy failures, while White colleagues may be granted more emotional expressiveness, including frustration or disengagement, without consequence.⁴

These dynamics are not simply cultural misunderstandings. They are structurally patterned outcomes of what Black feminist scholars have long identified as affective labor: the unpaid and often unrecognized work of managing one’s emotions and those of others in hierarchical contexts.^5,6 Hartman’s analysis of slavery’s afterlife illuminates how contemporary emotional regulation among Black individuals often represents a continuation of survival strategies developed under conditions of racialized violence.⁷ In psychiatry, this labor often takes the form of self-censorship, hyper-composure, or what could be described as “strategic calm” among racialized patients and professionals alike. The emotional asymmetry becomes both a survival strategy and a barrier to care.

Psychiatric diversity models, as currently practiced, often remain silent on these dynamics. They focus on increasing representation or delivering culturally competent care without interrogating the affective substrates of racism or institutional betrayal. But without a framework for affective accountability, or an understanding of how power shapes emotional expectations and interpretations, even well-meaning interventions can reproduce harm. What is needed is a shift from optics-based DEI to structurally informed emotional realism.

The following 3 clinical commitments are essential:

• Treat emotional responses to injustice as data, not deviance. When a patient is angry, withdrawn, or distrustful, consider the structural conditions under which that affect has formed. What histories of betrayal, silencing, or misrecognition might be shaping this response?
• Interrogate the emotional norms of psychiatric settings. Whose emotions are expected to be managed, and whose are tolerated or even valorized? What types of emotional expression are welcomed, and which are punished or pathologized?
• Build diagnostic humility. Recognize that DSM categories often reflect dominant cultural scripts about normative emotion. Be open to reinterpreting symptoms in light of systemic stressors and lived experience.

The task before us is not to abandon clinical judgment but to deepen it. To ask not only what someone feels but why their feelings are seen the way they are, and what structural dynamics shape that perception. In doing so, we begin to develop a psychiatry that does not simply include diverse patients but that listens to them on their own terms.

Case Vignette

“Maya,” a 27-year-old Afro-Caribbean woman who was recently diagnosed with major depressive disorder, is referred for therapy after an unsuccessful trial of selective serotonin reuptake inhibitors. In sessions, she appears emotionally flat, rarely makes eye contact, and is reluctant to discuss family history. Her therapist, a White clinician trained in cognitive behavior therapy, interprets her disengagement as “guardedness” and raises concerns about a possible comorbid personality disorder. But when a peer support worker of similar background joins a session, Maya shares a detailed account of racist bullying in her workplace and her fear that speaking candidly would result in retaliation or misinterpretation. The peer worker contextualizes this as a common form of emotional suppression among Black professionals in predominantly White institutions, describing it as a strategy of “strategic silence” used for safety rather than deception. The treatment plan shifts to incorporate narrative therapy and structural validation, with improved engagement.

Discussion

This vignette underscores the stakes of emotional misrecognition. Without a structurally informed lens, Maya’s protective behaviors were mistaken for pathology. With affective insight, they became part of the clinical narrative. Judith Herman’s framework for understanding trauma responses helps illuminate how protective behaviors, including emotional numbing, hypervigilance, and avoidance, are adaptive responses to systemic harm rather than intrinsic pathology.⁸

Psychiatry cannot afford to keep mistaking its own blind spots for diagnostic clarity. When it ignores the affective residues of history, how racial science, institutional betrayal, and emotional silencing have shaped psychiatric norms, it mistakes emotional protection for pathology. We must ask not only who is feeling but whose feelings are systemically misread, minimized, or erased. Emotional asymmetry is not a flaw in patient behavior; it is psychiatry’s mirror. It reflects the field’s unfinished reckoning with power, perspective, and pain.

What would it mean for psychiatry to treat emotional asymmetry not as a flaw in patient behavior but as a mirror held up to its own practices? It would mean recognizing that emotional expressions cannot be universally standardized without reproducing harm. That the language of “insight” or “appropriateness” is shaped by culture and power. That psychiatry’s tools, however evidence-based, still operate within a historical framework that has often misread emotion as deviance. As Audre Lorde reminded us, the master’s tools will never dismantle the master’s house.⁹ Psychiatric frameworks that pathologize justified anger while demanding emotional performance cannot simultaneously heal the wounds they create.

This does not mean abandoning diagnostic rigor. It means supplementing it with a critical awareness of how emotional meaning is constructed. It means valuing cultural formulation interviews not as sidebars but as central to clinical epistemology. And it means building interpretive frameworks that allow for complexity and that do not demand emotional performance as the price of care.

Concluding Thoughts

Psychiatry must move beyond the optics of inclusion and into the depths of emotional justice. Emotional asymmetry is not an abstraction; it is a daily reality for patients and clinicians navigating systems not built for their truths. Let us build a field that meets them there.

Dr Fields is an associate research scientist in the Department of Psychiatry at Yale School of Medicine.

References

1. Comas-Díaz L, Hall GN, Neville HA. Racial trauma: theory, research, and healing: introduction to the special issue. Am Psychol. 2019;74(1):1-5.

2. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. 2nd ed. Zed Books; 2012.

3. Fanon F. Black Skin, White Masks. Markmann CL, trans. Grove Press; 1967:232.

4. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271-286.

5. Hill Collins P. Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. Routledge; 2009.

6. Hochschild AR. The Managed Heart: Commercialization of Human Feeling. University of California Press; 2012.

7. Hartman SV. Scenes of Subjection: Terror, Slavery, and Self-Making in Nineteenth-Century America. Oxford University Press; 1997.

8. Herman JL. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. Basic Books; 1997.

9. Lorde A. Sister Outsider: Essays and Speeches. Crossing Press; 1984.

Beyond Compliance: Addressing Indigenous Mental Health and What Is Missing in Clinical Practice

Jennifer Gereda, DSW, LCSW

Indigenous communities across the United States and globally experience disproportionate rates of trauma, mental illness, poverty, and institutional mistrust. Despite these realities, dominant models of mental health treatment pathologize Indigenous behaviors and beliefs, ignoring systemic oppression and intergenerational trauma. This article explores what is missing in mental health practice for Indigenous populations and introduces decolonizing, culturally grounded models of care.

What Is Missing: Colonized Mental Health Models

Western psychiatry and clinical practice often isolate symptoms from social and historical context. This framework invalidates Indigenous knowledge systems, communal values, and healing traditions, replacing them with Eurocentric norms. Mental health professionals frequently misinterpret traditional parenting or survival strategies as dysfunction. For example, expecting adolescents to contribute financially to the household may reflect cultural interdependence, not neglect. Additionally, families from diverse cultural backgrounds rely heavily on one another and often engage in shared caregiving responsibilities. This interconnectedness can sometimes be misinterpreted as enmeshment, rather than being understood through a communal or collectivist cultural lens.

These misinterpretations lead to punitive interventions. One such example is child protective services (CPS), which may view Indigenous parenting through a deficit lens, often pressuring families to assimilate into White middle-class norms to maintain custody of their children.¹

Case Vignette 1

“Calista,” an Indigenous Guatemalan mother with no formal education and a history of trauma, was referred to CPS for parenting concerns, including poor supervision and inconsistent school attendance. CPS viewed her expectations of a mid-teenager contributing to rent and work as inappropriate.

Through an in-home support program led by a clinician grounded in a decolonizing framework, Calista and her family were approached with cultural sensitivity and an understanding of their historical context. Instead of pathologizing Calista’s parenting, the clinician highlighted her strengths, especially her resilience and dedication to family unity—while also recognizing the systemic and historical forces that shaped her experiences.

When it came to the family’s financial hardship, the clinician created a safe space for the eldest daughter to share her perspective. The youth spoke about her deep love for her family, the extreme poverty that led them to leave their home country, and her role in contributing to rent as the oldest sibling. She also spoke about her mistrust of CPS and feeling that things were worse off with their involvement. She shared that she chose to leave her home and rent a bedroom on her own, given the challenges she and her family were facing. Through her living independently and reflection in sessions, she recognized the unique burden she carried compared with her younger siblings, who were raised primarily in the United States. She noted how working at a young age was necessary in her context but would be considered inappropriate or unnecessary in her siblings’ more economically stable upbringing.

This insight helped reframe her experience not as exploitation but as an expression of care, sacrifice, and cultural responsibility. The youth was then able to move forward and work toward obtaining her high school diploma through an adult education program while also keeping a job to support herself. She also continued to see her family and siblings. The clinician’s approach to bridging was neither shaming nor punitive. The intent was not to endorse underage employment but rather to meet the youth where she was at, with empathy and cultural humility—acknowledging the independence, responsibility, care, motivation, and resilience she has developed through her experience. The clinician also had to do their part in educating themselves on the history of the Indigenous population they were serving and to understand the historical and generational traumas that underpinned the family’s story, and to uplift the resilience and humanity they had.

A decolonizing approach requires this delicate balance: supporting the family’s unique needs while also ensuring safety to prevent further CPS involvement. In this case, it meant the youth refusing to see CPS but allowing herself to take advantage of the support of the in-home program that CPS put in place and funded. The strengths she possessed were then reframed as protective factors that could support her financial literacy and contribute to her long-term goals and self-determined future.

When servicing families, it is through modeling and actions that one can be an exemplar to others in the field who may not be accustomed to or know about this lens and approach. This approach helped prevent family separation and demonstrated the critical value of culturally grounded care.

What Works: A Decolonizing Clinical Framework

1. Neurodecolonization and mindfulness: Neurodecolonization recognizes how colonization shapes brain responses and trauma expression. Mindfulness rooted in Indigenous traditions can regulate the nervous system and promote healing.² This includes grounding, storytelling, and rituals tied to cultural identity, which offer more relevance than Western therapeutic techniques alone.³

2. Trauma-informed, culturally responsive parenting support: Programs must adapt to the literacy, language, and experiences of Indigenous families.^1,4 Instead of imposing behavioral norms, clinicians should validate survival strategies and cocreate culturally aligned parenting plans.⁵ For example, if the parent does not read or write, supporting the way they find easiest to navigate their world is more beneficial than inserting judgment about their lack of literacy skills or pushing them to take English classes. If the parent answers her phone reliably and does not use text message, then the clinician must shift their expectations and norms to that of the client. If there has been a concern around the parent’s engagement in services and the parent has 2 jobs and is not able to attend, it would be most ethical to offer an early Saturday session to meet the family’s reality. If the parental subgroup had previous difficulty setting boundaries around who was entering the home, a plan could be that the parent will work with the clinician in setting boundaries with family or unfamiliar individuals and considering other options to gather with friends so that the children in the home feel safe at all times.

3. Cultural genograms and talking circles: These tools allow families to map intergenerational trauma and resilience. Talking circles, in particular, create communal healing spaces where family members are seen, heard, and affirmed.⁴ Given that mental health professionals have perpetuated the ways of thinking of the West, constructing a binational genogram was reportedly helpful with migrants experiencing the transitions and tribulations of crossing borders.³ Bilingual social workers trained in biculturality and the use of natural helping and community-based healing were effective in working with Latine communities.³

Healing circles have been shown to facilitate resilience and support within undocumented communities.^6,7 According to the Talking Circle for Young Adults (TC4YA) intervention, they have demonstrated significant improvements in stress reduction, cultural identity, and behavioral health outcomes among Indigenous youth.⁶

Decolonizing Supervision: Supporting Ethical Practice

In the United States, Indigenous people have poorer health outcomes compared with other populations. The United States Census Bureau reported in 2018 that Indigenous communities had a poverty rate of 23.7% compared with 9.3% for non-Hispanic White Americans. Some Indigenous communities have 50% poverty rates.⁸ This demonstrates the negative impacts of systemic oppression. In the United States, European settlers engaged in war for land and brought disease, resulting in the death of 99% of Indigenous people.

The National Association of Social Workers’ Code of Ethics, ethics in research, and the Council on Social Work Education expect social workers to support the self-determination of oppressed groups,^9,10 underscoring the alliance needed from mental health professionals with Indigenous communities as well as emphasizing the responsibility of supporting justice, beneficence, and respect.

One of the current challenges in advancing decolonizing supervision is the influence of neoliberalism on social work, which reinforces managerial priorities and limits relational depth in the field. Unspoken norms—such as discouraging personal disclosure or enforcing rigid boundaries—can prevent clinicians from engaging in truly authentic supervision. By decentering (rather than rejecting) Western frameworks and integrating Indigenous and culturally grounded practices, supervision can become more aligned with social work’s core ethical values.^11,12 For instance, a supervisor might misinterpret a clinician’s effort to incorporate alternative ways of knowing as overidentifying with the client, rather than recognizing it as a culturally responsive approach to understanding the client through a different lens.

Horizontal Approaches

The history of social work and other mental health professions can be strengthened by honoring a wider range of ancestors and knowledge traditions. Doing so offers diverse perspectives on how the profession is understood and practiced around the world. Representation matters—when people see role models who reflect their identities and experiences, it helps them envision a meaningful path forward. Because Western frameworks tend to emphasize individualism, social workers and supervisors must also learn from Indigenous perspectives that value community, shared responsibility, and horizontal relationships.

Supervisors, in particular, should reflect on how their own personal and professional histories shape their approach to leadership. It is essential to recognize the colonial roots embedded in dominant ways of thinking to avoid unintentionally reinforcing oppressive systems. Many evidence-based practices are built on positivist epistemologies, which often exclude or silence other valid ways of knowing. To be truly inclusive, evidence-based approaches must make space for multiple ways of understanding and healing.²

Mayor and Pollack emphasize the Indigenous worldview as interconnected with the community, land, and holistic identity.^12,13 The helper is seen in their entirety. Reflexive practices must go beyond performance; they require understanding one’s complicity in oppression and acting accordingly.^12,13

Social work as a profession is global, yet its recognized founders are predominantly Western. Decolonizing supervision helps provide a decentered perspective. Recognizing only Western founders erases other knowledge systems and ways of being.¹ While one African model provides a local approach, there is a need for literature specific to Indigenous populations who have migrated and are navigating the tension between resistance and assimilation.

Referencing Laenui’s model of decolonization and Engelbrecht’s 3 stages (decolonization, authentication, and application) used in South Africa, US-based mental health professionals can adapt a localized model to mitigate the harm caused by hegemonic supervisory practices. Laenui’s stages of decolonization must be considered when advocating for oneself and supervisees. Engelbrecht’s framework can guide localized supervision models.¹¹ Using positionality, supervisors should reflect on their own lenses and how they influence supervision.¹²

Case Vignette 2

“Sara,” a Guatemalan immigrant, feels connected to her Indigenous roots and is in various stages of decoloniality. She resides on the Native lands of the Quinnipiac, Paugussett, and Wappinger peoples.¹⁴ Having experienced colonial trauma in her native country, she wrestles with her mixed identity of carrying indigeneity and European roots. Supervisors supporting communities like Sara’s must embed the 3 stages of decolonization and the 5 steps in authentic supervision into practice.¹⁵ Doing so offers a pathway out of assimilationist norms and toward authenticity. Engelbrecht outlines criteria for authentic social work supervision, which can be found in the Table.⁶

TABLE. Engelbrecht’s Criteria for Authentic Social Work Supervision

Reflections From the Front Line

I carry my patients’ stories, struggles, strength, and love with me in every breath. A hiatus is not about forgetting what I have seen or felt in the community; it is about restoring the energy I need to show up more wholly. I step back to replenish, to reflect, and to come back stronger, more organized, and more prepared to continue standing beside my patients and peers. I am not above them. I do not serve them as an outsider. I serve with them, as one of them—nothing less and nothing more. They are my people. They have always shown up for me, and it is their spirit that gives me the strength to heal others. The love, the resistance, and the resilience I have witnessed is what fuels my own healing.

But let me be clear: My anger is real. The things I have witnessed—families harmed by systems that pretend to help, cultures misunderstood or erased, children pathologized for surviving—have lit a fire in me. That fire is not bitter; it is purpose. It is what motivates me to keep returning, to keep fighting, to keep holding space for the community to heal, to reclaim, and to retain our beautiful culture and sacred ways of being.

Reimagining Mental Health for Indigenous Communities

To meet the ethical obligation of social work and ensure relevance to local populations, mental health clinicians need to have a decolonizing approach when working with individuals that carry Indigenous roots. Supervision must also be decolonized.² This involves expanding its scope, embracing cultural knowledge, and resisting the positivist, assimilationist, and colonial frameworks that have long dominated the field.² Decolonizing supervision requires attention to positionality, critical reflection, and local cultural understanding.¹¹ Supervisors should model humility, encourage reflexivity, and challenge institutional norms that devalue Indigenous knowledge.¹⁰

To adequately serve Indigenous communities, mental health systems must do more than integrate cultural elements into existing Western paradigms. They must reimagine their foundations. This includes decentering Eurocentric assumptions, embracing Indigenous epistemologies, and committing to relational, community-oriented care.¹¹

Healing is not just clinical. It is historical, cultural, and political. Mental health professionals must partner with Indigenous communities to jointly create pathways of liberation and healing that restore what colonization has attempted to erase.

Dr Gereda is a social worker in New Haven, Connecticut. Her opinions are her own.

References

1. Choate PW. The call to decolonise: social work’s challenge for working with Indigenous peoples. Br J Soc Work. 2019;49(4):1081-1099.

2. Clarke K. Reimagining social work ancestry: toward epistemic decolonization. Affilia. 2021;37(2):266-278.

3. Gray M, Coates J, Bird MY, Hetherington T. Decolonizing Social Work. Routledge; 2016.

4. Morales FR, González Vera JM, Silva MA, et al. An exploratory study of healing circles as a strategy to facilitate resilience in an undocumented community. J Lat Psychol. 2023;11(2):119-133.

5. Anastas JW. Ethics in research. In: Encyclopedia of Social Work. Oxford University Press; 2013.

6. Lowe J, Millender E, Best O. Talking Circle for Young Adults (TC4YA) intervention: a culturally safe research exemplar. Contemp Nurse. 2022;58(1):95-107.

7. Mehl-Madrona L, Mainguy B. Introducing healing circles and talking circles into primary care. Perm J. 2014;18(2):4-9.

8. American Community Survey. US Census Bureau. 2018. Accessed July 7, 2025. https://www.census.gov

9. Weaver HN. Native Americans overview. In: Encyclopedia of Social Work. Oxford University Press; 2013.

10. National Association of Social Workers. Code of Ethics. NASW Press; 2021.

11. Engelbrecht LK. Towards authentic supervision of social workers in South Africa. Clin Supervisor. 2019;38(2):301-325.

12. Mayor C, Pollack S. Creative writing and decolonizing intersectional feminist critical reflexivity: challenging neoliberal, gendered, white, colonial practice norms in the COVID-19 pandemic. Affilia. 2022;37(3):382-395.

13. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. 3rd ed. Zed Books; 2021.

14. Native Land. October 8, 2021. Accessed July 7, 2025. https://native-land.ca/

15. Laenui P. Processes of decolonization. In: Battiste M, ed. Reclaiming Indigenous Voice and Vision. UBC Press; 2006:150-160.

Advocating for Students in the School Discipline Process

Onyi Okeke, MD

By the time I met “Jayden,” he had already been suspended from school 3 times this school year. He was 10 years old.

Jayden is a Black boy with significant emotional and behavioral needs. His anxiety often shows up as frustration and difficulty with transitions—responses any clinician would recognize as signs he needs more support. He was never violent, but he spoke up when he felt mistreated, sometimes using profanity.

Even though Jayden was in special education and had a one-on-one support person, an obvious sign that he needed a lot of support, his school did not see his behavior as a signal of distress. Instead, they labeled it as defiance and punished him accordingly.

I submitted a detailed clinical letter to the school administration outlining Jayden's diagnosis and recommending adjustments to accommodations and how suspending him further isolates him and feeds the cycle of unwanted behaviors. I expected at least a conversation. What I received was silence. The letter was ignored. No meeting. No follow-up. No adjustments to his educational plan.

As a Yale-trained child and adolescent psychiatrist, I can confidently state that this is not just Jayden's story. It is a pattern that demands our immediate attention. Jayden's experience reflects a larger, troubling trend. According to the US Centers for Disease Control, in 2023, 23.1% of Black students reported unfair discipline—higher than White (18.1%) and Hispanic (18.4%) students.¹ Additionally, while overall suicide rates in the US have declined, the rate among Black males has risen in recent decades.² Additionally, suicide stands as the third leading cause of death for Black males, an alarming sign of a growing public health crisis.³

Time and again, Black boys facing emotional struggles are punished instead of helped.⁴ What should be seen as a cry for support is too often treated as defiance or disruption. Many mental health professionals are unfamiliar with school protocols and education laws, but this gap costs our patients profoundly.

Under the federal Individuals with Disabilities Education Act, schools are required to conduct a manifestation determination review (MDR) when a student with known or suspected disabilities is removed for more than 10 consecutive school days.⁵ This review assesses whether the behavior was directly related to the disability or resulted from a failure to implement supports, such as a 504 plan or an individualized education program, also known as special education. If so, the student cannot be suspended or expelled.⁶ Instead, schools must conduct a Functional Behavioral Assessment (FBA) and develop or revise a Behavioral Intervention Plan (BIP) tailored to support the child.

In Jayden's case, no health professional was involved in the review. A determination about whether his behavior was a manifestation of his mental health challenges was made without my input—despite being his treating psychiatrist. He kept getting suspended while I tried to stabilize his mental health needs. I had not realized how to intervene according to the law and the rights of my patient until I educated myself and learned how often providers are left sidelined in crucial decisions about their patients. I realized that legal steps are sometimes skipped, especially when families are unaware of their rights, or a child’s behavior is particularly challenging.⁷ As a result, children are pushed out of classrooms without the protection or assistance they deserve.

To be sure, it is well known that educators are under pressure, often lacking mental health training themselves.⁸ Each year, there are increasing requirements and expectations for them to manage the classroom, meet parameters, and respond to students’ needs without additional time or compensation to do so.^9,10 The goal is not to vilify educators but to join in our shared effort to help students reach their full potential.

As the academic year draws to a close, it is a moment for us to reset and prepare for the upcoming academic year. The next school year presents a fresh opportunity to improve. Psychiatric care does not end with a diagnosis and a prescription—it extends into understanding the school environment, and we need to be there with them.

What we can do is empower families to request 504 plans and formal “social-emotional evaluations” in writing to start the process of getting more support for their child. Write support letters to school administration that explicitly link mental health diagnoses to classroom challenges. Familiarize ourselves with MDR, FBA, and BIP processes. Connect directly with school staff, as our clinical authority can provide school administration with clarity and context for disruptive behavior.

Jayden did not need another suspension. He needed acknowledgment, validation, and support for his emotional and behavioral needs. These repeated suspensions were not just disciplinary actions but further fueled his anxiety and feelings of isolation. Each suspension further reinforced his belief that he was a “bad kid” and that he did not belong in this school. It worsened his self-esteem, he continued to fall behind academically—and the cycle of behavioral struggles continued.

If we, as mental health professionals, do not stand up for our patients where they are mischaracterized, who will? Our actions can make a significant difference where it counts—at school.

Dr Okeke is a double board certified, Yale-trained child, adolescent and adult psychiatrist at Community Health Center, Inc, in Middletown, Connecticut. Her clinical work focuses on school-based mental health, with an emphasis on integrating psychiatric expertise into classrooms to better support students with emotional and behavioral needs.

References

1. Krause KH, Bell C, Jordan B, et al. Report of unfair discipline at school and associations with health risk behaviors and experiences — Youth Risk Behavior Survey, United States, 2023. MMWR Suppl. 2024;73(4):69-78.

2. Black populations. Suicide Prevention Resource Center. Accessed June 25, 2025. https://sprc.org/about-suicide/scope-of-the-problem/racial-and-ethnic-disparities/black-populations/

3. Adams LB, Thorpe RJ. Achieving mental health equity in Black male suicide prevention. Front Public Health. 2023;11:1113222.

4. Robinson MA. Black boys don't need more discipline, they need mentors. Ed Post. July 23, 2018. Accessed June 25, 2025. https://www.edpost.com/stories/black-boys-dont-need-more-discipline-they-need-mentors

5. Individuals with Disabilities Education Act (IDEA). US Department of Education. Accessed June 25, 2025. https://www.ed.gov/laws-and-policy/individuals-disabilities/idea

6. Aligning discipline policies and procedures with section 504: a guide for school and district leaders. Frontline Education. Accessed June 25, 2025. https://www.frontlineeducation.com/special-ed-software/504-discipline-guidebook/

7. Gittings R. When schools fail to follow the IEP - what North Carolina parents can do. North Carolina Legal Services. May 14, 2025. Accessed June 25, 2025. https://www.northcarolinalegalservices.org/article/when-schools-fail-to-follow-the-iep-what-north-carolina-parents-can-do

8. Collins BR. Teachers and students are not okay right now. More mental health training would help. The Hechinger Report. August 7, 2023. Accessed June 25, 2025. https://hechingerreport.org/opinion-teachers-and-students-are-not-okay-right-now-more-mental-health-training-would-help/

9. Wahab NYA, Rahman RA, Mahat H, Hudin NS. Impacts of workload on teachers’ well-being: a systematic literature review. TEM Journal. 2024.

10. Allegretto S. Teacher pay penalty still looms large. Economic Policy Institute. September 29, 2023. Accessed June 25, 2025. https://www.epi.org/publication/teacher-pay-in-2022/

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