Barriers to Access on the Front Lines of a Brooklyn Psychiatry Ward  

Chanelle Ramsubick is a 31-year-old third-year psychiatry resident working in Brooklyn, New York. Most of the patients at her hospital are immigrants, people of color, and people from low socioeconomic backgrounds, and Ramsbuick has become focused on understanding how mental illnesses disproportionately affect marginalized communities, as well as the individual barriers to treatment that they face. We spoke to her about her experiences in the industry and the unique vantage point that comes from being one of the few women of color working in the psychiatric field. 

How did you decide you wanted to go into mental health?

I went into medical school thinking that I wanted to do dermatology, because I had my own skin issues and I wanted to help other people who have gone through something that I've gone through. It wasn't until I actually did my rotation in psychiatry that my fascination with mental health really began. I was working in an emergency room for psychiatric illness in an area of New York that was really hit by Hurricane Sandy, and I was seeing people of a really low socioeconomic status. That was the first time I saw what we would call acute mental illness – people who were psychotic, depressed, suicidal. When you read about it in books, it's so different than actually having a patient in front of you. I realized that every single depressed patient that I met in that psychiatric ward is so unique and different. Sadness has such a spectrum across people. I think that's what really drew me to it, the uniqueness of human experience. Also, seeing how treatment can really drastically change somebody's life. If somebody is a cardiothoracic surgeon and someone has a heart attack, you can go in and clear up their arteries and prolong their life. But in psychiatry, you really increase the quality of someone’s life. 

"I realized that every single depressed patient that I met in that psychiatric ward is so unique and different. Sadness has such a spectrum across people. I think that's what really drew me to it, the uniqueness of human experience"

What does the research tell us about how mental illnesses disproportionately affect marginalized communities?

Our understanding is that people have genetic vulnerabilities as well as environmental factors that can put them at risk of developing mental illness. For example, we know that depression is about 40% genetic. But that doesn't mean that everybody that has genes that make them vulnerable will actually get depression. There needs to be some sort of environmental impact, some sort of stress, trauma, or change, that can activate those genes. What I found is working with marginalized populations – specifically immigrants, people of color, people of lower socioeconomic status – is that those people often have a lot of trauma on their day to day basis. And that puts them at more risk of getting mental illness.

And how do those dynamics play out in your work?

I live in New York and I work at a hospital that's considered a community-based hospital. We take a lot of uninsured people and people that are undocumented. Our hospital serves about 84% African Americans. The majority of patients I see fit exactly into these marginalized populations, and they have a lot of things stacked up against them. When I speak to them about the things that they're going through, I realized that they need more than just medication. Often my patients don’t have jobs, they don't have adequate housing, they may not have family members. When it comes to their treatment, I have to do a lot more than just give them medication. I really need to address all those inequalities in their lives.

"Often my patients don’t have jobs and adequate housing, and they may not have family members. When it comes to their treatment, I have to do a lot more than just give them medication. I really need to address all those inequalities in their lives."

Chanelle (when she's not on the ward).

When someone comes in to see you and their depression or anxiety is stemming from these very real stressors – like not having a visa or a job, or being able to pay the bills – how do you treat that?

There’s been a lot of research on what is called social determinants of health, meaning that it's not just genes that are the cause of somebody's health; there are also social factors like lack of housing, lack of social support, unemployment. Living in New York, we have extensive programs that help to address those social determinants. I do not work in isolation, I have a team. As well as psychiatrists like me who give medication and therapy to address the illness, we also have social workers that are really well versed in all the different social programs. So for example, if my patient comes in and doesn't have housing, I can bring this up to a social worker, and they'll be able to get them to a shelter, or make sure that they get Section 8 housing, which is low income housing. We also have case managers assigned to different patients who we can help them keep up with all their appointments and medications. And then we also have the nurses and medical doctors who are looking after their medical health, because people who have mental illness are also less likely to be able to take care of medical illnesses. 

How do you deal with the weight of some of the stuff that you hear from your patients, and what do you do to make sure you don’t bring that stress home with you every day? 

I'm in my own form of therapy, because I think to be a good practitioner, I have to also be in my own treatment. I also am a firm believer in good coping skills for stressors. Everything I teach my patients I do myself. I practice progressive muscle relaxation. I do Bikram yoga. I journal every single morning; I do a gratitude journal to increase positive thoughts in the morning. I do a lot to help mitigate all the stress that happens at work.

"I'm a firm believer in good coping skills for stressors. Everything I teach my patients I do myself"

What are some of the barriers to treatment that marginalized groups face ?

The majority of my friends who are people of color will tell me that they are looking for a practitioner of color, but unfortunately, there just aren't that many people of color who are mental illness practitioners. I think about 7% of psychiatrists [in America] are black. And I don't think there's anything wrong with somebody wanting to have a practitioner that is within their culture, because when you're working with somebody that has a shared experience with you, you feel understood. In therapy, you need to be vulnerable. If you don't feel understood or heard from the person sitting across from you, [then the thought is that] there's really no point in getting the treatment. 

The other thing I hear from my friends a lot is the money issue. If you're in America, you need insurance, but really good practitioners often don't take insurance. So if you are rich, and you can afford it, you're going to get adequate treatment. But if you're not, you're probably going to have to take some second-rate type of treatment. That being said, there are social workers and psychologists who charge much less, but those are the ones that can be hard to find. 

"If you don't feel understood or heard from the person sitting across from you, [then the thought is that] there's really no point in getting the treatment"

What about barriers that come from the stigma certain communities have around mental illness? 

In the African American population, it's definitely a problem. It leads to a lot of people in denial about their illness, and that denial will often not allow them to get what they need. Also within the African American population there is this notion of strength, and I think that mental illness is looked at as a weakness. With Caribbean populations, too, this idea of being considered crazy is the worst thing that you can be called. The effect of stigma on mental illness is so pervasive. 

When I was working in a psychiatric ER, I would see people that came in that were so severely ill, and then I would talk to the family about it. It would seem like the family had noticed that this person was ill long before, but there was such a denial associated with it. Stigma is also what causes a lot of people not to talk about mental illness. It's much easier for people to talk about the nuances of what causes a headache than the triggers associated with panic attacks, depression, and schizophrenia. So the stigma allows families to let their relatives get to very dire conditions. And when those people who have gotten to such severe conditions finally do get into treatment, they’re often less likely to want certain medications because of that stigma of: If I'm on medications, I must be crazy, right? 

"Stigma is also what causes a lot of people not to talk about mental illness. It's much easier for people to talk about the nuances of what causes a headache than the triggers associated with panic attacks, depression, and schizophrenia"

What are some preconceptions that you had before you started this job that your patients helped you to upend?

You really can't assume anything. Everybody's life is so complex and so different. Although two people may have the same experiences, the impact can be completely different. I’ve realized what might be best for somebody, is not what they want in that moment. And you need to try and understand: what is it that they want? Why are they coming to you, why are they sitting in front of you? Some people don't even understand why they are sitting in front of you, and you need to help them figure that out.