By: Madhuri Jha, LCSW, MPH (she/her/hers) – Director, Kennedy-Satcher Center for Mental Health Equity
Washington Heights, New York took the big screen by storm this month, as Lin-Manuel Miranda’s spectacular movie production of In the Heights sparks dialogue across the globe about representation and inclusivity in film. In the Heights is Miranda’s homage to a culturally rich, beautiful, and diverse pocket of uptown Manhattan, where 70% of the population is Spanish-speaking. It is a particular victory in the film equity movement for Latinx people. While the movie is being celebrated for its on-location shoots and having a majority Caribbean and Latinx cast, the issue of colorism is being highlighted by some who feel Afro-Latinx people were deprived of an opportunity to shine as the leads. In my own role in the mental health equity movement, it is always interesting to see how the legacies of colonialism, systemic oppression, and racism rear their heads, as we see increasing demands for cultural inclusivity trend in today’s climate.
For years, I lived in and served upper Manhattan as a full-time bilingual (Spanish-English) child and family psychotherapist. Washington Heights is designated by HRSA as a medically underserved community, which means that it has too few primary care providers, high infant mortality, high poverty, and a high elderly population. The shortage of mental health services is exponential in medically underserved communities, speaking to the historically low priority that funding for mental health services receives overall. The outpatient, Article 31 clinic I worked in was my first job out of graduate training. A first-generation Indian-American myself, I was a brown-skinned social worker, who happened to speak Spanish. I was eager to see how my education could be translated to a high needs community that reflected an immigrant culture that was similar in many ways to mine growing up in Chicago. What I was not prepared for was that the experience challenged so many things I had been trained to believe were integral to effective care. The concepts of confidentiality, self-disclosure, trust building, and language choice were tested because I realized quickly that western medical ideals surrounding treatment boundaries were not entirely conducive to an environment where we were treating an entire neighborhood in one clinic space. For me, the experience redefined my belief in what an affirming, inclusive therapeutic environment actually is. It redefined the language I used to see a patient go from crisis to wellness.
Many immigrants come from places where mental health services barely exist. Stigma around mental illness can permeate through existing norms in home country culture and persist through survival mechanisms that are activated during the assimilation process once here in the US. New York state healthcare laws afford leeway to allow for undocumented and documented patients alike to receive care. In mental health, that translates to Medicaid and private insurance coverage for documented immigrants and an affordable sliding scale fee for those who are undocumented. Mental health clinicians are trained to use language to inform patients on their treatment course, outcomes, and progress. Often, however, our field misses the mark in acknowledging how many cultural dimensions language carries for our work — the language our patients feel comfortable with, the inflection in our tone, and the physical space in which we communicate.
Our clinic waiting room was a true reflection of the community. Neighbors, friends and church-goers could convene and converse in Spanish about family updates and their latest travels home, while also safely saying out loud, “Estoy esperando a mi terapeuta,” – I am waiting for my therapist. That environment alone was an exercise in stigma reduction – a true depiction of normalizing mental illness. The waiting room was a vibrant and emotionally safe gateway, leading to a space behind the office door where a kid could confidentially tell his therapist about involvement in neighborhood gang activity or fears about coming out as gay to Catholic parents. And yet, it being the only clinic in the community, admission wait times for services were often months on end after intake, coupled with frequent turn over of staff and inability to meet the demand for patients of higher risk.
What the debate about In the Heights has brought up for me is that I can feel both things. I can appreciate affirming, inclusive spaces in the mental health field like my old clinic, and I can challenge myself to think about how our therapeutic norms themselves may be an oppressive barrier to engaging a population that is already so isolated. From that purview, I choose to #CelebrateImmigrants who achieve triumph in communities like Washington Heights where even though the clinic space is not “traditional,” mental wellness has become a part of entire community’s everyday experience. Ironic, because that is exactly what our traditional treatment goals dictate should be the desired outcome for a patient in our care.