Discriminatory Practices in the German Mental Healthcare System: An Intersectional Grounded Theory Study

Discriminatory practices within mental healthcare are a major barrier to the equitable provision of care to <i>all</i> mental healthcare service users. Understanding mechanisms of discrimination is a prerequisite for developing suitable measures to address them. Intersectionality, a framework rooted in Black feminism, has proven to be a powerful tool for understanding the specific forms and experiences of discrimination within interconnected systems of oppression. This study is the first to use an intersectional lens to examine discriminatory practices within the German mental healthcare system from the perspectives of service users, providers, and psychosocial counselors. In collaboration with local organizations in Bochum, Germany, we conducted 17 semi-structured interviews. The data were analyzed according to constructed grounded theory methodology. Our results indicate that discriminatory practices undermine access to and quality of healthcare delivery for marginalized mental healthcare service users. On an interpersonal level, these practices included stereotyping, devaluation, Othering, invalidation, silencing, withholding information, and treatment refusals. On an organizational level, care was undermined by a lack of interpretation services, discriminatory admission practices and documentation procedures, a lack of competencies among mental healthcare providers, as well as suitable treatment options and environments for marginalized service users. Service users described various strategies to navigate mental healthcare, including confrontation and selective narration. Mental healthcare providers showed various reactions toward discriminatory practices, ranging from defensiveness to acknowledgment. We discuss the results in their interrelationship with institutional Whiteness, cis-heteronormativity, and mental illness.