Inequities in Mental Health Services: It’s Time for a Reckoning and Rectification
By Karen Zilberstein
August 25, 2020
Originally posted in Mad in America
As the country confronts the coronavirus crisis and the ways it has exposed racism and inequality, it is time for the mental health field to look inwards and reckon with its own shortcomings. Similar to other American institutions and disciplines, racial and socioeconomic inequalities tend to be replicated in the accessibility and appropriateness of treatments offered to vulnerable individuals and families.
Numerous disparities exist in service provision and outcomes for children and families of color. Across the country, communities with high proportions of people of color are more likely to be situated in mental health deserts lacking high quality care. Compared to white people, they are more likely to lack or lose health insurance, which restricts their ability to access services. When clients from nonwhite ethnic groups begin psychotherapy, they are less likely to trust and remain in treatment, despite higher exposure to racism, trauma, and other adversities that are known contributors to emotional difficulties. Whereas a high proportion of distressed European Americans engage mental health services, fewer than a third of African, Latinx, and Asian Americans do so.
Reasons for the disparities abound, including clinician biases and assessment instruments that are not culturally sensitive. Standardized measures and interview protocols often do not account for ways different ethnic groups express distress, leading to either an over exaggeration or underreporting of symptoms. Asian Americans, who can be tentative about disclosing thoughts and feelings, may find their suffering overlooked and appropriate treatments not offered. Conversely, Black and Latinx youth are more likely than their white peers with similar difficulties to be pathologized and diagnosed with conduct difficulties or severe mental illness rather than traumatic reactions, learning difficulties, or other treatable conditions. As a consequence, they are more likely to receive punitive rather than ameliorative interventions.
Even when appropriate assessments occur, children and families may encounter interventions that do not adequately recognize the difficulties they face. Experiences of racism and discrimination are too often overlooked by white clinicians and their traumatic impact left unstated and unaddressed. Despite evidence that experiencing racial violence, disparagement, and/or discrimination serve as risk factors for numerous physical and mental health difficulties, neither standard trauma screens nor the popular Adverse Childhood Experiences screening tool asks about experiences of racism as potential traumas or adverse experiences. Without adequate acknowledgement of the impact of racism on mental health, treatments will continue to overlook this prime and important factor.
Not only is a comprehensive understanding of and attention to treating racial trauma absent from many therapies, so too are interventions that reflect diverse cultures. Despite attempts to improve cultural competence, only a handful of treatments, practiced in few locales, weave indigenous methods of assessment and healing into their protocols. In many cultures, healing occurs in spiritual and communal realms, not in the private offices of practitioners. Fellowship and the collective expression of emotion through prayer, singing, and praise assume therapeutic functions in the Black church. Connection to and harmony with the land and cosmology bestow comfort and resilience to the Inuit people of the Canadian Arctic.
Part of the reason that not enough alternative treatments have been created is because western psychotherapies draw heavily on individualistic cultures and modes of thought. The most commonly offered treatment approaches in American mental health facilities are individual psychotherapy, cognitive behavioral psychotherapy, group psychotherapy, and psychotropic medication. Those therapies base their interventions on ideas of health and development that view the rectification of difficulties as primarily personal or family responsibilities, even when the circumstances that tip a person into distress result from inequality, racism, poverty, or other adversities.
Thus, instead of addressing structural inequities head on, interventions focus on their sequelae: managing stress, regulating emotions, and improving relationships. Families and individuals are expected to be resilient and self-sufficient, or to work on becoming so. Society holds them responsible for coping with whatever adversity gets thrown their way.
The mental health field’s emphasis on individual coping can inadvertently contribute to inequities. Researchers studying low-income African American youth in rural Georgia found that the effort required to beat the odds inflicted a cost. Youngsters high in self-control and competence, who showed social-emotional resiliency, also exhibited substantial markers of poor metabolic health. Persevering through poor schools, rampant poverty, discrimination, and inadequate supports precipitated physiological stress. When current mental health treatments ask youth facing the highest hurdles and fewest resources to strive the hardest, the results appear mixed.
The individualistic bent that dominates modern psychotherapies burdens individuals with managing environmental risks that could be better solved by government, civic institutions, and advocacy. Providing families with adequate income, safe neighborhoods, greenspaces, and quality schools has been shown to increase the well-being and achievement of children. Yet psychotherapists are rarely trained in tools to engage or create services that could reduce structural inequities. More often, mental health treatment is viewed as a separate service offered to individuals or families rather than part and parcel of a coordinated remedy.
Reducing disparities and increasing treatment options for clients from marginalized groups must begin by naming and making more visible the prejudices and omissions that exist in current treatments and assessment methods. Psychotherapists need to examine their own biases about poverty, race, racism, and individual modes of healing, and determine their fit for different populations. Clinicians must also ask about and validate clients’ experiences of racism, microaggressions, and cultural insensitivities both inside and outside of the consulting room. For those whose mental health difficulties derive from the offshoots of racism and structural inequities, treatment may need to include ways to reconnect individuals and groups to their culture, strengthen community supports, aid with racial identity development, and encourage resistance and collective struggle.
The mental health field needs to shift focus from primarily examining and strengthening personal and family factors underlying health and well-being to include social and environmental determinants. Assessments should include an examination of the sociopolitical realms in which clients live, with an ear to discerning environmental risk and protective factors. Interventions should not only emphasize skill building and changes to the self, but also consider the benefits of altering a person’s circumstances.
Psychotherapists should consider it part of their role to help clients advocate for health insurance, social programs, and opportunities, as well as abating the discrimination and structural barriers they face. To that end, clinical education must include more training in macro skills that help build the supports, policies, and community infrastructures under-served clients need. Mental health workers can also build backing for programs and policies by calling out the damaging consequences of economic hardship, racial discrimination, and other types of inequality, and the importance of reducing those risks.
The advancement of environmental change could begin with institutions that serve individuals and families, such as courts, child welfare agencies, schools, religious centers, and doctors’ offices. Clinicians should do more to educate those entities about the mental health needs of their clients and work with them to institute the types of programs and care that would best benefit the individuals and families they serve. Partnerships with neighborhood institutions could provide communal sources of healing and build culturally congruent rituals and supports. As important referral sources to mental health care, schools, doctors, courts, and other institutions should also demand that local mental health centers institute treatments and services that reflect the needs and backgrounds of the clients in their communities.
In order to create and deliver more culturally and socioeconomically competent interventions, increased efforts should be made to cultivate the wisdom, experience, and social capital of researchers and clinicians from diverse backgrounds. According to studies conducted by the U.S. Census Bureau and APA, the psychology workforce remains heavily white, although rising numbers of black and Latinx workers are entering the field. Particularly important will be the recruitment of leaders and innovators from communities which are currently ill-served who can bring fresh perspectives.
Inequality in mental health and society will only cease after enough people, both within and outside of the field, speak up, demand better, and work together on solutions.