Building a More Inclusive, Equitable Mental Health System Requires Addressing Multiple Issues

In mid-2020, a confluence of events ignited a mental health crisis that had been bubbling under the surface of our collective consciousness.  

Suicides rose among African American men in several states, including Maryland and Illinois, while Black men and women experienced some of the highest spikes in depression and anxiety between Spring and Fall 2020 when compared with other ethic/racial cohorts.   

In the midst of these collective traumas, we’ve reached a mental health tipping point. Millions of African American men and women sought psychiatric care for depression, anxiety, and suicidal ideations. But the US mental health system was ill-prepared to engage with them. 

And until recently, few professionals have begun to address the psychological effects of institutional violence and racism on Black Americans with the goal of acknowledging and treating high-level traumas, internalized beliefs and externalized racism impacting African American patients. For African Americans and other people of color, we’re only beginning to scratch the surface to comprehend the urgent need for change.

Addressing the Barriers to Inclusive Behavioral Health

Mental Health America screening data suggests more Black and African American individuals who screen positive for depression plan to seek help. However, there’s an ongoing disconnect between interest and continued utilization of mental healthcare services.

A 2015 NCHS Data Brief revealed that only 26.4% of Black and Hispanic men ages 18 to 44 who experienced daily feelings of anxiety or depression were likely to have used mental health services, compared with 45.4% of non-Hispanic White men with the same feelings. A similar 2020 brief published by the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that among the nearly 5 million African Americans living with a mental illness, close to 70% hadn’t received treatment.

Driving these trends is the fact that the default mode of behavioral health therapy isn’t designed to treat and improve the mental health of men and women of color, who suffer from multiple internal and external crises.

Consider the origins of the of the US mental health system. Writing for the National Alliance on Mental Illness in a July 2020 post, author Kyle M. Smith, PhD, observed that physicians have stated since the early 1800s that African Americans were biologically “inferior.” Physician Samuel Cartwright “published a report in 1851 that proposed new names for ‘psychiatric’ disorders, draeptomania and dysaesthesia aethiopica, to characterize the tendencies of enslaved people to run away or to resist hard work as mental illness. 

While Civil Rights legislation in the 1960s challenged this research, Black men and women are still, 50-some years later, less likely to receive guideline-consistent care, and less likely to be included in research, the American Psychiatric Association has noted.

As a result, behavioral health providers begin their therapy careers without developing a sense of cultural humility and responsiveness to treat patients with diverse backgrounds.

Amplifying these challenges, only 4% of mental health professionals identify as Black, and 1% as multi-racial, according to APA data, compared with 86% who identify as White. While the racial identity of a mental health professional doesn’t guarantee that professional will more skillfully engage and treat patients of similar racial and/or cultural background, race and culture can influence the patient’s therapy experience. When therapists can’t emotionally connect with their patients or empathize with their experiences, they can’t provide culturally intentional therapy that empowers them.

Therefore, it’s not surprising when patients abandon mental healthcare after 2 or 3 visits. While figures vary, we’ve seen data that shows that people of color are 50% more likely to prematurely terminate mental health treatment due to the lack of therapeutic alliance or connection with their mental health provider.  

Navigating a More Culturally Intentional Approach to Mental Healthcare

Acknowledging the bias in our education and the inadequacy of the mental health system to equip professionals with the skills, empathy, and responsiveness needed to serve minorities is an important first step toward change.

As behavioral health providers attempt to improve their practice to be more inclusive, there are several areas they should focus on:

• The impact of stigmas: “Speaking from experience, I know how Black men grow up in (a) culture that tells us ‘men are not supposed to cry,’ that we ‘should deal with problems on our own,’ ” podcast host Hafeez Baoku noted in a blog post on the National Alliance on Mental Illness website. Doing our part to destigmatize mental healthcare by engaging in conversations around the effectiveness of quality mental healthcare in our community can help to destigmatize it.
• Access to care: Since the COVID-19 pandemic began, American attitudes toward teletherapy have shifted and many individuals have come to prefer virtual care over in-person encounters. Expanding teletherapy programs can help to ensure that transportation, time, and the availability/location of an appropriate medical health professional are not barriers to receiving care.
• Policies: One of the biggest historical barriers to care is limitations of telehealth coverage from CMS and private payers. Mental health professionals need to continue to advocate for stronger telehealth parity laws, beyond the provision of the CARES Act of 2020.
• Ongoing education and training: Taking a 2-hour course to learn more about the experiences of people of color does not make a therapist culturally aware or intentional. But while a therapist can’t meaningfully learn everything about someone’s culture and traumas in a few hours, mental health professionals can improve their skillsets around cultural responsiveness and humility in a therapeutic environment by seeking out more comprehensive, ongoing training and working with an organization that intentionally provides unique support for these populations.
• Mobile tools and mental health apps: A number of mental health mobile apps that offer culturally sensitive “text therapy,” meditation, and/or other mental health support tools can help to enhance care and recovery, although they don’t replace the effectiveness of dedicated mental health professionals who can offer more personalized care tailored to a patient’s specific, complex needs. But for individuals who are not actively seeking in-person treatment, professionals (e.g., primary care physicians, social workers, therapists) should encourage patients to seek out mental health apps, supporting those tools and apps created specifically with cultural humility in mind.

What’s needed now among behavioral health professionals is a deeper understanding of why the mental healthcare models we created a century ago no longer work. To move forward and embrace a more inclusive mental health practice, professionals, societies, and education systems need to radically rethink their cultural bias, training, responsiveness, and patient engagement. 

Kevin Dedner, MPH, is the Founder and CEO of Hurdle Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.