Abstract
Systemic racism is a public health crisis that needs to be urgently and effectively addressed. Historical racism, contemporary biases, and prejudicial attitudes have persistently affected and damaged the mental health of people of color (POC) throughout the world. Although the 2021 apology from American Psychological Association (APA) acknowledged the profession’s contribution to racism, much more work needs to be done to rectify and address past and current harm. A comprehensive, actionable, and concrete plan is needed to catalyze change. Adopting a socioecological approach can help tackle the multiple levels in which discrimination and unequal treatment take place. This necessitates more than just addressing the social determinants of illness, but also transforming the cultural competence of providers, organizations, and the mental health delivery system. Key to improving outcomes for POC domestically and abroad is increasing the affordability and access to care, diversifying and improving the cultural competence of the mental health workforce, and developing culturally adapted and effective care tailored to meet the culture-specific needs of diverse communities. Progress can only happen through proactive action and utilization of an anti-racist stance that commits significant financial and scientific resources to promote institutional, structural, systemic, and policy changes.
In October of 2021, the American Psychological Association (APA) issued a public “Apology to People of Color for APA’s Role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in the United States” In order to move beyond aspirational and performatory anti-racism, a roadmap that outlines specific strategies to counteract systemic racism in mental health care and psychological services is needed. This paper uses an Antecedents, Behaviors, Consequences, and Recommendations for Change (ABC-R) model for highlighting important issues and framing the discussion. The Antecedents (A) section documents historical issues and antecedents of bias and racism (e.g., human hierarchy and colonialism). The Behaviors (B) section discusses the prejudicial and racist behaviors of researchers and mental health care providers that perpetuate bias and racism within service delivery. The Consequences (C) section details the harm that these antecedents and prejudicial behaviors have had on people of color (POC), which have exacerbated mental health disparities and served as barriers to quality and effective care. The Recommendation (R) section provides concrete and tangible strategies for enhancing research and improving access to quality and culturally competent care.
Given that racism is systemic and driven by a myriad of factors, a socioecological and public health framework will be used to understand and address this multi-level problem (Center for Disease Control and Prevention, 2020). This approach helps address the complex interplay between individual, interpersonal, community, societal, systems, research, and policy level issues (Bronfenbrenner, 1977) and is elaborated upon further below. Primary recommendations to affect change include increasing research and funding to help influence policy and change across various domains, diversifying and increasing the cultural competence of the mental health workforce and organizations, increasing access and reducing barriers to care, and culturally adapting and tailoring care to improve effectiveness and congruence with client needs.
Antecedents (A) to Systemic Racism in Mental Health Care
The history of racism and bias toward people of color (POC) is deeply rooted in false beliefs of human hierarchies and White/Euro-centric supremacy, which fueled atrocities such as imperialism, colonialism, genocide, enslavement, and subjugation of POC across the world (APA, 2021a; Cummings & Cummings, 2021). White supremacy and belief in manifest destiny fueled hundreds of years of racial oppression, justifying the conquering, murder, and enslavement of POC all across the world. White superiority and the inferiorization of POC were used to justify these heinous acts and rationalize the genocide and domination of native and indigenous peoples. Every aspect of White society was seen as superior (e.g., religion, culture, values, intelligence, and society) and used to justify the conquest and dehumanization of POC (APA, 2021a; Cummings & Cummings, 2021).
White supremacy thus created the foundation for the new world order, and overt racism and systems of oppression were purposefully embedded into society at every level to exclude POC and prioritize White people, including institutions, structures, and systems (Braveman et al., 2022). Not only were genocide and slavery legalized, POC were denied basic human rights and equality, which created barriers for social and economic mobility, crystallized racial hierarchies, and reinforced the status quo and power dynamics. In addition, because racism was institutionalized and legalized, bias and discrimination against POC became normalized and widespread, with White people often believing and behaving as if they were inherently superior. It was not until the civil rights movement in the 1970s where overt forms of racism and discrimination made illegal (e.g., segregation and citizenship rights), but by this time the damage was already done and systemic and interpersonal racism were already embedded in social structures and continued on in more covert forms, leading to White privilege and systems of disadvantages for communities of color (COC) that had devastating consequences across generations (Braveman et al., 2022).
Racist Behaviors (B) that Hurt Communities of Color and Damage Faith in the Profession
Critical Race Theory (CRT) provides a multi-disciplinary and interdisciplinary framework to better understand the complex impact of historical and contemporary racism on COC (Kolivoski et al., 2014; Moodley et al., 2018; Teo, 2022). CRT argues that because overt and legalized racism were institutionalized and embedded at every organizational level for hundreds of years (e.g., law, education, finances, and health care), racism is now endemic and has become pervasive and systemic. Conversely, White privilege is also embedded in our society, conferring to White people unearned economic, social, and political advantages relative to POC.
There were many instances of racial oppression that caused mental health issues and acted as barriers to care (Cummings & Cummings, 2021; Shim, 2021; Suite et al., 2007). For example, genocide, slavery, and overt racism and discrimination traumatized communities of color and intergenerational transmission of mental health problems were often left untreated. Family separation, forced sterilization, and removal traumatized American Indian communities, leaving them destitute and impoverished. Asian immigrants were denied basic citizenship rights and racially excluded from coming to the United States through racist immigration laws, and refugees of color were differentially treated and denied access to services. In the fields of psychology and psychiatry, biased tests, assessments, and diagnostic labels have been historically used to reinforce racial hierarchies. The eugenics movement played a significant role in legitimizing these hierarchies and promoting the notion of White superiority in intelligence. It was also used to supported segregation, which limited opportunities for educational and economic advancement and was used to deny mental health services to COC (Cummings & Cummings, 2021). When African Americans were frustrated with slavery and wanted to be free and equal, they were labeled and pathologized as being psychotic and delusional, and diagnosed with drapetomania, a fallacious psychiatric illness that was used to perpetuate slavery (Shim, 2021). The inferiorization and marginalization of POC consequently damaged the mental health status of racial groups and obstructed access to quality mental health care (Suite et al., 2007). Even when services were available, they were often subpar and unaffordable, and POC were segregated and prevented from using mainstream services (Cummings & Cummings, 2021).
Although overt racism and discrimination were illegalized after the civil rights movement, systemic and covert racism remain pervasive to this day, with significant mental health consequences for COC (e.g., exposure to race-based stress and trauma that trigger mental illness and the denial of equitable access to services) (Institute of Medicine [IOM], 1999; United States Department of Health and Human Services [USDHHS], 2001). Both agencies note that racism is institutionalized and embedded within the mental health system and perpetuated by racial stereotypes, prejudice, and bias, which can act as barriers to access, and affect POC at point-of-entry and lead to differential outcomes within the care system.
Prior to APA’s apology, in January 2021, the American Psychiatric Association also issued its own mea culpa for its support of racism toward POC and created a presidential task force aimed at addressing systemic and structural racism (American Psychiatric Association, 2021). They acknowledged that since psychiatry’s inception, the profession has subjected Black, Indigenous, and People of Color (BIPOC) to abusive treatment, experimentation, and discriminatory practice, which resulted in betrayals of trust, unequal treatment, and biases in diagnostic, prescription, and treatment practices. BIPOCs were institutionally segregated, overly diagnosed as psychotic, and prescribed older medications even when newer more effective medications with fewer side effects were available. The field of psychiatry has also acknowledged that providers are biased and tend to commit racial microaggressions that affect every day clinical encounters, which create a hostile and inhospitable environment for those who are suffering and in need of help (American Psychiatric Association, 2021). Although both public apologies mark an important initial step, additional substantive and collaborative efforts are needed to address systemic racism and transform mental health care (Shim, 2021).
The Consequences (C) of Racism on the Mental Health and Care for Communities of Color
The mental health profession has not only failed to act earlier and challenge notions of White superiority and normativity but has also failed in providing equitable services for COC (APA, 2021a, 2021b). The impact of historical and contemporary racial bias is still palpable today and has detrimental consequences for POC. Although overt racism is now less socially accepted, we know that systemic, institutional, organizational, interpersonal, and scientific racism continue to harm COC, primarily through more covert and modern-day racism, implicit biases, and power dynamics. For example, the professions have exhibited bias by acting as gatekeepers and marginalizing and excluding POC from the field and key position. Because of segregation and barriers to educational access that remained post desegregation, POC were denied the education and training they needed to become mental health professionals, limiting their ability to provide culturally responsive care to their own communities, and creating additional barriers for those seeking help to be treated by people who spoke their language and understood their struggles. In addition, exclusion from leadership positions and seats at the scientific table impacted funding and policy decisions that could have mitigated barriers to care and marginalization of COC. At the same time, psychology also overlooked the necessity of training White clinicians to be culturally competent and adept at treating clients from COC (APA, 2021a, 2021b). Advancements were made in developing evidence-based interventions, best practices, and treatment guidelines, but they were developed and tested on predominantly White populations, with POC being left out of the conversation at scientific, provider, and consumer levels (APA, 2021a, 2021b; IOM, 1999; PTFRPHE, 2023; USDHHS, 2001).
In addition, the professions have engaged in scientific racism, a pseudoscientific ideology that misused the methods and legitimacy of science to argue that cognitive, socioeconomic, behavioral, and other racial differences are due to the supposed superiority of White people and the inferiority of POC (APA, 2021a, 2021b; Cummings & Cummings, 2021; Smedley & Smedley, 2005). Scientific racism comes in many forms and has been used to justify societal inequities through prejudicial behaviors and the denial and lack of attention and resources needed to remediate these problems (Smedley & Smedley, 2005). In addition, Teo (2022) argues that the CRT framework can also help us better understand that scientific racism has been colored by a White epistemology that entraps the field in a biased paradigm that has detrimental effects for COC and confers advantages to White people. In order for psychological science to be truly inclusive, the field needs to be decolonized and an active anti-racist stance needs to be implemented to overcome historical and contemporary racism and bias. Inclusivity in science can help mitigate the effects of scientific racism and help ensure that all people have a voice in producing empirical evidence that can be leveraged to improve policy and affect change, as well as to fund and create culturally accessible and effective care.
POC are still left out of the majority of psychological studies examining the prevalence and correlates of mental illness, as well as clinical trials that inform the development of clinical interventions (IOM, 1999; PTFRPHE, 2023; USDHHS, 2001). Many research studies still fail to report on the diversity of their samples or actively recruit POC, which means they are inappropriately excluding COC using time, cost, or difficulty in data collection as excuses. The lack of inclusion in research participation obfuscates our understanding of the extent of the problem, and denies access to data needed to support policy changes that can help address mental health disparities. Moreover, there is a growing body of research documenting racial and gender biases in grant funding (Nguyen et al., 2023). It was not until 2021 that the National Institutes of Health (NIH) started the UNITE initiative to identify and address systemic and structural racism in biomedical research across its various institutes (NIH, 2021).
Because POC were othered and inferiorized, there was no historical or systematic tracking of mental health disparities, nor prioritization for developing and providing culturally competent and effective care. Addressing mental health disparities is critically important because compared to White people, POC are less likely to seek, have access, and receive mental health care, and even when they do, they receive poorer quality care, are less satisfied with treatment received, and evidence higher dropout rates (IOM, 1999; USDHHS, 2001). More recently, a report from the National Center for Health Statistics (2016), which featured research on racial and ethnic health disparities, highlighted accumulated research on the overwhelming evidence for unequal access and availability of quality treatments for POC, along with differential treatment outcomes. Regarding mental health services, POC sought help at less than half the rate of White people, and when they did receive treatment they were more likely to report negative experiences and hold negative beliefs about treatment effectiveness, as well as drop out for a variety of reasons including cost, financial disparities, stigma, perceived need, transportation, and lack of locally available services (Fortuna et al., 2010; Green et al., 2020; Mowbray et al., 2018). These mental health disparities are evident not only in adults but also in youth of color who evidence higher dropout rates than White people, especially early in treatment (de Haan et al., 2018). Racial minority adults and youth are also more likely to be misdiagnosed than White people (Liang et al., 2016; PTFRPHE, 2023; Schwartz & Blankenship, 2014; Teplin et al., 2023). For example, there is abundant evidence highlighting the overdiagnosis of psychotic and substance abuse disorders about African American and Latinx populations, and it is also possible that some racial groups such as Asian Americans are underdiagnosed. This disparity in access, utilization, diagnosis, treatment, and outcomes of mental health services is the consequence of both historical and present-day systemic racism, which failed to prioritize the mental health and well-being of POC. Greater care and attention are needed to reduce structural inequities (e.g., financial and insurance disparities) and address cultural barriers (e.g., stigma and lack of prioritization to psychoeducation) that serve as barriers to care (IOM, 1999; USDHHS, 2001).
These disparities are also evident among veterans, where POC were less likely than White people to receive a minimal trial in psychotherapy and pharmacotherapy, reported subpar therapeutic relationships with their providers (i.e., perceived providers as less warm, more emotionally distant, less communicative, and met with them for shorter appointment durations), and were more likely to drop out of treatment prematurely (Spoont et al., 2017). Because of these discrepancies, much more work needs to be done to train clinicians to be more culturally competent and effective, which requires providers to develop skills to work with diverse populations and on culture-specific issues, as well as introspective awareness on their automatic and implicit biases. Reducing structural barriers to care while at the same time improving therapeutic experiences is essential to improving outcomes.
Maura and Weisman De Mamani (2017) reviewed the literature on medical and mental health facilities, and reaffirmed the aforementioned disparities in treatment, as well as the historical and present-day tendency to over pathologize severe mental illness (SMI) (e.g., psychotic disorders) in COC. Furthermore, they noted that POC are more likely to use emergency services, enter emergency services by means of law enforcement, be hospitalized and involuntarily hospitalized, be overly prescribed higher dosages of antipsychotics, less likely to receive second generation antipsychotics, and less likely to receive treatment for co-occurring disorders such as depression compared to White people. In addition, POC with SMI are less likely than White people to receive psychotherapy, case management, regular outpatient visits, minimally adequate treatment (i.e., medication management and at least four follow-up visits with a provider), and follow-up visits after hospitalization—particularly in counties that do not provide specialized services for racial/ethnic minorities. These experiences erode trust toward the profession, creating a barrier to help seeking and impeding individuals and communities from recovery. Unsurprisingly, even when they do receive treatment, POC with SMI experience worse psychological outcomes, experience less improvement in functioning, and are also less likely to return to work than White people, even after adjusting for socioeconomic differences. Based on research evidence, the authors suggest several strategies, including targeting and reducing stigma; improving mistrust toward the mental health system by providers and clinics; improving provider-patient relationships and engagement; increasing ethnic match and racial/ethnic providers available; improving cultural knowledge, competence, and skills while reducing racially stereotypical beliefs; promoting family involvement and supportive services; addressing religiosity and spirituality as a protective factor; and addressing explanatory models and cultural beliefs to improve help seeking, culturally adapting mental health care services, and creation of more ethnic-specific services (ESS).
Recommendations (R) for Achieving Mental Health Access and Equity
The consequences of the mental health field not making a fundamental and cultural shift to address mental health inequities have significant implications for COC, both domestically and internationally. Not only is the United States projected to continue becoming more racially and ethnically pluralistic, the proportion of non-Hispanic White people are expected to decrease by 2060 (Vespa et al., 2020). From an international perspective, it is important to keep in mind that racial minorities (RMs) are actually the people of the global majority (GM or PoGM) and comprise approximately 85% of the world population (Campbell-Stephens, 2021). In fact, some have argued that the term RM and POC should be replaced with PoGM to emphasize that POC represent more than three-quarters of the world population. Regardless of the terminology used, if left unaddressed, health disparities will continue to disproportionately impact POC, exacting a huge economic and social toll on the global burden of disease and leading to unnecessary suffering, premature deaths, vocational disability, and family dysfunction (Ngui et al., 2010).
It is important to underscore that mental health care disparities are preventable and achieving equity is our professional and ethical responsibility (Kelly, 2022). This is because health inequities are caused by social determinants (e.g., racism, sexism, discrimination, poverty, trauma, and violence) and societal inequities in access to quality health and mental health care. Much more work needs to be done to reduce structural barriers (e.g., financial inequity and lack of health insurance), as well as barriers to care caused by the lack of diversity and cultural competence within the health care system and workforce. Traditionally, cultural competence has been defined as consisting of three primary components: a therapist’s awareness of oneself and their own biases, knowledge about the cultural background of clients they serve, and the skills they employ in the treatment process to improve therapist-client relationships and facilitate positive outcomes (Sue & Torino, 2005). The importance of cultural competency has not always been recognized in psychology. Only after the civil rights movement and decades of fighting against racial inequality and oppression did the field of psychology accept that cultural competence is important, and began the process of transformational change.
Increasing Cultural Competence Among Providers Improves Relationships and Outcomes
At the individual level, research demonstrates that practitioners can enhance their abilities to work with diverse populations and help improve multicultural competencies through training and education, which in turn improve racial attitudes (Smith & Trimble, 2016). A recent meta-analysis found that when clients perceive their therapist to be multiculturally competent, this not only improved therapeutic outcomes but also helped foster a stronger working alliance, repair alliance ruptures, facilitate goal consensus and collaboration, improve emotional connection, and increase feelings that their therapists were more genuine and empathic (Tao et al., 2015). In another meta-analysis, client ratings of therapist cultural competence were also strongly related to outcomes, but therapist self-reported cultural competence was not, indicating that therapists may not be the best reporters of their own competence, possibly due to social desirability effects and lack of humility (Soto et al., 2018).
Cultural humility, defined as a person’s ongoing ability to self-reflect, self-critique, and acknowledge one’s own biases, power, and privilege when learning how to interact and work with others, is critically important for reducing interpersonal racism (Tervalon & Murray-García, 1998). Cultural humility reduces defensiveness, helps providers and organizations understand their own limitations and shortcomings, and fosters individual and institutional accountability through a commitment to action. More than just a philosophical stance, it emphasizes the tangible work required to become culturally competent and recognizes that providing culturally effective care is meaningful and part of our ethical and moral responsibility. Moreover, the burden and onus of responsibility for understanding how culture influences mental health and treatment should rest with the provider, not patients who are grappling with stress and mental health challenges and are too often asked to educate providers on this complex issue.
Modern-day racism affects POC across a number of domains including hiring decisions, salaries, promotions, school admissions, and clinical care. It is more covert and difficult to combat because it takes on many indirect and unconscious forms. One manifestation of this is implicit bias, which is an unconscious form of prejudice that stems from internalization of racial stereotypes and attitudes, and it might explain why providers may be less responsive toward POC (Greenwald & Pettigrew, 2014). Implicit biases enable discrimination to occur even when a provider has no malice toward POC, and it also reinforces ingroup favoritism even among those who espouse egalitarian values. This favoritism could manifest in various ways, such as taking on a White client over a POC (especially when one’s caseload is nearing full), or preferential treatment toward clients who are YAVIS (i.e., youthful, attractive, verbal, intelligent, and successful) (Schofield, 1964). Biases can also influence therapy processes, affecting the working alliance, level of eye contact, warmth, willingness to provide sliding scale, flexibility in scheduling, and amount of time spent with a client. Research shows that implicit bias is prevalent among mental health professionals and can have a detrimental impact on access to care, crisis response, screening, diagnosis, and treatment processes and outcomes (Merino et al., 2018).
Unfortunately, most providers are not conscious of their own biases toward POC, and there is typically less self-reflection among those who are aversively racist. Aversive racism has been defined as a form of prejudice where individuals outwardly endorse egalitarian values while denying the possibility that one’s own thoughts, motives, and actions can be prejudicial or discriminatory (Dovidio et al., 2017). That is, aversively racist individuals are often liberal, support racial equality, sympathize with racial injustices, are adamant that they treat everyone equally, and are immune to prejudice, finding the notion that they could be racist to be aversive. Because the belief one is a “good” person overpowers an individual’s willingness to examine their own contributions to systemic racism, a provider’s ability to learn and grow might be hindered. Consequently, they continue to perpetuate bias, racial microaggressions, and cultural incompetence. Research demonstrates that aversive racism is problematic not just for clinical practice, but also for research and academic medicine (Chen et al., 2021; Dovidio et al., 2017).
It is important to acknowledge that most providers, who are usually well-intentioned and uphold egalitarian beliefs, do not view themselves as racist. For example, some adopt a “colorblind” approach, which is another covert form of racism that disavows individuals’ cultural backgrounds and lived experiences while simultaneously perpetuating their self-perception that they are “a good person” and therefore can’t be racist (Cunningham & Scarlato, 2018). Others believe they provide equal opportunity and equitable care no matter what the cultural background of the client is. Yet, because of their lack of cultural humility and inability to recognize their own biases, they succumb to what I call the equitable knowledge fallacy. This fallacy is especially dangerous, because providers simply do not possess equitable knowledge about different cultural groups. For example, their understanding of Hmong or Sudanese refugee culture is not as extensive compared to that of White American culture. As a result, they can’t provide equal opportunity care, no matter how good intentioned they may be, unless they make concerted efforts to deepen their cultural understanding. This becomes evident when I conduct cultural competency trainings and ask providers whether they read a whole bunch of books about a specific diagnosis when they got their first client with a particular condition—everyone raises their hands. Similarly, when learning new theoretical orientations, providers also raise their hand and acknowledge that they read many books on the topic. However, when asked how many of them read a whole bunch of books on a client’s cultural background, practically no one raises their hand. This brings to mind Gordon Paul’s (1967) quote “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” It seems like the field has shifted to a focus on diagnosis and treatment, leaving people, arguably the most important variable, out of the equation.
Although the vast majority of providers and administrators have positive intentions, they often fall short of undertaking the necessary work to become culturally competent. According to The APA’s Ethical Principles of Psychologists and Code of Conduct (2017a) Principle D (Justice), providers have a responsibility to provide equality in access, process and procedures, and unbiased services. By definition, psychology is the study of all people, not just the study of White people. The hope is that providers would value learning about different cultures and develop competency in treating people from a variety of backgrounds. Not having the experience or skills to treat cultural others should not be a blanket excuse to not treat POC. If White providers continually refer out POC due to their perceived lack of skills or training background to treat those culturally different, then a large number of POC are denied access to the help that they need because there is a shortage of racially diverse mental health professionals. Providers are gatekeepers to care, and their responsive interactions at point-of-entry are critical to receiving help and establishing positive consumer perceptions about the profession. There is a growing body of research documenting the bias and lack of responsiveness that providers have toward help seekers of color and those who have ethnic names compared to White people (Hwang et al., 2021; Hwang & Fujimoto, 2022). If POC have repeated negative experiences seeking help and providers do not contact them back, they may feel demoralized and frustrated and never seek help again. Critical to achieving health equity and combatting systemic racism is the recommendation to improve cultural competence through a commitment to justice in equity, diversity, and inclusion efforts (JEDI). This helps rectify the historical injustice through present action and promote societal equity by proactively dismantling barriers to advancement and care. The integration of social justice principles highlights the importance of being anti-racist, and this approach recognizes that inaction or being a bystander equates to complicity in a system that normalizes and reinforces a system of oppression. By taking a social justice stance, the mental health profession sends a clear message of accountability that we will not tolerate racism and understand that it has a detrimental effect on people’s well-being. More specific recommendations for improving individual and organizational competence are provided further below.
Utilizing a Socioecological Approach to Addressing Systemic Racism and Improving Care
Multi-level prevention and intervention strategies need to be utilized to address the impact that racism has on public health because it is a societal disease driven by a myriad of factors. A socioecological approach is needed to address the complex interplay between individual, interpersonal, community, societal, systems, research, and policy level issues (Bronfenbrenner, 1977). This approach has been adopted by the World Health Organization (Krug et al., 2002) and the Center for Disease Control and Prevention (2020) to address societal and medical issues. Similarly, the APA’s Multicultural Guidelines (2017b) uses a framework called the Layered Ecological Model of the Multicultural Guidelines (LEMMG) to address context, identity, and intersectionality in treatment that can be adopted here to address systemic racism. The LEMMG consists of five nested levels, including (a) bidimensional model of self-definition and relationships, (b) family, school, and community context, (c) institutional impact on engagement, (d) larger societal context that includes domestic and international climate, and (e) outcomes.
The socioecological approach makes clear that an individual approach is insufficient to address an endemic disease that affects the entire system, including the systems of care that individuals and providers operate within. The socioecological approach also informs the next steps for addressing systemic racism in mental health care, which include education and preventive intervention along a number of fronts targeting the interrelationships between individual, family, communities, and the professionals they interact with, the institutions professionals work within (e.g., schools, clinics, hospitals, and jails/prisons), the local and national governing bodies and professional organizations that oversee the profession and resources allocated to funding and policy changes (e.g., APA, state licensure, professional boards, and funding agencies), and the broader society and cultural climate that all of the aforementioned are nested within. Although a number of concomitant strategies are needed, the APA Presidential Task Force Report on Psychology and Health Equity (PTFRPHE, 2023) has identified targeted areas in which change needs to occur, including education and training (e.g., curricular transformation in provider training and recruitment and retention of POC to diversify the workforce), research and funding (e.g., increasing funding for health equity across research agencies, diversity requirements for research participation and to help mitigate biases in reporting, and increased representation in leadership and editorial boards), and improvements in professional practice (e.g., developing culturally competent professional practice models, inclusive treatment guidelines, and expansion of different types of service and reimbursement that are more far reaching). Because policy changes cannot happen without additional research and funding across all levels and domains of mental health care, priorities need to shift and more investment needs to be made to address systemic racism and increase the cultural competence of the system and workforce (Alvarez et al., 2022). In addition, there are three particularly important and concrete strategies that we can implement right now to improve mental health care and solidify a pathway to actionable change. They include: (a) increasing workforce diversity and increasing cultural competency in training and licensing, (b) addressing access and barriers to care, and (c) provision of culturally competent treatment and culturally adapted care. More detailed recommendations are provided in these respective sections.
Increasing Workforce Diversity and Improving Individual and Organizational Cultural Competence
In order to improve mental health outcomes and increase help seeking, we need a more diverse mental health workforce that is culturally competent and trained to work with diverse populations (Alvarez et al., 2022; Galán et al., 2021; PTFRPHE, 2023). This can be accomplished in multiple ways, by training more therapists of color and by improving provider and organizational cultural competence. It is important to note that increasing provider cultural competence alone is insufficient to address a systemic problem, and that organizational, institutional, and system competence is also needed for equitable care (Cross et al., 1989). This can be achieved by five primary elements, including valuing diversity, capacity for cultural self-assessment, consciousness of the dynamic interplay between cultures, institutionalizing cultural knowledge, and adapting the system to meet the needs of diverse populations. Anderson et al. (2003) further illuminated five culturally competent interventions to improve health care systems, including recruiting and retaining diverse staff at all levels, provision of translations services and having bilingual staff, cultural competence training for providers, use of linguistic and culturally effective health education materials, and providing of ethnic-specific services and culture-specific health care settings.
The American Hospital Association (AHA) also published an equity of care report to guide organizations toward culturally competency (Health Research and Educational Trust, 2013). They noted that increasing organizational competence requires a commitment to (a) gather community, hospital, and systems data and implementation of surveys, (b) communicate findings with the community to determine priorities, and (c) educate and provide trainings to staff and providers who interact with patients. Moreover, they underscored that a culturally competent organization can be beneficial and increase participation and help seeking from the community, improve outcomes and reduce health care disparities, lower costs and increase savings, improve preventative care, reduce missed visits, improve efficiency of care, increase market share for organizations, and foster mutually collaborative, respectful, and trusting relationships.
To increase cultural competence and effectiveness at the organizational level, the educational system needs to take an anti-racist approach that celebrates diversity and sees being cross-culturally effective as a necessity, rather than a luxury. Applying the ecological approach, this would involve diversifying the workforce from top-down, and ensuring that cultural competence is promoted at each level from boards, administrators, faculty, supervisors, administrative support, and advising services, as well as increasing outreach, recruitment, support, funding, and retention of students from underrepresented communities.
Moreover, cross-cultural training needs to be infused into all undergraduate courses and graduate curriculum, and diversity-specific course requirements that help practitioners become multiculturally competent are needed. Supervisors should be required to complete courses on multicultural supervision competence, and accredited training programs should also be reviewed for their ability to train graduates to be culturally competent. Diversity requirements should also be implemented into licensing, continuing education, and renewals. This will help foster provider cultural humility and competence and reduce explicit and implicit biases. Curricular changes can help reduce provider microaggressions and help arm both practitioners and help seekers with microintervention strategies to intervene when confronted with racism (Sue et al., 2021). Finally, more work should be done to address service delivery gaps and shortage of licensed providers. One possibility is to increase the amount of culturally competent community health workers who are more racially diverse and may better positioned to help people by providing in-home services, thereby reducing costs and increasing accessibility for those who cannot afford care, lack transportation, or have childcare issues (Alvarez et al., 2022).
Increasing Help Seeking, Improving Access, and Reducing Barriers to Care
Critical to improving help seeking is to improve equitable access and remove barriers to care for POC. Structural barriers such as lack of insurance and financial difficulties disproportionately affect POC and hinder their ability to access both physical and mental health care (IOM, 1999; USDHHS, 2001). In addition, linguistic and cultural barriers also pose significant challenges and need to be addressed. For instance, in cases where linguistically matched therapists are not unavailable, culturally competent translation services should be provided. Research demonstrates that ethnic-specific services (ESS) can potentially help improve client access, satisfaction, and outcomes (Anderson et al., 2003; Lau & Zane, 2000; Maura & Weisman De Mamani, 2017). Therefore, creation of ESS services is critically important, especially in areas with a significant POC population. Greater preventive and interventive efforts are also needed to address the mental health needs of refugees. The development of immigrant and refugee adjustment programs, as well as enhancing pathways to citizenship can help reduce stress, facilitate recovery, provide vocational opportunities, and increase social mobility. Furthermore, requiring insurance panels to have a sufficiently diverse mental health workforce would help ensure equity of access, and expansion of culturally competent telehealth services would also reduce transportation barriers and increase access for those with childcare responsibilities (Hwang et al., 2021; Hwang & Fujimoto, 2022).
In addition, expanding affordable mental health services, increasing school based mental health, and diversifying the counseling center staff in schools and universities would help improve student experiences. Addressing mental health care in the justice system and ensuring access to care during incarceration and post-release are paramount to reducing recidivism and effective transition back to the community and workforce. Critical to increasing help seeking is to increase mental health awareness, reduce stigma, and to use a community-participatory approach in the design, decision-making processes, and implementation of programs and services to help increase culturally accessibility and engagement (Hwang, 2009, 2016). Funding the creation of new programs that target culture-specific issues and address stressors faced by the community (e.g., immigration stress, intergenerational family conflict, and race-related stress and trauma) are also important. At the provider and agency level, much more work needs to be done to improve cultural competency, increase treatment satisfaction, and ensure that patients are supported throughout different phases of treatment and do not encounter barriers at point-of-entry.
Increasing the Availability of Culturally Competent, Effective, and Adapted Care
In order to increase help seeking, reduce dropout, and improve outcomes, prevention and intervention programs must be culturally responsive and address the unique cultural needs of COC and POC (Hwang, 2016). This necessitates the creation of treatments tailored to culture-specific needs and culturally adapting existing care to be more culturally relevant, congruent, and less stigmatizing. There is an extensive and growing body of both domestic and international literature indicating that culturally competent and adapted interventions are advantageous compared to non-adapted treatments, with most meta-analyses demonstrating a moderately beneficial effect size (Escobar & Gorey, 2018; Griner & Smith, 2006; Hall et al., 2016; Soto et al., 2018; Tao et al., 2015). Overall, these studies elucidate the significant role that culturally adapted treatments play in improving outcomes, engagement, retention, satisfaction, and working alliance. Moreover, deep structural adaptations, or those that address the cultural values and beliefs systems, tend to be more effective than those that target surface structure adaptations (e.g., ethnic and linguistic matching) (Escobar & Gorey, 2018; Hwang, 2016; Resnicow et al., 1999). Nevertheless, it is important to highlight that many studies did not make clear what adaptations they made, provide clear rationales, nor utilize theoretical frameworks to guide adaptations. A combination of theoretically driven top-down and community-participatory bottom-up approaches would help integrate science and practice and provide justification for adaptations which could be later tested in dismantling studies (Hwang, 2009, 2016).
Delivering as-is interventions may not be the most appropriate or effective. Developing culture-specific interventions for each and every group may be prohibitively time-consuming given the global mental health crisis and may lead to training difficulties if providers are asked to learn too many different treatment modalities. There is some preliminary evidence that culturally adapted interventions are as effective as culture-specific interventions (Li et al., 2023). However, this doesn’t negate the benefits of studying and creating culture-specific interventions, and much more work needs to be done in this arena since this field is still in its infancy and few resources have been committed to development culture-specific treatments. For now, culturally adapted interventions may be the most promising strategy as we continue to research the benefits of different cultural and indigenous healing methods and extant cultural strengths of the POC, which would ultimately help improve the culture-universality and effectiveness of global mental health services for all people (Hwang, 2006, 2009). For instance, one simple improvement that we found while culturally adapting services for Asian Americans was to present symptoms in clusters (e.g., mental vs. physical symptoms), rather than the DSM’s current method of haphazardly listing symptoms. Such improvement of the DSM to cluster symptoms would help people from all cultures feel less stigmatized, facilitating an understanding that psychiatric disorders are actually mind-body illnesses, which can potentially increase help seeking and reduce dropout (Hwang, 2016). Nevertheless, the diversity within larger racial umbrellas also need to be considered, and a one-size fits all approach does not address ethnic-specific variability, differences in immigration status, and intersectionality. Another possible strategy for flexibly adapting care is to create culturally relevant content-based modules to evidence-based interventions (Lyon et al., 2014). Although this would not address process-related issues, the creation of a modularized data-base library that could be tailored and translated for different groups and address culture-specific issues and stressors could help reduce costs and increase flexibility for local adaptation and access.
Conclusion
Although APA’s public apology is a positive initial step, it is insufficient and a strategic plan is needed to affect change. A socioecological and anti-racist approach is needed to address systemic racism in mental health care. This involves recognizing the complexity involved in institutional, organizational, societal, and interpersonal racism, and using proactive strategies to address discriminatory and unequitable practices at multiple levels. Mental health practitioners and scientists need to be at the forefront of this public health challenge, increasing their cultural competency and ability to flexibly adapt and tailor services to address content and improve clinical processes and outcomes. A more inclusive psychology that values and celebrates cultures from around the world can help integrate extant cultural strengths. This includes not only addressing diversity within the United States but also increasing efforts to improve competence in addressing international mental health disparities and outcomes. Commitment to diversity science not only enhances the effectiveness of clinical science and practice but also improves the culture-universality of mental health care. This demands proactive efforts to reduce barriers to care, increase the cultural competence of providers and the system, and culturally adapt mental health care to be more accessible, relevant, and effective.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
