White supremacist philosophy embedded in institutional and systemic structures carried out through racist thought and human action, both historically and presently, create disparities in access to services and resources that support a thriving life for African American, Black, Indigenous, and other People of Color (BIPOC).
Since the “abolishment” of enslavement, Marcus Garvey, Harriet Tubman, Malcolm X, Martin Luther King, Angela Davis, John Lewis, Katie Cannon, and bell hooks, along with countless others, have fought for equitable access to resources and services, which the Constitution “guarantees” for all Americans. Yet here we are in 2023, still beating the drum for equitable access to a quality of life that African American and BIPOC Americans continue to be systematically denied.
Thus, the more things change, the more they stay the same. Even though a small percentage of BIPOC people have climbed the economic ladder, most people in these communities still struggle with the essentials of life.
Two categories that measure a person’s and/or community’s wellness are social and health determinants. The social determinants of health are the conditions under which people are born, grow, live, and age, with four factors that are measured as a basis for positive social determinants—education, income level, gender, and environment—and five health determinants: genetics, behaviors, social circumstances, environment, and access to equitable and responsive medical care.
A social determinant that has the most powerful negative impact is poverty. Poverty has been shown to have a direct correlation to the other health and social determinants. When you intersect class, gender, and race, African American women are the hardest hit when they live in poverty. Hence, the way forward to minimally reducing the impact must be more than just hastily throwing more dollars at creating yet another non-cross-functional, culturally unresponsive, tone-deaf “community” initiative.
Make no mistake: Funding for well-thought-out, legitimate initiatives is a necessary ingredient to change the landscape. However, if we are not providing practical services for those served, then we compound the problem.
For the remainder of this article, we will home in on the lack of access to equitable, culturally responsive, and effective mental health and wellness services and resources, particularly for those living at or below the poverty line.
As a licensed clinical and forensic psychologist with a focus on the injustice of the prison system, known as the “New Jim Crow,” and a licensed psychotherapist with a specialty in couples and families, we have a combined 50 years of experience. We have borne witness to the pervasive effects of systemic and institutional racism at the hands of humans with racist philosophies and embedded biases.
This has created a history of traumatized African American and BIPOC individuals, families, and communities, which has created an intergenerational transference of trauma and mistrust toward the healthcare system. It has produced maladaptive behaviors because of the disparities in access to healthcare resources, especially those that support mental health and emotional wellbeing.
This trauma has led to a distrust of the establishment and continues to be a huge barrier for marginalized communities, especially for African American people and BIPOC to receive and have access to effective and equitable services for their mental wellness. Specifically, we should note a few concerns:
- Only 1 in 3 Black adults who need mental health care receives it.
- Black adults with mental illness disproportionately receive treatment in emergency and hospital settings and are at a higher risk of incarceration.
- There are many reasons Black Americans often do not seek mental health services, including facing prejudice and discrimination, cost and insurance, and structural barriers, like lack of transportation or lack of information about how to obtain services, implicated by racism.
- Black adults in the United States who seek mental healthcare or who are living with serious mental illness (SMI) disproportionately lack access to culturally responsive care.
- When treated, Black adults are more likely to receive poorer-quality care due to systemic racial disparities.
An additional barrier is the number of African American and BIPOC mental health professionals available and paucity of researchers doing clinical trials with African American and BIPOC individuals and communities. Only 2% of psychiatrists are Black and 4% of psychologists are Black. It should also be noted that women represent over 70% of therapists.
Therapists by ethnicity:
- Asian, 10.6%, which potentially adds an additional barrier for BIPOC males seeking support
- Hispanic or Latino, 6.3%
- Black and/or African American, 4.1%
- Unknown, 2.2%
- American Indian and Alaska Native, 0.4%
As stated, historically, research has been minimal, mostly an afterthought, in African American and/or BIPOC communities. One glaring reason for a small number of marginalized members is the mistrust in those communities due to blatant racism and inappropriate experimentation on African American and Indigenous people.
This lack of inclusion in clinical trials and research studies exacerbates the troubling outcomes highlighted in this article. If those in BIPOC communities, especially Black and Latinx communities, are not included in research and clinical trials, we miss the opportunities to learn from them about their “real-world” experiences with healthcare systems and providers that have not sought their input about how to best serve BIPOC communities, and/or take the individual into consideration, as well as community needs of BIPOC, especially in underserved populations.
One organization to finally acknowledge and outline a memorandum for reparations is the American Psychological Association (APA). In 2021, the APA published an apology for the racist ideology that historically pathologized African Americans as inferior, aggressive, and unstable, which created barriers to African Americans seeking careers in mental health. The APA has now instituted programs to help address the inequities, such as mentorships, scholarships, and intentional recruitment through career fairs for African American and BIPOC individuals. The APA also dedicated its 2021 annual conference to equity.
In addition to the APA’s acknowledgment and action steps to correct past indiscretions against BIPOC people and communities, Janssen Neuroscience, a division of Johnson & Johnson, has stepped up to address the paucity of research and clinical trials geared toward African American and BIPOC persons, by developing a comprehensive plan as part of their Community Health Equity Alliance initiative.
A major driver of this alliance was the formation of a steering committee of diverse health equity experts in the fields of advocacy, SMI clinical care, population health, faith, healthcare professionals, and academia to inform strategy and priorities. The alliance prioritizes community-informed solutions that address SMI care at the state and local levels. Its aim is to improve the trusted delivery and pursuit of equitable mental healthcare for Black adults in the United States.
The alliance has established state coalitions that have launched tailored resources in areas of importance to Black communities, such as systems of navigation, peer support, and faith-based community engagement.
Coalitions have been established in California, Georgia, North Carolina, and Texas, based on unmet needs at the state level affecting care for diverse patient communities, including:
- Prevalence of SMI
- Rates of access to care for Black adults living with SMI
- Social justice considerations that affect mental healthcare, delivery, and services
- Diverse mental health professional shortage areas
The examples of transformational leadership that the APA and Janssen Neuroscience have displayed are wonderful reminders that organizations/institutions are made up of people, and just as people/institutions can create and maintain a status quo of racism, discrimination, and culturally insensitive responses to BIPOC persons and communities, the reverse is also true: People/institutions can be the change we want to see.
If we are to move the needle for diversity, equity, and inclusion in research, clinical trials, treatment, and access to resources in mental healthcare, we must take seriously the mantra that those for whom we hope to provide services must be active participants in developing models for mental wellness based on culturally informed, culturally sensitive, and culturally responsive researchers, clinicians, and service providers.
Thus, we recommend that more multi-dimensional and cross-functional community, corporate, and nonprofit collaborations be developed. Only then can we assertively move away from the status quo of racial discrimination in access to and delivery of mental healthcare services, supports, and resources.
It is our sincere hope that the information in this article resonates with readers and each will do their part in dismantling the systems that prohibit all Americans from access to equitable resources and mental health care and wellness, so a change actually does come!
H. Jean Wright II, Psy.D. is a clinical and forensic psychologist and population health administrator. Ann L. Colley, LMFT, MBA, M.Div. is a psychotherapist and Diversity, Equity, Inclusion, and Belonging consultant.