President Joe Biden has committed to tackling the scourge of systemic racism that has plagued our nation since its inception. To that end, he signed executive orders on racial equity on his first days in office and on Wednesday night at a town hall on CNN recommitted his administration to this goal, particularly the need to change the relationship between communities of color and the police.
This Black History Month, we call upon the Biden administration to prioritize the mental health of Black and brown communities by addressing their lack of access to such care.
But to fully address the impacts of racial inequity in our society — to meet the promise of these executive orders and to truly contend with the structural racism that he noted imbues the criminal justice and other systems — access to culturally competent mental health and addiction treatment is needed. This Black History Month, we call upon the Biden administration to prioritize the mental health of Black and brown communities by addressing their lack of access to such care.
Right now in America, symptoms of depression are three times as high as they were pre-pandemic, and as of January, 41 percent of adults reported symptoms of anxiety and/or depressive disorder — up to four times as high as reported pre-pandemic levels. But that burden isn’t shared equally. While pre-pandemic rates of substance use, depression, anxiety and serious mental illness among Black Americans are more or less similar to the general population, access to treatment is significantly lower for Black Americans across the board, especially during Covid-19.
Prior to the coronavirus, Black Americans were experiencing mental health impacts born of intergenerational trauma, community violence, lack of culturally competent care and a higher likelihood of a misdiagnosis of schizophrenia. Met with a lack of access to medication and therapeutic supports resulting in untreated mental illness, this all too often has resulted in targeting by and entanglement with law enforcement and the legal system, as opposed to involvement with the health and social system, thus perpetuating further cycles of trauma and violence.
Prior to the pandemic, an estimated 119 million people were already living in a Mental Health Care Professional Shortage Area — also known as a mental health desert — meaning they were unable to access mental health care because of the low number of mental health providers relative to the needs of the population. Most of those living in mental health deserts are people of color and those in rural areas. For instance, in the Bronx, one of the areas of New York City hardest hit by the pandemic, 91 percent of residents insured by Medicaid live in a mental health desert. The vast majority of them are Black and brown and low-income.
This is a portrait that is painted in communities of color across the country. The Health and Human Services Office of Minority Health finds that African Americans living below the poverty level are twice as likely to report psychological distress as those over twice the poverty level. Yet less than half of Black adults who need mental health care for serious conditions receive it.
But it’s not just a lack of providers making it hard for Black and brown Americans to access care. They need to receive culturally competent and trauma-informed care. Such care is comprised of skills and approaches to create stronger patient engagement, empathy and trust. They can be learned, or come from or be enhanced by shared experiences and backgrounds. This trust and engagement are especially crucial in relationships in behavioral health in order to communicate and connect with disordered thoughts, moods or other behavior that can affect a person’s everyday function.
According to the American Psychological Association, about 86 percent of psychologists in the U.S. workforce were white in 2018 and about 15 percent were from other racial and ethnic groups, compared to 62 percent versus 38 percent for the country as a whole. This means that Black and brown Americans often see mental health providers that do not have shared racial, ethnic or cultural experiences, all of which can influence the quality and effectiveness of the care they receive.
There are other kinds of structural barriers as well. Black and brown communities are disproportionately likely to be uninsured or underinsured than their white counterparts. We need to build on Biden’s recent executive order protecting and expanding Medicaid and the Affordable Care Act by ensuring the effective creation of a public option for health insurance, including sustained engagement, education and outreach to communities of color, and we must construct a glidepath toward universal coverage. This will have a significant impact on access to mental health care.
But expanding insurance coverage is just a start. We also need to grow the mental health workforce, especially in known mental health deserts, by advancing a series of policy solutions that will not only encourage the next generation of graduates to enter mental health by reducing their debt burden, but also focus on expanding the existing community workforce through shifts to managed care and reimbursement for team-based models of care.
We must put in place measures to encourage more people of color to enter health care, especially behavioral health professions like social work, psychology, addiction medicine and psychiatry. Expanding federal loan forgiveness programs and encouraging school admissions criteria for health professionals that value life experiences, as well as standardized testing ability, would advance this goal.
Despite its toll, Covid-19 might provide a silver lining. Technology has the potential to overcome localized workforce shortages.
To achieve cultural competence, we must start by expanding cultural humility and racial justice training and workforce development programs for the existing health and mental health workforce. We must also create a trauma-informed health workforce to address the short- and long-term health and mental health impacts of trauma from violence — especially police violence and over-surveillance— that is endemic in low-income communities of color, and is often combined with chronic social and economic stressors like unaffordable housing, underresourced school systems and lack of access to capital and economic opportunity.
Federal support should help health, social and public service employees — anyone who interacts directly with community members — receive specific training on what trauma-informed interactions, de-escalation and safety techniques and empathic communication look like. We also need to build workforce systems, like human resources and workforce wellness, that emphasize trauma-informed engagement for employers.
Despite its toll, Covid-19 might provide a silver lining. Technology has the potential to overcome localized workforce shortages, and the temporary changes put in place during the pandemic increased access to care via telehealth and telemental health care. Let’s make these temporary fixes permanent and also ensure that virtual and in-person services, as well as mental and physical health care, are reimbursed equally.
Mental health deserts are not just a result of lack of access to providers and health care, however, but also of community supports such as housing programs and holistic community-based mental health services like those provided by Fountain House. We need massive expansion and investment in community models of recovery such as these to ensure that punishment and institutionalization — which disproportionately land on Black and brown people living with mental illness— are not the default option.
Dr. Ashwin Vasan is president and CEO of Fountain House and an assistant professor in public health and medicine at Columbia University in New York.