Addressing Inequities in the Quality of Mental Health Care: Immediate-Term Policy Solutions

Focus Area:
State Health Policy Leadership
Mental Health Health Equity

Researchers and policymakers are increasingly acknowledging the importance of addressing racial and ethnic inequities in mental health. Black, Indigenous, and People of Color (BIPOC) are more likely to require behavioral health services and less likely to access them — and more likely to have poor clinical outcomes. These disparities have been exacerbated by the COVID-19 pandemic and recently highly publicized killings of BIPOC. While attention has been directed toward increasing diversity in the mental health workforce to improve quality of care for BIPOC, more immediate solutions, such as cultural humility training for mental health providers and required assessments of the influence of race and culture on a client’s mental health, are needed.

Driver of Disparities in Care Quality

Research shows that BIPOC receive lower-quality mental health care, which in turn may drive them to leave treatment prematurely. There are also documented disparities in behavioral diagnoses by race and ethnicity, with clinicians being more likely to misdiagnose BIPOC and refer them to inappropriate treatments. Disparities may also be explained, in part, by BIPOC experiences in therapy. White clinicians, who comprise the majority of the behavioral health workforce, may lack the cultural humility — a focus on self-reflection and acknowledgement of one’s own biases as a prerequisite to working through them required to provide culturally robust treatment. For example, white clinicians are likely to avoid topics of race and racism unless they are first raised by a client, which not only damages the therapeutic relationship but also contributes to BIPOC’s perceptions that therapy is less effective with white clinicians.

Increasing diversity in the mental health workforce may address these issues in the longer term. The relationship between a therapist and client (i.e., the therapeutic alliance) is closely linked to treatment outcomes and has been shown to be stronger when clients and clinicians share racial and/or ethnic backgrounds. However, given existing educational requirements and licensing laws, it may take several years to effectively increase diversity in the workforce. Lay health workers (i.e., individuals without formal mental health training) may represent another longer-term opportunity to increase diversity within the workforce. Given the immediate need to address racial and ethnic inequities in mental health, policymakers must also consider alternative approaches to improve quality of care in the nearer term.

Increasing Cultural Humility in the Existing Workforce

Our own research with community mental health clinicians in Washington State has highlighted the importance of training and supporting clinicians — even BIPOC clinicians — to effectively work with BIPOC clients. Some leading states have instituted continuing education requirements to improve cultural humility among healthcare providers. For example, all health care professionals in Oregon are required to complete cultural humility continuing education courses in order to maintain an active license. Courses must be approved by the Oregon Health Authority and must meet set criteria, which are reflective of four domains of culturally competent practice and training: self-awareness and assessment; acquisition of knowledge; acquisition of skills; and, specific educational approaches for acquisition of knowledge and skills. This requirement was established by the Oregon state legislature after years of community advocacy and failed legislative attempts.

Cultural humility requires continual self-reflection and awareness, and the field’s understanding of multicultural counseling is also constantly evolving. As such, requiring annual cultural humility training may prove to be helpful in ensuring clinicians remain up to date with current knowledge and practices in the field. This solution might also require relatively fewer resources than other solutions that may require states to create, implement, or regulate new programs, given that independent entities can create the courses and licensing laws already require completion and tracking of continuing education credits.

Including Race and Ethnicity in Standard Assessments

However, simply requiring cultural humility training may not translate into higher quality of care. It is imperative that clinicians apply this knowledge in their clinical practice. A potential way to provide this structure is to require an assessment of the influence of race and culture on a client’s mental health when they initially present for treatment. A number of state legislatures have established minimum standards for screening for and assessment of mental health and substance use disorders; these apply to all providers and are included in Medicaid contracts. Despite the influence of race and culture on behavioral health and notable disparities in treatment, race and culture are typically excluded from these standards. Requiring clinicians to ask about race and culture in therapy — either by amending current legislation or enforcing new regulations from relevant government agencies — would create an opportunity for clients to discuss those issues. By facilitating this discussion, clinicians would not only improve their understanding of their clients’ mental health problems — addressing disparities in diagnoses — but also strengthen their therapeutic alliance. In our own research and experience in clinical practice, standardized assessments also offer more comfort to clinicians who may have anxiety about discussing race or racism with their clients.

Although the root causes of racial and ethnic disparities in behavioral health are broad and entrenched, we need immediate-term solutions that can improve the quality of behavioral health services for BIPOC. By mandating such solutions, such as requiring cultural humility continuing education courses and assessments of the role of race and culture on mental health, state policymakers and regulators can advance these improvements.