Richard Youins struggled with his drug addiction for more than 25 years. Youins is from New Haven, Conn., which is home to both Yale University and a number of less affluent neighborhoods. Substance use clinics and treatment sites are available, but he felt they overlooked who he was as a person. Youins, who is black, says that the needs of the community weren't being addressed.
Youins felt that traditional mental health care ignores the social, economic, emotional and faith-based needs of underserved communities. Youins works as a peer-support specialist with the Connecticut Mental Health Center, and he has seen how COVID worsened mental health challenges in his city.
Rates of mental illness were already high in the U.S., but the pandemic intensified everything: Illness, loneliness, job loss, grief, and other stressors related to COVID caused a nationwide rise in anxiety and depression. Some groups have been hit harder by the Pandemic than others. Poor mental health is a result of social and economic inequalities. Those in rural America are less likely to receive mental health care. People of color are less likely to receive mental health care and are more likely to be hospitalized due to COVID. The consequences have been profound for those who were unhoused.
The director of the Kennedy-Satcher Center for Mental Health Equity at the Morehouse School of Medicine witnessed how COVID impacted unhoused people with serious mental illness when she led a mobile behavioral health unit in New York City. There was no way to account for the people who went missing.
The mental health field has to confront ugly truths in the American health-care system, including structural racism and classism.
The mental health care and delivery industry was woken up by the Pandemic. They are looking at how they can improve equity. To succeed in underserved communities, they need solutions that foster a sense of belonging. Expanding access to care, improving research on community mental health and empowering people to tackle their own problems are some of the things that are included.
The Center for Social Medicine at U.C.L.A.'s David Geffen School of Medicine believes that combining these efforts leads to the most robust and long- lasting response. She says that the way our system is set up now is deliberately designed to exclude certain people, such as unstable housing or lack of insurance.
Youins learned that mental health care services did not mean they were accessible. Equal access to mental health care is acknowledged as a civil right, but many still struggle to get it. Many mental health practitioners don't accept insurance because insurance companies don't pay them enough. People who can pay out of pocket are more likely to be in therapy.
Universal health care is the obvious solution to expanding access in the U.S., according to Shim. Mental health organizations that are designed by and serve marginalized communities can play a role in overcoming cost-related and social factors that reduce access to care.
Some groups have arisen to do that. Youins works with a project that helps Black and Latinx people overcome drug and alcohol use disorders within a church setting. A group called the Asian Mental Health Collective, formed in response to the rise in anti-Asian violence during the Pandemic, connects 30 people per quarter to eight free sessions of therapy with an Asian American provider through its subsidized therapy program.
Stigma around mental illness is one factor that might prevent people from seeking care. The AMHC and Rural Minds aim to expand access to care in their communities by confronting and dismantling negative stereotypes about mental health.
Jeff Winton's nephew, who worked on the family dairy farm in upstate New York, took his own life. Winton should tell people that the death was caused by natural causes. In rural areas, mental health is not considered an illness; it is considered a character flaw. People lined up to share their experiences with mental illness.
Even when people want care, they often cannot find a therapist in rural America. More than 35 million Americans in rural areas lack access to a mental health provider.
Telehealth exploded in popularity during the Pandemic and has shown promise. The technology has made it possible for Pravesh to talk to patients who otherwise wouldn't have been able to. Up to 40 percent of his practice is made up of appointments through the internet. He was able to connect with a patient in a rural area who needed support communicating with their conservative family. The client was better able to have conversations after their calls.
Telehealth has a primary disadvantage. It is useless when someone lacks an internet connection, a private place from which to call, a computer or mobile phone, or the ability to navigate a digital environment.
Growing up near Yale, Youins noticed that a number of the university's mental health studies were focused on the city's Black population, but his community rarely saw any lasting impacts. He says that they use us as a testing ground. You can't measure if the projects really work because they would come and go.
It is important to gather data on the experiences of marginalized groups. Current research tools are not always sensitive enough to gather information about nonwhite populations, so a data set is useless if it is not collected in a culturally sensitive way. Non-English speakers are usually not represented in mental health data because they don't understand survey questions. Because people self-identify in a number of ways, racial and ethnic demographic can be difficult to capture.
Measurement of suffering can be inaccurate because of historically biased systems. Mental health stigma makes it hard for people to seek care and report symptoms. They are often misdiagnosed as a result of racialized diagnostic biases, which the psychiatric community has only begun to address. Black Americans are more likely to be misdiagnosed with a mental illness than white Americans.
It is not possible to understand what the solutions are if you focus on measuring the community's deficiencies rather than its strengths.
Good data can only be useful when applied correctly. For research to translate into something that serves the people it is about, it must involve them throughout the scientific process, from conceptualization to dissemination of the results. The communities that the research is focused on do not see any of that.
Allowing communities to be involved in their own care may be the most important step towards achieving mental health equity.
Youins is a peer coach at Imani Breakthrough, which has been recognized as a successful model for community mental health support. The program was developed by psychiatrists Ayana Jordan of New York University and Chyrell Bellamy of Yale University. The sessions are led by people from the local Black and Latinx communities, usually a member of the church and a coach who has lived with substance use. People in the program can overcome hesitancy in seeking care because of discrimination they may face at traditional clinics. A church with cultural significance is a good place to hold classes.
Crisis Assistance Helping Out On The Streets (CAHOOTS), a mobile mental health crisis intervention program in Eugene and Springfield, Ore., is more than 30 years old. Causts diverts mental health calls away from the police and toward its own team of trained specialists, who handle crises without weapons or law enforcement. It is funded by the Eugene and Springfield police departments and mostly serves people who are marginalized by racism, classism and ableism.
Daniel Felts has worked for the organization as an EMT and crisis worker for five years and is one of the survivors of mental health crises. Six police officers with guns showed up when Felts attempted suicide. He was a danger to himself, he says, but he became aware that these people could take his life if he made the wrong move.
CAHOOTS did not bill its patients, prioritized comprehensive care, and provided a non-violent response to mental health crisis calls. It wants to meet people where they are and be sensitive to the intersectionality of our patient population.
Provider burnout is a cost of administering equitable mental health care. A survey of more than 20,000 health-care workers between May and October 2020 found that 49 percent had been burned out. Providers who are Black, Indigenous and people of color caring for their own disproportionately affected communities are among the hardest hit. Female, Black and Latinx workers have reported higher stress levels than their male and white counterparts.
There is a certain need for mental health care. A record number of psychiatrists and therapists are leaving their jobs. It was difficult to retain burned-out staff even at a community-led group.
The founder and lead clinician of a program that offers culturally sensitive mental health therapy to Latinx patients at a Kaiser Permanente center in California says she has seen more clinicians leave the company because they felt under valued. Non-English-speaking patients have wait times that are much longer than their English-speaking counterparts because there are fewer bilingual clinicians.
In October of 2021, mental health clinicians working for Kaiser Permanente in California and Hawaii voted to go on strike after the provider rejected their union proposal to increase staffing. Some locations have no contract. Kaiser has highlighted the diversity and inclusion success story of La Clínica.
The community has been decimated. They can not work for a company that doesn't value them or that wants to harm their community by denying them what they need.
It takes a rethinking to give communities what they need. Youins has seen that culturally competent mental health care can be life-changing. The crisis of inequity can't be fixed by individual organizations and providers alone. The fundamental problem is bigger than the health-care system in which they work. It's ingrained in American society. Improving access to traditional care is not enough according to Hansen and others.
Mental health care needs equity across the board. The drivers of health include access to healthy food, a clean environment, job security, and freedom from racism. They have things that I cannot therapy away.
People have a remarkable ability to keep going. Youins sees this resilience when he meets with his Imani group, which gathers at one of the oldest Black churches in New Haven. There, he says, people are finding miracles.
Youins says the traditional way has its place.
An editorially independent special report that was produced with financial support from Takeda Pharmaceuticals includes this article.
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