Jasdeep Kler

Addressing Minority Mental Health Disparities

Introduction
Background
Mental health is an often-touted societal problem that is used to explain away violence in

the United States (U.S.) but is otherwise neglected. An estimated 49.5% of adolescents in the

U.S. have a mental illness with 22.2% having a severe impairment (Merikangas et al., 2010).

However, the burden of this crisis has disproportionately fallen on disadvantaged groups —

those marginalized, including members of the LGBTQ+ community, people of color, and

immigrants, experience multiple barriers to effective care including inadequate surveillance,

inadequate access/availability of quality mental health services, and inadequate effectiveness of

widely disseminated evidence-based practices (EBPs). Simultaneously, those disadvantaged hold

less power and face a more significant burden of known mental illness risk factors.

For the rest of this paper, mental health disparities among racial-ethnic minorities will be

addressed and may serve as a broader framework that can be applied to other disadvantaged

groups in diverse settings. Also, it is vital on the onset to acknowledge the American

conceptualization of race and ethnicity are social constructs that are continually transforming.

Historically, race distinctions were seen as biologically derived while ethnicity was viewed as a

proxy for culture. However, recent findings have proven there is no biological foundation of

race; there are more genetic similarities between perceived racial groups than within racial

groups. Since then, race and ethnicity have become nearly synonymous - indicators of one’s

culture and a convenient construct to examine inequality, injustice, and discrimination (Cauce et

al., 2015). Therefore, from here on “racial-ethnic” will be used to refer to our modern

conceptualization in which there are five major race-ethnic groups identified by the U.S. Census:

White European Americans, African Americans, Asian Americans/Pacific Islanders, Native

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Americans, and Latino/Hispanics. Similarly, following our widely accepted colonial

conceptualization, “minorities” will be used to refer to individuals who are not White European

Americans or “white.”

Addressing minority mental health disparities (MMHD) is especially important

considering our current sociodemographic trends. In 2016, the U.S. foreign-born population

reached a record 43.7 million, or 13.5% of the U.S. population, following immigration trends

that started in 1965 when the U.S. replaced the national quota system. If current immigration

trends continue, immigrants and their descendants are projected to account for 88% of U.S.

population growth through 2065. These immigrants have increasingly been of Asian origin while

the percentage of immigrants of Hispanic origin has steadily decreased since 2000 (Lopez et al.,

2018). It is estimated by 2044 the U.S. will shift from being majority white to a pluralist society

where no one racial-ethnic group holds a majority. With these impending demographic changes,

we must address the mental health disparities among minorities or risk facing a worsening

mental health crisis in the near future.

Minorities in the U.S suffer a disproportionate burden of adverse childhood experiences,

mass incarceration, chronic stress, financial stress, discrimination, and much more (Okazaki,

2009; Davis and Chapa, 2015; Woolf, 2017). These disparities are well known and documented;

in 2001 the U.S. Surgeon General completed a major report assessing racial-ethnic disparities in

mental health and mental healthcare. After a broad review of the literature, the authors

documented the existence of “striking disparities for minorities in mental health services and the

underlying knowledge base. Racial and ethnic minorities have less access to mental health

services than do whites. They are less likely to receive needed care. When they receive care, it is

more likely to be poor in quality” (Office of the Surgeon General., 2001).

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These mental health disparities are also inextricably linked with how many other

institutions, including education, criminal justice, housing, and healthcare operate. This vast

entangled web means an approach that focuses on only one institution will not adequately

address MMHD. Instead, we need to fix “root causes” that contribute to these MMHD including

racial discrimination, stigmatization of mental illness, and a lack of minority representation and

power which are all linked to a societal lack of empathy and compassion.

Racial Discrimination
As we all know, the U.S. was founded on racist and patriarchal ideals which have

continued to plague American society to this day. It is well documented that minorities regularly

face racial discrimination in daily life. This discrimination can come in multiple forms including

individual, institutional, and structural discrimination (Pincus, 2000). Individual racial

discrimination is what we are most familiar with; a personal act of discrimination directed

towards a minority group member (i.e., someone shouting racial slurs). Institutional racial

discrimination is when dominant group members create and enforce policies that are intended to

have a differential impact on minority groups (i.e., racial “redlining” which led to housing

segregation). And lastly there is structural racial discrimination when dominant group members

create and enforce policies which are minority neutral in intent but in practice have a differential

impact on minority groups (i.e., until recently there were policies that prevented Sikhs from

serving in the U.S. Military due to disproven fears their unshorn beard and turbans would make

gas masks less effective).

It is likely no surprise that these multiple forms of racial discrimination have detrimental

impacts on minorities. At the individual level, several studies have shown that even subtle

racism, like stereotype threat, can elicit harmful stress responses from minorities. A more

traumatic racial victimization experience can also cause lasting psychological injury and hyper-

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vigilance towards potential racial re-victimization (Okazaki, 2009). At the institutional and

structural level, racism has led to socioeconomic disparities and exposure to poor living

conditions that adversely affect minority mental health while limiting access to effective mental

healthcare. Lastly, some minorities may internalize inferiority leading to impaired psychological

functioning (Williams and Williams-Morris, 2000).

Although all minority groups face similar barriers to mental health services, these

disparities manifest themselves in different ways. Within the population that received mental

health services, Black individuals are overrepresented while Asian and Latinx individuals are

underrepresented (Bui and Takeuchi, 1992; Sue et al., 1991). These differences have been

primarily attributed to the increased interaction Black residents have with government systems.

Minority communities, especially those that are predominantly Black, experience over policing

for small infractions, a policy derived from the idea of “broken window policing,” and punitive

punishments, like mandatory minimums or three strikes laws. Simultaneously, Black

communities face under policing when it comes to more serious crimes often due to a lack of

resources and community trust. This mentality has gone beyond policing and now includes

education and child welfare where institutions have taken a “zero-tolerance” policy resulting in

more frequent court-mandated mental health services for Black adolescents. These differences

can be demonstrated by who referred an individual to mental health services. For minorities,

referrals tend to come from other non-mental health-related social service agencies, including

judges and school counselors, whereas for those who are white and privileged referrals come

from family and friends (Cauce et al., 2002).

Stigmatization of Mental Illness (Gary, 2009)

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Mental illness is a heavily stigmatized condition in the U.S. There are a multitude of

factors that contribute to this stigmatization including media associations of crime with mental

illness, politicians and pundits use of mental illness to avoid discussing gun reform, and the

biomedicalization of minority emotions among others. This stigmatization manifests itself in

three principal ways: public stigma, self-stigma, and mental health system/provider stigma.

Public stigma impacts the way those diagnosed with a mental illness are perceived and

treated. In the public domain, those diagnosed with mental illness are often associated with

violence, seen as incompetent of self-care, and blamed for their condition. Self-stigma impacts

the way those diagnosed with a mental illness perceive themselves and behave. Individuals

diagnosed with a mental illness may come to believe they are less valued in society resulting in

behaviors that avoid risk. Mental health system/provider stigma impacts the degree to which

those diagnosed with a mental illness can receive effective care. Those diagnosed with a mental

illness are more likely to be misdiagnosed while being subject to conscious and unconscious

stereotyping and limited access to services.

In addition to the stigma described above, minorities also face stigmatization from within

their own cultural community which is compounded by the racial discrimination and barriers

they experience. Lastly, it’s important to note stigmatization impacts those diagnosed with the

condition as well as friends and family members. Friends and family may experience guilt

struggling to provide care, cover associated costs, and maintain relationships. The additive

impact of these forms of stigmatization is those that need mental health services are afraid to

seek them.

Lack of Minority Representation

Several governmental and organizational reports have explicitly pointed out the lack of

minority mental health professionals and a lack of culturally competent care among the current

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predominantly white workforce (Gary, 2009). This lack of representation and competency can be

attributed to a broader lack of minority representation/power. In every step of the mental

healthcare process, there is a lack of minorities with power and agency.

In academic settings, mental health researchers and study participants are predominantly

white. In commercial settings, investors and purveyors of evidence-based practices (EBPs) are

predominantly white. In healthcare settings, mental healthcare professionals are predominantly

white (Gary,2009; Vega and Rumbaut, 1991) This lack of representation and power has meant

the EBPs with the most scientific evidence, funding, dissemination, and support are often

ineffective among minorities in practice (Aisenberg, 2008).

Summary of the Problem

While researching these root causes, I came to a pivotal question; why is our American

society this way? The best answer I could come up with is as a society we have always lacked

empathy. We engage in racial discrimination, stigmatize mental illness, and refuse to diversify

institutions because we lack empathy. In a highly racialized and divided society, we view those

who are different as threats to our own status and privilege thereby behaving in ways that build

our own power and wealth. This conclusion, however, is highly subjective and would be nearly

impossible to prove with scientific evidence. Therefore, I will primarily focus on the three root

causes while providing modest solutions to the empathy concern.

The three primary root causes discussed above, racial discrimination, stigmatization of

mental illness, and a lack of representation have resulted in striking MMHD. In addition to

universal barriers to effective care (i.e., cost or fragmentation of services), minorities experience

additional barriers including mistrust, fear, discrimination, and linguistic/cultural differences

(U.S. DHHS, 2001).

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In practice this has meant: minorities are at increased risk for mental illness due to a

disproportionate burden of risk factors, have less access to mental health services, are less likely

to receive needed services, are underrepresented in mental health institutions, and those that are

receiving treatment likely experience poorer quality or ineffective care (Miranda, Nakamaru, and

Bernal, 2003).

Theory of Change
Equality vs. Equity
One of the initial questions that arose was whether to take an equality or an equity

approach to addressing mental health. An equality approach allocates resources by giving

everyone the same quantity and quality of resources, regardless of need. An equity approach, on

the other hand, allocates resources according to individual need or capacity. Therefore, using an

equity approach promotes fairness by allocating a higher proportion of resources to the

disadvantaged compared to the privileged. In most cases, an equity approach is utilized when

addressing disparities. However, I believe when addressing mental health, we must employ both

strategies with a greater emphasis on equity.

As discussed earlier, minorities do face multiple barriers to mental well-being that whites

do not. However, even among the white population in the U.S., there are wide disparities

between the rich and poor, the urban and rural, and white collar compared to blue collar workers.

Even among the privileged in the U.S., mental health is an issue that has been inadequately

addressed, resulting in an actionable burden in all communities. Furthermore, addressing

concerns of only a subset of the population will not fix the “root causes” discussed earlier.

Instead, this paper will use a framework that addresses broad societal concerns that impact all

Americans while also advocating for initiatives that help the disadvantaged communities in the

U.S.

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Social Justice Perspective (Ruger, 2004; VanderWeele, 2017)

We must utilize a social justice lens to address health disparities. While avoiding the

depths of philosophical debate, the lens I will use is that of “human capability.” This perspective

is rooted in Aristotelian philosophy and holds the belief that healthcare is of special social

significance because it allows for human flourishing. In layman’s terms, we should strive for the

complete physical and mental well-being of all because every human intrinsically deserves to

flourish. Unlike other utilitarian perspectives, this view values health intrinsically rather than

solely due to an individual’s “instrumental” contribution of social goods (i.e., income).

In practical terms, healthcare is viewed as one component in an array of social

determinants. Healthcare is undoubtedly related to health, and therefore should be addressed, but

these healthcare reforms are necessary but not sufficient to address broader inequities. Instead,

we need to take a comprehensive approach that reforms every institution. The “human

capability” approach also has equity implication regarding access to mental health resources and

how to finance them. The cost of healthcare resources act as a regressive barrier to health;

disproportionately burdening the marginalized and disadvantaged. Therefore, from a “human

capability” perspective, a robust social safety net, that includes health insurance, is necessary to

address these equity concerns. All citizens should share the economic burden of healthcare

through progressive financing that redistributes resources from the well to the sick and from the

rich to the poor.

This perspective is useful in addressing MMHD because it acknowledges the critical role

of healthcare reform within a broader system of change that addresses the full breadth of social

determinants of health, including but not limited to housing, poverty, nutrition, education, and

the built environment. The “human capability” approach also actively maintains the individual’s

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humanity while striving for justice and equity. Lastly, this perspective acknowledges the

importance of financing but does not consider economic viability a priority in the initial

conceptualization of an equitable and just system.

Etic vs. Emic Approach

Historically, mental health research and practice have utilized an etic approach where

professionals employ an “outsider” perspective and try to apply preexisting theories and

conceptualizations of mental health to an alternate environment or culture. For example, the

Diagnostic and Statistical Manual (DSM) definition of most mental disorders is a byproduct of

Western culture. The conditions that are deemed “mental health disorders” are always changing,

it wasn’t until 1973 that homosexuality was removed from the DSM as a diagnosable mental

illness, as are the behaviors that are deemed symptoms. Therefore, applying DSM criteria to non-

Western cultures may be inappropriate because minority communities may not consider the same

actions as symptoms or disorders and mental illnesses may manifest themselves in alternative

ways. For Asian and Black individuals, mental illness symptoms are often perceived as physical

ailments, not mental disorders. For some minorities, the mind-body connection isn’t an

internalized norm (Holden et al., 2014). One hypothesis that attempted to explain MMHD

suggests there is a gap between epidemiologically assessed need (determined using the DSM

criteria), functional impairment, and subjective perception of need for minorities while no similar

discrepancy exists for those belonging to the majority culture (Cauce et al., 2015). In practice,

this means minorities are less likely to receive care especially care that addresses their particular

concerns.

The mental health community should shift to more of an emic approach to address these

disparities. An emic perspective is where professionals take on the perspective of community

members and conceptualize symptoms, diagnoses, and treatments within the specific cultural and

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environmental context of the community. Utilizing this approach would promote cooperation and

trust while allowing researchers and professionals to address the specific needs of communities

in a culturally appropriate manner.

An emic approach is also radical in that it actively redistributes power and resources from

the predominantly white and privileged, who are disproportionately represented in government,

academia, and business, to minorities, who have less privilege, resources, and representation. An

emic approach also shifts the direction of this paper; instead of advocating for a specific EBP I

will focus on institutional and structural changes that will, in the long-run, redistribute power and

resources allowing minorities to set the agenda and priorities. Many of the recommendations I

make will attempt to build capacity within minority communities so they may address mental

health most appropriately and effectively.

Model of Help-Seeking (Waheed et al., 2015; Cauce et al., 2015)

Individuals with mental illness often undergo a similar process of help-seeking. At each

of these steps, minorities face barriers. The first step is problem recognition; for minority

communities, there is limited quality mental health surveillance and a real gap between the

epidemiologically defined need and the perceived need. This often means that minorities view

their maladaptive behaviors as rational actions in response to their environment rather than due

to an underlying mental health concern. The next step is deciding to seek help; for many

minorities, this decision is complicated by accessibility and availability barriers including a lack

of financial resources or adequate transportation. This has meant minorities receiving mental

health services often underwent a coercive process, usually through the criminal justice or

education systems, or received emergency care once their condition was no longer bearable. The

third step of the process is selecting a service; for minorities, there are several barriers including

a distrust of mental health providers and a lack of cultural competence and representation in

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service providers. Black communities, in particular, have conveyed they have little faith in

mental health interventions which is rooted in a fear that contact with a provider will result in

institutionalization. For Asian families, formal treatment is often used as a last resort after every

attempt to deal with the problem within the community has been made. Unsurprisingly,

minorities also consider cultural, linguistic, and ethnic differences between providers and clients

and often show a strong preference for providers who are similar to themselves and may be more

sensitive to their needs and cultural context. Unfortunately, this means many minorities may not

seek help due to a lack of representation in mental health practices. The last step involves

retention; for many minorities, the lack of representation and culturally appropriate interventions

has led to high attrition rates and ineffective interventions. These barriers at each step of the

decision-making process are significant contributors to MMHD and must be addressed.

Prevention, Detection, or Treatment (Holden et al., 2014)

If we want to address MMHD most effectively, should the focus be on prevention,

detection, or treatment? The truth is, we must address all three because disparities at each level

contribute to the disproportionate burden of mental illness among minorities. Prevention efforts

are important because they address individual risk and protective factors, resulting in large

diffuse benefits that help everyone in the population including those with both clinical and

subclinical mental health symptoms. Detection is essential for allocation of resources, evaluation

of ongoing initiatives, and early intervention. Lastly, treatment, especially when effective,

accessible, and holistic, is where we can truly promote equity and address the mental health

burden minority communities face. The benefits of treatment are often concentrated in a smaller

number of people that experience a substantial mental health burden.

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Summary of Theory of Change

The root causes of MMHD are broad and entrenched in individuals, institutions, and

structures. The current mental health crisis is not attributable to a failure in any one system but is

a result of disparities across almost all systems including education, child welfare, immigration,

criminal justice, education, and healthcare. Therefore, the best approaches to address MMHD

should impact root causes in society thereby affecting multiple systems.

Furthermore, the only way to ensure institutions and systems can adequately serve the

most marginalized members of society is to redistribute power and resources. Community

members fully understand the local culture, context, and need. Therefore, these community

members should be the ones that set the agenda and priorities for the future and our role is to

provide support and help build capacity.

Proposal
Prevention
Mindfulness-Based Stress Reduction (Beigel et al., 2014; Kristeller and Johnson, 2005) –

Mindfulness is a practice that has recently come into the Western consciousness but has a long

history in South and East Asian cultures. Mindfulness-based stress reduction (MBSR) often

refers to an eight-week curriculum which contains a set of meditation practices that have been

scientifically assessed to reduce perceived stress and the biological stress response. There are

many adaptations of MBSR, including MBSR-T for teens, which have been proven to be

effective. MBSR-T is an intervention that requires minimal resources besides initial training for

instructors and therefore can be widely disseminated. MBSR-T is also flexible and effective

across diverse study populations making it one of the few approaches that may be truly universal.

Certain MBSR practices, like loving kindness meditation which has origins in Indian meditative

practices, can also promote empathy, compassion, and altruism. Implementing MBSR-T in

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schools, community centers, and juvenile detention centers will have a broad diffuse positive

benefit in improving the mental health of all teens in the U.S. while promoting prosocial

emotions and behaviors.

Destigmatize Marginalized Communities and Mental Illness (Gary, 2009) – Stigma against mental

illness and marginalized communities is a significant contributor to the U.S. mental health

burden. Many different campaigns have been working to destigmatize the “other” including the

“Green Bandana Project,” “Spread the word to end the word,” and “We Are Sikhs.” Many of

these initiatives have not been critically evaluated, but anecdotally the campaigns have reduced

stigma and can act as a model for other local efforts.

The “Green Bandana Project” was designed by the University of Wisconsin chapter of

the National Alliance on Mental Illness (NAMI-UW) and is an ongoing project. The primary aim

is to spread awareness of available mental health resources by distributing lime green bandanas

to students along with resource cards. The idea is students will place the bandana on their

backpack indicating anyone can approach them with a mental health-related concern, and the

student with the bandana can then share the resources available on campus. This initiative has

been highly effective with a green bandana on almost every backpack on campus resulting in

campus-wide solidarity where mental health is no longer stigmatized. The University Health

Services has said the project resulted in an increase in help-seeking and utilization of services.

“Spread the word to end the word” was a movement that attempted to remove “retard”

from the common vernacular in an attempt to destigmatize individuals with disabilities and is

supported by the Special Olympics and Best Buddies. From my experience, this initiative was

also highly effective. In my high school, within a year student went from using “retard” as a

common insult to a social norm that the word was inappropriate. Lastly, “We Are Sikhs” was

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started by the National Sikh Campaign in an attempt to contextualize and add nuance to the Sikh

identity. After 9/11 and the 2016 election, there was a spike in hate crimes against Sikhs, who

wear a turban as an article of their faith, in the U.S. primarily due to a fear that was perpetuated

by media and politicians. The National Sikh Campaign conducted polls before and after the “We

Are Sikhs” campaign and found the project had made the public more open to Sikhs. These

initiatives are examples of how destigmatizing campaigns can play a role in reducing social

barriers to seeking mental health services and reducing the stigmatization of marginalized

communities.

Detection (IOM, 2009; Vega and Rumbaut, 1991)

The U.S. mental health landscape is covered by a patchwork of surveillance systems that

exhibit one or many vital flaws including they do not adequately establish diagnoses based on

DSM criteria, they do not measure known risk or protective factors associated with mental

illness, they involve questions with parents instead of the child or adolescent, they measure only

a specific subset of mental health disorders (usually substance abuse or depression), they ask

adults to report onset of symptoms retrospectively, and they do not provide data on the state or

local level.

In addition to these vital flaws that affect all citizens, minority surveillance includes

additional deficiencies. First, many surveillance systems utilize the racial-ethnic breakdown

established by the U.S. Census which includes White European Americans, African Americans,

Asian Americans/Pacific Islanders, Native Americans, and Latino/Hispanics. However, this

classification often erases significant nuance and disparities within racial-ethnic groups. For

example, Indians, Chinese, Hmong, Vietnamese, and Taiwanese individuals would all be

classified as “Asian,” but they have very different cultural norms and beliefs regarding mental

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illness. Furthermore, different ethnic and national groups also have significantly different

histories. Many Americans who identify as Hmong or Vietnamese came to the U.S. as refugees

after the American wars in Laos and Vietnam, respectively, while those who identify as

Taiwanese or Indian often came to the U.S. as highly skilled and educated workers. These

histories significantly impact the resources available to each community; differences that are

erased when these diverse groups are grouped into the one racial-ethnic category of “Asian.”

Similar within-group differences exist for each of the five racial-ethnic groups. Next,

surveillance systems often use a Western conceptualization of mental illness using language that

may be exclusionary. For example, the word “depression” has a specific meaning in Western

cultures, but in some Asian cultures, like the Rohingya, there is no equivalent conceptualization

of “depression.” In other cultures, like the Punjabi, using the English word “depression” is

heavily stigmatized and therefore not used. Similarly, some minority groups “somatize”

psychological problems which is the process by which an individual experiences, perceives, and

describes a mental health symptom as a bodily illness. For example, an Indian patient may

describe symptoms associated with depression as originating from the gut rather than from a

social or emotional disturbance. Lastly, many surveys fail to take into account acculturation and

generational status. First generation Americans, those who immigrated to the U.S. within their

lifetime, have much different life experiences, needs, and views of mental health compared to

later generation Americans. As an ethnic group spends more time in the U.S., they undergo

acculturation and often build communities that act as a source of social support.

The only way to serve all Americans is to create a robust mental health surveillance

system that is regularly conducted using a culturally competent interview process. In addition to

interviews, we also need regular national surveys that are culturally appropriate, contain nuanced

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self-reported demographic information (including generational status), and include known risk

factors, protective factors, diagnosable conditions, and DSM symptoms at the local, state, and

national level. Effective detection is essential for creating policies and practices that are

responsive to specific community needs.

Treatment
Culturally Centered Integrated Care (Holden et al., 2014; Sue et al., 1991; Betancourt, 2003;

Flaskerud, 1986) – Within the last decade, there has been a shortage of mental healthcare

providers which has severely limited the access to mental health services for minorities and those

living in rural settings. As a response to this shortage, more Americans are going to their primary

care provider to seek mental health services. According to one study, as many as 70% of primary

care visits stem from psychosocial issues while the World Health Organization has indicated

more than 50% of patients receiving mental health treatment obtained at least some services from

a primary care setting while 30% of patients received all of their care from a primary care

setting. Minorities, in particular, are more likely to report mental health symptoms to their

primary care physician than to a mental health specialist. Unfortunately, many primary care

physicians are ill-equipped to adequately detect and treat mental health symptoms especially

among minority populations.

Many Americans are more comfortable going to a primary care setting especially after

building a relationship with their primary care provider. Therefore, the primary care setting is an

ideal site to address MMHD. Rather than relying on primary care physicians to address mental

health needs, we should fully integrate mental health providers into primary care settings.

This approach has three significant advantages: (1) on-site mental healthcare will help

improve supervision and compliance since most people have better access to primary care

settings compared to specialized mental health settings, (2) incorporating services will allow for

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necessary interfacing between primary care providers and mental health providers to best address

the physical and mental health concerns and coordinate care, and (3) incorporating services also

reduces the stigma associated with seeking mental health treatment since the reason for your visit

would remain unknown to the public.. These benefits of integrated care will address some of the

factors that contribute to MMHD. However, the integrated care must be culturally centered.

Incorporating suggestions from multiple sources I came up with some recommendations

for mental health practitioners working in primary care settings: (1) establish collaborative

partnerships with primary care physicians and case managers to better coordinate care, (2) assess

cultural biases, stereotypes, and ethnocentric views that may impact relationships with patients

seeking care by first undergoing cultural humility training, (3) use culturally sensitive methods

and material for screening, assessment, and treatment, (4) acknowledge the ways different

minority communities address mental health concerns differently, and (5) establish parallel

services that are specifically devoted to addressing unique barriers experienced by minorities.

Another essential step to address these disparities and increase access to integrated services is to

provide universal healthcare, so all Americans have access to preventative and treatment

services. These recommendations are an initial step to promote equity, justice, and an emic

approach but fail to redistribute power and resources.

Promote Diversity and Representation in all Mental Health Institutions (Vega and Rumbaut,

1991; Fisher et al., 2002; Miranda et al., 2003; Waheed, 2015; Devia et al., 2017) – As a field,

we had known for at least two decades that there were significant racial disparities when it came

to mental and physical health. However, we have failed to actually address the issue, and many

of the disparities have persisted or gotten worse. This failure is rooted in our inability to

redistribute power and resources adequately.

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Many of the institutions related to mental health, including healthcare providers,

researchers, and EBP purveyors are predominantly white and privileged. Furthermore, many of

the best practices that have the greatest amount of financial, political, and social support were

created in and tested among predominantly white study populations. This lack of representation

and the resulting inequitable distribution of power and resources has meant minorities are

neglected in every step of the process from creation, implementation, evaluation, and large-scale

dissemination.

The first step to address this issue is to institutionally address the lack of minorities

among researchers and academic institutions. Having a more diverse workforce will allow

institutions to truly embrace an “emic” approach. For research, this means institutions will be

able to create interventions that are truly culturally appropriate and effective in communities of

color. Furthermore, a representative research staff will make it easier to recruit ethnically diverse

study participants thereby mending the relationship between research institutions and

communities of color. Recruiting diverse study participants will also help academics assess the

effectiveness of current EBPs in diverse minority settings. A current widely used tool to

incorporate community voices in research is the use of community based participatory research

(CBPR). CBPR is a collaborative research approach that creates equitable partnerships between

community stakeholders and researchers. When used effectively, CBPR can foster social

cohesion, build local capacity, and help strengthen leadership within and between community

partners. Furthermore, by redistributing institutional power and resources from researchers to

community members, CBPR can be used as a tool to pursue procedural, distributive, and

structural justice.

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In addition to increasing diversity among researchers, we should simultaneously improve

the diversity of mental health practitioners. Having practitioners that represent the community’s

culture and language is vital for effective treatment and retention of minority patients. The best

way to address the lack of representation is to aggressively implement affirmative action policies

while incentivizing minorities to enter the field through loan forgiveness programs and other

forms of academic and financial support. This diversity should also be at all levels of an

organization to show minority communities their voices are being heard and represented.

The next step is to actively survey and address barriers that are specific to their

community which may include relevant transportation or local governance concerns. Lastly,

mental health organizations should attempt to partner with diverse community organizations

including faith-based organizations, civil rights organizations, and other cultural groups. By

actively engaging and addressing local concerns, mental health organizations will also improve

their relationships with diverse community members.

These initial steps are necessary to ensure in the long-run mental health services will

continuously improve and address the needs of all communities, not just the most privileged.

Also, giving people of color more power and resources will help them lobby politicians for

policy changes and funding. As mentioned repeatedly, mental health impacts almost every social

and governmental institution. Ideally, the representation initiative I proposed would be replicated

across all institutions including but not limited to education, social work, immigration, policy-

making, policing, and criminal justice so we can properly address disparities throughout all

aspects of society.

Conclusion
Mental health is a complex topic that impacts all aspects of society and politics.

Marginalized and disadvantaged groups, including immigrants, racial-ethnic minorities, and

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members of the LGBTQ+ community face a disproportionate burden of mental illness.

Disparities within institutions, including education and criminal justice, partly contribute to the

mental health disparities but the root causes are racial discrimination, stigmatization of mental

illness, and a lack of minority representation and power which are all linked to a societal lack of

empathy. I have attempted to make some recommendations that will help make the U.S. a more

empathetic, representative, and equitable society by addressing barriers in prevention, detection,

and treatment. In the long-run, the only way to ensure we continuously address the needs of

transforming communities is to uplift voices of diverse citizens while redistributing power and

resources. As academics invested in mental health, we must embrace a supportive role and

embrace humility. We may assume most aspects of mental health are “universal,” but the reality

is, they are not. We may know which practices have been promising in studies, but that does not

mean they are effective in real-world settings. More than anything, we must actively listen to

marginalized communities giving them the resources and agency to appropriately address

community needs.

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Works Cited
Aisenberg, E. “Evidence-Based Practice in Mental Health Care to Ethnic Minority Communities:
Has Its Practice Fallen Short of Its Evidence?” Social Work, vol. 53, no. 4, 2008, pp.
297–306., doi:10.1093/sw/53.4.297.
Betancourt, Joseph R., et al. “Defining Cultural Competence: A Practical Framework for
Addressing Racial/Ethnic Disparities in Health and Health Care.” Public Health Reports,
vol. 118, no. 4, 2003, pp. 293–302., doi:10.1093/phr/118.4.293.
Biegel, Gina M., et al. “Mindfulness-Based Stress Reduction for Teens.” Mindfulness-Based
Treatment Approaches, 2014, pp. 189–212., doi:10.1016/b978-0-12-416031-6.00009-8.
Bui, Khanh-Van T., and David T. Takeuchi. “Ethnic Minority Adolescents and the Use of
Community Mental Health Care Services.” American Journal of Community Psychology,
vol. 20, no. 4, 1992, pp. 403–417., doi:10.1007/bf00937752.
Cauce, Ana Mari, et al. “Cultural and Contextual Influences in Mental Health Help Seeking: A
Focus on Ethnic Minority Youth.” Journal of Consulting and Clinical Psychology, vol.
70, no. 1, 2002, pp. 44–55., doi:10.1037//0022-006x.70.1.44.
Davis, Sandra L., and Deborah W. Chapa. “Social Determinants of Health: Knowledge to
Effective Action for Change.” The Journal for Nurse Practitioners, vol. 11, no. 4, 2015,
pp. 424–429., doi:10.1016/j.nurpra.2015.01.029.
Devia, Carlos, et al. “Advancing System and Policy Changes for Social and Racial Justice:
Comparing a Rural and Urban Community-Based Participatory Research Partnership in
the U.S.” International Journal for Equity in Health, vol. 16, no. 1, 2017,
doi:10.1186/s12939-016-0509-3.
Fisher, Celia B., et al. “Research Ethics for Mental Health Science Involving Ethnic Minority
Children and Youths.” American Psychologist, vol. 57, no. 12, 2002, pp. 1024–1040.,
doi:10.1037//0003-066x.57.12.1024.
Flaskerud, Jacquelyn H. “The Effects of Culture-Compatible Intervention on the Utilization of
Mental Health Services by Minority Clients.” Community Mental Health Journal, vol.
22, no. 2, 1986, pp. 127–141., doi:10.1007/bf00754551.
Gary, Faye A. “Stigma: Barrier To Mental Health Care Among Ethnic Minorities.” Issues in
Mental Health Nursing, vol. 26, no. 10, 2005, pp. 979–999.,
doi:10.1080/01612840500280638.
Holden, Kisha, et al. “Toward Culturally Centered Integrative Care for Addressing Mental
Health Disparities among Ethnic Minorities.” Psychological Services, vol. 11, no. 4,
2014, pp. 357–368., doi:10.1037/a0038122.
IOM Report on Prevention of Council, N. R. & I. o. Medicine. 2009. Preventing Mental,
Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.
Washington, DC: The National Academies Press.
Kristeller, Jean L., and Thomas Johnson. “Cultivating Loving Kindness: A Two-Stage Model Of
The Effects Of Meditation On Empathy, Compassion, And Altruism.” Zygon, vol. 40, no.
2, 2005, pp. 391–408., doi:10.1111/j.1467-9744.2005.00671.x.
López, Gustavo, et al. “Key Findings about U.S. Immigrants.” Pew Research Center, Pew
Research Center, 30 Nov. 2018, www.pewresearch.org/fact-tank/2018/11/30/key-
findings-about-u-s-immigrants/.
Merikangas, K. R., J. P. He, M. Burstein, S. A. Swanson, S. Avenevoli, L. Cui, C. Benjet, K.
Georgiades & J. Swendsen (2010) Lifetime prevalence of mental disorders in U.S.

21
 Jasdeep Kler

adolescents: results from the National Comorbidity Survey Replication--Adolescent

Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry, 49, 980-9.
Miranda, Jeanne, et al. “Including Ethnic Minorities in Mental Health Intervention Research: A
Practical Approach to a Long-Standing Problem.” Culture, Medicine and Psychiatry, vol.
27, no. 4, 2003, pp. 467–486., doi:10.1023/b:medi.0000005484.26741.79.
Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute
of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to
Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and
Mental Health Services Administration (US); 2001 Aug. Chapter 1.
Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44246/
Okazaki, Sumie. “Impact of Racism on Ethnic Minority Mental Health.” Perspectives on
Psychological Science, vol. 4, no. 1, 2009, pp. 103–107., doi:10.1111/j.1745-
6924.2009.01099.x.
Pincus, Fred L. “Discrimination Comes in Many Forms.” American Behavioral Scientist, vol. 40,
no. 2, 1996, pp. 186–194., doi:10.1177/0002764296040002009.
Ruger, Jennifer Prah. “Health and Social Justice.” 2009,
doi:10.1093/acprof:oso/9780199559978.001.0001.
Sue, Stanley, et al. “Community Mental Health Services for Ethnic Minority Groups: A Test of
the Cultural Responsiveness Hypothesis.” Journal of Consulting and Clinical
Psychology, vol. 59, no. 4, 1991, pp. 533–540., doi:10.1037//0022-006x.59.4.533.
U.S. Department of Health and Human Services, National Institute of Mental Health.
(2017). Mental illness. Retrieved from https://www.nimh.nih.gov/health/statistics/mental-
illness.shtml
Vanderweele, Tyler J. “On the Promotion of Human Flourishing.” Proceedings of the National
Academy of Sciences, vol. 114, no. 31, 2017, pp. 8148–8156.,
doi:10.1073/pnas.1702996114.
Vega, W. A, and Rubén G Rumbaut. “Ethnic Minorities And Mental Health.” Annual Review of
Sociology, vol. 17, no. 1, 1991, pp. 351–383., doi:10.1146/annurev.soc.17.1.351.
Waheed, Waquas, et al. “Overcoming Barriers to Recruiting Ethnic Minorities to Mental Health
Research: a Typology of Recruitment Strategies.” BMC Psychiatry, vol. 15, no. 1, 2015,
doi:10.1186/s12888-015-0484-z.
Williams, David R., and Ruth Williams-Morris. “Racism and Mental Health: The African
American Experience.” Ethnicity & Health, vol. 5, no. 3-4, 2000, pp. 243–268.,
doi:10.1080/713667453.
Woolf, Steven H. “Progress In Achieving Health Equity Requires Attention To Root Causes.”
Health Affairs, vol. 36, no. 6, 2017, pp. 984–991., doi:10.1377/hlthaff.2017.0197.

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