Should We Trust You? Strategies to Improve Access to Mental Healthcare to BIPOC Communities During the COVID-19 Pandemic

Abstract

Black, Indigenous, and People of Color (BIPOC) communities have weathered centuries of racism, causing transgenerational mental health consequences and hindering access to quality treatment. In this commentary, we describe the systemic challenges of engaging BIPOC to promote mental health equity during the COVID-19 pandemic. We then describe an initiative that illustrates these strategies, provide recommendations and further readings for academic institutions seeking to partner with community organizations to provide equitable mental health services to populations that have been traditionally overlooked.

Background

Structural racism has been documented throughout macrolevel systems that normalize disenfranchisement and marginalization based upon race, ethnicity, immigration status, and other intersectional identities (Hankerson et al., 2022). Importantly, structural racism is the “totality of ways in which societies foster racial discrimination via mutually reinforcing inequitable systems” (Bailey et al., 2017). BIPOC communities have extensive histories of abuse in white mental healthcare (Medlock et al., 2016). Enslaved Africans were accepted as payment (Jones, 1954), eugenics advanced biological racial inferiority, and racially-biased practices advantaged white patients over others with similar presenting problems. Today mental health professionals routinely overdiagnose Black people with chronic psychiatric disorders (Harnett & Ressler, 2021; Shim, 2021), and provide substandard care despite profound intergenerational implications (Hankerson et al., 2022). When Black people resist substandard treatment, they are pathologized rather than recognizing these responses as appropriate reactions to trauma and oppression (Bailey et al., 2017; Shim, 2021).

The underrepresentation of BIPOC mental health professionals adversely affects mental health help-seeking (Taylor & Kuo, 2019). Inequities within institutions—from admission and residency, to fellowship and securing faculty positions—have long impeded the advancement of BIPOC mental health professionals (Wills, 2021). Although White people make up 54% of psychiatry residents they only account for 29% of the applicant pool (Wyse et al., 2020). Cultural differences are also largely not incorporated in students’ medical training (Medlock et al., 2016). Academic institutions that neglect to actively dismantle systemic racism are perpetuating a disparity that has implications for providing quality care to diverse patient populations. Without options for providers who share cultural, linguistic, and other intersectional identifiers that could provide culturally humble and competent care, BIPOC are likely to remain distrustful (Nicolaidis et al., 2010). This was further exacerbated by a plethora of co-existing inequities evidenced during the pandemic phase of COVID-19. Importantly, many BIPOC experienced the higher burden of a lack of social determinants of health (Ali et al., 2022), namely a lack of access to quality education, housing instability, under- and unemployment, economic instability resulting from furloughs, employment in jobs that elevated viral exposure prior to the availability of vaccines, and higher rates of mortality due to lack of access to quality care (Neighbors et al., 2023; US Department of Health & Human Services, 2020). Despite increased stressors, BIPOC continued to experience structural barriers that precluded their mental health help-seeking efforts. Notably, there is a dearth of access to culturally salient interventions, a paucity of quality of mental healthcare, increases costs for service, and challenges related to health insurance (Burkett, 2017; Hankerson et al., 2015; Hudson et al., 2018; Nicolaidis et al., 2010; Redmond et al., 2017; Waller et al., 2022a; Woodward et al., 2008).

Establishing and Nurturing Relationships

In addressing these challenges, lessons can be learned from community engaged research (CEnR) (Jones & Wells, 2007). CEnR center the community (Sanders Thompson et al., 2021). Community members constitute anyone with a stake in the delivery or outcome of an intervention or policy. CEnR emphasizes the community as expert, promotes shared decision-making, and operationalizes shared values, goals, communication processes, and power (Collins et al., 2018). They are often guided by an advisory board that includes community members who provide counsel throughout the project. Other strategies central to CEnR include compensating community members, communicating funding realities, and emphasizing safety and trust (Collins et al., 2018). Employing CEnR increases community engagement and improves treatment relevance (Jones & Wells, 2007; Paris et al., 2016).

Approaches that center equitable relationships are also needed. Authentic relationships are fundamental for meaningful outcomes. Strategies for developing such relationships exist in a range of disciplines. From a clinical perspective, basic therapeutic approaches provide a foundation for relationship building, including deep, active listening; meeting people where they are; co-creating goals; naming challenges and differences; and creating shared ownership. Asset-framing centers a strengths-based narrative that highlights aspirations. A researcher’s self-awareness, humility, and understanding of positionality is foundational for fostering meaningful relationships. This includes understanding one’s motivations in working with others, as well as how prospective partners may respond to social identities. Undergirding many of these strategies is frequent communication. Adept communication skills can be underused and undervalued. Continual communication is a gateway to deep commitment. Taken together, these strategies can inform the critical task of trust-building with historically underserved communities.

Of great relevance is how to employ these strategies to foster meaningful and mutually-beneficial academic-community partnerships. Below we share the work we are doing with ENGAGE (Engaging CommuNities to Gain Mental WellbeinG and Equity) in New York.

ENGAGE

ENGAGE is a pilot initiative to (1) train a lay workforce to expand screening for common mental disorders, (2) provide interventions to those who otherwise could not access care, and (3) provide access to financial resources to improve social determinants of mental health. The initiative builds upon community health programs developed in low-resource countries by a research team at Columbia University Irving Medical Center/New York State Psychiatric Institute (CUIMC/NYSPI), and uses a digital platform to assist trained lay personnel to screen, provide initial care and referrals.

This pilot is one of the first in the U.S. to use this model and involves a partnership between two community-based mental health services organizations and the Mental Wellness Equity Center at CUIMC/NYSPI. Initial training and certification in three evidence-based interventions: Interpersonal Counseling (IPC) for depression; Safety Planning Intervention (SPI) for clients contemplating suicide; and Motivational Interviewing (MI) for substance use disorders will be followed by full deployment of the workforce to provide care to those awaiting services.

Most of the workforce are from backgrounds that represent the communities their agencies serve (i.e. Black/African American, Hispanic, LGBTQ +). At the agency serving a predominantly Spanish-speaking population, services are delivered in Spanish. Training in IPC and MI involves a three-day, in-person workshop followed by several months of trainees working with three training clients, one at a time, under weekly supervision. A two-day, in-person training is facilitated for SPI. Training in financial wellness assessment and referral occurs through weekly meetings with staff to co-create the tools and approach, followed by a one-day workshop.

Staff are currently being trained, and evaluation of this process is underway. Once staff are certified to deliver the EBIs, outcome measures to be assessed include those at the level of the client (clinical effectiveness, impact of financial wellness package); service (safety, equity, efficiency, timeliness); and implementation (acceptability, feasibility, access, uptake, quality, fidelity, sustainability, cost).

The pilot is funded through the New York State Office of Mental Health (NYS OMH). Early engagement with OMH policymakers shaped the pilot. For instance, OMH was interested in retaining staff members from a time-limited COVID-19-related crisis counseling program. To address this priority, we worked with an agency to transition staff onto the ENGAGE team.

An important component of the engagement process from the perspective of the academic team was to bring early-stage ideas to stakeholders to meaningfully co-develop program design. The academic team came to policy-makers and community agencies to determine implementation details, such as the population to be targeted through the initiative. A priority was addressing long wait lists. The academic team strove for an attitude of humility about policy and agency needs, enabling the centering of community needs during the project’s initial phases.

Work with the agencies included processes to facilitate a collaborative approach. At the onset, teams engaged in an explicit discussion of the process of collaboration, including how to set meeting agendas and address issues. Teams prioritized in-person contact as an initial stage of relationship-building. This resulted in a two-day interactive workshop with members of the new workforce to identify and prioritize social determinants of mental health in their agency’s catchment areas, allowing further refinement of goals. Ongoing relationship-building takes place through weekly meetings that facilitate continual communication.

The importance of sustainability is a key element of ENGAGE. It can be harmful if a project launches, gains momentum, and then has no mechanism to be continued beyond the time-limited period of initial funding. To mitigate this risk, ENGAGE explored approaches to sustainability, including the potential for trained community providers using a fee-for-service mechanism to bill Medicaid, funding opportunities within Certified Community Behavioral Health Clinics, and future possibilities if Medicaid moves toward greater use of value-based payment structures.

Recommendations for Doing this Work

Communication

Communicating with your partners throughout the lifespan of the project is critical for engagment and fostering trust. Trust takes time and can be a challenge to build, particularly when connecting with communities that have historically been harmed by the academic institution. As such, it is important to understand dynamics surrounding social identity, power, and privilege (Jones & Wells, 2007). Developing interpersonal norms for communication is key to fostering honest, thoughtful, routine, and transparent communication that recognizes past and present inequities and abuses (Datta, 2018a; Jones & Wells, 2007). These are critical components to establishing trust and should be approached with humility.

Co-construction

Cultural humility is fundamental for co-constructing possibilities. This allows you the freedom to interrogate and assess contexts, explore beliefs and glean from your community partner. This also means you will need to constantly challenge, unlearn and dismantle hierarchies that are normative in academic environments (Kendi, 2023; Waller et al., 2022b). Co-constructing also is a pre-requisite for joint ownership, which is essential for community-partnered, as well as community-led, sustainability. Importantly, this article was co-constructed with members of the BIPOC community (Jones & Wells, 2007). The first and fourth authors are both Black women scholars who reside within underserved and underresearched communities in New York that ENGAGE aims to serve. The first author leads the community engagement arm of ENGAGE. She has partnered with faith-based organizations and assisted with implementing community-led intiatives for more than a decade. For the last several years the fourth author has also been at the forefront, ensuring that her community’s needs are heard and centered throughout all phases of clinical research. Both scholars agree that co-construction with anti-Black and antiracist frameworks translate to higher rates of acceptance, uptake, dissemination and lower rates of attrition (Kerkhoff et al., 2022; Nicolaidis et al., 2013; Shelton et al., 2021).

Commitment

Institutional commitment should be steadfast, immersive and holistic. BIPOC communities need to know you before a problem arises. Once you establish your identity, communicate your value and dedication to their overall wellbeing, and remind them often. This can be done by developing and fully leveraging the nuanced knowledge and expertise your community advisory board throughout the project’s continuum (Jones & Wells, 2007), engaging indigenous vendors, and diversifying your team to reduce the potential for tokenism and minority tax. Tokenism occurs when only a select number of BIPOC are hired by a predominantly white institution (Tokenism, 2020). This strategy provides a veneer of diversity. In actuality, those selected experience a minority tax. Minority tax includes the additional burden that BIPOC professionals experience in predominantly white institutions (Balzora, 2021; Campbell & Rodríguez, 2019). They are often tasked with additional workloads related to mentoring and advocating for diversity, equity and inclusion (DEI) initiatives while they are simultaneously marginalized, isolated, bereft of mentorship and sponsorship, and overlooked for plum clinical assignments (Campbell & Rodríguez, 2019). The weight is multiplied when the BIPOC employee is a woman (Balzora, 2021). It is important to recognize from the outset that there will always be a natural tension between the community’s and academic institutions’ needs that will require ongoing reassessment and balancing. Authentic and unwavering investment can reap meaningful rewards in terms of forging and maintaining a genuine partnership that can best meet community needs.

Recommendations for Further Reading

The positioning the authors took are grounded in emancipatory and decolonizing methods, as well as antiracist and anti-Black racism. This interdisciplinary lens is reflective of the diversity of our team and spans from psychiatry and psychology to social work and public health. In order to expand the mental health field’s understanding and engagement in dismantling systemic racism across the ecological landscape, it was vital to incorporate varying methodologies outside of this practice in order to be more holistic in our approach. Some examples of resources in decolonizing research includes the work of Ranjan Datta; specifically “Decolonizing both researcher and research and its effectiveness in indigenous research” and “Decolonozing methodologies: A transformation from science-oriented researcher to relational/participant-oriented researcher” (Datta, 2018a, 2018b). Both posit the researcher and the research in a western context in their approach, and the need to center the indigenous communities’ perspective and realities in order for research to be ethical rather than exploitative. Regarding emancipatory research, Lett et al. examine the ways that health equity tourists are neglecting to center community needs and sense of autonomy in “Health equity tourism: Ravaging the justice landscape (Weerman & Abma, 2019).

Finally, a dearth of publications can be used as an entry point to understanding antiracist praxis, in particular, anti-Black racism. The resources include, but are not limited to Ruth Shim’s “Dismantling structural racism in psychiatry: A path to mental health equity.” This piece provides insights into ways to decreasing structural inequities; and. “Mental health inequities in the context of COVID-19,” which identifies major depressive disorder as a burgeoning public health crisis in tandem with COVID-19 and the social determinants of health that healthcare practitioners and policy makers need to address to invest in lowering the cases, and risks of major depression (Shim, 2020, 2021). Mosley et al.’s “Critical consciousness of anti-Black racism: A practical model to prevent and resist racial trauma” and Waller et al.’s “Just research: Advancing antiracist and antioppressive social work research” acknowledge social work’s complicity in upholding white supremacy (Mosley et al., 2021; Waller et al., 2022b). In doing so, these articles explore different models, and theories to evolve from just publishing scholarship, to being intentional in adapting frameworks, and practical approaches towards combatting anti-Black racism. Lastly, Bailey et al., identifies structural racism as a legacy of the trans-Atlantic slave trade in “How structural racism works –racist policies as a root cause of U.S. racial health inequities,” and provides historical examples ranging from redlining, segregation and the police state and its impact on population and individual health (Bailey et al., 2021).

Funding

NIMH, T32 MH096724, Bernadine Waller, L30 MH131137, Bernadine Waller

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

The opinions in this article are of the authors. No ethical approval was needed.