Power Redistribution and Upending White Supremacy in Implementation Research and Practice in Community Mental Health

Naming the influence of White supremacy is only the first step toward change. We therefore also provide action-oriented recommendations tailored to community mental health, consistent with recent guidelines for promoting equity and addressing structural racism in implementation science (2, 4, 8).

First, implementation scientists must acknowledge the racial inequities within the field itself and commit to multilevel transformative action. Change will require both interpersonal awareness and institutional transformation. For example, implementation scientists can reflect on how White supremacy affects their own experiences of power and privilege and their relationships with community partners and how it shows up in their institutions that perpetuate the hiring and promoting of White academics and a White supremacist work culture (9). Within research teams and partnerships, implementation scientists can discuss their own positionality (i.e., social position based on intersecting social identities and experiences) and limitations to the ways in which EBIs for mental health care were developed and tested and can express honesty and humility about potential challenges (9). Moreover, implementation scientists can provide intentional mentorship to people of color and individuals with other minoritized identities, examine mechanisms of racial inequities in hiring and promotion within research and clinical institutions, and develop strategies to address those mechanisms (e.g., creation of pathways to research and leadership opportunities at multiple training and career stages). At the funding level, implementation scientists and funding agencies can advocate for programs such as NIH UNITE, developed to identify and address structural racism within the scientific community, or the NIH FIRST (Faculty Institutional Recruitment for Sustainable Transformation) initiative, which supports underrepresented scientists. Importantly, equity goes beyond representation, and academic institutions and individual implementation scientists must invest resources into the creation of safe spaces where people’s voices, knowledge, and lived experience are valued.

Second, as has been widely described, investing in community engagement throughout all aspects of implementation research and practice is necessary for the redistribution of power and equitable provision of mental health services (6, 8, 9). One recently described model—the Community Coalition for Equity in Research—provides concrete steps and structures for increasing authentic engagement between researchers and community members. This model includes training community members in research principles, prioritizing sharing of power and resources, supporting colearning, centering community strengths, and emphasizing long-term and system changes (10). The model can be applied to implementation practice in community mental health clinics by creating a coalition of community clinicians, clinic staff, and individuals with lived experience sharing equal power in decision making regarding which services and training areas are prioritized within the clinics. In addition, the transcreation framework (11) provides an example of how to codevelop and coimplement mental health services by understanding a community’s context and mental health needs, combining both scientific evidence and local knowledge and resources for mental health promotion to develop an intervention and building community capacity by hiring and training community members as interventionists and study staff.

The common element in these models is that power is held and shared with community partners in an authentic way that includes their integral involvement throughout the research and practice process with appropriate compensation. Community-engaged work requires authentic relationship building, takes time, and does not fit the traditional research infrastructure that prioritizes proliferation of products (e.g., publications and grants) over transformation of mental health systems and clinical practices. Leaders in the field and those in positions of power can and must resist this prioritization and invest in systems and structures that support community-driven work. This investment may include funding through a mental health services organization (e.g., the Substance Abuse and Mental Health Services Administration and local foundations) or programs recently developed within national funding agencies that specifically support the development of community-partnered work (e.g., the Patient-Centered Outcomes Research Institute Engagement Awards program, the Community-Based Participatory Research Program of the National Institute on Minority Health and Health Disparities, and the NIH Common Fund’s Community Partnerships to Advance Science for Society).

Third, we need to rethink EBIs as the centerpiece of implementation science in mental health. Promoting EBIs as the solution for addressing community mental health needs can ignore structural challenges experienced by both clients and community clinicians and perpetuate mental health inequities in care (12, 13). Instead of focusing primarily on barriers and facilitators to EBI implementation, we ought to broaden determinants to measure structural racism and other mechanisms of inequities in engagement and mental health outcomes for minoritized clients (14, 15). Specifically, within community mental health, interrelated multilevel factors at the client level (e.g., social determinants of health, mistrust of systems of care, experiences of racism and other discrimination, and mental health stigma), clinician level (e.g., biases, lack of cultural humility, financial strain, and secondary traumatic stress), intervention level (e.g., lack of culturally responsive care), and systemic and structural level (e.g., underrepresentation of clinicians of color in mental health care, insurance and billing requirements, and clinic attendance policies that disproportionately affect low-income patients of color) all contribute to disparities in receipt of high-quality care but are not commonly included as determinants in implementation science research. Implementation strategies can then be developed to specifically address determinants of mental health equity (14, 15), such as cultural assessments to help clinicians tailor care to their clients’ unique background and improved reimbursement rates for clinicians caring for youths covered by Medicaid.

Great strides have been made in the field of implementation science, but we can and must do better. Implementation science can play a role in ushering in a more equitable and just era of delivery of mental health services. However, undoing centuries of White supremacy will not be easy or quick; it requires willingness, an investment of time, and a redistribution of power.

The authors acknowledge Dr. Rachel Shelton for sharing her expertise and time in reviewing this Open Forum.