Racism and Mental Health Equity: History Repeating Itself

Since the December 1970 issue of the American Journal of Psychiatry, mental health treatments have greatly advanced. Several new classes of medications have made care safer. Promising neuromodulatory therapies have been developed, including deep brain stimulation, repetitive transcranial magnetic stimulation, and vagal nerve stimulation. However, policy inequities between mental and general medical health persist. The Medicaid Institutions for Mental Disease (IMD) payment exclusion—unique to psychiatry—prohibits reimbursement for many accredited inpatient psychiatric facilities. Reimbursement for outpatient mental health care trails other specialties, and few psychiatrists take insurance, including Medicaid (3). As a result, few people with mental health and substance use disorders can afford mental health care (4). Nevertheless, successful advocacy, including the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA), has diminished these inequities and promoted parity among general medical and mental health care.

But forces beyond mental health care—including food insecurity, income inequality, adverse early childhood experiences, and additional social factors—drive poor mental health outcomes. These social determinants of mental health are responsible for inequitable outcomes and are created by unequal distribution of opportunities and advantages in society (4). Structural racism, defined by the Aspen Institute (5) as “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity,” is the underlying mechanism that drives the unequal distribution of opportunities and advantages in society. Structural racism ties together mutually reinforcing social, economic, and legal systems that inequitably distribute power (e.g., wealth, rights, and education) (2).

Individuals who make differential, race-based assumptions about the abilities and motives of others are racially prejudiced. Actions motivated by these prejudicial racial assumptions constitute discrimination, which is the differential treatment of others on the basis of race. But unlike prejudice and discrimination, racism requires an account of power relations (6). By accounting for power differences among racial groups, structural racism explains racial group differences better than individual prejudice and discrimination alone. For example, long-standing racial inequities in educational opportunities and in the accumulation of wealth and influence between Blacks and Whites explain the overwhelmingly White representation in institutional positions of power within our health care institutions better than individual racial discrimination alone.

Relevant to mental health care providers, structural racism predicts which groups of patients can and will access mental health care services. Without considerable wealth, access to mental health care is limited by the paucity of mental health care providers who accept insurance, including Medicaid (3, 4). Fewer Black people have wealth, in part because of the historical exclusion of agricultural and domestic workers (who were disproportionately Black) from New Deal unemployment and retirement benefits (2). Simultaneously, the Federal Housing Administration practiced redlining, a structurally racist policy that barred Black Americans from affordable home loan financing (2). As a result, during one of the longest sustained periods of economic growth in 20th-century America, Black families often were forced to defer their dreams of homeownership—the primary vehicle of intergenerational wealth accumulation for middle-class Americans—and depend on personal, familial, and communal resources when they could not find or participate in work. In part because of these policies, the net worth of White Americans is almost 10 times that of Black Americans (7). Most U.S. residents continue to live in racially segregated neighborhoods in which economic investment, public services, schooling, exposure to environmental toxins, and access to general medical and mental health clinics favor White Americans and the neighborhoods and communities in which they most commonly reside (2). Through financial power, which enables access to mental health care, structural racism insulates more Whites than Blacks from the toxic stressors of poverty.

Although structural racism is the driving force behind mental health inequities, perceived racial discrimination is also highly relevant because it is associated with increased depression, anxiety, posttraumatic stress disorder, psychological stress, negative affect, and poor sleep outcomes (2). Importantly, structural racism, through racist ideas, compels some White Americans to inflict self-harm. For example, as described in Metzl’s Dying of Whiteness (8), many White Tennesseans resisted and rejected the ACA despite suffering from treatable, chronic, and deadly illnesses potentially curable through health care services that would have been financed through that state’s Medicaid expansion. Local and state politicians repeatedly invoked the ACA as government overreach that enabled “Mexicans” and “welfare queens,” leading vulnerable White people with serious health conditions to reject ACA policies that were designed to improve treatment and promote recovery (8). Similar to stigma about mental health care, racist ideas fed by structural racism and disseminated via interpersonal discrimination prevent some of the most vulnerable people from accessing life-saving care.

Advocacy and attention are required to dismantle structural racism and to rebuild policies that support mental health equity. But no MHPAEA or ACA exists for structural racism. This conspicuous absence speaks to an individual and institutional aversion to discussing racism in mental health. Many mental health professionals find race discussions uncomfortable. The risk of being labeled racist after one verbal misstep outweighs the considered benefits of dialogue. When mental health professionals do engage, they often do so cautiously, and observed compensatory behaviors include avoiding participation through silence, defensiveness, or claims that racial perspectives are biased (6).

Unwritten norms for discussing race (and especially racial hierarchies) encourage superficial, vague, dispassionate conversation that discourages any challenges to the status quo (6). And yet, this allegiance to the status quo neglects the highest priority: our patients. Over 30% of Black people, 20% of Latinx people, and 23% of Indigenous people report avoiding medical care because of experiences of personal discrimination due to their race or ethnicity in health care settings (9). Mental health professionals have the power to heal patients, but they also have an equal responsibility to ensure that patients are not harmed when seeking care. Racial discrimination in health care settings and a lack of attention to this issue are failures to effectively care for patients with mental health and substance use disorders.

With an understanding of structural racism, it is evident that people are not inherently racist or antiracist but commit individual, moment-to-moment actions that can be described either as racist or antiracist (10). The emphasis on action underscores the power, consequences, and measurable impact mediating racist harm. Regardless of race, one can commit racist or antiracist actions in daily practices, decisions, and ideas (10). Under this formulation, there is no nonracist middle ground between racism and antiracism because every decision and every policy either promotes or undermines equity between racial groups. In general, all policies and actions have consequences for racial equity. By centering racial equity as the standard of antiracism, the responsibility to pursue antiracist action is not only applicable to individuals but also scalable to mental health institutions. To begin centering racial equity, mental health professionals can take several antiracist actions, described below.

Acknowledging individual and structural racism by examining racist policies and implementing antiracist policies is the first step toward achieving mental health equity. We have advanced the clinical science of mental health care and engaged multiple sectors over several decades to address other social determinants of mental health but have failed to identify racism as a determinant of mental health with comparable intensity, despite its profound impact on patients. This neglect stems from an aversion to honest dialogue about race and racism.

To paraphrase writer and activist Audre Lorde, our silence will not protect us. Race, as a form of caste system, empowers White patients and mental health professionals at the expense of patients and mental health professionals of color. The result is a fragmented mental health care system that does not effectively serve most people, regardless of racial identity. In response, mental health professionals must take an active stance to implement antiracist policies and examine power structures. The mental health field—and psychiatry in particular—must take these actions collectively so that in 2070, our profession will not again need to address racism by asking simply for its acknowledgment.