Assessing Racial Equity Impact in Mental Health Policymaking: Reflections and Recommendations

Racism has a long and unique history in the practice and policy of mental health in the United States. In colonial times, for example, it was a common belief that Blacks did not have the intellectual capacity to experience mental illness. In later periods runaway slaves were diagnosed with “drapetomania,” or flight from home madness, when they attempted to flee the “loving arms” of their master. In our more enlightened times, we still see the results of structural racism and personal stereotyping—more children of color enrolled in public schools are receiving medication for mental disorders, and mental health itself, operating on a social gradient where income and race predicts mental health outcomes. Striking disparities in mental health outcomes for people of color as compared to whites are documented in the 2001 Supplement to the Surgeon General’s Report on Mental Health.

Given the history of structural racism in the United States in general and in the mental health field in particular, racism is perpetrated at the micro and macro societal levels. It is important to recognize the consequent control inherent in the gate-keeping roles that social service agencies exercise in terms of access to resources and supports. The goal of achieving real equity requires no less than building anti-racism accountability into the very fabric of service provision

It is with this goal in mind that agency executives, managers, and providers who completed the Undoing Racism™ Workshop conducted by the People’s Institute for Survival and Beyond convened as a group to advocate for the integration of anti-racism principles into mental health policy and service delivery. It is our goal to develop a framework to promote meaningful and equitable outcomes and advance organizational effectiveness.

Communities of color have been traditionally victimized by institutional bias and discrimination. Local budget and resource allocation practices are traditionally biased toward more affluent and white residents of local jurisdictions. By measuring the overall equity in a few representative areas, policymakers can advance anti-racist policy, spread the burden of regulation fairly, and help address historic patterns of institutional bias and discrimination. Likewise, agencies also have a responsibility to advance anti-racist policies and programs to better serve their clients.

Most social services including mental health services are funded by contracts issued by government agencies. Like most agencies, funding requirements and guidelines drive process and outcomes. Currently the Mayor’s Office for Contract Services is in the process of developing a universal New York City contract that governs the way all human services are provided within the City.

As the City moves forward in developing a universal approach to vetting human services contracts, we recommend that all contracts be evaluated through the lens of a racial impact assessment process. Since funding requirements and guidelines drive process and outcomes, the expectation of eliminating structural racism should be reflected in the language of all contracts and require that they include steps for engaging undoing racism activities and clear accountability statements relating to the goal of racial equity in outcomes. Compliance with government contracts will enable policymakers to advance anti-racist policy and help address historic patterns of institutional bias and discrimination. Likewise, agencies will have a responsibility to advance anti-racist policies and programs to better serve their clients and promote racial equity.

Policymakers, executives, managers, and service providers who serve as gatekeepers should consider several factors in developing policy and programs. One approach for developing and maintaining an anti-racist focus is to consider integrating racial impact statements into the policymaking and program development process. The Applied Research Center has proposed a series of questions to guide this process:

  • Which communities carry the greatest burden if the policy is implemented? Which gain the most benefit?
  • Will this proposed policy or program affect compliance with state, federal, and international anti-bias and anti-discrimination policies? In what ways?
  • How will the policy or program affect access to livelihood (i.e., affordable housing, jobs, transportation, food access, medical care, school access and quality)?
  • Will the policy or program compromise/improve quality of life? How and for whom?
  • How does this policy or program change or maintain the status quo? If it maintains the racial or cultural status quo in some manner, is it still worth considering? Why? Why not?

While these five questions can generate much debate and disagreement in the policy decision-making and program development processes, we believe that a clear and meaningful consideration of these areas will in the long-term benefit those receiving mental health services and result in a more efficient and effective use of mental health resources. These questions alone, however, are only a beginning. A deeper and more meaningful commitment to equitable outcomes would require organizations to evaluate all dimensions of their infrastructures. To ensure racial equity at every level of decision making should include a re-examination of the organization’s vision and mission statements, board composition, operational policies and procedures, hiring practices and how they present themselves to their clients. For some agencies, for example, creating positive changes will mean a reconsideration of orientation programs for new employees to reflect an anti-racist agenda. Anti-racist training may be approached in a similar manner as mandated child-abuse training which is a requirement for state licensure for all professional groups that have contact with children.

Whether it is through compliance with government contracts or agency policy changes that leads to anti-racism in mental health, we believe that the overall result will be better mental health outcomes for clients of color. Therefore, following are suggested as key areas for governmental officials and agency administrators to consider in integrating anti-racist policies in the contracting process and implementing these in agency operational procedures and practices:

  • All funding should require a racial impact analysis that considers the historical and structural nature of racism in mental health services.
  • Public contracts should identify the elimination of the impact of historical and current racism as important.
  • Leaders in agencies should recognize the importance of identifying and understanding the role of historical and current racism in mental health practice.
  • Policymakers should establish accountability measures, such as community expert panels of community members to not only participate in decision making but to also provide oversight that ensures anti-racist policies are followed. Those advisory groups include the Racial Ethnic Federation groups, Black Agency Executives, Hispanic and Asian Federations.

And finally, the education and training of mental health professionals and educators requires a paradigm shift that would retool mental health models for racial relevance and demand an understanding of the role of structural racism as it is maintained in mental health practice. Traditional mental health theories using Eurocentric and privileged notions of what is considered “normal” have failed to incorporate an analysis of societal oppression into an understanding of human behavior. This has resulted in the creation of a system that has poorly served members of marginalized groups and contributed to the under-development of theories to inform effective practice with people of color, and contributed to glaring racial and ethnic disparities in mental health outcomes.

In the case of social work education, the discipline with the highest visibility in the field of mental health, the work of infusing anti-racist principles must occur at all levels of academic programming in degree bearing and post graduate certificate programs. The profession must also evaluate the implications of credentialing to guard against its being covertly used as a gate keeping device which diminishes access and availability to mental health services for people of color that are provided by qualified professionals with relevant cultural expertise.

We believe that to change policies and practices that have contributed to disparities in mental health outcomes for people of color will require a meaningful commitment to anti-racist work. This in turn will require an appraisal of how racism is ingrained in all societal institutions including the mental health system. In the words of The People’s Institute, “racism destroys humanity and undoing racism brings humanity back.” We should settle for nothing less. Our collective mental health depends upon it.

Mimi Abramovitz is Chair of Social Welfare Policy at Hunter College, School of Social Work. Sandra Bernabei, LCSW, is a Founding Member, Anti-Racist Alliance, is a community organizer, and is a private practitioner. Carmen Collado is Director of Public Policy and Government Relations, Director Immigrant and Latino Services, JBFCS; and President, Hispanic Mental Health Professionals. Robert Hawkins is McSilver Assistant Professor in Poverty Studies at the McSilver Institute on Poverty Policy and Research, of the NYU Silver School of Social Work. Wayne Ho, MPP, is Executive Director, Coalition for Asian American Children and Families. Eri J. Kim is Director of the Safe Horizon Manhattan Community Program. Larry Mandell is Former President and Chief Executive Officer of the United Way of New York City. Jonathan Morgenstern is Director of Preventive Services at the NYC Mission Society. Gabriel Sayegh is State Director of the New York Drug Policy Alliance. Michael Stoller is Executive Director of the Human Services Council of NYC.

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