In the wake of the COVID-19 pandemic, the George Floyd Uprising, and the Stop Asian Hate movement, ethnically and racially marginalized individuals in the United States need access to quality mental health care now more than ever. According to the Centers for Disease Control, the national suicide rate peaked in 2018 and has since been on a decline. However, when examining the data by ethnoracial identity, every non-White racial and ethnic group saw either increased or steady rates of death by suicide in 2020 (Curtin et al., 2021). These circumstances underscore the imperative mental health professionals have to better meet the needs of these historically neglected populations.
BARRIERS TO CARE
Prior research has identified three main categories of barriers to mental healthcare for people of color (POC): Access, Retention, and Effectiveness.
Regarding access, financial disparities experienced by POC contribute to reduced ability to afford therapy, lack of knowledge about where to access services, less free time, and poorer insurance coverage—all of which reduce access to mental healthcare (Henly & Lambert, 2014; Lê Cook et al., 2014; Walker et al., 2015). Additionally, POC report heightened stigma towards mental illness, which reduces their likelihood to seek treatment (Eylem et al., 2020; Lipson et al., 2018).
The literature is more mixed on ethnoracial disparities in mental healthcare retention and effectiveness. Some studies have found no differences in these realms between ethnoracial groups (Owen et al., 2017; Hayes et al., 2015, 2016). However, overall, POC are less likely to receive any care compared to White individuals, and the services they do receive are less likely to be quality services (Lê Cook et al., 2014; Walker et al., 2015; U.S. Department of Health and Human Services, 2019).
Systemic racism in the economy, the healthcare system, and the field of clinical psychology perpetuates the disparities in access, retention, and effectiveness of mental health services. The added effects of gender on these associations, however, are not well understood.
OUR STUDY
Our team at Florida State University (FSU) sought to study differences in access to, retention throughout, and effectiveness of therapy across gender, ethnic, and racial groups in our local community of Leon County, Florida. The FSU Psychology Clinic is a training clinic staffed by doctoral students and housed within the university’s clinical psychology PhD program. Our clinic functions as a community mental health center that offers care with few exclusion criteria, on a financial sliding scale, and with flexible scheduling.
We utilized data from over 2,000 clients who received services anytime between 2000 and 2021 in our clinic. For access to services, we compared the demographic makeup of our clinic to that of people with mental disorders in Leon County. For retention, we examined premature termination, number of no-shows, and number of sessions attended. Finally, to study effectiveness, we used clients’ and therapists’ ratings of Clinical Global Impression (CGI; Guy, 1976), a general assessment of a client’s level of illness and functioning.
In our paper published in The Journal of Consulting and Clinical Psychology, we found that although therapeutic outcomes (i.e., CGI improvement ratings) did not differ by gender, race, or ethnicity, our clinic is failing to meet the mental health care needs of Leon County’s Black population at nearly every prior step of the process. Every racial or ethnic group is adequately represented or overrepresented in our clinic except for the Black population . Also, the Black men we served reported relatively less severe symptoms at intake. Black clients discontinued services in our clinic before intake completion at a significantly higher rate (i.e., 43.3%) than others and the overall rate (i.e., 30.2%). Finally, the proportion of no-shows to sessions attended was higher for Black clients than for others.
It’s promising that when Black clients are retained, there are no differences in actual treatment effectiveness. As we also found no effects of gender: women and men appear to benefit similarly from our services. Notably, an exploratory analysis we conducted revealed that racial match for Black clients (i.e., when both the client and therapist identified as Black) was associated with more sessions attended.
WHAT DOES THIS MEAN?
Our findings have wide-ranging implications for actionable ways to improve our services and outreach. Given that our clinic is a doctoral training clinic, the finding that racial match may impact outcomes emphasizes a need to recruit and support diverse cohorts of graduate students in clinical psychology PhD programs.
In addition, our program has taken several steps to address diversity and equity, such as through the implementation of a department-wide Diversity Committee, a clinical area Diversity Committee, a diversity reading group, and a required diversity discussion course. The presence of these training opportunities may have helped decrease potential ethnoracial disparities in treatment effectiveness in our clinic.
Despite these efforts, representation of Black clients in our clinic remains suboptimal. Our findings suggest that lowering some of the most easily-remedied structural barriers to accessing care (e.g., cost and time) is not enough to increase access to community mental health clinics. We must begin addressing the more difficult barriers to treatment, such as improving knowledge about mental healthcare options and reducing stigma surrounding mental health.
The FSU clinical area Diversity Committee has begun to address these deeper barriers by using grant funds from the Society for a Science of Clinical Psychology and from FSU to improve our clinic’s outreach to Black individuals in the local community. We’re using a community-embedded approach (i.e., participating in existing events held by local institutions, such as churches) to improve our understanding of local needs and provide information on service options. As mental health providers within an institution, we must continue engaging in community outreach to erase treatment gaps.
Our findings highlight the importance of studying socially marginalized groups with nuance regarding intersecting identities, as well as the necessity of engaging community partners to meet the access needs of historically neglected populations. In the end, culturally responsive and effective treatments cannot make a difference in the lives of those who need it if they never receive it.
TARGET ARTICLE
Joiner, T. E., Robison, M., Robertson, L., Keel, P., Daurio, A. M., Mehra, L. M., & Millender, E. (2022). Ethnoracial status, intersectionality with gender, and psychotherapy utilization, retention, and outcomes. Journal of Consulting and Clinical Psychology, 90(10), 837–849. https://doi.org/10.1037/ccp0000726
DISCUSSION QUESTIONS
- What are ways that systemic racism has played a part in the history of the field of clinical psychology, and vice versa?
- What factors could cause disparities in access and retention for the Black community specifically?
- What are community-centered outreach methods that you can use to improve mental healthcare access for socially marginalized groups in your own community?
- What role do clinical psychologists have in social justice work?
ABOUT THE AUTHORS
Lee Robertson (they/them) is a 2nd year clinical psychology PhD student at Florida State University (FSU). They study suicide, the effects of minority stress on mental health, and treatment outcome disparities, with specific focuses on POC, LGBTQ+ individuals, and incarcerated individuals. They have also volunteered as a lobbyist with Equality Florida at the Florida state legislature, represented graduate students on the FSU Psychology Department’s Diversity Committee, and worked on the executive board for the graduate student labor union at FSU. Prior to graduate school, Lee studied psychology and philosophy at Vanderbilt University, where they graduated as one of the 2021 recipients of the Vanderbilt Office of LGBTQI Life’s Advocate of the Year Award. Lee can be contacted at robertson@psy.fsu.edu.
Lushna M. Mehra, M.S. (she/her) is a 4th year student in the Clinical Psychology doctoral program at Florida State University. Her research focuses on identifying biomarkers of anxiety and depression in children and adolescents, with a specific interest in clarifying the role of interpersonal stressors as vulnerability factors for these symptoms. Lushna is an active member of several diversity, equity, and inclusion organizations, and she is a co-founder of an international, student-led group, named Dismantling Systemic Shortcomings in Education and Clinical Training (DiSSECT), dedicated to facilitating antiracist initiatives in mental health graduate training programs. Lushna can be contacted at mehra@psy.fsu.edu
Thomas Joiner, Ph.D. (he/him) is The Robert O. Lawton Distinguished Professor in the Department of Psychology at Florida State University. Dr. Joiner’s work is on the psychology, neurobiology, and treatment of suicidal behavior and related conditions. Dr. Joiner is the Editor-in-Chief of the journal Suicide & Life-Threatening Behavior and the Director of the U.S. Department of Defense-funded Military Suicide Research Consortium (msrc.fsu.edu). He can be contacted at joiner@psy.fsu.edu.
REFERENCES CITED
Curtin, S. C., Hedegaard, H., & Ahmad, F. B. (2021). Provisional Numbers and Rates of Suicide by Month and Demographic Characteristics: United States, 2020. https://archive.hshsl.umaryland.edu/handle/10713/17347
Eylem, O., de Wit, L., van Straten, A., Steubl, L., Melissourgaki, Z., Danışman, G. T., de Vries, R., Kerkhof, A. J. F. M., Bhui, K., & Cuijpers, P. (2020). Stigma for common mental disorders in racial minorities and majorities a systematic review and meta-analysis. BMC Public Health, 20, 879. https://doi.org/10.1186/s12889-020-08964-3
Guy, W. (1976). ECDEU assessment manual for psychopharmacology. US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs.
Hayes, J. A., McAleavey, A. A., Castonguay, L. G., & Locke, B. D. (2016). Psychotherapists’ outcomes with White and racial/ethnic minority clients: First, the good news. Journal of Counseling Psychology, 63(3), 261–268. https://doi.org/10.1037/cou0000098
Hayes, J. A., Owen, J., & Bieschke, K. J. (2015). Therapist differences in symptom change with racial/ethnic minority clients. Psychotherapy: Theory, Research, & Practice, 52(3), 308–314. https://doi.org/10.1037/ a0037957
Henly, J. R., & Lambert, S. J. (2014). Unpredictable work timing in retail jobs: Implications for employee work–life conflict. ILR Review, 67(3), 986–1016. https://doi.org/10.1177/0019793914537458
Lê Cook, B. L., Zuvekas, S. H., Carson, N., Wayne, G. F., Vesper, A., & McGuire, T. G. (2014). Assessing racial/ethnic disparities in treatment across episodes of mental health care. Health Services Research, 49(1), 206–229. https://doi.org/10.1111/1475-6773.12095
Lipson, S. K., Kern, A., Eisenberg, D., & Breland-Noble, A. M. (2018). Mental health disparities among college students of color. Journal of Adolescent Health, 63(3), 348–356. https://doi.org/10.1016/j.jadohealth.2018.04.014
Owen, J., Drinane, J., Tao, K. W., Adelson, J. L., Hook, J. N., Davis, D., & Fookune, N. (2017). Racial/ethnic disparities in client unilateral termination: The role of therapists’ cultural comfort.
US Department of Health and Human Services, & Office of Disease Prevention and Health Promotion. (2019). Healthy people 2030. https:// health.gov/healthypeople/objectives-and-data/social-determinants-healthPsychotherapy Research, 27(1), 102–111. https://doi.org/10.1080/10503307.2015.1078517
Walker, E. R., Cummings, J. R., Hockenberry, J. M., & Druss, B. G. (2015). Insurance status, use of mental health services, and unmet need for mental health care in the United States. Psychiatric Services, 66(6), 578–584. https://doi.org/10.1176/appi.ps.201400248