Behavioral health issues may finally be starting to get the attention they have long deserved from the philanthropic community. For too long, substance use and mental health have comprised only a fraction of philanthropic investments (~1%), but a number of funders—especially over the last 12 months—have responded to the mental health and substance use crisis in our country by increasing investments in this area. Additionally, the COVID pandemic has created a unique opportunity for philanthropy: the widespread experiences of social isolation and loneliness have (hopefully not temporarily) reduced stigma and opened up space to talk about behavioral health. And the policy changes that have supported telemedicine—backed by a surge of private investment—have opened up new possibilities for where and how behavioral health services can be delivered.
At the same time, the COVID pandemic and the movement for racial justice have elevated the role that racism continues to play in shaping outcomes in our society. Early research suggests that communities of color have been disproportionately affected by both the opioid epidemic and drug-related deaths during the COVID pandemic. This is piling onto a system in which people of color are less likely to access mental health services and are more likely to receive poor-quality care.
Foundations that focus on behavioral health must seize this moment to address persistent racial inequities in behavioral health.
In this post, we briefly cover racism and behavioral health issues that we have encountered in our client work for you to consider and invite you to take a brief self-assessment to help you explore opportunities to center racial equity in your behavioral health work.
Racism and Behavioral Health: A Brief Introduction
Racism is a common root cause of behavioral health inequities, driving a lack of access to care, a lack of a diverse set of providers, lower quality of care, misdiagnosis and under-diagnosis, and differential ways in which mental health and substance use are criminalized. For example:
- Racism can raise the risk of poor behavioral health. Research points to the role of racism in both behavioral health outcomes and health-harming behavior. For instance, self-reported discrimination is associated with the symptoms of mental illness and defined mental health disorders. And the subjugation of the culture, values, and traditions of racially marginalized communities through racist media, along with the internalization of inferiority that comes with it, is associated with alcohol misuse.
- Racism impedes access to high-quality services. Residential segregation and disinvestment have left communities of color with too few options for mental health services. As a result, people of color are less likely than their white counterparts to have their mental health needs met. Moreover, racist policies mean that behavioral health issues are often treated as criminal issues in our country, particularly for people of color. An increasing share of the U.S. prison population suffers from behavioral health concerns, and a disproportionate number of them are people are color, for whom the incarceration system is the de facto mental health system.
- Racism has shaped the evolution of the behavioral health system. Our nation’s leading behavioral health institutions are reckoning with the role the field of psychiatry has played in supporting racist ideas and contributing to behavioral health inequities. Samuel Cartwright, a noted physician, contrived a mental illness—“drapetomania”—to classify the desire of enslaved Africans to seek liberation and to justify slavery. Further, the definition of schizophrenia shifted throughout the twentieth century, from an innocuous condition associated with intellectuals and middle-class white women to a condition of violence and aggression associated with Black men—a shift coinciding with the emergence of the civil rights and Black Power movements. And recent studies point to the continued over-diagnosis of schizophrenia and under-diagnosis of mood disorders in the Black community. Not surprisingly, this history of racial marginalization has contributed to a disproportionately white workforce—while the U.S. population is 62% white, 9 in 10 psychologists are white, risking perpetuating inequities in behavioral access and quality.
Driving Meaningful Change
This is a crucial moment for continued reckoning, repair, and change among institutions with power in the behavioral health ecosystem—including foundations. It’s an urgent moment to earn the trust of marginalized people and build a shared sense of community. To what extent is your foundation making progress here? Take this brief assessment:
We’re eager to hear your comments, questions, or reflections on this post and on your assessment. Don’t hesitate to contact us:
 As Ibram X. Kendi defines it, racism is a powerful collection of racist policies (written and unwritten laws, rules and regulations, procedures and processes, and guidelines that govern people) that create or sustain inequities among the racialized groups in the U.S. These policies are substantiated by racist ideas (beliefs/norms that suggest one group is inferior or superior to another). In other words, as described by Dr. Camara Phyllis Jones in a seminal article on racism and health, racism can be structural or institutionalized (policies), interpersonal (everyday, personally mediated prejudice and discrimination), or internalized (accepted stereotypes or narratives of inferiority). These “forms” of racism are also closely associated with the concept of “cultural racism,” as described by Dr. David Williams, where the dominant, power-holding group in society devalues the symbols, imagery, values, language, and unstated assumptions of marginalized, racialized groups.
List of References / Additional Reading
American Psychiatric Association. “Mental Health Disparities: Diverse Populations.” https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts.
Kendi, Ibram X. How to Be an Antiracist. First Edition. New York: One World, 2019.
Luona Lin et al., “How Diverse Is the Psychology Workforce?”, https://www.apa.org/monitor/2018/02/datapoint.
Malawa, Zea, Jenna Gaarde, and Solaire Spellen. “Racism as a Root Cause Approach: A New Framework.” Pediatrics 147, no. 1 (January 1, 2021). https://doi.org/10.1542/peds.2020-015602.
Metzl, Jonathan. “The Protest Psychosis,” June 9, 2010. Michigan Today. https://michigantoday.umich.edu/2010/06/09/a7776/
More than Ever Mental Health Needs to Be a Top Priority for Philanthropy and Here’s Why, Insigh Philanthropy. https://www.insidephilanthropy.com/home/2020/6/28/more-than-ever-mental-health-needs-to-a-top-priority-for-philanthropy-heres-why
NCRC. “Redlining and Neighborhood Health”. September 10, 2020.
NPR.org. “Drug Overdose Deaths Surge Among Black Americans During Pandemic.” https://www.npr.org/2021/03/03/970964576/drug-overdose-deaths-surge-among-black-americans-during-pandemic.
Perzichilli, Tahmi. “The Historical Roots of Racial Disparities in the Mental Health System,” May 7, 2020. Counseling Today. https://ct.counseling.org/2020/05/the-historical-roots-of-racial-disparities-in-the-mental-health-system/.
Philanthropy Must Invest in BIPOC Mental Health for a More Equitable Society, Inside Philanthropy https://www.insidephilanthropy.com/home/2021/7/7/philanthropy-must-invest-in-bipoc-mental-health-for-a-more-equitable-society
Phyllis Jones, Camara. “Levels of Racism: A Theoretic Framework and a Gardener’s Tale.” American Journal of Public Health 90, no. 8 (August 2000): 1212–15. https://doi.org/10.2105/AJPH.90.8.1212.
Schwartz, Robert C, and David M Blankenship. “Racial Disparities in Psychotic Disorder Diagnosis: A Review of Empirical Literature.” World Journal of Psychiatry 4, no. 4 (December 22, 2014): 133–40. https://doi.org/10.5498/wjp.v4.i4.133.
Villarosa, Linda. “How False Beliefs in Physical Racial Difference Still Live in Medicine Today.” The New York Times, August 14, 2019, sec. Magazine. https://www.nytimes.com/interactive/2019/08/14/magazine/racial-differences-doctors.html.
Warner, Judith. “Psychiatry Confronts Its Racist Past, and Tries to Make Amends.” The New York Times, April 30, 2021, sec. Health. https://www.nytimes.com/2021/04/30/health/psychiatry-racism-black-americans.html.
Williams, David R., Jourdyn A. Lawrence, and Brigette A. Davis. “Racism and Health: Evidence and Needed Research.” Annual Review of Public Health 40, no. 1 (April 2019): 105–25. https://doi.org/10.1146/annurev-publhealth-040218-043750.
Zimmerman, Ken. “Amid Hopeful Signs, This Is the Moment for Philanthropy to Buckle Down on Mental Health.” Inside Philanthropy. https://www.insidephilanthropy.com/home/2021/8/16/amid-hopeful-signs-this-is-the-moment-for-philanthropy-to-buckle-down-on-mental-health