Mental healthcare for marginalized groups: Barriers to access

The concept of structural racism describes the inequities that exist due to the interaction between institutional and broader sociocultural factors that continue to operate with stereotypes and racial discrimination at their core.

Structural racism thus refers to laws, practices, and social norms that perpetuate inequities in access to housing, employment, education, healthcare, justice, and finance.

Residential segregation along racial lines is a prominent example of structural racism, and some experts note that it is one of the primary causes of health disparities in the U.S. Federal government policies instituted since the 1930s and rigged lending practices have resulted in residential segregation, which persists to this day.

Residential segregation is associated with high levels of poverty, lack of access to jobs and education, and lower investment in infrastructure. Notably, underinvestment in Black neighborhoods has resulted in fewer hospitals and under-resourced facilities, influencing access to mental health services.

The intergenerational effects of lack of homeownership have resulted in a persistent wealth gap between Black and white residents. The lack of financial resources may also prevent Black individuals from accessing mental health services.

Residential segregation has also affected Latino communities, and individuals residing predominantly in these communities tend to have limited access to specialty mental health professionals.

Systemic racism also encompasses social and cultural norms influenced by racial prejudices, which can lead to unconscious or implicit biases. Implicit biases may manifest themselves in the form of microaggressions, which are subtle verbal or nonverbal slights towards marginalized individuals that may or may not be intentional.

Diagnosed mental disorders require sustained treatment, and the healthcare provider-patient relationship plays a critical role in determining treatment success. Discrimination by healthcare providers in the form of microaggressions or stereotyping can reduce adherence to treatment and lead to the discontinuation of treatment.

There is also a mistrust of mental healthcare services among minoritized ethnic groups, owing to the history of racism in mental healthcare, which involves the categorization of cultural differences as mental illness.

Provider discrimination and mistrust of mental healthcare may discourage individuals from marginalized communities from seeking further treatment.

Mental healthcare providers may also lack awareness about cultural factors that tend to shape the experiences and needs of individuals from minoritized ethnic groups, undermining the patients’ trust in the provider.

A recent study conducted by the 1928 Institute — a non-profit organization researching and representing the experience of British Indians — surveyed 1,747 British Indians to determine what barriers they face in accessing mental healthcare in the United Kingdom.

Kiran Kaur Manku, the co-founder of the 1928 Institute and a research assistant at the University of Oxford, told Medical News Today:

“Many participants gave examples of how their values, philosophies, or spirituality were dismissed in the assessment stage of accessing mental healthcare, resulting in them being told they don’t need or qualify for treatment. Critically, many community members also gave examples of general practitioners being unaware of how we often present with physical symptoms of mental health issues (psychosomatic disorders).”

Similarly, Dr. Benjamin Lê Cook, an associate professor at the Harvard Medical School, told MNT: “At the intake interview, racial and ethnic minority community members have serious reservations about their interactions with specialty mental health care providers out of concern that they may be reported to the police or child protective services if they express feeling unsafe or that they may harm themselves. And they may be asked questions or asked to fill out structured diagnostic interviews that don’t resonate with the pain they are experiencing.”

“Our community partners have also reported that when topics of intergenerational effects of systemic racism are raised, the conversation becomes uncomfortable to the point where some providers recommend seeking help from other providers that have more expertise with effects of racism,” he added.

Cultural factors, such as internalized stigma and language barriers, may also result in marginalized ethnic groups abstaining from or discontinuing treatment.

Some minoritized ethnic groups perceive mental health issues, such as depression, as problems to be overcome using willpower and mental toughness. Among some communities, individuals with mental health issues may thus be erroneously perceived as either posing a danger to community members or having a weak will.

Therefore, some individuals from minoritized ethnic groups may fear being judged or discriminated against by others, or they may internalize these prejudices about mental illness.

The stigma attached to mental illness among some historically marginalized groups may prevent individuals from acknowledging their mental health symptoms until they become severe. Some individuals from minoritized ethnic groups may also have reservations about the benefits of mental health treatment.

Stereotypes such as the model minority myth, often ascribed to Asian Americans, can adversely impact whether or not individuals access mental healthcare. The model minority myth regards individuals from historically marginalized groups, particularly Asian Americans, as exclusively hardworking, intelligent, and law-abiding.

While, on the surface, this may appear to be a positive assessment, this stereotype is associated with higher levels of pressure to succeed, which can result in mental distress. Moreover, espousing this positive stereotype may also deter Asian Americans from seeking treatment for mental illnesses.

Language may also act as an obstacle for first-generation Hispanic and Asian migrants in scheduling an appointment or communicating their problems to a therapist.

Dr. Wooksoo Kim, a professor at the University of Buffalo, explained for MNT that:

“Language is a persistent and consistent barrier to mental health service use as well as other basic services for newcomers. When you belong to multiple minority statuses, it is even worse. For example, if you are a member of a cultural minority group with low English proficiency, the access to mental health services is even more limited. Simply having an interpreter in the room does not solve the incompatibility of language. Even when interpreters are available, linguistic challenges may still be present due to the inherent difficulties of translating from English to native languages and vice versa.”

“Given the translation difficulties in combination with a lack of understanding about mental health and persistent stigmas around mental health issues, we can only imagine the number of barriers piled up before they get proper help,” Dr. Kim pointed out.

Health literacy, which refers to the ability to obtain basic information about medical conditions and utilize it to seek the necessary care, may also contribute to disparities in mental healthcare access. Individuals from minoritized ethnic groups tend to have lower health literacy levels than white individuals.

That may be partly due to internalized stigma around mental health, and partly because of the complexities associated with health insurance and the healthcare system in the U.S.

Lower mental health literacy levels are associated with higher rates of mental illnesses such as depression and anxiety, lower adherence to medication, and underutilization of mental health services.

Although the passage of the Affordable Care Act in the U.S. improved healthcare coverage among all ethnic groups, Black and Hispanic individuals are still more likely to be uninsured or lack adequate insurance than their white counterparts.

The high costs of treatment and insufficient health insurance are major obstacles to the utilization of mental health services by minoritized ethnic groups.

Dr. Cook explained: “The way that healthcare systems and payments are set up now is incredibly unwelcoming for individuals that need help for their mental health challenges. It is even more unwelcoming for many individuals and families from racial and ethnic minority backgrounds.”

“If you do not have health insurance, then mental health treatment is too expensive. If you do have health insurance, the co-pays and deductibles are unaffordable. Insurance often covers only a small number of visits,” he continued.

“To gain access to a specialty mental health provider, you often have to first visit a primary care provider for a referral and wade through a lot of paperwork. If that hurdle is overcome, the waitlist for specialty mental health providers is incredibly long, a year in length at times, to the point where some primary care providers have stopped making referrals.”

“If one does find a specialty provider, the provider is likely to practice in a community that can be a number of bus rides away during a time when full-time employees work or when caregivers need to care for their children,” added Dr. Cook.

Dr. Kim pointed out that:

“It is a structural failure of our society if we do not actively intervene in these issues within vulnerable communities. In many cases, we have seen victim blaming where their cultures and lack of knowledge of the patients are discussed as the major barriers to mental health services. The barriers exist on both [the] provider and patient sides.”

Addressing how cultural barriers to mental healthcare use can be overcome, Dr. Kim noted that “[i]n practice, we need to have a two-pronged approach to address disparities in mental health for minority groups.”

“First, at the systems level,” she said, “a simple yet reliable mental health screening routine in the primary care setting would promote greater recognition of mental health problems and increase service use among minority populations. At the same time, the cultural competence of healthcare professionals can be improved by their willingness to learn. Cultural competence is a continuous process rather than a single goal.”

“Second, one size doesn’t fit all,” Dr. Kim added. “We need to focus on developing culturally responsive ways for each minority group to help them. It should be a two-way street: We need to focus on educating the minority communities, decreasing cultural stigmas, and providing a resource list.”

“If there is a strong stigma around mental health issues, we should design and implement culturally appropriate educational programs for the community. If there is a language barrier, we should secure extra resources to develop a multilingual mental health workforce as well as equitable language access through interpreter services.”

– Dr. Wooksoo Kim

Similarly, Manku noted about the situation in the U.K. that “[i]t is critical that the [National Health Services] adopt a multidimensional approach to address disparities in mental healthcare.”

“In our report, we found over 95{cfdf3f5372635aeb15fd3e2aecc7cb5d7150695e02bd72e0a44f1581164ad809} of British Indians called for healthcare professionals to embody curiosity, compassion, and cultural nuance. These principles, with recognition of bio-psycho-socio-spiritual components of health and geopolitical histories, have the potential to overcome disparities in access to mental healthcare,” she emphasized.

“These disparities could be overcome through targeting training that is co-created with the community and innovative models of monitoring and evaluation,” added Manku.

These recommendations need to be backed by increased funding for research to understand the effects of cultural factors and other barriers to the use of mental health services.

Expanding health insurance coverage could increase access to mental health services, but studies show that this may not be sufficient to increase the use of mental health services. Access to health insurance thus needs to be combined with approaches that enhance the engagement of minoritized ethnic groups.

Some researchers have suggested that telemedicine and mobile health clinics that provide mental health screening and basic care could help improve access.

“[T]he changes that are necessary on the payer side are improving coverage for psychiatric services and reducing the gatekeeping role of primary care providers,” Dr. Cook also went on to explain. “Healthcare systems need to find a way of improving the supply of specialty mental health providers that practice with cultural humility and awareness, placing them in communities where there is high need, at hours that match the community’s time.”

“Providers need to work with community members and peers with lived experience in order to better understand systemic and intergenerational racism and structural barriers and how these can lead to psychological distress. Teams that include peers specialists, primary care providers, social workers, psychologists, and psychiatrists are needed to provide appropriate wraparound care for individuals in distress,” he advised.