My Mind, My Body, My Journey™ 

May is Mental Health Awareness Month, so we will see many hashtags on social media. Major companies will share tidbits about mental health and may even have “wellness” events for their staff. Special interest groups will explore mental health topics that pertain to their group such as children’s mental health, mental health in corrections, and mental health for minorities. In my opinion there is nothing wrong with raising awareness on social media and highlighting the need for mental health treatment in special communities. However, we must go beyond what we are currently doing for this month and think of ways to transform how mental health care is viewed in America. For us to do this we must transform our mental health system in America, to create a system and process that works for everyone. These are the steps needed for this to occur:

1. We need to acknowledge the biases in the mental health system.
   1. The mental health system is inherently biased as it was a historically White male dominated profession. Additionally, many of the theories and interventions were not evidence-based or culturally sensitive. For example, the popular psychodynamic theory is neither evidenced-based, or culturally sensitive yet it is used by many mental health providers in settings such as child welfare and juvenile justice where the population is overwhelmingly individuals of color from low-income backgrounds. Psychodynamic theory was historically used to treat very wealthy White women whose privilege allowed them to attend 2–3-hour long therapy sessions each day to process unconscious thoughts and repressed childhood issues. More importantly, psychodynamic theory was created by Sigmund Freud who was dependent on cocaine and created many of these unproven theories and assumptions under the influence of cocaine. We should be asking ourselves why psychodynamic theory is preferred in many settings, and who decided that it should be used to address the mental health needs of underserved children and families of color?
2. 1. Most leaders and key stakeholders in mental health care today are not people of color, and biases in the mental health system have not improved in over 30 years. Currently, there is no actual desire to address the racial biases in mental health care that have led to misdiagnosing and improper care of individuals of color. There is also no current desire to incorporate and fund culturally sensitive or specific interventions, despite the provisions and additional funding being available at the federal level. Furthermore, the employment opportunities for clinicians of color have not improved in community mental health or hospital settings despite most clients in those settings being people of color.
3. 1. The most important bias within mental health care is the perception that only certain people can be impacted by mental health conditions. Mental health can impact anyone regardless of age, gender, sexual orientation, race, ethnicity, income, education level, employment status, and profession. Yet many services are only available to people within a certain income range and others are only available for those who can afford to pay for care or have robust insurance coverage options. Both the underserved and wealthy deserve access to the same level of care, yet this country is nowhere near being able to provide this service to all citizens. We also need to acknowledge that there is a lack of support for mental health treatment among certain professions such as those in law enforcement and doctors. We often hear things like what a millionaire has to be depressed about? Or how does a medical doctor have barriers to getting mental health treatment?
4. We need to acknowledge that mental health care is not consistently viewed as medical care.
   1. Unfortunately, we do not view mental health care as medical care in the United States. Mental health conditions are considered medical conditions according to the International Statistical Classification of Diseases and Related Health Problems (ICD). This specific classification was created by the World Health Organization (WHO) but was not regularly used in mental health treatment in this country until the publication of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In the US, there was a separation of mental health disorders from physical health disorders. This was not seen in other countries who have routinely included mental health and physical health conditions under the same classification system. Therefore, the United States is behind other countries with their classification of mental health conditions and their overall view of health.
5. 1. Since the US had not treated mental health conditions properly as medical conditions, we did not have equity in treatment until the controversial Affordable Care Act (ACA) was passed. The ACA was this nation’s first attempt label mental health and substance use treatment as “essential health benefits.” Preliminary data has suggested that the ACA has provided positive impacts on mental health care. The Mental Health Parity and Addiction Equity Act (MHPAEA) further improved access to mental health and substance use treatment as health insurers were required to offer mental health and substance use disorder benefits equal to benefits for medical/surgical care. So, because of this Act, mental health copays must be identical to physical health copays. Although I like what this Act has created, I dislike that the language continues to frame mental health treatment as something that is not traditional medical care. The Act strives to make mental health treatment the same as medical care but continues to separate mental health treatment from medical treatment. In my opinion, this is no different than the “separate but equal” legislation that was part of our nation’s failed attempt to improve race relations. I will touch on how this “separate but equal” care causes additional barriers in treatment by insurers in the next section.
6. We need to hold providers, health insurance companies, and funders accountable for the quality of mental health care in America.
   1. Many providers need to be accountable when it comes to the quality of mental health treatment in America. Mental health care in America is often fragmented, with a lack of communication, coordination, and collaboration among providers. Certain providers have a monopoly on mental health care due to political influence and not actual competence and qualifications. Many mental health providers are territorial with resources, training opportunities, and niches because they do not want competition with clients. Therefore, resources are not shared which could benefit clients. Newer mental health professionals are not supported with training opportunities and opportunities to develop and establish a niche due to similar concerns with competition. In my opinion this competitive and non-supportive nature of the profession has contributed to the shortage of mental health providers. The field is one that does not pay well, requires an extensive amount of continuing education and certifications that are expensive and non-reimbursable, has high caseloads, has high burnout potential, and is very politically motivated. Politicians determine which providers should be hired and receive insurance reimbursement based on their allegiance to certain political parties and not actual credentials and qualifications. If you follow politics, you will notice that social workers are the default and preferred profession. It is important to note that not every social worker is qualified to provide mental health treatment because social workers are a generalist profession which could include mental health treatment, but could also include social services, policy, administration, and even teaching. According to the National Association of Social Workers (NASW) social work is “a helping profession” with a mission to “enhance human well-being and help meet basic and complex needs of all people, especially the poor, oppressed, and most vulnerable¹.” Those who attend accredited social work programs complete core coursework and then complete specialty coursework which could include clinical mental health treatment, but that may not be the case for all social work majors. The social work profession has strategically made themselves integral to the political climate in this nation, which has been advantageous for their profession. The problem with this relationship, is that politicians give the impression that every social worker has a clinical background and therefore is the best candidate for mental health positions, when this is not the case due to the broad spectrum of the social work profession and curriculum. Consequently, someone who studied counseling, clinical or counseling psychology, and marriage and family therapy is someone with a distinct educational training and specialty in mental health treatment. This person is more likely to have solid clinical training to treat a variety of mental health concerns, which often include substance use treatment. I want to note, that I am not saying that social workers are not qualified to perform mental health treatment, but I want to point out that only social workers with clinical training should have those opportunities as opposed to generally lumping the entire profession as qualified simply because politicians like them.  So, providers and politicians should be exploring who is best qualified to provide mental health services as opposed to which profession has made themselves more politically connected.
7. 1. Health insurance companies typically have a negative reputation. Historically, these companies have not provided adequate and equitable care and have operated on the most cost-effective approach. Coverage varies significantly depending on the type of insurance provided, such as Medicaid, Medicare, Tricare, HMOs, and PPOs. Despite the significance of the ACA, barriers remain in place that relate to insurance coverage of mental health treatment. For example, Applied Behavioral Analysis (ABA) therapy which is the evidenced-based treatment for autism related disorders is not covered by most insurance plans. Certain medications for attention deficit hyperactivity disorder (ADHD) are not covered by insurance plans and certain medications to treat substance use disorders such as Vivitrol are not covered. The MHPAEA requires equity with coverage, but it does not require coverage of all forms of treatment. Recall, I mentioned that the treatment must be equal to medical treatment coverage as far as co-payments, deductibles, and other out of pocket expenses. Since the MHPAEA considers mental health and substance use treatment to be separate from medical/surgical treatment it fails to protect benefits such as ABA therapy, certain ADHD medications, and certain medications for substance use disorders. For example, it is standard practice for individuals with cancer to receive chemotherapy, radiation, and surgery as part of treatment, insurance companies would cover those forms of treatment for a person with a cancer diagnosis. However, for those with autism, ABA therapy is the standard treatment option; however, it is not covered by many insurance companies. No insurer would deny chemotherapy for a cancer patient, but they commonly deny coverage for mental health and substance use treatment. “Separate but equal” is the current model for mental health care in America, the services may be separate, but they are not equal. Fortunately, the federal government provides some support for barriers to insurance coverage. The US Department of Health and Human Services has resources and help lines to address insurance barriers to mental health coverage. There are also methods to file complaints for lack of coverage with your state. More information can be obtained from this website. https://www.hhs.gov/programs/health-insurance/mental-health-substance-use-insurance-help/index.html#:~:text=The%20Mental%20Health%20Parity%20and%20Addiction%20Equity%20Act,and%20services%20that%20they%20do%20for%20medical%2Fsurgical%20care.
8. 1. Funders can improve the system by ensuring that only evidenced-based and culturally sensitive services are being provided by their grantees. Therefore, more grantors should require impact and outcome evaluations or only fund fidelity models/interventions. They can also avoid funding organizations with documented cases of racial discrimination among staff and clients. Many organizations have historically avoided hiring clinicians of color, which has resulted in EEOC and Department of Labor complaints which can be viewed publicly, yet these organizations seem to continuously receive funding and support from government grantors, private foundations, and other funding groups. We need to ask ourselves whether we are serious about dismantling racist systems or promoting mental health equity and improvement, based off who we continue to offer funding.

Mental Health Awareness should be more than a social media hashtag and training topic for the month of May. Everyday should be an opportunity to improve the system and ensure that every American has access to quality mental health care, because mental health conditions are medical conditions, it is well past the time for us to recognize this in the United States.

Wishing you health and happiness

Reference

1. What is Social Work? Definition, Careers, and Key Topics. Maryville University Website. https://online.maryville.edu/online-bachelors-degrees/social-work/resources/what-is-social-work/. Accessed May 20, 2023.