Barriers to Care

We asked Marissa Coleman, PsyD, a practicing clinical psychologist and the Vice President of Diversity, Equity and Inclusion at The University of Vermont Medical Center, to share what she thinks people should know about the unique mental health challenges members of historically marginalized communities face. Below, Dr. Coleman pinpoints five major obstacles to addressing these problems effectively and compassionately.

1. “Minority” is not a useful term

July is Minority Mental Health Month, so we’re focused on groups that have been systemically oppressed or pushed to the margins of society. The term “minority” means a relatively small group of people, especially one commonly discriminated against in a community, society, or nation, differing from others in identity. Using a term like “minority” reinforces that these communities are only a small part of society. They are not. For example, people of color are the global majority as it pertains to race.  Health care professionals should try to shift the language we use when discussing historically marginalized communities. Prioritizing mental health for these communities begins with the language we use when discussing their lived experiences.

2. Mental health disparities are deeply connected to systemic inequities

Mental health issues are difficult for anyone to deal with. But for members of marginalized groups, there are added systemic obstacles they must overcome to address their psychological and emotional needs. These include, but are not limited to: lack of insurance and underinsurance; language barriers, fear of prejudice and discrimination.

The barrier that I see most often is from clinicians who lack cultural humility and cultural curiosity about their patients and the communities in which they live. Mistrust of mental health providers is real and providers that do their own cultural identity development work are much better equipped to collaborate with patients to create safe and welcoming treatment environments.

Mental illness is no more common or severe in historically marginalized populations, but treatment barriers are the reason why members of marginalized groups are more likely to suffer negative mental health outcomes. According to the American Psychiatric Association, “Ethnic/racial minorities often bear a disproportionately high burden of disability resulting from mental disorders.” The APA also reports that depression for Black People and Hispanic people is more likely to persist than for White people, even though rates of depression for white people are higher. One needs to ask themselves what are the causes of the persisting mental health symptoms.

3. Don’t underestimate the power and prevalence of trauma

Trauma, a major contributor to mental illness, is more widespread among marginalized groups than it is elsewhere due to the violence and discrimination that members of these groups routinely experienced for generations. We cannot fully understand somebody’s individual suffering until we better understand their place in society and history. Just as trauma can be inherited from our ancestors, so is our resilience.  Treating all patients from a strengths-based approach is vital.

Trauma is often passed from one generation to the next, and inherited trauma can be difficult to identify if mental health care providers don’t prioritize learning about the historical background of their patients. In the absence of this work, post-traumatic symptoms will often go misdiagnosed or undetected.

4. View culture as a treatment strength

Behavior that is considered typical or positive in one culture can easily be stigmatized in another. We see this in parenting behaviors cross-culturally. Parents of children who hold historically marginalized identities often think of their children’s psychological and physical safety in hyper vigilant and adaptive ways. This adds to the mental load of parenting and these parents may be stigmatized by professionals as being “too strict” or “lacking warmth,” when truly, for many, it is about ensuring their child’s survival. Bias of this type plays a large part in how health is perceived in certain communities and how we go about diagnosing and treating it.

True cultural humility involves acknowledging that the patient is the expert of their own experience and needs to be a critical partner in building their wellness plan. We have to learn how to understand and learn from one another. As providers, we also have to make sure we recognize the limits of our own knowledge and understand the intersections of all of our cultural identities. By doing so, we are more likely to approach patients with cultural humility and curiosity.

5. Improved mental health is dependent on representation and access

Right now it’s too difficult for members of marginalized communities to access mental health care. There are too few available providers and too many practical barriers, like housing and economic insecurity.   

In our region, the mental health care access problem is worsened by the lack of providers within historically marginalized communities. Working with a provider that you feel understands your lived experience is crucial for the success of mental health treatment. It’s all in the relationship.

If you’re interested in learning more about these subjects, the following books are a good place to start:  

• "Just Medicine" by Dayna Bowen Matthew
• "The Racial Healing Workbook and Queer and Transgender Resilience Workbook" by Dr. Annalise Singh 
• "Killing the Black Body" by Dorothy Roberts
• "Liberation Psychology: Theory, Method, Practice, and Social Justice" by Lillian Comas-Diaz and Edil Torres Rivera
• "The Politics of Trauma" by Stacy Haines
• "The New Jim Crow" by Michelle Alexander
• "My Grandmother’s Hands" by Resmaa Menakem

The Pride Center and Inner Space in Burlington and All Brains Belong in Montpelier are also wonderful resources for people looking to learn more.