In order to effectively understand and address the social determinants of mental health (SDMH), health professionals must be able to understand their patients’ cultures, the barriers they face, the opportunities at their disposal, and the context in which they live their lives. If health professionals are drawn from the community that they serve, they will more likely be able to fulfill this role. The Minority Fellowship Program (MFP) at the Substance Abuse and Mental Health Services Administration (SAMHSA) is designed in part to address this issue, said Wendi Schweiger, director of international capacity building at the National Board for Certified Counselors, Inc. and Affiliates. The MFP was originally created in 1973 by the National Institute of Mental Health and later transferred to SAMHSA to “increase the number of ethnic minorities in mental health professions and to provide more culturally competent care to an increasingly ethnically diverse population” (SAMHSA, 2020) in the United States. Organizations representing mental health disciplines apply for grants to support the administration and award of funding for students and new professionals who are committed to providing services, creating policy, and advocating for minority populations.
A total of seven organizations representing the mental health professions administer minority fellowship programs, and three of them were represented at the workshop:
- The American Psychological Association (APA) has administrated a minority fellowship program since 1974. The program provides opportunities for guidance through graduate-level and postdoctoral fellowships in areas related to behavioral health services for ethnic minority communities. This program also offers a summer institute and interdisciplinary mentoring for social and behavioral scientists. APA has awarded more than 2,000 fellowship opportunities since the founding of the program.
- The Council on Social Work Education (CSWE) also founded its minority fellowship program in 1974, and it has had more than 800 recipients since the program’s founding. CSWE’s program offers fellowships to doctoral-level and master’s-level students who are dedicated to working in practice, research, teaching, and policy on behalf of underrepresented or underserved persons.
- The National Board for Certified Counselors (NBCC) is the newest mental health professional organization with a minority fellowship program; it was awarded funding from SAMHSA beginning in 2012. Grants from SAMHSA allow NBCC to distribute both doctoral-level and master’s-level fellowships to graduate students, with more than 400 fellowships awarded so far.
These three organizations alone, Schweiger said, have awarded fellowships to more than 3,200 mental health professionals with the intention of diversifying the mental health behavior workforce and mentoring professionals who wish to serve in underrepresented populations. In addition to these three, organizations representing nursing, psychiatry, marriage and family therapy, and addiction professionals also administer minority fellowship programs.
THE NEED FOR MINORITY MENTAL HEALTH PROFESSIONALS
Workshop participants heard from three individuals associated with the MFP, each of whom discussed the importance of minority mental health professionals. Robert Horne, assistant professor of counselor education and director of the Addiction Studies Certificate Program at North Carolina Central University, said that there are approximately 60 million people with a mental health or substance use disorder, yet there are only approximately 260,000 qualified counselors for this population (BLS, 2019). This equates to about 1 counselor per 230 people with a current disorder. Horne said that this means there are “enough clients for all of us to stay employed” and there is no need for competition among various health professions. In fact, to best serve these clients, professionals should be providing holistic care by working collaboratively with physicians, counselors, psychiatrists, social workers, and others. In addition, only 10.3 percent of all mental health counselors are non–European American, he said. There is a large group of untapped people who could be recruited into the profession, including ethnic and cultural minorities as well as social minorities (e.g., lesbian, gay, bisexual, transgender, queer or questioning populations). People with mental health and substance use disorder are looking for assistance, and “they are looking for people who look like them to serve them.” There is a misconception, Horne said, that some minority populations simply do not access some services, such as counseling. Horne said that in his observations as an ordained minister, “it’s not so much that African Americans don’t go to counseling … they just don’t go to you.” People tend to go to the cultural institutions that they trust, he said, which is something that should be kept in mind as health professionals are recruited and trained.
Duy Nguyen, director of the minority fellowship program at CSWE, shared his experiences growing up in a Vietnamese immigrant family. Having been raised in a bicultural, bilingual world brought him into the helping professions, he said, and an interaction at summer camp showed him that he had unique capacities to bring to his work. Early in his social work career, Nguyen worked at a summer camp for children with emotional and behavioral disorders, and he met a camper who spoke Vietnamese. Because of their shared language and culture, Nguyen said, she opened up to him in
ways that she had not done with other counselors. This relationship convinced him that his upbringing could be an asset and spurred him to pursue working in community mental health with Southeast Asian refugees. He said that this path was not well worn: a professor once told him he would have to make his own way working with this community, and he is one of only a few Vietnamese licensed social workers in the state of Illinois.
Dolores Subia BigFoot is a presidential professor who directs the Native American programs at the Center on Child Abuse and Neglect at the University of Oklahoma Health Sciences Center. She is also an enrolled member of the Caddo Nation of Oklahoma. BigFoot grew up in a rural, poor community and has used her connections and experience to encourage and support young people from similar circumstances to pursue their goals of becoming health professionals and serving their communities.
The speakers discussed many elements they identified as critical for recruiting, supporting, retaining, and promoting a diverse workforce, including the following:
- Organizational support
- Opportunity to be authentic
- Support for students and professionals
- Integration with community
- Community definitions of well-being and success
- Self-care and support
Building an educational program centered on social determinants and community engagement, Horne said, requires educational institutions to be on board and to be ready for change. Sometimes the institution is simply not ready, he said, but there are ways to move forward anyway. Fellows—such as those from the minority fellowship program—can sometimes “be the change” themselves. Even if an institution is resistant to change and unwilling to offer adequate support, fellows can create networks, connections, and resources in order to sustain a program and keep fellows motivated and supported.
Opportunity to Be Authentic
In his experience as director of the minority fellowship program at CSWE, Nguyen said that he has found that one of the key benefits of the
program for fellows is seeing and working with other people like them. While the fellows are drawn from different racial, ethnic, and cultural backgrounds, many of them have shared experiences, and for many, it is the “first time they’re in a room with other folks” similar to themselves. The program, Nguyen said, builds on this by affirming and validating the fellows’ life experiences, building a space where fellows can be authentic, promoting self-efficacy, building community, and empowering creativity.
Support for Students and Professionals
Recruiting and retaining diverse young people into the health professions requires work on several fronts, Nguyen said. First, there needs to be a clear path to financial stability for students, whether through grants, fellowships, loan forgiveness, or other programs. Second, the economic models of community-based organizations that deal with minority health need to be examined in order to address disparities in grants, contracts, reimbursement, and employee compensation. Minority members of the workforce need to see that there are sustainable and economically viable career options. Third, students need to be engaged early—as early as high school—and to be supported all along the academic pathway. Supporting students includes addressing class and privilege in predominantly white institutions, ensuring that the curriculum is not geared toward educating primarily non-Hispanic white students, and making certain that minority students feel seen, heard, and understood in their institutions and classes. A more diverse faculty—from instructors to deans—can help minority students feel more represented and less isolated, Nguyen said. Finally, Nguyen said that “we cannot assume” that students from minority communities will necessarily “be interested or committed to addressing the behavioral health needs of their community.” It will be necessary to recruit and train a larger number of diverse students in order to yield a sufficient number to work in underserved communities.
Horne followed up on this discussion by observing that minority faculty members are few and far between. While more minority students are pursuing doctorate degrees, the number of people of color working in academia “has barely budged,” he said. Horne said that he has observed that minority faculty tend to circulate between institutions, starting over every few years when they do not receive tenure. Horne said that when his students or mentees are deciding where to pursue opportunities, he encourages them to look for places where they feel accepted and comfortable and to scrutinize the actual number of minority faculty who are getting tenure because “that’s where the rubber meets the road.”
Integration with Community
Educating health professionals to address the SDMH, Horne said, requires engagement with and attachment to the local community. A health professions education program must be engaged in volunteering and advocacy in the community, and there must be a relationship of mutual trust so that people can learn from one another and their experiences. Horne cautioned that simply conducting research in communities is not sufficient for true engagement; accurate research requires a “trusting relationship where people will openly and honestly tell you what they think, versus telling you what they think you want to hear.”
Instructors can encourage and facilitate this type of engagement by creating assignments that require students to actually get into the field and communicate and network with people in the community, Horne said, adding that there is an “elitist” attitude that community members or clients are simply passive recipients of assistance from health professionals. Given this, he encouraged health educators to promote the idea that both community members and health professionals have things to learn from one another and that they can both gain from the experience of working together. Horne added that community engagement can be accomplished through less traditional means as well—such as volunteering as a coach—and that simply getting involved can help break down the stigma of mental health counseling.
BigFoot discussed the importance of mentoring and said that her life trajectory—from growing up in a poor, rural, multi-generational home to becoming a professor, director, and leader in her field—would not have been possible without mentorship, support, and encouragement from others. BigFoot said that her advisor at the University of Oklahoma, Wayne Rowe, gave her a message that she has carried throughout her career: “We selected you to get into the program, and my job is to make sure that you get out successfully.” The main role of a mentor is forging a path that supports the mentee in achieving as much as possible, she said. BigFoot repaid this support by mentoring and encouraging other young people, in both formal and informal ways, she said, and she shared two stories about young women’s lives that she has affected. The first was an 11th grade girl from a reservation in Montana who contacted BigFoot 3 years after meeting her on a plane. BigFoot had encouraged the girl to apply for summer classes at Harvard University, and while the girl was not able to attend, she had graduated high school, was working on graduating college and going to graduate school, and was working as an advocate at a domestic violence shelter. The second young woman was 14 when she heard BigFoot speak
at a University of Oklahoma Upward Bound summer program. At this event, BigFoot had talked with enthusiasm about her work as a helper and a healer and had described her job as the “most perfect job in the world for me.” These statements encouraged the girl, who grew up in rural and poor circumstances that were similar to BigFoot’s, to become a child psychologist, and she told BigFoot that her words had sustained her through her high school, bachelor’s, and master’s degrees and as a Ph.D. candidate.
In her work, BigFoot said, she has had the opportunity to formally mentor and support students and professionals through supervising postdoctoral residents and offering practicum experiences at the Indian Country Child Trauma Center. She has also mentored American Indian faculty, and one faculty member whom she has mentored for about 15 years is now a tenure-track professor with multiple publications and national recognition of her work, BigFoot said. This professor is also a mentee through the National Institute on Drug Abuse’s Native-to-Native mentorship program. Part of what BigFoot offers to these mentees, she said, is a cultural lens based on an indigenous worldview, which brings a multi-generational perspective and an understanding of how indigenous people fit into the world and, more specifically, into the professional arena. Nguyen endorsed this idea, saying that while some mentees need specific technical or career support, many are simply looking for an individual who looks like them to show them that there is a path to success and who understands the unique challenges and roadblocks that one experiences as a minority in the field.
Horne said that there is a need to “normalize” the mentor–mentee relationship because this is a society that encourages isolation and independence rather than connection and interdependence. Both mentors and mentees have something to give and something to gain from a relationship, he said, and the profession certainly always gains from people working together and helping each other out. One of the major benefits of having a mentor, Horne said, is that mentors have already forged a path and lit the way for others to follow; young professionals do not have to create the path themselves or travel it alone.
Another important aspect of mentorship, Frost said, is teaching grit, tenacity, and resilience. Frost asked the panelists how they convey these attributes to their mentees and students. Nguyen said that part of it is affirming the mentee’s goals and supporting the mentee through the process necessary to meet those goals. In particular, he said, mentors can instill hope by demonstrating their own examples of success and by encouraging mentees to persevere through roadblocks. BigFoot added that people need to learn from a young age how to make decisions for themselves and to understand that there are consequences to the decisions they make. Giving young people opportunities to learn what they are capable of, including allowing them to direct their own actions, can help build grit, determination, and motivation.
Community Definitions of Well-Being and Success
Because exploring the social determinants of health (SDH) and the SDMH requires an understanding of health and well-being, BigFoot discussed the issue of how to define those two terms. While health professionals might have a certain way of thinking about well-being, she said, communities have their own lens through which they think about desirable outcomes. For example, BigFoot said that she asked a room of Native Alaskans how they would define child well-being, and their answer was “smoked salmon.” The rituals and traditions of gathering and preparing salmon meant that this community was
able to come together as families; as family groups, they were able to be together, talk together, work out difficulties, they were able to talk about safety, about food preparation, they were able to tell stories, they were able to go back to a location … they were able to have times for different kinds of conversations, they were able to move forward and to see the results of their harvest and be able to say we’re going to make it through this next season.
Looking through a community lens can help professionals better understand and define well-being for their clients and communities. Mildred Joyner, president-elect of the National Association of Social Workers, added that there is a common misconception that people who have difficult life circumstances cannot be healthy or happy, so it is important to ask people how they themselves would define health or happiness and work from there.
She continued that, in addition to seeking and acknowledging community and patient definitions of well-being, it is important for health professionals to define their own ideas of well-being and what professional success means to them. Horne cautioned that while mentors can help young professionals forge a path ahead, ultimately, professionals are responsible for creating a space for themselves within the profession and for ensuring that the space is in line with their authentic selves. If professionals are authentic and honest with themselves, he said, they will find clients and a practice that give them peace and a sense of purpose. BigFoot added that creating space and being authentic require people to be vulnerable and uncomfortable, but that is where personal and professional growth comes from.
Self-Care and Support
BigFoot talked about her conception of self-care and how to “retain our helpers and healers that we have nurtured” and help them to have balance. BigFoot said that, to her, self-care includes understanding that “each individual is a spirit being with a physical body, capable of emotional
reactions, an ability to think and process information, and is connected from self to others by different kinds, intensit[ies], and qualit[ies] of relationships.” BigFoot said that the drum beat is a good example of embracing self-care, as it allows for the grounding of the physical body, brings feelings that can wash over prior unpleasant feelings, allows for thinking about sensations, and builds a relationship with the drum and with other people who are invited in by the drum beat.
Darla Spence Coffey, president and chief executive officer of CSWE, thanked BigFoot for introducing the concept of self-care, because health professionals are likely to feel additional stress as they take on the expanded role and responsibility of addressing the SDMH, and they will need to take care of themselves. Coffey urged participants to view addressing the SDH as the responsibility of health systems and of entire teams, not of individual practitioners. Putting the burden on individuals will “be completely overwhelming” and will cause practitioners to retreat, she said. BigFoot added that perhaps the word “self-care” is the wrong word to use because it implies individual responsibility. People in the helping professions need support and resources in order to “do the job at the level they would like to do it.”
Launette Woolford, vice president of Northwell Health, added that while focusing on addressing the SDMH of patients and clients is important, health professionals must place equal importance on addressing the mental health of the workforce itself. The workforce has its own social determinants, biases, and mental health issues, and these must also be addressed. Horne agreed and said that there is a stigma in the helping professions attached to seeking help. Health professionals fear being labeled if they acknowledge their own humanity, issues, and concerns, he said. There is a tendency to see patients and clients as “others”—the ones with problems or disorders—rather than seeing everyone as human and susceptible to mental health issues.
BLS (Bureau of Labor Statistics). 2019. Occupational outlook handbook. Bureau of Labor Statistics. https://www.bls.gov/ooh (accessed January 22, 2020).
SAMHSA (Substance Abuse and Mental Health Services Administration). 2020. About the Minority Fellowship Program. https://www.samhsa.gov/minority-fellowship-program/about (accessed February 12, 2020).
This page intentionally left blank.