Diversity in the Mental Healthcare Profession: Then and Now
| Nina Chamlou
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While psychology has been a female-led field for decades, the discipline lacks adequate representation when it comes to people of color, LGBTQ+ people, and individuals with disabilities.
According to 2019 data from the American Psychological Association (APA), about 83% of the U.S. psychology workforce is white. This is barely an improvement from 10 years ago, when 85% of the workforce was white. According to the same report, Hispanics represented the second largest group at 7%, Asians represented 4%, and African Americans just 3%.
If the psychology workforce had racial parity, about 60% of practitioners would be white, 18% Hispanic or Latino/a, 13% Black or African American, 6% Asian, and 3% other, according to the U.S. Census Bureau.
Race isn't the only area of disparity within the psychology workforce. Only 5% of psychologists have disabilities, while 25% of the U.S. population has some kind of disability. That 5% figure has remained stagnant over the last decade.
Little research has been done to measure the percentage of psychologists who identify as LGBTQ+, although many LGBTQ+ individuals have reported difficulty finding a therapist that suits them. Studies also show that sexual minority groups experience difficulty finding mental healthcare.
History of Lack of Diversity in Psychology
The mental healthcare field's homogenous nature dates back to its beginning. The earliest leaders in psychology were almost exclusively white, heterosexual men. As a result, some foundational psychological concepts were rooted in racism, sexism, and homophobia.
For instance, hysteria — an outdated psychological term applied to women — was considered a legitimate diagnosis until the 1980s. Homosexuality was considered a diagnosable mental illness until the 1970s. Conversion therapy, which attemps to change a patient's sexual orientation or gender identity, is legal in more than 20 states.
Fortunately, most of these prejudiced belief systems have been disproven or are being phased out.
The APA has made attempts to address racial injustices in the field, writing in 2021 that the organization "ignored the opportunity to take a formidable stand to address poverty, racism, and social concerns affecting African Americans, despite the strong advocacy of our members, some of whom consequently left the organization."
Unfortunately, diversity in mental healthcare still hasn't caught up.
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Bottlenecks Toward Diversity
The field's continued lack of diversity stems from educational barriers. In the U.S., prospective clinical psychologists spend 10 or more years in higher education, typically earning a bachelor's degree, a master's degree, and a doctorate.
Some groups experience difficulty in higher education because of systemic barriers. For example, disabled students have overall college completion rates of about 38%, compared to about 51% of nondisabled students.
The odds are also stacked against BIPOC students, who are less likely than white students to complete their undergraduate degrees. According to data from the U.S. Department of Education, only about half of Black and Latino/a students finished their bachelor's degrees after six years, compared with nearly 70% of white students.
This does not relate to academic ability, as students' GPAs were similar regardless of race, but financial factors. Black and Latino/a families are more likely to experience poverty than white families.
Students from these racial groups are also more likely to default on their student loans, which relates to the level of financial aid for minority students and financial assistance they receive from their families.
"It's not cheap to get a doctoral degree. It's especially difficult if you don't have financial support and you don't want to get saddled with incredibly high loans," says Dr. Anica Mulzac, Psy.D. The average cost of a doctorate costs nearly $115,000.
Dr. Mulzac is a licensed clinical psychologist, Executive Clinical Director and Provost at Resilience Lab and founder of Race (+) Positive, LLC, a consulting firm that aims to dismantle "all expressions of racism, prejudice, and bias in every unique sphere of influence."
"There are so many factors that influence who even gets accepted into [psychology] programs," Mulzac says, "who is seen as qualified, what experiences we judge as qualifications for entry into the programs, even being able to pay for the GRE to apply to the school — that's a costly exam."
She continues, "And then there is the cost of getting tutoring and support to prepare for the exam so you have scores that are desirable."
"There are so many pieces along the way that go into getting into and completing a program successfully that you can see the many cracks that people of color and people with [minoritized] identities can just fall through," Mulzac says.
Students with marginalized identities also lack support once they are accepted into programs. Mulzac was involved in a project analyzing the mental health of Black faculty in higher education and the unique struggles they face.
"Because there are so few Black faculty, a lot of the students who identify as Black or people of color come to them for support. But there's a limited number of people who can serve as mentors for them," she says.
"And if [the faculty] are burnt out or overwhelmed, then the quality of support that they can give students goes down. So, your white peers may have lots of spaces that they can go to and get guidance, get support, get tips, and tricks."
Higher education, in addition, has had difficulty hiring, retaining, and supporting Black faculty. This can negatively impact a minoritized student's academic success and deter them from pursuing higher degrees.
This is a familiar theme in disciplines that lack diversity, like STEM and finance. When a minority group is underrepresented, it sends a message that they don't belong. Those who may want to enter an underrepresented field are deterred, creating a vicious circle.
Like students of color, the same pattern discourages disabled students from pursuing careers in psychology, says a group of academics who started the Disability Advocacy and Research Network (DARN). DARN aims to connect psychology students with disabilities to faculty members and promote mentorship.
Why Diversity Matters
You can look to any industry lacking diversity to see why representation matters. For example, American women are more likely to die or be injured in car crashes because most crash-test dummies are of the average man.
Healthcare faces similar challenges. While women represent three-quarters of the healthcare workforce and African Americans represent 16%, only about one-third of physicians are female and a mere 5% are Black. Unsurprisingly, many women and African American patients report instances in which doctors don't take their health concerns seriously or underestimate their pain.
"We look at the rates of women who are Black dying in childbirth and they face a much higher mortality rate even than white women because when they express having a need or feeling something, their needs are dismissed, minimized, or not seen as credible," Mulzac says.
Research shows that people feel each other's pain more strongly when they are part of the same group, such as culture, religion, race, or even a sports team. This may be why patients are more likely to be satisfied when they see a physician of the same race as themselves.
Experts say this likely relates more to implicit bias rather than conscious prejudice. Regardless, it demonstrates why racial diversity and gender parity matter.
Understanding the link between shared experiences and the capacity for empathy is especially important for mental healthcare professionals. A therapist must empathize with their patients to provide effective therapy.
In states with mental healthcare worker shortages, minorities often receive lesser care because "there tends to be little diversity among mental health providers" and a "decreased understanding about the different mental health needs across minority groups," writes the University of Southern California's Department of Nursing.
"If we just think of this from a clinical perspective, failing to address the entirety of the person, their cultural differences, how that is shaping their lived experiences and what they're dealing with," Mulzac says, "we really run the risk of failing to address very critical information that could inform the way that we practice that can inform the treatments and interventions that we use."
She adds that when you are speaking with someone with a shared background "there are things that you feel or that you experience that may not necessarily have to be questioned or overly explained."
Mulzac continues, "You don't have to necessarily run the risk of that person invalidating your experience, which can be called racial microaggressions."
Similarly, many LGBTQ+ individuals and people with disabilities may prefer to work with therapists who identify with their own experiences.
"Now, does that mean … that only people who look like you can help you? The answer of course is no, because if that were the case, we would be in deep trouble. So, you'll have a ton of people seeking help from people who do not look like them," Mulzac explains.
We must continue striving for diversity in therapy and making up for its current lack. This is why cultural competence is important.
Increasing Cultural Competence
The APA defines cultural competence as "the ability to understand, appreciate and interact with people from cultures or belief systems different from one's own." Research shows that treatment can be more effective when therapists demonstrate cultural competence.
However, the concept is somewhat murky.
At what point does one become "culturally competent," if ever? While most psychology programs require at least one class that discusses multiculturalism, one or two courses cannot fully equip most students to help individuals from all kinds of backgrounds.
"I really prefer the term 'culturally humble,' [meaning that one is] willing to work on where they are lacking, learn what their blind spots are, and then educate themselves around it," Mulzac says. "I think when we are coaching about this idea of humility, it invites a curiosity and a desire to continuously learn and build on it."
That's why she cautions therapists against "feeling like you've arrived." Rather, she views it as an ongoing process.
"[Some people think], 'Okay, I've taken the multicultural classes, I've read how to be anti-racist, I'm done with that.' But that frame of mind is not helpful," she says.
She recommends that psychologists take continuing education credits related to culture and racial identity to understand "how they intersect into the work that you're doing clinically."
"I think [it is positive] that the APA has been willing to come out and say, 'Here's how we have messed up and not done our part,' and made resolutions for the ways that they're going to be committed," she says.
In the APA's apology statement, the organization said it plans to "prioritize efforts in training, opening pathways, and workforce development … [and to] promote mentorship of psychologists of color."
"Every program that is APA-accredited will now perhaps be held to a standard that maybe they weren't held to as tightly before. Having cultural humility and cultural competency weaved in, not just in a segmented course that you take, but in every part of the curricula, I really do think that there's value in that," Mulzac says.
Paige J. Gardner, Ph.D.
Paige J. Gardner is an assistant professor of student development administration at Seattle University. Gardner previously served as assistant dean of students at Loyola University Chicago and has 12 years of experience in crisis management, facilitating diversity and equity training, and identity development workshops. Her research centers race and gender equity in the workplace and the experience of emotional labor at historically white institutions.
As a queer, Black, cisgender woman of color, Gardner is invested in advocating, empowering, and building solidarity-based coalitions with and for those on the margins of society.
Paige Gardner is a paid member of the Red Ventures Education freelance review network.
Page last reviewed January 11, 2022
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