Chapter 12
Structural Racism and Community Mental Health
Chapter Overview
This chapter examines how structural racism continues to shape mental health disparities in the United States by tracing its roots from slavery, segregation, and eugenics to contemporary inequities in diagnosis, access, and treatment. Historically, racist psychiatric practices and institutions, such as the Georgia Lunatic Asylum and Crownsville State Hospital, mischaracterized Black resistance and legitimized discriminatory approaches to care. These legacies persist today through redlining, socioeconomic exclusion, provider shortages, implicit bias, and the criminalization of mental illness, all of which disproportionately harm marginalized communities. The chapter also highlights how Asian, Hispanic/Latino, and Arab American populations also face unique barriers to mental health services, including stigma, cultural mistrust, immigration-related stress, and limited culturally competent care. In analyzing both historical and current policy landscapes, the chapter underscores the limitations of existing reforms and the ongoing need for systemic accountability, including recent acknowledgments of institutional racism by the National Association of Social Work (NASW) and the American Psychological Associations (APA). Recommendations focus on expanding culturally responsive care, increasing workforce diversity, implementing community-driven solutions, and advancing structural policy changes. This chapter argues that equitable mental health care requires confronting the deep-rooted systems that perpetuate racial inequities across generations.
Video
Join Dr. Marquis Chandler and Sandile Manzini as they introduce their chapter on structural racism.
Reflective Questions
Designed to encourage critical thinking, real-world application, and meaningful discussion.
- How does structural racism differ from individual prejudice?
- What historical policies continue to shape present-day disparities?
- How do diagnostic and treatment disparities reflect structural patterns?
Resource Connect
Links to professional standards, policy frameworks, and cross-referenced chapters that support deeper exploration.content.
AHRQ National Healthcare Quality and Disparities Report Data Tools
The Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report Data Tools allow users to examine national and state-level patterns in healthcare access, quality, affordability, care coordination, and treatment outcomes. The interactive dashboards include comparisons by race and ethnicity, income, location, condition, and care setting. Students can select a mental-health-related measure, compare population groups or states, and identify where overall improvements may coexist with continuing disparities. Data can also be downloaded for classroom analysis.
SAMHSA: Racial/Ethnic Differences in Mental Health Service Use
The Substance Abuse and Mental Health Services Administration’s Racial/Ethnic Differences in Mental Health Service Use Among Adults and Adolescents uses nationally representative survey data to compare outpatient treatment, inpatient treatment, prescription medication, and other forms of mental-health service use across racial and ethnic groups. Instructors can use the charts to help students distinguish the prevalence of mental-health conditions from access to and utilization of services. Because the chartbook combines data collected from 2015 through 2019, it should be used to examine established patterns and research methods rather than as a source of current annual statistics.
National CLAS Standards: Behavioral Health Implementation Guide
The U.S. Department of Health and Human Services’ Behavioral Health Implementation Guide for the National Standards for Culturally and Linguistically Appropriate Services translates the National CLAS Standards into behavioral-health settings. It includes practice scenarios, implementation strategies, and organizational examples addressing leadership, workforce development, language assistance, community engagement, data collection, quality improvement, and accountability. The guide can be used for an agency equity audit in which students examine whether culturally and linguistically responsive care is embedded throughout organizational operations or depends primarily on the efforts of individual practitioners.
Structural Competency Working Group Training Materials
The Structural Competency Working Group develops open-use curricula for health and behavioral-health professionals. Its Structural Competency Training Curriculum includes facilitator guidance, sample agendas, readings, case-based exercises, participant materials, and modules on structural violence, structural vulnerability, the naturalization of inequality, and interventions within and beyond clinical settings. Instructors can adapt individual exercises rather than presenting structural competency only as an abstract concept.
Cross-reference: See Chapter 6 Mental Health with Justice-Impacted Individuals for discussion of racialized patterns in policing, detention, forensic evaluation, involuntary treatment, diversion, and reentry; Chapter 5 Immigration Trauma and Resilience for the effects of legal status, language access, discrimination, detention, and institutional exclusion; and Chapter 15 Collective Trauma and Collective Loss for analysis of historical trauma, community violence, institutional mistrust, and the cumulative effects of structural harm.
Further Resources
Suggested readings, research areas, and materials for extended learning.
Structural Racism and Structural Competency
Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126–133.
Metzl and Hansen introduce structural competency as a framework for recognizing how clinical encounters and health outcomes are shaped by institutions, markets, policies, and social and economic conditions. The article is useful for comparing structural competency with cultural competency and for asking what practitioners can address inside clinical settings, through organizational reform, and through policy advocacy.
Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453–1463.
This article examines structural racism across interconnected systems, including housing, education, employment, healthcare, and the criminal-legal system. It provides a foundation for tracing how historical policies and present-day institutional arrangements influence exposure to adversity, access to resources, and population health outcomes.
Structural competency should not replace cultural humility or individualized assessment. It expands the analysis by asking how systems shape the choices, risks, and resources available to clients, communities, practitioners, and organizations.
Racial Disparities in Diagnosis and Access to Care
Olbert, C. M., Nagendra, A., & Buck, B. (2018). Meta-analysis of Black versus White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities? Journal of Abnormal Psychology, 127(1), 104–115.
This meta-analysis examines persistent Black–White disparities in schizophrenia diagnosis and whether structured diagnostic assessments reduce those differences. It provides a useful basis for discussing clinician judgment, diagnostic procedures, referral pathways, assessment settings, and the limits of standardization as a response to inequity.
Lee-Tauler, S. Y., Eun, J., Corbett, D., & Collins, P. Y. (2018). A systematic review of interventions to improve initiation of mental health care among racial-ethnic minority groups. Psychiatric Services, 69(6), 628–647.
This review examines collaborative care, service colocation, case management, psychoeducation, screening, and referral interventions intended to improve entry into mental-health treatment. Several integrated-care interventions reduced disparities in the initiation of psychotherapy or antidepressant treatment, although the evidence varied across populations and program models.
Diagnostic and service-use disparities should not be interpreted without considering where and how people enter care. Emergency, correctional, involuntary, and crisis settings may produce different assessment and treatment patterns than accessible, continuous, community-based care.
Equity-Centered Reform and Community Action
Williams, D. R., & Cooper, L. A. (2019). Reducing racial inequities in health: Using what we already know to take action. International Journal of Environmental Research and Public Health, 16(4), Article 606.
Williams and Cooper review evidence concerning healthcare access and quality, socioeconomic conditions, residential segregation, early childhood development, discrimination, and community conditions. The article is useful for moving classroom discussion from documenting disparities to identifying interventions at clinical, organizational, community, and policy levels.
National Academies of Sciences, Engineering, and Medicine. (2017). Communities in Action: Pathways to Health Equity. National Academies Press.
This consensus report examines structural barriers and community-based strategies for advancing health equity. Its accompanying Tools for Communities materials provide examples involving housing, education, transportation, employment, public safety, healthcare, and cross-sector collaboration. Students can use the framework to develop a community mental-health intervention that addresses both service delivery and the conditions contributing to unequal mental-health outcomes.
Equity-centered reform should be evaluated through measurable changes in access, service quality, client experience, coercive interventions, continuity of care, and outcomes. Mission statements, staff training, and diversity initiatives are insufficient when organizational procedures continue to produce unequal results.