Who are mental health services for?

Written by Daniel L. Kalin, MA and Erica D. Marshall-Lee, PhD, ABPP on behalf of Atlanta Behavioral Health Advocates

As I was completing my practicum at a university counseling center, my supervisor encouraged me to ask all my clients the following question: “Which part of your identity is most influential to you?” This not only gave these young people an opportunity to reflect on their identity, but it also highlighted to me the importance of bringing identity to the fore when considering interventions. This was immediately evident in the case of a student I supervised whose parents immigrated from East Asia. Instead of encouraging him to pursue a values-driven major like literature instead of a parent-driven major like computer science, I explored with him the cultural values ​​he was upholding by following his parents’ wishes and how he could simultaneously honor his passions. The “one size fits all” treatment approaches I had been taught were actually closer to “one size fits all.” Rather than a single approach being available to most clients, most approaches seemed primarily available to the white majority for whom they were developed.

The field of psychology has not had a clean history when it comes to including minority populations in the development and dissemination of mental health services within the United States. Many of the practices we consider evidence-based treatments (EBTs), from therapeutic interventions to neuropsychological assessments, were developed from a Western perspective, primarily by and for white adults. Consciously or not, psychologists often adopt a “good enough” mentality when providing these treatments to individuals for whom they were not developed. The idea of ​​adapting EBTs for people with different identities is not new (Fuertes et al., 2001; Lau 2006). Yet, even as these considerations have become more prominent in training and practice, treatment gaps still exist (Joiner et al., 2022; Lorenzo-Luaces et al., 2024). Our approaches to treatment development and delivery have evolved, but they are still not available to everyone.

Digital mental health interventions (DMHIs) are one of the contemporary developments that aim to increase the accessibility of mental health services, from companion apps to virtual therapy sessions. Studies investigating the impact of DMHIs on various populations (Goodarzi et al., 2023; Jones et al., 2020) and symptom presentations (Firth et al., 2017; Forman-Hoffman et al., 2021) support DMHIs as an effective way to connect psychological services, especially for those who live in “therapy deserts” or who may have difficulty accessing physical clinic spaces. However, the potential for accessibility does not equate to universal benefits in terms of engagement and outcomes. Recent studies have found that characteristics such as gender, age, and race significantly influence these benefits (Aschbacher et al., 2023). However, simply acknowledging that these identity factors influence engagement and outcomes risks missing the nuances that lead certain groups to engage with these services differently than others, especially when considering culture and race.

Just as researchers and providers have worked to adapt EBTs to minority and underrepresented populations, we have a responsibility to explore the effectiveness and accessibility of DMHIs beyond the “default” White consumer. Several research groups have already begun to explore accessibility and relevance issues regarding DMHIs, with a wide range of findings. Over 40% of mental health app studies do not consider accessibility for marginalized groups (Ramos et al., 2021). This includes racial and cultural considerations as well as adaptations for the blind and hearing impaired. Research samples included in the development of DMHIs often consist primarily of White participants, even when culturally adapted DMHIs emerge (Ellis et al., 2022). Failure to consider the diversity of user databases can lead to apps that are too costly, not user-friendly, or not culturally sensitive. In addition to these concerns, research has shown that several barriers exist that may prevent individuals or groups from utilizing DMHIs. These include user-related (e.g., mental health status, demographics), program-related (e.g., perceived usefulness, social connectedness), and environment-related (e.g., privacy, implementation) factors (Borghouts et al., 2021).Not surprisingly, knowing your audience and what concerns they have about a resource may influence the likelihood that they will use it.

Consider the recent development of a smartphone-based mindfulness app for African Americans. The group’s pilot study, which involved the development and distribution of an app created to address specific concerns raised by African Americans seeking mental health support, found significant reductions in stress levels and improved emotion regulation abilities ( Watson-Singleton et al., 2021 ). The group’s dedicated research into identifying the attributes most appealing to underrepresented populations (e.g., audio recordings by people of color) made a difference not only to engagement with the app, but also to its effectiveness.

The bottom line for mental health providers is that identity and culture are not just an add-on to consider in treatment, but an integral part of the work we do with our clients. When it comes to face-to-face interventions, all the fidelity in the world means nothing if our clients don’t find it useful or accessible. The same is true for digital interventions. We can use our personal resources to be mindful of the apps that might be most helpful for our clients, whether that be through discussions with colleagues or by using a curated list of expert-reviewed apps like the One Mind PsyberGuide. Additionally, our clients may directly or indirectly tell us what’s not working, and we need to listen. Are the costs of an online self-guided skills training module more than our clients can afford? Is our devout Christian client hesitant to use a mindfulness app that draws heavily on Eastern religions? As health care providers, we have a responsibility to provide the best care for our clients. That means offering the treatments that this client is most likely to use and benefit from, not just the most popular treatments or those that have worked for other clients. Our skills of listening with curiosity to our clients and adapting to their needs remain powerful tools as we navigate an increasingly digital world of care.

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