SAMHSA helps address disparities and the unique needs of diverse population groups across the nation.
Behavioral Health Disparities and Cultural Awareness
Being culturally competent and aware is to be respectful and inclusive of the health beliefs and attitudes, healing practices, and cultural and linguistic needs of different population groups. Behavioral health practitioners can bring about positive change by better understanding the differing cultural context among various communities, and being willing and able to work within that context. For more information on this important issue, refer to the SAMHSA Office of Behavioral Health Equity. In addition, SAMHSA’s Strategic Prevention Framework offers good guidance on culturally appropriate practices.
SAMHSA-affiliated organizations focusing on cultural awareness and competency include:
- The National Network to Eliminate Disparities (NNED) in Behavioral Health is dedicated to promoting equality in behavioral health services for individuals, families, and communities. NNED, with help from SAMHSA and the National Alliance for Multi-Ethnic Behavioral Health Associations, builds coalitions of racial, ethnic, cultural, and sexual minority communities and groups dedicated to removing disparities in behavioral health care. Learn more about what NNED offers to support culturally competent practices.
- Funded by the SAMHSA Center for Substance Abuse Treatment, the Addiction Technology Transfer Center (ATTC) Network’s website provides many resources, guides, and publications about cultural awareness.
- The SAMHSA-Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions (CIHS) provides guidelines on how to provide culturally relevant services.
- The National Technical Assistance Center for Children’s Mental Health (TA Center) in the Georgetown University Center for Child and Human Development focuses on children and youth at risk for mental health challenges. Read about the TA Center’s resources, trainings, webinars, and initiatives and about its cultural and linguistic competency component.
For additional guidance on advancing and sustaining culturally and linguistically appropriate services for the workforce, SAMHSA’s Center for the Application of Prevention Technologies (CAPT) lists the elements of a culturally competent prevention system.
A number of efforts to address behavioral health disparities in the United States, including the Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and other mechanisms, are described in SAMHSA’s report, Behavioral Health, United States, 2012, which analyzes the changing landscape of mental health and substance use care for Americans of all ages.
SAMHSA Administrator’s Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues – 2013, Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018, and Action Plan for Behavioral Health Workforce Development – 2007 (PDF | 1.9 MB) all provide compelling data on the populations that SAMHSA’s various programs, initiatives, and technical assistance centers serve.
Children and Youth
SAMHSA is working to increase the number of practitioners in the United States who work with children, adolescents, and youth ages 16-25. Project Advancing Wellness and Resilience in Education (AWARE), a component of the president’s Now Is The Time initiative, is designed to help local educational agencies train school personnel and other adults who interact with children and youth in school and community settings to detect and respond to mental illness. In another component of the Now Is The Time initiative, SAMHSA is funding a special Minority Fellowship Program to develop professionals who specialize in working with youth.
In addition, in partnership with HRSA, SAMHSA is funding over $30 million to support over 100 new Behavioral Health Workforce Education and Training (BHWET) grants to expand the mental health and substance abuse workforce that will treat children, adolescents, and young adults with, or at risk for, a recognized behavior disorder. Visit HRSA’s FY 2014 Awards webpage for a list of award winners.
Behavioral Health Workforce Education and Training (BHWET) for Professionals
Funds support pre-degree clinical internships and field placements for master’s-level social workers, psychologists, professional counselors, psychiatric-mental health nurse practitioners, and marriage and family therapists; and, doctoral-level psychologists.
Behavioral Health Workforce Education and Training (BHWET) for Paraprofessionals
Funds support education and training of students in community and technical colleges, including tribal colleges and universities, who are seeking to obtain a certificate in a paraprofessional field focusing on the behavioral health needs of at-risk youth and families. Paraprofessional certificate programs may include community health workers, outreach workers, social services aides, mental health workers, substance abuse/addictions workers, youth workers, promotoras, and peer paraprofessionals.
More needs to be done to develop this sector of the behavioral health workforce. For instance:
- The Annapolis Coalition on the Behavioral Health Workforce reported in 2007 that by 2020, there will be a need for 12,624 child and adolescent psychiatrists, a number far exceeding the projected supply of 8,312.
- The Annapolis Coalition also found that of the 6,300 child and adolescent psychiatrists practicing nationwide in 2007, relatively few were located in rural and low-income areas.
- The Association for Addiction Professionals (NAADAC) has identified a severe lack of credentialed staff in the United States to treat substance use disorders among adolescents. This is partly due to states’ lack of adolescent-specific provider certification.
- As identified in the January 2013 Now Is The Time initiative, although three-quarters of mental illnesses appear by the age of 24, less than half of children with diagnosable mental health problems receive treatment. Transitional age individuals, referring to those people ages 16-25 years old, are at high risk for mental illness, substance abuse, and suicide, but they are among the least likely to seek help. Experts often cite the shortage of behavioral health services providers as one reason it can be challenging for this population to access treatment.
SAMHSA has a number of programs and initiatives in place to increase the number of minority group members in the behavioral health workforce:
- SAMHSA’s Minority Fellowship Program (MFP) seeks to reduce disparities in health care. About 260 MFP Fellows are trained in an average year under the program.
- In response to the request in the President’s Budget, Congress appropriated expansion of the MFP to support master’s level trained behavioral health providers in the fields of psychology, social work, professional counseling, marriage and family therapy, addiction counseling, and nursing. This expansion will allow for an increase of 240 trained professionals with a focus on youth and an increase of 60 trained professionals focusing on addiction counseling.
- SAMHSA’s grant program for Historically Black Colleges and Universities (HBCU)-Center for Excellence is dedicated to continuing the effort to network the 105 HBCUs throughout the United States. The HBCU-Center for Excellence promotes workforce development by expanding knowledge of best practices and leadership development to enhance the participation of African Americans in the substance abuse and mental health professions.
- The National Hispanic and Latino Addiction Technology Transfer Center Network provides workforce development resources, manuals, webinars, and curricula in an effort to increase the substance use disorder workforce’s skills in providing culturally and linguistically sensitive services and increase the number of Hispanic and Latino individuals in the substance use disorders workforce.
- Three Addiction Technology Transfer Centers, focused on workforce development and the use of evidence-based practices, are located at Minority Serving Institutions (Morehouse University School of Medicine, Universidad Central de Caribe, and University of Illinois Chicago).
However, as outlined in the 2013 SAMHSA report to Congress, more needs to be done to develop this sector of the behavioral health workforce. For instance:
- The substance use disorders treatment workforce is primarily female, older, and Caucasian, differing from their predominantly young, male, and minority clientele.
- There is a scarcity of providers who can render culturally competent services for minority populations. This behavioral health workforce issue contributes to the current disparities in mental health and substance use treatment and services.
- According to a 2010 report (PDF | 757 KB) on the strategic development of a mental health workforce for Latinos published by the Department of Health and Human Services’ Office of Minority Health, there is a severe shortage of Latino professionals working in behavioral health. For instance, Latino clinical psychologists only comprise about 1% of that sector of the U.S. health care workforce.
Lesbian, Gay, Bisexual, and Transgender Populations
SAMHSA has developed a number of training curricula for behavioral health and primary care practitioners to help them assess, treat, and refer LGBT clients in a culturally sensitive manner. A resource kit (Top Health Issues for LGBT Populations – 2012) provides prevention professionals, health care providers, and educators with information on current health issues among LGBT populations. A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children – 2014 also offers information and resources to help practitioners throughout health and social service systems. Learn more about SAMHSA’s LGBT resources and behavioral health workforce development initiatives.
More needs to be done to develop this sector of the behavioral health workforce. According to SAMHSA’s report Behavioral Health, United States, 2012:
- Just over half of middle and high schools in the United States provide mental health services tailored to gay, lesbian, or bisexual students.
To better coordinate SAMHSA’s internal resources in support of American Indians and Alaska Natives (AI/AN), SAMHSA has established the SAMHSA American Indian and Alaska Native Team (SAI/ANT). The SAI/ANT ensures positive behavioral health outcomes of AI/AN people are addressed through the agency-wide coordination of resources and services. SAI/ANT membership includes leaders; managers; and project, grant, and policy staff who strive to ensure SAMHSA’s resources are culturally appropriate and accessible to tribes/tribal organizations and the AI/AN population at large.
The SAMHSA Center for Mental Health Services and Center for Substance Abuse Prevention collaborate on suicide prevention and mental health promotion programs for American Indians and Alaska Natives. For tips on how to enhance cultural awareness while providing services to American Indians and Alaska Natives, visit CultureCard: A Guide to Build Cultural Awareness – 2009.
The National American Indian and Alaskan Native Addiction Technology Transfer Center provides workforce development resources, manuals, webinars, and curricula in an effort to increase the substance use disorder workforce’s skills in providing culturally and linguistically sensitive services and increase the number of American Indians and Alaskan Natives in the substance use disorders workforce.
However, more needs to be done to develop this sector of the behavioral health workforce. According to the American Indian/Alaska Native Behavioral Health Briefing Book – 2011 (PDF | 2.7 MB):
- Reservation hospitals often lack the mental health resources needed to serve them.
- There are about 101 Native American mental health care professionals for every 100,000 Native Americans, in contrast to the 173 available for 100,000 non-Natives. This may contribute to the low rates of American Indians and Alaska Natives seeking services.
Financing the Workforce
Working closely with a variety of federal and other partners, SAMHSA is exploring the use of coverage and payment levers to incentivize cost-effective use of the health care workforce. Some of the issues to be addressed include:
- Within behavioral health, reimbursement levels are often determined by practitioner rather than service type. In an effort to increase the efficiency of behavioral health workforce financing, barriers and opportunities for ensuring that payment better aligns with services delivered and expected outcomes could be explored. For example, in a fee-for-service environment, Medicaid, Medicare, or commercial insurance may pay rates based on the license of the delivering practitioner rather than on the quality of the service or outcome for the client.
- Within substance abuse treatment, many direct care workers started as people in recovery. In many states, credentialing bodies do not credential peer workers, and services delivered by peers are not billable to Medicaid, Medicare, or private insurance. As an approach for expanding the behavioral health workforce, there is a need to explore strategies for developing payment mechanisms that incentivize hiring and credentialing peer workers, and credentialing or allowing billing by mid-level workers who have a lot of experience but perhaps not the usual academic credentials, especially for substance abuse services.
Mental and Substance Use Disorder services are not always covered by state Medicaid, Medicare, or private insurance, and even when covered they are often funded at inadequate levels that do not meet the costs. SAMHSA has successfully engaged with Medicare to address same day billing issues and is now working to address those issues with Medicaid as well.
Data on the Workforce
Through a number of activities and initiatives with HRSA, SAMHSA will utilize available data to determine how many of what kinds of behavioral health practitioners for what kinds of populations need to be developed and variances from availability of actual practitioners need to be tracked and reported
- When tracking workforce related data, service location information is not routinely collected making it difficult to identify the range of settings in which providers are practicing. To address these and other data issues, SAMHSA and HRSA are collaborating to implement a Minimum Data Set (MDS) that will allow for more specific tracking of behavioral health workforce patterns and outcomes. This effort needs resources to continue and expand to understand the behavioral health workforce needs for today and the future.
- In order to track the complexities of the issues in the behavioral health workforce, efforts need to be made to track and identify when and where general practitioners, such as family physicians, internists, pediatricians, nurses, and others work, whether primarily in behavioral health settings or with persons with behavioral health needs. Similarly, behavioral health practitioners, such as social workers who are working in education or human services settings rather than in behavioral health clinical services, also need to be tracked.