Power Redistribution and Upending White Supremacy in Implementation Research and Practice in Community Mental Health

In today’s era of racial reckoning, the call to center health equity and antiracism within implementation science is paramount (1, 2). Despite immense progress, practitioners and researchers in the field of implementation science cannot fully embrace antiracist implementation science without recognizing that the field is built on a foundation of White supremacy—a network of structures, policies, and practices that prioritize Whiteness and contribute to unequal distributions of power (3).

Recently, thought leaders in implementation science have highlighted the role of antiracism and racial power dynamics in this field (1, 2, 4). This Open Forum builds on this work by operationalizing the ways in which implementation science may sustain White supremacist ideas in community mental health. The following questions will guide the discussion in this Open Forum: What information is valued and considered evidence? and How do power differentials within implementation research and practice manifest? This piece is representative of the perspectives of both implementation scientists (A.L.S., M.L.F., R.S.B.) and community partners, that is, individuals with experience in supervision (L.P.C.), administration (N.L.D., M.H., E.S.), direct care provision (N.L.D.), and youth advocacy (D.I.). Our objective is to call out the underlying structural and systemic factors that undermine our shared goals of a just and equitable mental health care system and to increase dialogue surrounding strategies for upending White supremacy within implementation science.

A common goal of implementation efforts in mental health is to increase access to high-quality mental health care by deploying evidence-based interventions (EBIs) in community-based mental health clinics (5). Centering EBIs as the main solution to transform mental health care may perpetuate White supremacy given what information is valued and considered evidence in distinguishing an intervention as evidence based. Of note, White Western methods of knowledge generation within academia—such as randomized controlled trials (RCTs) that indicate an intervention’s effects on outcomes selected by researchers—have been prioritized in the development of EBIs. Historically, reviewers and research funders have been less likely to positively review and fund studies outside of the traditional RCT model or investigations measuring outcomes that do not fit within the Western notion of how to address mental disorders (e.g., systems change and collective healing). Such an approach can delegitimize and undervalue other vital forms of evidence (e.g., practice-based evidence, lived experience, and stories and images).

EBIs were largely developed by White researchers in middle- and upper-income White communities and rely on Western beliefs about mental health and illness and ignore forms of healing within more collectivist cultures. For example, EBIs often focus on internal and individual conceptualizations of mental health (e.g., unrealistic thinking patterns) and underplay external factors such as the effects of structural racism (e.g., lack of safe housing and of affordable education, as well as presence of chronic stressors). EBIs were not often designed by or for people with minoritized identities, yet they are seen as the foundation from which to adapt and therefore center Whiteness as the default human experience. The evidence base of current clinical research and practice is therefore inherently flawed. This limitation does not mean that core features of EBIs cannot be useful for individuals from minoritized backgrounds; rather, it means that without careful attention to the needs and cultural context of minoritized communities, implementation scientists could perpetuate disparities in receipt of high-quality care.

In the following, we explore how power differentials manifest within implementation science. Implementation processes follow an implicit relational pattern characterized by power imbalance. We (the implementation scientists) need to convince them (community clinicians) to do a thing (an EBI) to solve a specific problem (such as a client or community issue). Adding to this already challenging power dynamic is the fact that most implementation scientists in the mental health field are White. This workforce issue further contributes to power imbalances, lack of culturally responsive services, and continued mistrust between researchers and communities. This deficiency is also evidenced by leading implementation frameworks that have not historically included determinants related to structural racism or client cultural context.

Additionally, although a cornerstone of implementation science is community partnership, partners whose perspectives are valued in decision making around provision of mental health services in community clinics are largely those in positions of power (e.g., administrators, policy makers, and insurance providers), creating a disconnect between people in power and those doing the work or receiving the care (6). For example, community clinicians have consistently voiced concerns regarding the lack of relevance of some aspects of EBIs for their clients’ culture and context (7), yet those concerns are often not sufficiently addressed and instead are overlooked in favor of large-scale implementation of EBIs in community mental health clinics. Clients, who have the most at stake, are even less likely to be included in the decisions about which mental health services they receive. For clients from marginalized communities, this lack of power in clinical decision making can be even more profound when combined with the historical and current mistreatment of people of color in medical settings. Indeed, clients and communities are often seen as the target of implementation rather than as an actor and significant partner in determining the factors contributing to their oppression (6).

Recommendations

Naming the influence of White supremacy is only the first step toward change. We therefore also provide action-oriented recommendations tailored to community mental health, consistent with recent guidelines for promoting equity and addressing structural racism in implementation science (2, 4, 8).

First, implementation scientists must acknowledge the racial inequities within the field itself and commit to multilevel transformative action. Change will require both interpersonal awareness and institutional transformation. For example, implementation scientists can reflect on how White supremacy affects their own experiences of power and privilege and their relationships with community partners and how it shows up in their institutions that perpetuate the hiring and promoting of White academics and a White supremacist work culture (9). Within research teams and partnerships, implementation scientists can discuss their own positionality (i.e., social position based on intersecting social identities and experiences) and limitations to the ways in which EBIs for mental health care were developed and tested and can express honesty and humility about potential challenges (9). Moreover, implementation scientists can provide intentional mentorship to people of color and individuals with other minoritized identities, examine mechanisms of racial inequities in hiring and promotion within research and clinical institutions, and develop strategies to address those mechanisms (e.g., creation of pathways to research and leadership opportunities at multiple training and career stages). At the funding level, implementation scientists and funding agencies can advocate for programs such as NIH UNITE, developed to identify and address structural racism within the scientific community, or the NIH FIRST (Faculty Institutional Recruitment for Sustainable Transformation) initiative, which supports underrepresented scientists. Importantly, equity goes beyond representation, and academic institutions and individual implementation scientists must invest resources into the creation of safe spaces where people’s voices, knowledge, and lived experience are valued.

Second, as has been widely described, investing in community engagement throughout all aspects of implementation research and practice is necessary for the redistribution of power and equitable provision of mental health services (6, 8, 9). One recently described model—the Community Coalition for Equity in Research—provides concrete steps and structures for increasing authentic engagement between researchers and community members. This model includes training community members in research principles, prioritizing sharing of power and resources, supporting colearning, centering community strengths, and emphasizing long-term and system changes (10). The model can be applied to implementation practice in community mental health clinics by creating a coalition of community clinicians, clinic staff, and individuals with lived experience sharing equal power in decision making regarding which services and training areas are prioritized within the clinics. In addition, the transcreation framework (11) provides an example of how to codevelop and coimplement mental health services by understanding a community’s context and mental health needs, combining both scientific evidence and local knowledge and resources for mental health promotion to develop an intervention and building community capacity by hiring and training community members as interventionists and study staff.

The common element in these models is that power is held and shared with community partners in an authentic way that includes their integral involvement throughout the research and practice process with appropriate compensation. Community-engaged work requires authentic relationship building, takes time, and does not fit the traditional research infrastructure that prioritizes proliferation of products (e.g., publications and grants) over transformation of mental health systems and clinical practices. Leaders in the field and those in positions of power can and must resist this prioritization and invest in systems and structures that support community-driven work. This investment may include funding through a mental health services organization (e.g., the Substance Abuse and Mental Health Services Administration and local foundations) or programs recently developed within national funding agencies that specifically support the development of community-partnered work (e.g., the Patient-Centered Outcomes Research Institute Engagement Awards program, the Community-Based Participatory Research Program of the National Institute on Minority Health and Health Disparities, and the NIH Common Fund’s Community Partnerships to Advance Science for Society).

Third, we need to rethink EBIs as the centerpiece of implementation science in mental health. Promoting EBIs as the solution for addressing community mental health needs can ignore structural challenges experienced by both clients and community clinicians and perpetuate mental health inequities in care (12, 13). Instead of focusing primarily on barriers and facilitators to EBI implementation, we ought to broaden determinants to measure structural racism and other mechanisms of inequities in engagement and mental health outcomes for minoritized clients (14, 15). Specifically, within community mental health, interrelated multilevel factors at the client level (e.g., social determinants of health, mistrust of systems of care, experiences of racism and other discrimination, and mental health stigma), clinician level (e.g., biases, lack of cultural humility, financial strain, and secondary traumatic stress), intervention level (e.g., lack of culturally responsive care), and systemic and structural level (e.g., underrepresentation of clinicians of color in mental health care, insurance and billing requirements, and clinic attendance policies that disproportionately affect low-income patients of color) all contribute to disparities in receipt of high-quality care but are not commonly included as determinants in implementation science research. Implementation strategies can then be developed to specifically address determinants of mental health equity (14, 15), such as cultural assessments to help clinicians tailor care to their clients’ unique background and improved reimbursement rates for clinicians caring for youths covered by Medicaid.

Great strides have been made in the field of implementation science, but we can and must do better. Implementation science can play a role in ushering in a more equitable and just era of delivery of mental health services. However, undoing centuries of White supremacy will not be easy or quick; it requires willingness, an investment of time, and a redistribution of power.