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Education and Training to Address Behavioral Healt ...
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Presentation and Q&A
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Hello and welcome. Thank you for joining the third national conference on advancing early psychosis care in the U.S. presented by SMI Advisor. My name is Steve Lopez. I'm a professor of psychology and social work at the University of Southern California, and I'm very pleased to moderate today's session focusing on education and training to address behavioral health disparities. And Dr. Pollard's prior presentations talked about competencies and training, and we're very fortunate to continue that discussion. Now I'd like to introduce to you the faculty for today's session, Dr. Zui Nguyen. Dr. Nguyen received his PhD, his license in clinical social work, as well as his MSW, and he's a director of SAMHSA's Substance Abuse and Mental Health Services Administration-funded Minority Fellowship Program at the Council on Social Work Education. So he's a director of the Minority Fellowship Program, which has been in existence for many years, for decades, and has supported a number of individuals both in social work and psychology and other disciplines as well. He's a gerontological mental health services researcher, and his grant-funded research has revealed how social cultural factors, especially differences among Asian ethnic groups in the aging process, affect health and mental health service use. As an educator, he's held faculty appointments at Columbia University, New York University, and Temple University, where he has taught courses in research, statistics, and human behavior in the social environment. A licensed clinical social worker, Dr. Nguyen earned his BA and MSW from Wash U, Washington University in St. Louis, an excellent institution, and his PhD from Columbia, equally a prestigious university. He's a fellow recognized by his colleagues in the Gerontological Society of America and the Society for Social Work and Education. I want to report that Dr. Nguyen has no financial relationships or conflicts, and so I'll turn over to Dr. Nguyen. Thank you very much for joining us. Thank you so much for the introduction, Dr. Lopez, and thank you, all of the participants who are joining this session. I know that you'll be sharing, putting, participating in the chat, and I see that there's some of you, there are some questions, some comments already in there, and you'll use the Q&A. What my plan is that we're going to, I'll take us to a little bit after the top of the hour, and then I'd like to open up some time, save some time for some questions and answers and some discussion. As I was talking to Dr. Lopez earlier, he was also an MFP fellow some decades ago during his training, and I was also an MFP fellow when I was a doctoral student at Columbia. I did want to bring up, these are three of the learning objectives for today, for you to be able to take away at least one recommendation to implement in behavioral health training that addresses the social determinants of health, that you'll walk away from this time, this session, with the ability to describe three of the key features of the CSWE MFP and how we've supported masters and doctoral fellows who are students in social work, and also to identify at least one strategy to engage students from historically underrepresented groups to address disparities in behavioral health and mental health, substance abuse, and so on. Today, we'll do a very quick overview of some of the behavioral health inequities. These are things I know that we spend a lot of time talking about in general, not just in the MFP and across the MFP programs, but in mental health programs, in substance use training as well. So we'll do a quick review of that. I'll give you a snapshot of the social work profession and kind of how social work students are, what backgrounds they come from, where social work students are going into the field, and I'll spend more time talking about the social determinants of health framework that the National Academies has put out in recent years and has been working on and how it applies to behavioral health training. We'll talk about the MFP at CSWE, as well as some recommendations for behavioral health workforce development. And so, as you undoubtedly know that racial and ethnic communities, minority communities, experience these persistent disparities in disease burden, in insurance coverage or lack of insurance coverage, and subsequent access to, and the level of behavioral health care, as well as treatment outcomes. This says nothing of the provider interactions and the challenges in interfacing with the mental health system, the substance use system, the health care system in general. Yet, racial ethnic groups make up more than 20% of the U.S. population, but fewer than 20% of American mental health providers are from ethnic minority groups. So part of my training has certainly gone back to when the Surgeon General Supplement on Mental Health, Race, Culture, and Ethnicity was coming out now some 20 years ago. But there was, and there still has been this conversation about this need for cultural competence. And we can talk about how that has shifted over time and how we've evolved from talking about cultural competence and the ways that it was done throughout the 90s. And saying that now we're looking at ways to address cultural humility. And I know in social work, there's so much, there's been a strong push given the social events, the Black Lives Matter movement, and following, and sort of that crescendo following George Floyd's death. But in terms of addressing anti-Black, anti-racist perspectives and pedagogy. And so it's something that I think we are seeing students experience, not just from their coursework and the degrees to which they are increasingly racially aware and increasingly aware of how their privilege in certain ways informs their professional identity as well as how they work with clients. And certainly as Dr. Lopez had pointed out, I am certainly privileged in my educational background and having been to receive my education and training from highly regarded institutions and having been able to contribute to faculties at similarly well-known institutions. So Maggie Alegria and her colleagues have kind of framed this work, right, that in how she's looked at our discourse around mental health treatment, how we engage with communities, how individuals, our patients, our clients are engaging with the mental health system. And she had recommended five basic points. One, that we need to adapt treatments, that we need to look at not just evidence-based practices, but we need to look at that cultural adaptation and what that means and how that looks and the hard work that goes into that. Certainly in my clinical practice, when I was more actively practicing as a clinical social worker, it was a frustrating piece in terms of engaging with individuals who were recently discharged from the state hospital in the Chicago area with a newly diagnosed schizophrenia condition and trying to assess, okay, so how can we, how can I ostensibly provide an evidence-based treatment for these individuals? And there are great manualized treatments that were in place, but that adaptation, that cultural adaptation, that linguistic adaptation is a difficult piece in terms of as a practicing social worker to be able to adapt on the fly and to assess that. And so that adaptation of treatments is an important piece. Integrating behavioral health services into existing social services is an area of import, right, that we are looking to see these natural help-seeking arenas that individuals from historically underrepresented groups seek care so that we can leverage some of those resources to improve mental health outcomes. Addressing the aspect of culturally adapted social marketing, how do we talk about mental health? How do we reduce stigma? How do we convey that through health messaging, through mental health messaging? And those are pieces that I think are important for us to think about as we move the field forward, especially in our current pandemic world and as we hopefully will gradually move out of that as well. So I'd said in terms of using culturally adapted treatments, interventions so that one, we can have them adapted from a research standpoint, but then we also have that piece of having them implemented into practice. But the final part, which is what I'll be spending most of my time today speaking on, is that aspect of diversifying and expanding the behavioral health workforce. Recognizing that there are limitations in terms of who is in the healthcare, in the behavioral health workforce, and how we can look to increase the representations of certain groups in particular in the behavioral health workforce. So some of the research that's out there in terms of these constraints are that racial and ethnic minority healthcare clinicians are more likely than their white peers to serve medically and minority underserved communities. So that there's this, we're not always able to get to ethnic matching. One of these pieces that I have commonly said when we're in these discussions with behavioral health workforces, we can't assume that, for instance, that Vietnamese trained social worker, psychologist, psychiatrist is going to work with the Vietnamese population. There might not be that interest. There might not be that fit. We can't make those cultural and linguistic assumptions. But we're seeing this in terms of who is providing care in these communities. From the psychological, the psychology profession, we're seeing that it's, that the data from earlier, from 2004, seems to suggest that racial and ethnic minority psychologists see racial and ethnic minority patients at twice the rate that non-minority psychologists do. So we have, on the one hand, a shortage of minority professionals trained in substance abuse, mental health, and other health disciplines to address these needs in the minority communities. But then we also have this countervailing need for a culturally competent workforce. And however we try to define that as a culturally competent workforce, that it goes from skills, attitudes, and behaviors to having people who have linguistic abilities to being able to look at ethnic and language matching. But we know that the demographic populations in the United States are changing. As a gerontologist, it's not only that is it graying, but that it is also a browning population. And so we're faced with this tension, right, that we have an insufficient number of professionals, but we have that need, and we have a particular need in communities of color. So one of these parts that I'll be talking about is out of this framework for educating health professionals to address the social determinants of health. This had come from the National Academies of Sciences. They had developed this through one of their work groups in 2016. And increasingly, we're trying to apply this in behavioral health settings. And so here on your screen is an overview schematic of that framework where there's socioeconomic and political context. There are structural determinants that impact intermediary determinants that ultimately have an impact on equity in health and well-being. There are organizational, community, and educational processes that take place within the pyramid. But I'm going to be spending time talking about the two ovals on either side of the pyramid that have the blue line under them. And it's looking at, on the left-hand side, the population, the future health care workforce. And then on the right-hand side, the workforce that partners in addressing the social determinants of health. And so we're setting up this idea of the pipeline. How do people get into the workforce, and then how does that workforce partner with communities to address the social determinants of health? As we talk about the pipeline, I think that it's important for us to take a step back and look at these vertical structures that impact education. I think in terms of mental health and substance abuse, we often think first of the graduate programs of study, those master's degree programs that lead to licensure, PhD-level training, PsyD, practice doctorate trainings, as well as MD training. We think of that level first, but then we also do, I think, have to keep in mind those earlier antecedents, that post-secondary education. How do we engage and look at folks who are in associate programs, especially for first-generation students? That's been an important pipeline in terms of the fellows I've spoken to, especially, as well as in terms of bachelor's programs. There are a bevy of options nowadays in terms of how one can impact mental health and be a mental health professional in any number of professions. How do we, in the field, address some of these sources as well? Really, if we even go to the high school level, how do we talk about behavioral health? How do we talk about mental health? Talk about substance use as professions, potential options in life. Certainly, there are lots of folks, and probably many of us who are in this session, we're among these, where in high school or in college, we think that, oh, we want to help people. Maybe the way that we think that helping occurs is by becoming a physician, but then also offering up other pathways, new pathways to individuals. We can think of that just in terms of how we stack and how we graduate the student experience from secondary experiences to post-secondary to graduate level. Then we also do have to think and keep in mind our educational structure, that we have students ostensibly and increasingly in the views of our our higher education as consumers. They're paying for a product. We have educators as the suppliers of that product, but then we also have administrators who oversee the visions of those programs and those institutions. I would contend that we need to take a look at those levels of administration, those levels of those institutions, whether they're high school, those are school systems, community colleges, undergraduate institutions, or research one institutions and graduate programs, that we need to be thinking about how do we address the needs of not just clients and patients who are from underrepresented racial and ethnic groups, but also of the students who are in those programs. How do we reach out to those students? How do we support those students? Part of what I'm going to be talking about is that that requires investment in educators as well as investment in administrators and having folks who are representative of our communities in those positions. I touched on this earlier, where there's this unmet need. We talk a lot in our mental health fields about underserved communities. One of those pieces of why communities are underserved and they're generally communities of color is that there's a general lack of individuals from individuals from our behavioral health, mental health back professions that constitute or come from communities of color so that there's almost a supply issue within the behavioral health workforce as well. I'm going to take a moment here to shift gears a little bit and talk more specifically about social work programs. I do work at the Council on Social Work Education, which sponsors our minority fellowship program. The Council on Social Work Education is the national accrediting body for social work programs at the bachelor's and master's level and is in the early stages of accrediting the practice doctorate or the DSW degrees. In addition to that, there are also educational initiatives, research, and member services that are provided by the Council on Social Work Education because we are the main association for social work educators since the 1950s. Some of actually this data has been increasing, but as of 2018, there were 590 institutions that were hosting 893 BSW and or MSW programs. And that number increases each cycle, each year on an annual basis as more programs are being created at start are started up at new institutions as well. There have been 17 practice doctorate programs, 17 programs that offer a DSW degree. I know there have been a couple more this year, so that may have shifted upwards. And there are 77 programs that offer a more research-focused PhD in social work. So we're seeing that most of these, not even most, many of these programs are at doctoral institutions, 40%. Only 15% are at Research 1 institutions. And most of them, 46%, are at master's colleges and universities. But we see that only about a quarter are at minority-serving institutions. And the definitions of minority-serving institutions are outside of the 7.7% that are at HBCUs are based on numbers, right? That has been how the Department of Education has defined Hispanic-serving institutions in particular, as well as Asian American and Native Hawaiian Pacific Islander institutions. And so we don't even have that type of data to talk about that angle of it because it's just a gap in terms of how we're reaching these students and how we're reaching these institutions. And the other piece is that the minority serving institution designation is at the undergraduate level and not in terms of graduate degree granting programs. In 2018, the CSWE had worked with a center at George Washington University to do a workforce study. And so here we're seeing where some of these, the respondents by race and by racial categorization fell in terms of pursuing a BSW or pursuing an MSW. And we do see some declines among some of the race ethnicities in terms of Asian-Americans. We see fewer, or we see more, I'm sorry, Asian-Americans who pursue the MSW than the BSW, but we do see that slight decline among African-Americans and some with multiracial individuals as well. In terms of Hispanic Latino ethnicity, we're roughly 15%, but then there's, in terms of language fluency and another language other than English, we see the higher proportion among those from a Latinx background. So I'm going to kind of skip over some of those pieces. And I just wanna talk briefly in terms of framing us as what is this behavioral health workforce? It's something that I think that we often take, it's easier to take a narrow view of it. And I take a slightly longer view of that, certainly where there's this continuum of services where people are working, as we know, from a institutionalized setting, state hospital, to various degrees of outpatient settings into a purely outpatient therapeutic environment. But we also do have to keep in mind the part about, and that's where it gets to that layering of the educational system. And that educators, I think, are a very important piece of the behavioral health workforce. Researchers are an important piece of the behavioral health workforce in terms of conducting that translational research, conducting that implementation science, conducting implementation science, so that we can have interventions, medications, psychosocial interventions, combination therapies, to be able to be delivered in these inpatient or outpatient settings. And so why do I care? Why do we care? And I think Dr. Lopez had alluded to this earlier that the Minority Fellowship Program has a long history. We've recently completed our 45th year of funding from the federal government. It had started in 1974 with funding for the first cohort from the National Institutes of Mental Health. Certainly the work was done before then. And the initial organizations that were funded for the MFP were social work, psychology, and nursing. So at the beginning, the funding was for DSW level researchers and practitioners. One of the pieces that it also accounted for was for native individuals. The goal was to fund them to get their MSW degrees. And that we are seeing, and using contemporary figures for that, individuals from American Indian and Native Alaskan groups constitute 1% of the US population, but account for less than two-tenths of a percent for all PhDs that were granted in recent years. After NIMH, or concurrent with NIMH funding in 2002, SAMHSA contributed funding for a program called the Clinical Fellowship. So they had picked up the Clinical Fellowship from NIMH, and NIMH for a period of time was only supporting a research fellowship until 2011 when NIMH ceased funding for standalone training programs like ours. And so since 2011, we've only been receiving funding from SAMHSA. And in 2014, SAMHSA added funding for master's fellowships. And so we've only in the last few years have begun supporting master's fellows at the master's level as well. As I had said, the MFP is funded by SAMHSA. There are additional MFP sister programs. In addition to CSWE, there are MFPs at the American Psychiatric Association, American Psychological Association, American Nurses Association, the Association for Marriage and Family Therapy, and at the NBCC Foundation that provides a fellowship for both certified counselors and substance abuse counselors. So here are some of the broad goals for the MFP that has been laid out with SAMHSA. But one of the pieces that, and so you see that there's collaboration, there's training, there's building that behavioral health workforce who can provide that leadership, consultation, training, services, administration to organizations throughout the behavioral health system. So we have had 650, more than 650 doctoral alumni. We have 245, I believe, master's alumni. This says nothing of our current fellows. We have actually, we were able to add funding for a 26th doctoral fellow, and we have actually 42 master's fellows. 42 master's fellows this year. And through the funding, we provide training, stipend, and mentoring to the fellows. And there is a two-year work requirement following completion of the fellowship in a behavioral health role. So some of our evaluation numbers indicate that 95% of our respondents have completed a degree, and four of the six had indicated who didn't, hadn't, are in the process of that. And contrasting that with our master's fellowship, where all of our master's fellows since 2014 have received their degree. Most of our fellows are employed in colleges or university settings, particularly in teaching and research environments. This is certainly driven by the fact that three quarters of our alumni are doctoral-level social workers, many who are contributing to faculties in social work and other disciplines around the nation. For our fellows who are in community practice among our master's fellows, about 20% are in community-based clinical practice, 16% are in hospital healthcare, and 15% are in school systems. The initial funding in 2014 from SAMHSA enabled us to focus on children, youth, and transition-age youth. And so that's where we see a larger proportion, especially among our earlier cohorts focused on children and adolescents within the last, since 2018, that distinction hasn't been in place. And so we've been able to accept fellows who are working in providing care to adults as well and older adults in different settings. Here we see that about a third said that fully 81% to 100% of their organization's client population were comprised of racial and ethnic minority groups. So we see a large proportion of our fellows who are in these settings providing care to racial and ethnic minority groups. When we look at doctoral education, we shine a little light on that. And we asked our fellows, would you go back and do it again? And I think it's striking that only six in 10 would go back and do a PhD again. About half would complete it in social work. Maybe they would have done it in a different field, but we see only 40% said they would go back and do it at the same institution. So I think that we're seeing these challenges in terms of training and preparation, but especially in terms of this culturally appropriate interpersonal skills. And I think that that's one of these pieces as I've been talking to the fellows, I've been the director of the MFP since 2018. So I've been able to see the MFP from the administrative side. I think that that's an increasingly sensitive point in their training in terms of learning these skills that are associated with success as it's been traditionally defined and how that, and the tension that is created with how that is consistent or in many ways incongruent with their own personal experience. And so what's one of these, what are some of these impacts of the MFP? And one of the pieces that we found is certainly that representation matters. It's important for our fellows when we've been able to gather in person and certainly for much of 2020, we haven't been able to gather in person, but it's to be able to be in these spaces where they're not alone, they're not isolated for being passionate about the topics that they're passionate about, whether that's how to work with individuals who are a varying documentation statuses, authorization statuses, to working with immigrants, working with refugees, working with black communities to help black communities heal and address the traumas that they've experienced and continue to experience. But that piece around representation is important and that piece around having a voice, whether it's within their school, with policymakers, within training programs as well. And I think that another piece of it is related to that representation and being able to see yourself there is that shared experience. That even though you might come from, you might be committed to bringing evidence-based practices to tribal communities, you understand the challenges of being in predominantly white institutions and share those challenges with somebody who is focused on Latinx communities or focused on Asian-American mental health. So that piece, not just to be able to see yourself and not feel so isolated, but also then to be able to share that experience and share your personal experience and interfacing with the needs of patients and clients who are from racial ethnic, underrepresented racial ethnic backgrounds and also your own personal journey, however that has looked in terms of your racial ethnic awareness and how you've integrated that into your own experience. And so I've tried to sum up how the MFP has embodied some of these values about representation and shared experience. And in some of the feminist literature on mentoring and training has really emphasized the need to listen. And so I want to say that we strive to listen to the fellows. We are at once validating their experience and empathic to the challenges that they may face within a practice setting, within a research environment, within an educational environment. We also do what we can to honor their legacies and certainly honor the MFP's legacies since the 1970s. And certainly the groundwork for that has took many, it took a lot longer to build to that, to be able to acquire funding from NIMH at that time. So we honor that our collective histories, but we're also having that eye towards future trends. And so that's keeping in mind that aspect of what's comes next. I know in social work, we spend a lot of time talking about how we don't, we need to increase our capacity to address substance abuse, substance use prevention, substance use treatment in our curriculum. And certainly that's one piece in terms of future trends that we look towards preparing our fellows for. We look for programmatic flexibility. So there's a degree where from the admin side, as I say, from this side of the podium, there are pieces that we're trying to provide a structured program that focuses their trainings, that will enable them to complete their program successfully, whether it's at the master's level, whether it's at the doctoral level, but also meet some of their goals and the various needs that they have that shift from year to year, from cohort to cohort. And so we, certainly it's difficult to plan educational training experiences that way, but it's something that we do try to empower our fellows to show that they have a voice in their training as well. And as well as giving alumni a voice in the training of future social workers, whether that's at the master's or the doctoral level. This fourth bullet in terms of balancing fellows needs with funding demands and expectations is certainly we are doing what we can to meet the parameters that we have stated to SAMHSA that we will do in our grant applications. But there's also this part of it. And certainly I think within the last, for most all of 2020, within the pandemic experiences, within the social, that the social movements, especially around Black Lives Matter has awakened, I think for all of us, this need to be human, this need to be individuals and understanding of that. And so we do try to balance some of those needs as individuals, especially as we work with mostly, well, the program has historically been targeted to members of underrepresented racial and ethnic groups. We do have fellows from any racial and ethnic group, all racial and ethnic groups are among our fellows because there is not that programmatic limitation anymore. And so there is always this balancing of needs with training expectations. So we're doing that through, I think, creating a learning environment. And I think that this is one of these parts that impact us in education and training, regardless of our disciplines, where we're trying to affirm and validate experiences. I was on a, hosting a panel recently with some fellows who were talking about their experiences as undergraduate or graduate students, and their experiences with racial and ethnic gaslighting, where people, whether that was students or professors or instructors who were just minimizing their experiences, minimizing the challenges that they have witnessed, that they have faced in their life. And so I think that that's one of these pieces that's crucial in terms of affirming that experience and validating that their personal experiences. I think something that we're worked on doing is promoting self-efficacy, identifying where they have self-efficacy in their own educational and training experience. But then it also tries to build community, and that's community of peer mentors within their cohorts, building community with alumni, with their mentorship, either their mentorship group or their formal mentors. We have mentoring groups in our master's fellowship that our master's fellows have urged us to have smaller groups. And in our doctoral fellowship, we were able to have individual mentoring matches, but that's one of these ways that we do try to build community and address some of those individual level needs. We're trying to empower their creativity, their thinking that they have these reasons why they had engaged in their training programs, why they are committed to addressing either mental health and or substance abuse, substance use needs in underserved racial and ethnic groups. So trying to foster that experience and that human aspect in terms of valuing authenticity that's empathic and that sees and understands their genuine selves. So going back to this social determinants of health model and in terms of education and training, I do want to reinforce that piece of talking and one of the things I guess I've been talking about in terms of the fellows and the MFP experience is that we're looking at that bridge between the population and the workforce. And so when we look at how do we move forward and where are we going to go? I had made this point earlier in terms of, we can't assume that just because you are from a racial and ethnic minority background that you'll work with or you're interested or committed to addressing some of those behavioral health needs from that racial and ethnic group that you come from. And so that I think at one level is we need to, we broadly in the field need to suspend some of those prejudicial thoughts and discriminatory sort of channeling that we may do in terms of the assumptions that we make for students as they go through training programs, as they become mental health professionals. So the consequence of that is that we need even more outreach, right? We need to have a larger pool of individuals in behavioral health programs in order to yield a professionally trained workforce that will engage in underserved communities. Something I think that we've been talking about a lot, certainly in social work over the last, within the last few years, and especially this year, is how do we address that role of class and privilege? Certainly there's those distinctions between predominantly white institutions and predominantly white private institutions, minority serving institutions and HBCUs. How do we value those, the experiences coming from those programs? How do we view individuals who are coming from those backgrounds? And in large part, some of those pieces are driven by the economics of the situation in terms of what access somebody has. And so it reinforces that need to look at that workforce pipeline from the high school level to the community colleges, bachelors and beyond. So within programs, we do need to look at that diversity and the diversity within programs, diversity within faculties and student bodies. It's hard for a student to not see themselves in the faculty. I know for myself, I distinctly remembered the day that I told my mother that I was going to go into social work. And before that, when I was going to major in psychology as an undergrad, and it was part of, I think, of that challenge is that there really wasn't a path, right? There wasn't a way to sort of indicate and to say, well, there are these individuals who have done that and that they have been successful so that there's not just one way to be successful and whether that's to go into engineering or to law or to medicine, but there might be another way. I think for students, what I've heard from the fellows is that they need to be seen in the curriculum, that it's challenging, it's detrimental when an African-American student sees the black experience represented in class from a deficit standpoint. And that increases the challenges that they face within their programs. Something that I think that we're struggling with in many social work programs, it is in particular and undoubtedly across our disciplines is are we training all students or are we specifically looking at how to train non-Hispanic white students? And if we're looking at being able to, and ostensibly, I think that there is a both and, right? That there is this need because if say 60, 70% of our student population is non-Hispanic white, that there is training that needs to be done around that for those individuals, but then there's also, how do we also ensure that students from populations of color are able to be seen in their programs? And I say that it's also important that we try to move towards a values-based system. I was having a conversation yesterday, actually, with a dean who, we were talking about mentoring, and then I asked this person about how her experience has been with the Black Lives Matter movement. It's something that their institution had been engaged with for a number of years. And it was very interesting to me to hear her say that they've moved away from trying to just use the language that using that language of, that we have an anti-black, anti-racist, that we adhere to anti-black, anti-racist pedagogies, but that they've defined a set of principles around those, just that language of anti-black, anti-racist pedagogies so that it's something that they can more easily access and say, well, this is the principle, this is the value that this particular activity connects to. I think that, especially for students from populations of color, I think that a workforce carrot is really important. We have that certainly through the MFP and federal funding. We see that in California with some of the behavioral health funding that's available for students in the California system, in the Cal State system in particular. We see that right now with the HRSA Behavioral Health Workforce Initiative. That is an ongoing call, or I think the call just recently came out in the last few weeks, to be able to increase the behavioral health workforce. But we also do need to kind of identify ways to leverage these opportunities, in particular for populations of color. There is pay equity issues, right? And it's an ever-present problem. I know in my own career and training, I took less money to work in an ethnic-specific behavioral health center than I could have made if I worked in the community mental health center down the street. But it raises this ethical issue of why should minority behavioral health work be paid less than other roles? And of course, this goes into the economic models that our community-based organizations, our mental health system is built upon, and disparities in reimbursement rates. And that's also in terms of Medicaid funding, Medicaid reimbursement versus private insurance, and what type and what level of private insurance. And those economic models, I think, have to shift as we move forward to be able to provide a sufficient carrot for individuals to engage in this work. So really, I do want to emphasize as we sort of unpack that piece on the community, and that it really is this interplay between consumers and patients and the community, behavioral health professionals, education at that high school level and post-secondary level, community-based organizations, researchers, educators, to work together because that's the only way we're going to be able to solve these complex issues that have been longstanding. These problems that are facing communities of color have not just been there for the last six months, the last nine months, but the last nine years, the last 90 years and beyond throughout the history of the United States. So it's going to take a concerted effort. And leadership through that to be able to do that. So I do say that we do need to sort of shift some of this peregrine dimes. I had brought up the issues of that shortage, but there's also this need for our communities to have a workforce that looks and sounds and can think like they do, and education and training curricula that honors the lived experience of these individuals. So actually I'm going to take a moment here to open up for questions because I realized that we're about 10 after the hour and we have about 10 or 15 minutes left together. I do have these pieces on our workforce needs, but I have also already touched on them throughout my talk so far. So I wanted to, I guess, welcome Dr. Lopez back onto the microphone and see what questions are coming up. All right, thank you so much, Dr. Nguyen, for the very comprehensive overview about the Minority Fellowship Program and more broadly about professional issues and training the diverse workforce. I think it's really important to recognize that the Minority Fellowship Program has been in existence for over 40 years. And given political shifts and given funding shifts, that is a major accomplishment. And the idea of representation and the idea of shared experience and developing that community is so critical to our needs as a nation. And all right, well, there are a number of questions that came up and I'll do my best to represent them. So Michelle Sermon and Kimberly White asked similar questions. Michelle Sermon asked, why the decline in African-Americans pursuing social work degrees? Any research underway to determine the factors? And then Kimberly White, a related comment or question said, interesting, I thought it was a decline in the non-AAs. I assume that's African-American. I thought it was a decline in non-African-American pursuing MSWs due to the lower pay range. Still not commensurate with what we do. Clearly social workers are not paid enough. No question about it. Yes. And across behavioral health professions, right? That there has always been that sort of depressed salaries. I think that it's, I'm not sure. And I think that that's an avenue for us to look at. We are looking at conducting a more comprehensive or another cycle of a workforce study to be able to look at what are some of those trends? Why are people not going into the continuing? Say from the bachelor's level to the master's level, there is that incentive, right? From the master's level in social work programs that from the bachelor's level, I mean that they can often receive advanced standing status in the master's program. So it's a shorter path to the master's degree. But I think that there are, as both of you have pointed out, these economic issues. There's economic issues in terms of being able to pay for a master's training. Even those advanced standing programs, I think that generally they are viewed as full-time programs. And so to be able to take a year of devoted to full-time study without considering of balancing other work needs is also coming from that position of privilege. All right, okay. Well, thank you. A related comment, a question that just came in is, what do you think is needed to be done to increase the wages of social workers and other behavioral health providers? And I was alluding to that towards the end in terms of, I think it gets to federal and state advocacy. I think it is in the fundamental ways that our mental health system is paid for. And that we essentially have two systems, right? We have a private system. Those who can access therapists and psychotherapists who are in private practice access psychiatrists who are in private practice. That's one system. And the publicly funded system is an underfunded system that negatively impacts community mental health across the country. And so I think I know that I'm aware of some of the initiatives in California that have tried to increase the number of students who are going into behavioral health, into mental health work, so that they're going to be working in particular counties of need in California. And I think those types of state initiatives are needed. And certainly at the federal level, which goes without saying, but certainly that's a harder nut to crack. Yeah. I wonder personally, if it's about the whole thing of stigma and mental health. I remember working at a regional center in the 90s, as well as working in mental health settings. The regional centers had really nice facilities for developmental disability, whereas the mental health facilities weren't as strong. And I wonder about the kind of prejudice stigma plays a role there. Yes. Okay. Anna Wells asked, she noticed, I noticed women were included in minority serving institutions, but it doesn't seem like they count in other statistics so far. Do you consistently include women as minority? So this ties to a specific aspect of your presentation. Yes, yes. You know, I think that it's a part of what, certainly it's embedded in all of what we do. Social work, I think as a profession, it has, I'm certainly in the minority. And certainly as a male-identified individual, I think that male-identified individuals account for about 20% of the social work in profession, 15 to 20%. And so there is that piece around, who's in the profession, who's in the classroom, and within social work that women are generally not underrepresented in that way. But I think that we do have to recognize that experience of women as well, and as well as LGBTQ populations. And gender non-conforming individuals, because all of these groups, as somebody has, I heard say recently, who said it so well, that when you're not the dominant, when you're not the default, you have women's studies, you have ethnic studies, you have African-American studies, Asian studies programs. In a way that we don't have men's studies programs, and we don't have white studies programs, because those are generally those default pieces. Okay. Michelle Sermon asked other questions. What are the racial and ethnic makeup of the fellows? And how many are attending minority fellowships? And how many are attending minority-serving institutions, particularly HBCUs? Yes. And then a related, I'll just combine these, what efforts does the Council for Social Work Education and SAMHSA make to bring the benefits of representation to the majority of racial and ethnic minority social work students? Yes. As a fellowship program cannot serve all of those in the work. So- Absolutely. What's the racial and ethnic makeup of the fellows, and how many are attending minority-serving institutions? And how about efforts for the greater group of folks who aren't fellows? Yes. So I think that, I was just looking through our list today. And so including HBCUs and HSIs, we have fellows at the master's level, I wanna say from about 20% of our master's fellows, 25% at least of the 45, so about 10 are from, at least 10 are from HSIs or HBCUs. Among our doctoral fellows, it's a little harder than to track in terms of those, not harder in terms of tracking, but there are fewer HSIs that are doctoral degree granting institutions. But I know that we have three of our 26 who are at HSIs or HBCUs. Oh no, four of our 26 from those programs. Racial ethnic background, we have, our numbers span all the racial ethnic categorizations. We have a lot of folks who are of mixed race. And so some of our racial ethnic numbers, because of being able to identify as more than one race, we do see that in large proportions. In terms of that last question about how to, how do we bring this out, right? How do we not make this such this exclusive club where we're able to serve maybe 70 people in a particular year? And I've been a part of some of those initiatives to try to break out of our walls and to instill some of these principles that we've developed in the MFP over time. We've started that for social work students who are pursuing doctorate education. There are interest groups that students are able to participate in through, in particular, the Society for Social Work and Research. And at the master's level, and actually through the doctoral level as well, it's having these types of conversations that I'm having today at this conference and being engaged in that conversation to be able to break out of these barriers of these pieces, because there's only so much that we can do with our funding from SAMHSA in any given year. And it's encouraging our fellows to be able to make those connections and to sow their seeds academically, professionally, through training, and how they can reach other individuals as well. Yeah, is there a role, Don Curry asked, is there a role for folks who are no longer students, who have been in the profession for a while, who can get involved in MFP? And so, on an annual basis, we do recruitments for volunteer mentors. And these individuals, it doesn't have, you don't have to be an MFP alum, like Dr. Lopez or like me, that we are always looking for people who can mentor. When our master's fellows said to me that they wanted us to try to get to one-on-one mentoring, and programmatically, I sit there and I say, it's hard to figure out how to do one-on-one mentoring with 40 people and finding enough people to be able to do that and to do that well. But on an annual basis, we do look for that. We do look for mentors to engage in our MFP and certainly in the other disciplines, MFPs, that they also look for mentors as well from, I know psychology, my colleagues over at APA, look for volunteer mentors, people to serve on their technical assistance committee. And actually, one thing I didn't mention is that there's a new interdisciplinary MFP that SAMHSA has funded. APA psychology is spearheading that effort and that's bringing together fellows from all of the disciplines that you had seen on the page, on the slide earlier, actually, except for psychiatry. So it's psychology, marriage and family therapy, nursing, social work, and certified counselors and addictions counselors to be able to have interdisciplinary training to address the needs of racial and ethnic groups from an interdisciplinary perspective. Actually, I sent in the chat the website to SAMHSA that lists all the different MFP programs. And we had two or three comments from nurses and I'm glad to hear that MFP also supports nurses. All right, one last quick question we have to leave in one minute. Are there any social work, since this is a focus on early psychosis, are there any social work programs that have structured programs and with coordinated specialty care early psychosis? I think- For 30 seconds, most every master's program in the nation has a clinical mental health track. And so there is coursework around early psychosis and particular around differential diagnosis. A lot of that work in social work is done in conjunction with their field placement sites. And so that's being those community partnerships between the School of Social Work and community organizations, hospital systems that are able to identify and provide the treatment that individuals with early psychosis need. All right, well, Dr. Zui Nguyen, thank you so much for a wonderful overview about training issues and how to increase representation, diverse representation and to improve our fields. Not just in social work because those same principles apply to the other disciplines as well. Thank you.
Video Summary
Dr. Zui Nguyen, the director of SAMHSA's Substance Abuse and Mental Health Services Administration, has presented on education and training to address behavioral health disparities. He discussed the Minority Fellowship Program (MFP), which has been in existence for over 45 years and aims to increase the representation of racial and ethnic minority professionals in the behavioral health workforce. The MFP provides training, stipends, and mentoring to fellows pursuing master's and doctoral degrees in behavioral health fields. Dr. Nguyen emphasized the importance of representation and shared experience in the workforce, as well as the need for diversity within faculties and student bodies. He also discussed the challenges of increasing wages for social workers and other behavioral health providers, highlighting the need for federal and state advocacy and changes to reimbursement rates. Dr. Nguyen stressed the importance of community partnerships and collaboration in addressing behavioral health disparities, and called for a shift towards a values-based system that honors the lived experiences of individuals from underrepresented backgrounds. The presentation also addressed the decline in African-Americans pursuing social work degrees and the efforts being made to understand the factors contributing to this decline. Overall, Dr. Nguyen emphasized the need to increase the diversity of the behavioral health workforce, expand access to education and training, and address the social determinants of health to better serve underserved communities.
Keywords
Dr. Zui Nguyen
SAMHSA
Minority Fellowship Program
behavioral health disparities
diversity
education and training
social workers
reimbursement rates
community partnerships
underrepresented backgrounds
social determinants of health
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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