Exclusion, Discrimination, and Systemic Harm in Mental Health Care Systems
- Brainz Magazine
- Sep 19
- 7 min read
Written by Sandi James, Psychologist
Sandi James is a psychologist who finds ways to help people with individualised and person-centred care. She is also a PhD candidate in Australia. Her specialties include long-standing eating disorders, addiction, and trauma and she is researching the harms that can happen during treatment for mental health challenges.
The mental health care system, ideally a safe space for healing, compassion, connection, understanding, and support, is often experienced as hostile, exclusionary, and harmful for countless individuals, particularly those from marginalized communities. Behind a facade of universal access, we find that a complex web of exclusion, discrimination, and systemic harm is deeply entrenched in policy, practice, and professional culture. This pervasive dysfunction results in significant disparities in access, quality of treatment, and long-term outcomes, transforming what should be a safety net into a source of enduring trauma for the most vulnerable in our society. Discourse on this ongoing crisis demands an analysis of its historical roots, its manifestations across diverse populations, mention of some of the forms of systemic harm, and the urgent reforms required to dismantle these entrenched inequities.
Historical and structural roots of systemic inequity
The exclusionary nature of modern mental health systems is a direct result of historical practices rooted in racism, ableism, and classism. From the 18th and 19th centuries, institutions were often founded on discriminatory assumptions. In the United States, for instance, racialized pseudoscientific theories were used to pathologize the psychological consequences of slavery and systemic oppression, leading to distinct, inferior treatment pathways for Black and other minority patients. This history of medical neglect, experimentation without consent, and the over-diagnosis of oppositional or aggressive disorders in minority populations has created a legacy of profound mistrust that persists today.
This historical context developed into the Structural Determinants of Mental Health (SDMH), which are the fundamental social and economic conditions that shape health inequities. Factors like residential segregation restrict access to high-quality care, resources, and stable housing, all of which are critical for mental well-being. Additionally, ongoing economic vulnerability imposed by systemic discrimination ensures that marginalized communities face disproportionately high rates of poverty and lack of adequate insurance coverage, translating directly into financial barriers to care. The system, therefore, begins its exclusionary work long before an individual steps into a clinic, by creating an environment where trauma is amplified and support is structurally out of reach.
Manifestations of exclusion and discrimination
The effects of systemic inequity are incredibly evident in the disparities experienced by marginalized groups, spanning racial, ethnic, sexual, gender, neurodiverse, and disability-based identities.
Racial and ethnic minorities endure a cruel paradox. While they report similar, or in some cases fewer, overall mental health disorders than the majority white population, the impact and severity of mental illness tends to be worse due to delayed or inadequate treatment. For example, research consistently shows that Black, Brown, Indigenous, and immigrant adults with moderate to severe symptoms of depression or anxiety are less likely to receive treatment than their white counterparts.
The barriers are layered and multidimensional. Cultural incompetence or ignorance in the current healthcare workforce reinforces a system built on "monocultural and reductionist frameworks." Providers often lack the training to understand how migration trauma, religious beliefs, or the constant stress of racial discrimination (leading to racial trauma) shape a patient's experience and presentation of symptoms. This leads to diagnostic bias, where symptoms of distress in children of colour, such as anger or sadness, are frequently misdiagnosed as behavioural issues like Conduct Disorder, while the same presentation in white children is more likely to be diagnosed as depression or anxiety. This diagnostic disparity shifts the intervention from therapeutic support to punitive control, driving individuals toward the criminal justice system rather than the care system. Furthermore, the chronic shortage of mental health providers of colour means that patients are often unable to find a clinician who shares their background, further compounding feelings of isolation and distrust.
The LGBTQ+ community, particularly transgender and gender non-conforming individuals, experiences heightened rates of adverse mental health outcomes, including mood disorders, substance use, eating disorders, self-harm, and suicidal ideation, largely due to minority stress stemming from systemic stigma and discrimination. Within the health care system itself, these individuals often face outright rejection, pathologizing of their identity, or a complete lack of culturally competent care that understands the unique psychological stressors of navigating transphobia or homophobia.
Individuals experiencing different physical or intellectual abilities (“disabilities”) also face multifactorial exclusion. Existing service models frequently fail to accommodate their needs, from physical inaccessibility of clinics to the assumption that their mental distress is solely a symptom of their disability rather than a response to environmental or social stressors. Structural stigma, manifesting in policies that underfund mental health research relative to other health conditions or limit community-based support, systematically curtails the opportunities for recovery and social integration for those with mental health challenges.
Systemic harm: Involuntary treatment, coercion, criminalization
One of the most profound and traumatic forms of systemic harm within mental health is the reliance on coercive and punitive measures, most notably involuntary commitment (or sectioning). While intended as a last-resort safety measure, the practice often inflicts deep psychological damage. The experience of forced hospitalization, physical and chemical restraint, and the resulting loss of autonomy can cause emotional distress, loss of trust, and refusal to seek further help, and the development of post-traumatic stress symptoms (PTSD) or exacerbation of current mental ill-health.
For marginalized groups, this harm is magnified. In regions or communities with poor access to preventative and community-based services, emergency departments, police contact, and involuntary hospitalization become the default entry points into the system. Indigenous people and people of colour with mental ill-health, for example, are more likely than other groups to enter secondary care services through non-health agencies, particularly the police, leading to a tragic criminalization of mental illness. This intersection of poor access and reliance on carceral interventions means that those who need care are met with force, further eroding trust and leading to devastating long-term outcomes. Data suggests that individuals evaluated for involuntary hospitalization are a highly vulnerable population, with significantly higher rates of death and criminal charges in the years following the evaluation, underscoring the systemic failure of the current crisis response model.
Paths to systemic reform and equity
Dismantling this deeply entrenched system of exclusion and harm requires an urgent, multifaceted, and revolutionary approach that shifts resources, policy, and procedure, and power dynamics.
Focus on structural determinants of health
Fundamental policy change must focus on the SDMH. This means advocating for universal and equitable health coverage, rigorous enforcement of mental health parity laws to ensure equal access for mental and physical health treatment, and widespread investment in community and neighbourhood resources (e.g., housing, employment, and education) that are the essential foundational protective factors against mental distress. Federal and local policy must be developed through an equity framework that recognizes and actively works to alleviate the stress imposed by generational poverty and socioeconomic disadvantage, generational and individual trauma, and structural oppression.
Redesigning models of care
Service delivery models and policies must be redesigned and transformed to be culturally and socially responsive and integrated. This includes:
Workforce diversification and quality training: We must develop effective and inclusive policies to recruit, train, and retain a mental health workforce that reflects the racial, ethnic, sociocultural, and sexual diversity of the population. All providers must receive mandatory, continuous training in cultural humility, implicit bias, and the impact of systemic racism and minority stress.
Integration and accessibility: Relocating some services out of specialized, isolated clinics and integrating them into easily accessible settings like primary care medical centres and community-based organizations. This strategy, often referred to as the "no wrong door" approach, helps avoid stigma and logistical barriers while providing more holistic and sensitive care.
Changing crisis response care: Investing heavily in mobile crisis teams and peer support programs that divert mental health emergencies away from the police and emergency rooms is essential. Peer support utilizes the power of shared lived experience to build trust and provide recovery-oriented, non-coercive assistance and connection.
Centre lived experience and focus on human rights
At the heart of any meaningful reform must be the voices of those with lived experience of mental illness and systemic harm. Policies must shift the power, moving resources and decision-making away from traditional, often paternalistic, psychiatric systems toward empowering individuals and communities. This means ensuring services are as least restrictive as possible, emphasizing fully informed consent and self-determination, and providing individuals with meaningful choices of providers and treatment modalities that are informed by their culture and context. The goal is to establish relationships between the care system and the individual on a foundation of trust, dignity, and respect, fundamentally altering the equation of power that has historically favoured coercion over compassion.
Final words
Exclusion, discrimination, and systemic harm are not mere side effects of mental health systems, they are core features, systematically perpetuated by historical injustices and maintained by current structural failings. The resulting disparities in health outcomes, the trauma of coercive practices, and the criminalization of distress represent a profound moral and public health failure. Rectifying this failure demands more than incremental adjustments, it requires an urgent, revolutionary commitment to health equity. By dismantling the structural determinants of poor mental health and radically redesigning a system that prioritizes cultural competence, community access, and self-determination over coercion, society can begin to fulfill the promise of mental health care as a true source of healing, support, and justice for all.
Read more from Sandi James
Sandi James, Psychologist
Sandi James is a psychologist who finds ways to help people with individualised and person-centred care. She is also a PhD candidate in Australia. Her specialties include long-standing eating disorders, addiction, and trauma. She is currently doing her PhD researching harms and adverse events that can happen during treatment for mental health challenges.
References:
American Psychiatric Association. (n.d.). Mental health disparities: Diverse populations.
CLASP. (2022, January). Core principles to reframe mental and behavioral health policy. Center for Law and Social Policy.
Department of Health and Social Care. (2018, December 18). Health matters: Reducing health inequalities in mental illness. GOV.UK.
HealthCity Editors. (2025, January 17). What is systemic racism in healthcare?: Causes, impacts, and solutions. HealthCity.
KFF. (2024, May 23). Racial and ethnic disparities in mental health care: Findings from the KFF survey of racism, discrimination and health. Kaiser Family Foundation.
Mental Health America. (n.d.). Interim public policy and equity framework.
Mental Health Foundation. (2023, March 20). Racism and mental health.
Racial disparities in mental health care: An explainer and research roundup. (2022, May 18). Journalist's Resource.
Shalev, A., Welle, B., & Bolotnyy, V. (2025, July 16). A danger to self and others: Health and criminal consequences of involuntary hospitalization (Staff Reports No. 1158). Federal Reserve Bank of New York.
Weeramanthri, T., Farrant, B., & Smith, J. (2024, January 12). The social determinants of mental health and disorder: Evidence, prevention and recommendations. The Lancet Psychiatry, 11(2), 114–124.
