A Tri-Country Analysis of the Effects of White Supremacy in Mental Health Practice and Proposed Policy Alternatives

The goal of this paper is to take a closer look at mental health care policies in Nigeria, China, and the United States. These nations were selected for their demographic diversity as well as for the shared on a multinational scale.

W estern-oriented psychotherapy 1 and mental health treatment have long held a dominant global position, while practices rooted in non-white cultures have been diminished or erased. As such, modern psychotherapy, to meet the needs of a diverse clientele in many countries and creates a gap between the intent of mental health policies-to provide mental practice (Koç & Kafa., 2019). With a culturally humble clinical approach, nuances and traditions and respect therapeutic alliances between clinicians and culturally diverse clientele. We use this frame to discuss approaches in Nigeria, China, and the United States (U.S.), and provide suggestions to address these issues. This paper posits that the current mental health policies and practices of Nigeria, China, and the U.S. do not fully support the mental wellbeing of respectively, have fostered perspectives built upon white supremacist health legislation and funding for state-operated Western psychiatric hospitals leave a backlog of patients with a limited number of providers to help (Abdulmalik et al., 2016). China's underfunding of traditional mental health practice and dearth of eligible providers in rural locations These phenomena are the result of increased hospital-based care following the introduction of Western-style psychiatric hospitals by 1898 and the gradual diminishing of community mental health programs such historical and cultural values as individuality, reductionism, measurement, materireliance on a medical model of alleviating symptoms (Koç & Kafa, 2019). during the 1966-76 Cultural Revolution (Liu et al., 2011). 2 The United States struggles with a lack of culturally conscious providers for those who are non-white, due to the high number of white providers Many non-white researchers and practitioners are actively working to incorporate culturally humble practices, but still the majority of mental health practices in the three focal countries undermine alternatives Gopalkrishnan, 2018).
Cultural humility is a critical consideration, both currently and historically, for mental health treatment for non-white populations within the United States, as well as for those living in nations with imperialist and colonist roots, such as China and Nigeria. Current practice in Nigeria, as well as the extent of such policy implementation within these countries. The term "traditional" will be used to encompass any mental that does not center white supremacist values. The term "Western" will be used to describe any practice that is eurocentric in nature and centers/is the result of white supremacist values. 3 BACKGROUND NIGERIA 2 Mental health system in China: History, recent service reform and future challenges is a source used for historical information and context. This source is not used for statistical data or present-day information.
3 "Eurocentric" refers to the tendency to interpret the world from the perspective of Euroof the mental health research published in the top six American Psychological Association journals have focused on either Americans or Europeans (Koç & Kafa, 2019). psychiatric symptoms through the lens of white supremacy in cultures that were traditionally non-western in nature (Studer, 2015). Colonial the British used reports from Nigerian psychiatric hospitals to maintain dominance over the colonies (Buoli, 2021). The introduction of Western culture and medicine produced an ideological culture clash and challenges often sought care from traditional healers known for treating clients holistically and reconnecting people with social and emotional resources rooted in community rules and relationships (Searight, supernatural or religious causes-causes colonial powers perceived as

CHINA
Traditional Chinese medicine encourages individuals to keep a dynamic balance of Yin and Yang to achieve a psychological and physiological state of stability (Zhang & Chi, 2013). Many traditional methods were developed to maintain this balance, such as massage, acupuncture, and physical and breathing exercises (Zhang & Chi, 2013). In the 19th century, traditional methods diminished from mainstream practice in held events like the "Hundred Days' Reform" in 1898 and advocated reforming previous political systems and, instead, studying Western ideology and technology (Kerr & Wright, 2015).
During the 19th century, facilities for individuals with mental health challenges did not exist. Due to limited resources and a lack of relatives with mental health challenges to their homes (Chiang, 2016). In 1898, American medical missionaries established and funded a Starting in 1966, the Cultural Revolution informed China's building of psychiatric hospitals throughout the country and the closure of many community-based programs (Li & Ran, 2021). As a result, traditional Chinese mental health practices continued to decrease, China's State Council issued a National Mental Health Work Plan which proposed a comprehensive coordination strategy focused on the improvement of the service system as a whole (Wang, 2017).
In addition to value discrepancies across mental health services, China resourced areas, the mental health system is rapidly reforming, whereas in under-resourced areas, such reforms are lacking (Liu et al., 2011).
community-based mental health practice, allocating funding to rural provinces. However, the country still faces issues of stigma attached to mental health providers, and general physicians lack the knowledge and skills for basic mental health treatment (Liu et al., 2011).

UNITED STATES
The U.S. is considered a melting pot, with a populace of diverse racial, racism in the U.S. guarantees policies deeply entrenched in white supremacist perspectives and values. In mental health settings, nonculturally humble practice, and academic and training institutions fail approaches are seldom applied in treatment.
U.S. mental healthcare has been historically shaped by white-centric practices, with the majority of treatment occurring in asylums and hospitals until the early 20th century. In the early 1800s, patients with mental health challenges were punished by practitioners who tied traditions that determined the worth of and punished those in poverty.
2006). Until the emergence of mental health institutions, families often sent relatives with mental health challenges to almshouses: residential the mid-1800s, the federal government responded to ongoing advocacy to human rights violations including a severe lack of informed consent, collaborated with policymakers to establish more humane mental diverting funding to community-based mental health services.
The 1963 Community Mental Health Act cemented the closure of these hospitals, instating a policy that reserved admittance to state facilities for patients who posed imminent danger to themselves or others (Testa & Wilson, 2021). While this legislation marked progress, the standards for those within the aforementioned high-risk demographic continue to pose concern today. Many social workers and activists believe these standards of imminent danger are harmful to individuals admitted to state facilities, citing a lack of informed consent and autonomy (Substance Abuse and Mental Health Services Administration, 2019).
Colonial mental healthcare, and resulting Western psychotherapy practices, continue to dominate U.S. practice, despite their failure to attend to diverse lifestyles and ideologies. An example is the use of diagnostic criteria in clinical settings, which often fails to account for Gambrill's work has supported this argument, asserting that the from environmental (social, political, and economic) context.
In addition, mental health clinicians in the U.S. are disproportionately white and their perceptions of non-white patients tend to be limited, often causing inaccurate stereotypes regarding type and degree of mental health challenges to be imposed (Luona et al., 2018). Black clinicians' services, and are perceived as less intelligent, more likely to abuse alcohol and substances, and less likely to be rational and comply with prescriptions (Yeager et al., 2013). White clinicians are also more et al., 2013).
Tendencies favoring white supremacist views on mental health of non-white individuals in the United States. In white-centric mental healthcare, non-white individuals often encounter microaggressions they do not encounter with clinicians from similar cultural, racial, or ethnic backgrounds. Many patients of color report that they are not carefully listened to or given proper explanations, are denied respect, and struggle to communicate with white clinicians (Yeager et al., 2013). This lack of cultural humility in services further causes non-white Though mental health treatment has continued to improve, about one and about 1 in 20 experience serious mental health challenges. Despite year (Mental Health by the Numbers, 2020). Additionally, as of 2020, access to mental healthcare, highlighting an urban-rural resource divide counties did not have a single practicing psychiatrist (Mental Health by the Numbers, 2020). Though the U.S. boasts a wide variety of mental health providers (psychiatrists, psychologists, licensed social workers, etc.), most are concentrated in and around urban areas.

COUNTRY VARIATION IN POLICY
Nigeria's government is based on democratic principles, with balanced power at the federal, state, and local levels. Mental health treatment is overseen by the federal government's National Health Policy, from which mental health is largely excluded (Abdulmalik et al., 2016). Given the country's status as a low-to middle-income country, health spending include mental health challenges; Prynn et al., 2019). As a result, mental health is not a priority. Abdumalik et al. (2016) found that unlike China, minimal coverage for mental health conditions (Finch, 2013). Although community-based insurance schemes and state and local social welfare payment. Treatment also most often occurs within primary care facilities, supplied by general practitioners trained to prescribe a limited array of psychotropic medications (Abdumalik et al., 2016).
In China, prior to the introduction of psychiatric hospitals, communitybased healthcare in the form of support from families, friends, and/or community healers was common practice (Liu et al., 2011). Today, most Chinese mental health treatment remains hospital-based. With a highly facilities and insurance providers; however, more research is needed to determine the true extent of mental health coverage from both public and private insurance. According to the most recent data in 2013, the costs for inpatient and outpatient psychiatric treatment was an average below the poverty line of $1.00 per day (Liang et al., 2017). magnitude of mental health needs and available treatment. Close to (Liu et al., 2011). With psychiatric hospitals receiving a majority of the government's budget for mental health care, individuals experiencing more common mental health challenges such as depression and anxiety are left with few resources to access treatment. China has less than a no counselors or social workers, as "social work" constitutes an entirely The capitalistic system in the U.S. impacts mental healthcare through high treatment costs only occasionally covered by insurance. Mental health costs are primarily associated with outpatient care and symptoms of mental illness but failing to address its root causes. U.S.
psychiatrists in the U.S. accept commercial insurance, and governmentpsychiatrists (Leonhardt, 2021). This phenomenon renders mental health treatment only accessible to those with economic means.
identity. Systemic oppression inhibits many Americans of color, most (Cook et. al, 2017). In this country, mental health challenges often coalesce with housing insecurity, incarceration, and racism, yet mental health treatment remains unacknowledged as a social justice issue. Instead, it is viewed as a privilege to which only some have access. When compared to the U.S., Nigeria and China experience a greater mental health (Zhou et al., 2019). Across all three countries, an extreme disparity in access to care exists between urban and rural areas. for all people" (MHAP, 2013, p.5). This approach focuses on the interconnections of both biological and social factors in one's life in order to understand the broader context of mental health needs, and is intended to result in more accurate diagnosis and treatment with a social justice lens (Susser et al., 2013). The MHAP is founded on the principle that mental health is a core element of individual and community health and is intrinsically linked to physical health (MHAP, 2013). This plan addresses the disparities between nation preparedness and execution of mental health treatment plans and legislation, primarily focusing on low-and middle-income nations such as Nigeria and China. Alternatively, high-income nations, such as the U.S., see greater progress in mental health care legislation (MHAP, 2013).
Nearly every aspect of the MHAP incorporates collaborative programs, community-based initiatives, and integrated care (MHAP, 2013). This plan calls on legislators to incorporate mental healthcare into practices, providing a collaborative and comprehensive approach to improving global mental healthcare. Comprehensive by nature, the plan incorporates "religious leaders, faith healers, [and] traditional healers" into policy guidelines and practice criteria (MHAP, 2013, traditional healing methods and provides lawmakers and leaders with tangible reasons to incorporate centuries-old practices into modern-day legislation and programming. Additionally, it highlights the importance of cultural humility in addressing the mental health needs of populations negatively impacted by white-centric approaches. In addition to the MHAP, in 2015 the UN added mental health to its Sustainable Development Goals and included in its declaration a call to access, the UN divided its mental health approach into three major areas: reducing premature mortality via care for mental well-being, preventing and treating drug use disorders, and achieving universal mental health legislation (Votruba et al., 2016).
Currently, global foundations of mental health education are based on Western practice and methodology, inhibiting non-Western nations from and treatment should integrate traditional and Western practices in a fashion that best supports the mental and social liberation of those oppression and social stigma across the globe.

POLICY ALTERNATIVES
supremacy, and racism present in mental health treatment in Nigeria, China, and the U.S., governments must respond with new policies and approaches to training mental health clinicians. In Nigeria and China, this includes centering traditional cultures, values, and methods. In the U.S., this includes more culturally humble and inclusive mental health practices centering non-white clientele.
Possible policy alternatives in these countries are vast. Increasing behavioral healthcare options in rural, under-resourced communities is one proposed approach. This could be achieved through government incentive programs for mental healthcare specialists to allocate time and resources in these areas. However, such programs will be costly, in lower-to-middle income countries like Nigeria.
Increased home-and community-based services, commonly found example would be implementing family-run groups that would support individuals with mental health challenges and their family members. Still, this approach could be challenging due to hospitals' incentives to be necessary.
Given these policy alternatives, a policy recommendation is proposed to address a combination of the outlined global needs. We recommend around the world to bolster their mental treatment plans. This is especially important for middle-to low-income countries to build upon their existing resources and ensure their most vulnerable populations experience increased access to mental healthcare. diverse identities to collaboratively gather baseline evidence on needed to priority, and treatment plans outlined for countries to access based on their own needs. Countries with low funding but high religious association, such as Nigeria, could access a plan that recommends collaboration between government entities and religious leadership to psychiatric care as opposed to outpatient care, such as China, could access a plan to increase investment in community-based mental health treatment. Countries with a history of racial, ethnic, or religious oppression, such as the U.S., could access recommendations on how to dismantle such systems.
With collaboration between international clinicians, researchers, academics, and other health personnel, this policy recommendation aims to integrate Western and traditional practices. Beyond a moral incentive for countries to support this initiative, countries would also healthcare costs associated with mental health disorders and their especially important to assess the power dynamics of those involved in the planning and research process.
Careful consideration would need to be given to identifying global mental health "experts," including entities such as the American Psychiatric Association, whose votes determine the disorders and voices, and lenses beyond national borders be centered throughout the implementation process. All parties involved would have the power and agency to determine criteria for evidence-based practice and diagnosis The proposed system will need to be nimble and responsive to global population shifts and constantly changing mental health issues and sense of cultural humility in its approach. The result would be a global to plans for individual populations.