_______ Christine Velez, PhD, MSW, Assistant Professor, Department of Social Work, Maria Mercedes Avila, PhD, MSW, Professor, Department of Pediatrics, and Esther Doh, MSW, a program coordinator, Department of Pediatrics, University of Vermont, Burlington, VT. Copyright © 2024 Authors, Vol. 24 No. 3 (Fall 2024), 628-638, DOI: 10.18060/27630 This work is licensed under a Creative Commons Attribution 4.0 International License. Lessons Learned From the Implementation of a Federal Behavioral Workforce Diversity Grant at a Predominantly White Institution Christine Velez Maria Mercedes Avila Esther Doh Abstract: The Health Resources Services Administration’s (HRSA) Behavioral Health Workforce Education and Training (BHWET) grant program is a unique opportunity for social work programs, as well as other disciplines such as counseling, to address shortages in the behavioral health workforce and support integrated care approaches and interprofessional collaboration. BHWET programs support Anti-Racist, Diversity, Equity and Inclusion and Justice (ADEIJ) goals through recruitment and training of historically underserved and underrepresented students. In this preliminary program review, we explain program structure, institutional context, and demographic data to share lessons learned after 3 years of program implementation. We provide specifics on financial institutional policies which created financial barriers to underserved and underrepresented students, particularly students of color, participating in this federally funded training grant program. Keywords: Health Resources Services Administration’s (HRSA) Behavioral Health Workforce Education and Training (BHWET), social work, Anti-Racist, Diversity, Equity and Inclusion and Justice (ADEIJ) There is a national shortage of behavioral health providers across the United States (US), as more than half of the US population resides in a Mental Health Professional Shortage (MHPS) area (Counts, 2023; Health Resources Services Administration [HRSA], 2023). There has been a historical underinvestment in behavioral health programs (Counts, 2023; Stuart et al., 2009). The Affordable Care Act of 2010 acknowledged these shortages, however, the opioid epidemic, housing, and climate crises to name a few, all exacerbated by the Covid-19 pandemic, have contributed to rising rates of suicide, overdoses, and depression (HRSA, 2023; Padykula et al., 2020). Provider shortages and lack of access are driving mental health disparities. A lack of racial and ethnic diversity persists amongst behavioral health providers, as the majority of clinicians in the US identity as white and female (HRSA, 2023). Social workers and mental health counselors make up the majority of the behavioral health workforce. With rising costs of higher education and provider burnout, recruitment and retention efforts are one strategy to address provider shortages, especially in rural areas. This article describes the lessons learned in the first three years of implementation of a federally-funded workforce diversity development training grant for graduate students in social work and counseling programs at a predominantly white institution (PWI) in the northeast, which also happens to be the state’s flagship institution. Our program focuses on building a diverse workforce through training and financial support. The Behavioral about:blank Velez et al./FEDERAL WORKFORCE DIVERSTY GRANTS 629 Health Workforce Education and Training (BHWET) Program, funded by the Health Resources and Services Administration (HRSA), aims to address the national shortage of “youth focused behavioral health providers within integrated care teams” (HRSA, 2023 para. 1). One BHWET program goal is to train a more diverse workforce. BHWET programs are aimed at addressing the need for high quality behavioral health care, particularly in integrated health settings, by providing specialized training in integrated and interprofessional team-based approaches to service provision (Kepley & Streeter, 2018). Eligibility requires that trainees be in their second-year internship, in settings serving historically underserved populations. Research has identified that significant exposure to unserved and underserved populations while as a student can influence a student’s desire to work in those settings post-graduation (Kepley & Streeter, 2018). In this paper we reflect on the challenges faced implementing this HRSA workforce development grant that centers interprofessional collaboration and diversity of the behavioral health workforce. We identify our grant funded program structure and discuss specific challenges faced in the first three years of program implementation. We reflect on structural hurdles we faced within the context of a PWI, and as a group of social workers and academics invested in equity and disparity issues impacting racially and ethnically diverse students. We present strategies employed to counter some of the challenges we faced. Although no formal evaluation documents were reviewed for this analysis, we do present demographic data of our student trainees to underscore the challenge in recruiting diverse student trainees as well as the dire need for more providers. We assert that we have valuable contributions to share regarding the implementation and execution of anti-racist, diversity, equity, inclusion and justice (ADEIJ) work in the context of a predominantly white institution (PWI). Since ADEIJ is an explicit component in the educational policy and accreditation standards outlined in the 2022 EPAS, HRSA BHWET programs have considerable potential in advancing said work as HRSA asserts that the lack of diversity amongst providers contributes to behavioral health disparities amongst racial and ethnic groups (Council on Social Work Education, 2022; HRSA, 2023). HRSA BHWET funding also brings unique opportunities to strengthen social work education and teaching in integrated and interprofessional care approaches. The principles of ADEIJ, which emphasize representation, inclusivity, and affirmation of one’s identities, align with anti-oppressive and anti-racist frameworks and focus on equity. We employ a framework of anti-oppressive practice to guide our assessment of program challenges we have encountered. An anti-oppressive informed approach centers equitable and collaborative approaches that have the potential to promote action-oriented responses at an institutional and systemic level (Danso, 2015; Mattson, 2014; Morgaine & Capous-Desyllas, 2014). An anti-oppressive approach also helps illuminate the PWI- specific challenges we encountered related to racial and ethnic diversity, as well as how we did our best to address them. This analysis, informed by anti-oppressive and anti-racist frameworks, acknowledges that provider shortages in behavioral health significantly impact communities of color and perpetuate mental health disparities. Inclusivity, diversity and representation matter and ADVANCES IN SOCIAL WORK, Fall 2024, 24(3) 630 have real life impacts. The following tenets of anti-oppressive approaches (Morgaine & Capous-Desyllas, 2014) guide our analysis: • We seek to avoid contributing to patterns of helping systems which might replicate/promote inequity and/or oppression (Smith et al., 2022). • Anti-oppressive frameworks use critical self-reflection as a tool of inquiry; as racially and ethnically diverse scholars ourselves, critical self and group reflection and discussion significantly guide this analysis. • We strongly believe that diversifying the behavioral health workforce can help to address mental health disparities, especially amongst racially and ethnically diverse groups. • Education and consciousness raising are vital components of anti-oppressive approaches (Smith et al., 2022). Federal Behavioral Health Workforce Diversity Funding The US faces an ever-increasing mental health crisis amongst people of all ages, particularly among children and youth (White House, 2022). Placing social workers in integrated behavioral health settings is one approach to address a rising national mental health workforce shortage. Although social workers are already important parts of the healthcare workforce, there is a continued need to expand and improve training and service delivery, which is often driven by cost saving measures aimed at simultaneously improving health outcomes (Fraser et al., 2018; Padykula et al., 2020; Zanskas et al., 2022). The Patient Protection and Affordable Care Act (PPACA) is focused on prevention and ADEIJ work both at our institution and in our state. We work and live in a predominantly white state, in a predominantly white institution, in predominantly white academic programs. Institutional Context Demographics of our institution and educational programs reflect demographics of our city and state: the state of Vermont is considered to be 92.9% white, our student population is 80.6% white, and faculty are 80.5% white (University of Vermont, 2023). Racially and ethnically diverse service users in our state are served by mostly white, female practitioners (Vermont Department of Health, 2023) and our social work and counseling programs reflect this demographic, despite previous efforts to racially and ethnically diversify both graduate programs. Of course, we understand the meaning of “diversity” as broad and one that includes more than race and ethnicity, although those are certainly important when considering structural inequities that perpetuate the oppression of marginalized communities. Our institution and state, like many others, have also made many commitments to improving and expanding ADEIJ related work. The support to pursue this HRSA grant, including structural support, is evidence of increased consideration to matters of diversity, inclusion and belonging. Increased attention to issues of representation, recruitment and retention are reflected in our own positionalities as women of color and scholars on our campus and in leadership positions. We leveraged these contextual factors and applied and were approved for a federal behavioral workforce training program funded by HRSA. Velez et al./FEDERAL WORKFORCE DIVERSTY GRANTS 631 Overview of Grant Program Structure Our program is one of 82 funded BHWET projects in 2021; there are similarities and differences amongst all programs. This training grant is for 29 graduate social work and/or counseling students each year of the grant, in their second year of study, and entering their second-year internship. Eligibility requirements also include that students must self- identify as historically underrepresented in the following categories: racial, ethnic, cultural, geographic, religious, linguistic, gender and sexual orientations (HRSA, 2021). Students’ second year internship placement must meet the requirement of an integrated and/or behavioral health setting, which includes K-12 school settings. Students were tasked with taking additional coursework and training in trauma-informed and resiliency specific practices. All trainees received a $10,000 stipend for participating in these training activities, paid directly to student accounts. Table 1, adapted from Sampson et al. (2020), identifies program goals and related activities. Table 1. Program Goals and Corresponding Activities All trainees must be MSW or counseling students in their second year of study and must be completing their second-year field placement in an integrated behavioral health setting Program Goals Program Activities Goal #1: Increase the diversity, skills, and professional self-efficacy of the behavioral health workforce Activities: (1) provided a meaningful financial stipend in the amount of $10,000 to reduce education-related expenses and (2) all recruited trainees identified as historically underrepresented in one or more of the following categories: racial, ethnic, cultural, geographic, religious, linguistic, gender and sexual orientations Goal #2: Enhance partnerships with community-based agencies that can serve as experiential training sites across Vermont Activities: (1) established new community partnerships sites in community-based integrated behavioral health settings serving high needs/high demands populations and (2) enhanced current partnerships by expanding internship positions and opportunities through already established relationships Goal #3: Enhance collaborative trauma-informed, culturally responsive didactic training/education Activities: (1) all trainees completed additional training in trauma-informed and resiliency-based content Implementation Challenges We experienced several noteworthy challenges in implementing this program; we assert that these insights could be helpful for other professionals interested in expanding and enhancing ADEIJ focused work. Additionally, for early career scholars on tenure track and/or pursuing tenure and promotion, these reflections can be useful in understanding the nuances and complexities of applying for and implementing federal grant programs, especially within the context of a PWI. ADVANCES IN SOCIAL WORK, Fall 2024, 24(3) 632 Our program was approved with funding in summer 2021, during a spike of Covid-19 infections in our state, nationally and globally. Agencies and organizations locally struggled with staff shortages and turnovers during this time, and many internship sites decided not to host students due to capacity issues around supervision. Our program also experienced challenges related to differing understandings around interprofessional and integrated care in field settings (Padykula et al., 2020). What follows are lessons learned as well as strategies for how we addressed them. Recruitment of Historically Underrepresented Students In our small state in the Northeast, there is an established lack of racial and ethnic diversity within the behavioral health workforce, which perpetuates racial and cultural inequities (Richards, 2017). Our institution is in a city that is 91.9% white (US Census Bureau, 2024). Since one of the goals of BHWET funds is to diversify the behavioral health workforce, one aim is to recruit diverse and historically underrepresented students. While we succeeded in recruiting the necessary number of students over the course of three years, few of these students identified as students of color. Ultimately, there is very little racial and/or ethnic representation amongst our student trainees in both years of implementing this grant (Table 2), and we do not think this is likely to change very much in coming years for several reasons. Eighty-seven percent of students in the sample identified as White, with no representation in any of the 3 years of Hispanic/Latina/o/x or Native American students. Black and African American and Asian students represented 4% and 3% of the sample respectively. We also believe the recruitment efforts, grants and scholarships availability, and application processes to attract diverse students need to be reassessed and implemented in meaningful ways to lead to recruiting students that reflect local and national demographic changes. Table 2. Sociodemographic Characteristics of Students Characteristic n (%) Year 1 (n=22) Year 2 (n=29) Year 3 (n=36) Full sample (n=87) Graduate Program Social Work 11 (50%) 22 (76%) 22 (39%) 55 (63%) Counseling 11 (50%) 7 (24%) 14 (61%) 32 (37%) Sex Female 18 (82%) 25 (86%) 28 (78%) 71 (82%) Male 2 (9%) 4 (14%) 4 (11%) 10 (11%) Non-Binary 1 (3%) 1 (1%) None or a combination of these 2 (9%) 3 (8%) 5 (6%) Race White 20 (91%) 29 (100%) 27 (75%) 76 (87%) Black or African American 4 (11%) 4 (4%) Asian 2 (9%) 1 (3%) 3 (3%) White/more than one race 4 (11%) 5 (6%) Note. n = 87. Participants were on average 32.7 years of age. Velez et al./FEDERAL WORKFORCE DIVERSTY GRANTS 633 However, this lack of racial and ethnic diversity meant higher rates of inclusion of other intersecting social locations and experiences that render individuals and communities “historically marginalized and underserved.” As such, our student trainees are “diverse” in many other identities and experiences such as first-generation college students, students with disabilities, religious minorities, students who have experienced adversity such as homelessness, substance use, and sexual and gender-based trauma, LGBTQIA students and veterans. This is consistent with ADEIJ initiatives which focus on broadening definitions of diversity (Nivet, 2015). Kirby et al. (2023) establish in their research that broadening the definition of diversity in this way might unintendedly contribute to what the authors identify as a “diluting of diversity initiatives” (p. 1) and potentially detract from the original purpose of efforts to diversify: These broad definitions omit or downplay demographic subgroups legally protected from discrimination, such as ethnic and religious minorities. Instead, they focus on differences related to personal perspectives and personalities- qualities that any individual may hold. Although this might seem more inclusive of a wider range of individuals, does it simultaneously erase oppressed groups? (p. 1). While it is certainly valuable to include the wide array of experiences and identities that categorize people as marginalized or underrepresented, we address the reality that students of color remain underrepresented and underfunded in most helping professions. Despite our efforts with this program, we have made no real inroads in diversifying race and ethnicity of our state’s behavioral health workforce. The lack of racial and ethnic diversity remains problematic and highlights the ways in which whiteness continues to dominate despite efforts to diversify (Kirby et al., 2023). When only one trainee who identifies as racially and/or ethnically diverse is at the table, it creates a dynamic in which the group will struggle to have meaningful engagement and conversations around complex topics such as race-based trauma (which is a topic covered in this training program) (Adams & McBrayer, 2020; de Saxe Zerden, 2016; Gershenson et al., 2021). The few racially and/or ethnically diverse trainees who are part of a grant centering interprofessional collaboration through learning and internship experiences shoulder the heavy burden of being the only one in the room with personal experiences with racism and racial/ethnic discrimination (Adams & McBrayer, 2020; de Saxe Zerden, 2016; Gershenson et al., 2021). This is not an ideal pathway forward for program implementation of a grant intended to support diversifying efforts of a behavioral health workforce to reflect growing racial and ethnic diversity trends amongst the population being served. Another troubling aspect is that while racial and ethnic diversity remains low in our state and at our institution, these demographics are slowly changing which increases the need for helping professionals to share demographics of those being served. Additionally, because this grant program used federal funds, we had to turn away international students who were interested in being a part of this training opportunity. Lastly, one of the most challenging aspects to navigate was the issue of white men applying on the basis that men as a category, are underrepresented in social work programs. ADVANCES IN SOCIAL WORK, Fall 2024, 24(3) 634 Stipend Disbursement and Subsequent Impact on Student Financial Aid Like most institutions of higher education, to disburse stipends to students, we are required to adhere to financial policies that are undergirded by federal policies. As much as we would have liked to have been able to simply write a check to each student, disbursing federal funds to students is a more complicated process. The disbursement of the $10,000 to students had to be managed by our institution’s Student Financial Services office. Thus, once the funds were released by our grants manager through our institution’s Special Projects Administration (SPA), student financial services applied the funds directly to a student’s account. The accounting process considers the amount of aid a student is already receiving into the financial aid award offered to them. As a result, the stipend is counted as income, and loan offers are recalibrated through an algorithm. In many cases, students who took out the most loans received less in that the accounting office applied the stipend to the total loan amount, leaving the student with no cash in hand to offset living expenses while completing their graduate studies. Another way to understand this is that graduate students essentially were forced to use funds to pay off student loans before they even graduate. The intention of a stipend is to offset the cost of living (Jimenez-Ekman & Gilmore, 2024), which is becoming increasingly expensive for graduate students. Whereas the average cost of a one-bedroom apartment nationally is around $1,000, the average cost of a one-bedroom apartment where our institution is located is around $1,500 (Brumer-Smith, 2024) and the cost of food, gas and other goods continues to increase. Additionally, students in the social work and counseling professions are required to complete two internships during their education. This usually amounts to an average of 600 hours an academic year in an unpaid internship. Ten thousand dollars has the potential to make a significant impact on the livelihoods and wellbeing of graduate students in helping professions, especially students who identify as marginalized and historically underrepresented. An unintended consequence of this financial policy was that some students declined the opportunity to participate in the program, as this approach to disbursement did not make sense for them financially. A major concern is that these types of financial barriers are likely discouraging students of color in social work and counseling (Ecton et al., 2021). All the students who declined happened to be students of color, once again perpetuating educational inequalities experienced primarily by racial and ethnic minorities and affirming findings from other scholars about students of color and financial aid access’s impact on graduate studies (Ecton et al., 2021). Although certainly we had trainees in our program who received the stipend in full, these were students who had taken out less in loans, or who had other tuition support (e.g., participant in child welfare title IV-E, recipient of GI Bill funding, etc.) A major concern is how these financial policies mirror welfare and public assistance programs, also through use of federal funds, that essentially keep people in cycles of poverty and financial insecurity through making sure that people don’t ever get “too much,” expecting them to thrive off of meager amounts of support. Our only recourse to addressing this challenge with stipend disbursement was to make future trainees aware of the potential impact of the $10,000 stipend disbursement and to Velez et al./FEDERAL WORKFORCE DIVERSTY GRANTS 635 encourage them to seek guidance from the student financial offices about the potential impact of this stipend on their overall award amount. Additionally, as many social justice- focused educators address economic injustice in their work, unfortunately, federal funds of this nature are unlikely to significantly impact income inequality. Future HRSA BHWET grantees should consider working with HRSA program officers to consider alternate ways of disbursing stipend funds to students. Although, technically, this approach to stipend disbursement might end up being applied to student loan debt amounts, when this occurs, it does little to relieve financial burden of students in the moment while they are trying to complete their graduate degrees. It furthermore perpetuates historical inequities disproportionately affecting racially and/or ethnically diverse students defeating the main goals of these programs. HRSA is clear that these funds should be used to offset the cost of living for current graduate students; if institutions and programs can find legal ways to disburse the entire stipend amount to students directly and allow students the choice to use funds in whatever way they need or to apply the stipend funds to their loans. This should ideally be the choice of the trainee, not dictated by institutional financial policies which operate to protect organizations and do not always have the best interests of students and student needs. Concluding Remarks and Implications for Social Work Programs such as HRSA’s BHWET can support efforts to address behavioral health provider shortages and diversity in the workforce. However, calling for more funding is simply not enough, as principal investigators, we must continue to disrupt the distributional policies and practices that curtail and restrict use of these funds (Laird, 2020). We support ongoing critical examination of how best to implement federal funds to address needs of underserved and underrepresented individuals and communities (Laird, 2020), especially for students of color. And we ultimately feel that schools of social work should continue to pursue this type of funding to support targeted, population specific training opportunities for students to continue to address the shortage of qualified behavioral health providers in underserved communities. It is also important to help improve the quality of care that vulnerable youth are receiving to address existing behavioral health disparities that persist in many marginalized communities (Held et al., 2019; Sampson et al., 2020). In our attempt to support efforts to increase diversity diversifying efforts of the behavioral health workforce in our state, we are concerned that we may be complicit in sustaining systems that benefit from whiteness (Kirby et al., 2023; Lerner, 2021). Although technically we met the requirements around recruiting a diverse group of students, racial and ethnic representation remains very low, cannot be overlooked, and has encouraged us to consider the impact of broadening the definition of diversity (Kirby et al., 2023). In a world where income inequality is exacerbated by sociopolitical structures benefiting from capitalism and neoliberalism. Those with the most financial need received the least amount from this stipend. In effect, it was difficult to attract and retain racially and/or ethnically diverse students to be a part of this program. We managed these challenges as best we could despite knowing our efforts were somewhat futile. We concur that a rigorous program evaluation design is needed on our part to be able to assess the impact and efficacy of this program (Sampson et al., 2020) and to structurally address the inclusion of racially ADVANCES IN SOCIAL WORK, Fall 2024, 24(3) 636 and ethnically diverse students in helping professions such as social work and counseling in predominantly white contexts. The Covid-19 pandemic and concurring workforce shortages made creating new internship placements, as well as enhancing existing ones, challenging. Despite these disruptions, we successfully navigated these obstacles and worked with our community partners to strengthen, innovate and improve existing internship sites. We conclude with insights into the demand for a diverse and skilled behavioral health workforce. We have to start a pathway to get historically underserved and marginalized students into the behavioral health field by first getting them into undergraduate programs and finding financial resources so professional degrees such as social work and counseling can be more accessible to underrepresented students broadly, and students of color specifically. We also believe meaningful efforts must be made to recruit, and more importantly, retain faculty from racially and/or ethnically diverse backgrounds. These efforts have proven futile in many PWI’s (Settles et al., 2022; Zambrana et al., 2017) and demand perseverance and accountability. In a country that is becoming majority racially/ethnically diverse (Jensen et al., 2021) it is imperative to support students in helping professions to obtain these degrees, and serve the communities they themselves are a part of. References Adams, T. L., & McBrayer, J. S. (2020). 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Author note: Address correspondence to Christine Velez, Department of Social Work, University of Vermont, Burlington, VT 05405. Email: cvelez@uvm.edu https://doi.org/10.1080/10437797.2021.1943585 https://doi.org/10.1080/10437797.2021.1943585 https://doi.org/10.1080/00221546.2021.1914494 https://doi.org/10.1080/00221546.2021.1914494 https://doi.org/10.1080/00221546.2021.1914494 https://doi.org/10.1080/10437797.2021.1943585 https://doi.org/10.2753/IMH0020-7411380104 https://doi.org/10.2753/IMH0020-7411380104 https://doi.org/10.2753/IMH0020-7411380104 https://www.census.gov/quickfacts/fact/table/VT/PST045224 https://www.uvm.edu/oira/enrollment https://www.healthvermont.gov/sites/default/files/document/HSI-stats-prov-sw22-report.pdf https://www.healthvermont.gov/sites/default/files/document/HSI-stats-prov-sw22-report.pdf https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/ https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/ https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/ https://doi.org/10.1111/soin.12147 https://doi.org/10.1111/soin.12147 https://doi.org/10.1080/26408066.2022.2049944 https://doi.org/10.1080/26408066.2022.2049944 mailto:cvelez@uvm.edu