


































CSWR Spring 2022 




COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   87   

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

KRISTEN M. FOLKERTS
ISRA MERCHANT
CHENXI YANG



88  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

WHITE SUPREMACY IN MENTAL HEALTH PRACTICE

ABSTRACT

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 
PUÅ\LUJL�[OH[�,\YVWLHU�JVSVUPaH[PVU��PTWLYPHSPZT��HUK�^OP[L�Z\WYLTHJ`�
J\S[\YL�OH]L�OHK�VU�[OLPY�LX\HSS`�KP]LYZL�TLU[HS�OLHS[O�WVSPJPLZ�HUK�
WYHJ[PJLZ��/V^�KV�OPZ[VYPJHS�HUK�J\S[\YHS�WLYZWLJ[P]LZ�HɈLJ[�KPɈLYLU[�
nations’ mental health policies and approaches (via a multi-nation 
JVTWHYPZVU�&�;OPZ�HUHS`ZPZ�HPTZ�[V�[HJRSL�[OPZ�X\LZ[PVU��KPZJ\ZZPUN� 
how cultural humility both currently and historically informs mental 
health treatment for non-white populations within the United State. In 
addition it examines imperialist and colonial mental health treatment of 
local populations in China and Nigeria. Finally, a global policy strategy  
is presented to promote the practice of cultural humility on a 
multinational scale. 

Keywords: Cultural humility, Decolonization, White Supremacy, Global 
policy, Global mental health



COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   89   

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG

W
estern-oriented psychotherapy1 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, 

KPJ[H[LK�WYPTHYPS`�I`�(UNSV�(TLYPJHUZ�HUK�,\YVWLHUZ��PZ�PUHKLX\H[L�
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 
OLHS[O�ZLY]PJLZ�[OH[�TLL[�[OL�\UPX\L�ULLKZ�VM�HSS�WLVWSL·HUK�[OLPY�
practice (Koç & Kafa., 2019). With a culturally humble clinical approach, 
^L�JHU�YLJVNUPaL�[OL�PTWVZZPIPSP[`�VM�M\SS`�JVTWYLOLUKPUN�HSS�J\S[\YHS�
nuances and traditions and respect therapeutic alliances between 
clinicians and culturally diverse clientele. We use this frame to discuss 
[OL�ULNH[P]L�PTWHJ[Z�VM�>LZ[LYUPaLK�TLU[HS�OLHS[O�WVSPJPLZ�HUK�
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 
[OLPY�JP[PaLUZ��;OL�JVSVUPHS�HUK�PTWLYPHSPZ[�OPZ[VYPLZ�VM�5PNLYPH�HUK�*OPUH��
respectively, have fostered perspectives built upon white supremacist 
PKLHZ�^OPJO�OH]L�OHK�SHZ[PUN�LɈLJ[Z��5PNLYPH»Z�SHJR�VM�\WKH[LK�TLU[HS�
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 
SLH]L�JP[PaLUZ�PU�[OVZL�HYLHZ�^P[OV\[�HJJLZZPISL�TLU[HS�OLHS[O�JHYL��
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 

��¸>LZ[LYU�WZ`JOV[OLYHW`¹�PZ�H�[LYT�\ZLK�[V�YLMLY�[V�[OL�PUÅ\LUJL�[OH[�>LZ[LYU�J\S[\YLZ��
ZWLJPÄJHSS`�[OL�<�:���OH]L�OHK�VU�WZ`JOV[OLYHW`�WYHJ[PJL��;OPZ�WYHJ[PJL�PZ�PUÅ\LUJLK�I`�
such historical and cultural values as individuality, reductionism, measurement, materi-
HSPZT��HUK�VIQLJ[P]P[ �̀�0[�HSZV�OPZ[VYPJHSS`�LTWOHZPaLZ�H�MVJ\Z�VU�WZ`JOVWH[OVSVN`�HUK�
reliance on a medical model of alleviating symptoms (Koç & Kafa, 2019).



90  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

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 
PU�[OL�ÄLSK�HZ�^LSS�HZ�LK\JH[PVU�PUÅ\LUJLK�I`�^OP[L�Z\WYLTHJ �̀�
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 
�L�N���UVU�>LZ[LYUPaLK�WYHJ[PJLZ�HUK�J\S[\YHSS`�[YHKP[PVUHS�WYHJ[PJLZ"�
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 
LHJO�VM�[OLZL�JV\U[YPLZ�WYPVYP[PaLZ�^OP[L�JLU[YPJ�TLU[HS�OLHS[O�]HS\LZ��
JVUZLX\LU[S`�KLSLNP[PTPaPUN�[YHKP[PVUHS�TLU[HS�OLHS[O�WYHJ[PJLZ��;OPZ�
WHWLY�YL]PL^Z�WVSPJPLZ�W\[�PU�WSHJL�I`�T\S[PUH[PVUHS�VYNHUPaH[PVUZ��
HUHS`aPUN�[OLPY�PTWHJ[�VU�KPYLJ[�WYHJ[PJL�PU�[OL�<UP[LK�:[H[LZ��*OPUH��HUK�
Nigeria, as well as the extent of such policy implementation within these 
countries. The term “traditional” will be used to encompass any mental 
OLHS[O�WYHJ[PJL�[OH[�PZ�UV[�¸>LZ[LYUPaLK¹�VY�WYHJ[PJLK�I`�JVSVUPaLYZ�HUK�
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

/PZ[VYPJHSS �̀�WZ`JOPH[Y`�WYHJ[PJLK�PU�JVSVUPaLK�JV\U[YPLZ��VY�JVSVUPHS�
WZ`JOPH[Y �̀��YLWYLZLU[LK�[OL�ÄYZ[�H[[LTW[�[V�Z`Z[LTPJHSS`�PU[LYWYL[�

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 Euro-
WLHU�VY�(UNSV�(TLYPJHU�]HS\LZ�HUK�L_WLYPLUJLZ��4LYYPHT�>LIZ[LY���(Z�HU�L_HTWSL�� ���
of the mental health research published in the top six American Psychological Association 
journals have focused on either Americans or Europeans (Koç & Kafa, 2019). 

WHITE SUPREMACY IN MENTAL HEALTH PRACTICE



COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   91   

psychiatric symptoms through the lens of white supremacy in cultures 
that were traditionally non-western in nature (Studer, 2015). Colonial 
WZ`JOPH[Y`�ZLY]LK�HZ�VUL�VM�[OL�ÄYZ[�PUZ[HUJLZ�VM�WVSP[PJHS�JVU[YVS��HZ�
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 
Z\IZLX\LU[�\ULX\HS�WV^LY�K`UHTPJZ�IL[^LLU�>LZ[LYU�HUK�PUKPNLUV\Z�
5PNLYPHU�TLKPJPUL��:LHYPNO[���������0UKP]PK\HSZ�^P[O�TLU[HS�OLHS[O�
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, 
�������/V^L]LY��TLU[HS�OLHS[O�JOHSSLUNLZ�^LYL�MYLX\LU[S`�H[[YPI\[LK�[V�
supernatural or religious causes—causes colonial powers perceived as 
\UZJPLU[PÄJ��6KLIP`P���  �����6]LY�[PTL��>LZ[LYU�TL[OVKZ�KVTPUH[LK�

)LNPUUPUN�^P[O�)YP[PZO�JVSVUPaH[PVU�PU�5PNLYPH��WLVWSL�^P[O�TLU[HS�
OLHS[O�PSSULZZ�^LYL��THKL�PU]PZPIPSPaL�HUK�^LYL�YLZ[YHPULK�VY�KL[HPULK�
�6U`LTLS\R^L���������(Z`S\TZ5 were introduced in 1906, aimed to 
house the growing number of houseless so-called “lunatics”6 in urban 
centers (Faleye, 2017, p. 137). Today, the Nigerian government is unable 
[V�JVTTP[�[V�[OL�\[PSPaH[PVU�VM�[YHKP[PVUHS�TL[OVKZ��;OV\NO�5PNLYPH�
HJOPL]LK�PUKLWLUKLUJL�MYVT�.YLH[�)YP[HPU�PU�� ����JVSVUPZ[�PUÅ\LUJL�
WLYZPZ[Z��:LHYPNO[���������;OL�NV]LYUTLU[�OHZ�THKL�NYLH[�LɈVY[Z�[V�
train health personnel and provide modern health facilities, largely 
disregarding their country’s traditional healers (Gureje et al., 2015). 
>LZ[LYUPaLK�WZ`JOPH[YPJ�MHJPSP[PLZ�^P[O�JSPUPJPHUZ�[YHPULK�PU�TL[OVKVSVNPLZ�
YVV[LK�PU�^OP[L�Z\WYLTHJPZ[�PKLHZ�HYL�PUHKLX\H[L�[V�TLL[�[OL�ULLKZ�VM�
HSS�5PNLYPHUZ��;OLZL�PUHKLX\HJPLZ�PUJS\KL�H�SHJR�VM�YLJVNUP[PVU�VM�[OL�
^H`�YLSPNPVU�HUK�ZWPYP[\HSP[`�PUÅ\LUJL�[OL�WZ`JOVZVTH[PJ�L_WLYPLUJLZ�
VM�THU`�WLVWSL��9LZLHYJO�OHZ�MV\UK�[OH[�JP[PaLUZ�L_WLYPLUJL�MLLSPUNZ�
of alienation and dissatisfaction toward government policies, including 

��Appraisal of the Mental Health Care Policy in Nigeria is a source used for its historical 
information and context. This source is not used for statistical data or present-day infor-
mation.
5 Centers for those with mental health challenges were historically referred to as asylums, 
which is now acknowledged to be a derogatory term.
��(�KLYVNH[VY`�[LYT�\ZLK�[V�KLÄUL�[OVZL�^P[O�TLU[HS�OLHS[O�JOHSSLUNLZ�

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



92  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

healthcare policy, a result of decades of economic exploitation during 
)YP[PZO�JVSVUPaH[PVU��6KLIP`P���  ���W������;OPZ�J\S[\YHS�KPZYLNHYK�
discourages Nigerians from seeking mainstream therapeutic facilities 
�6KLIP`P���  ����

Though mental healthcare-promoting bills have been proposed, such 
as the Mental Health and Substance Abuse Bill in 2020, there have 
ultimately been few positive legal developments (Ugochukwu et al., 
�������(������>VYSK�/LHS[O�6YNHUPaH[PVU��>/6��YLWVY[�ZOV^LK�[OH[�
HIV\[�ZL]LU�TPSSPVU�WLVWSL�PU�5PNLYPH�HYL�Z\ɈLYPUN�MYVT�KLWYLZZP]L�
KPZVYKLYZ��HUK�����TPSSPVU�WLVWSL�HYL�Z\ɈLYPUN�MYVT�HU_PL[`�KPZVYKLYZ�
(Depression and Other Common Mental Disorders: Global Health 
Estimates���������-\Y[OLY�ÄUKPUNZ�OH]L�ZOV^U�[OH[�ML^LY�[OHU����
percent of those with mental health challenges have access to 
healthcare due largely to the country’s outdated laws and poor 
budgetary allocation that can be tied back to the economic exploitation 
and management of the colonial era (Soroye et al., 2021). 

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 
*OPUH��(M[LY�SVZPUN�[OL�:LJVUK�6WP\T�>HY��*OPUH�^HZ�\UHISL�[V�YLZPZ[�
[OL�LJVUVTPJ��WVSP[PJHS��HUK�J\S[\YHS�PUÅ\LUJL�VM�^OP[L�PTWLYPHSPZ[�MVYJLZ�
�)VYN���������6]LY^OLSTLK�I`�>LZ[LYU�PTWLYPHSPZT��*OPULZL�YLMVYTLYZ�
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 
HJJLZZ�[V�TLU[HS�OLHS[O�Z\WWVY[��THU`�MHTPSPLZ�PU�*OPUH�JVUÄULK�
relatives with mental health challenges to their homes (Chiang, 2016). 
In 1898, American medical missionaries established and funded a 

WHITE SUPREMACY IN MENTAL HEALTH PRACTICE



COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   93   

WZ`JOPH[YPJ�OVZWP[HS��;OPZ�ZL[�[OL�Z[HNL�MVY�H�JVUZVSPKH[LK�>LZ[LYUPaLK�
TLKPJHSPaH[PVU�HUK�PUZ[P[\[PVUHSPaH[PVU�VM�TLU[HS�OLHS[O��3P�
�9HU���������
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, 
HUK�>LZ[LYUPaLK�TL[OVKZ�L_WHUKLK��0U�������[OL�.LULYHS�6ɉJL�VM�
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 
HSZV�MHJLZ�HU�PULX\P[HISL�KPZ[YPI\[PVU�VM�TLU[HS�OLHS[O�YLZV\YJLZ��0U�^LSS�
resourced areas, the mental health system is rapidly reforming, whereas 
in under-resourced areas, such reforms are lacking (Liu et al., 2011). 
6]LY�[OL�SHZ[�[^V�KLJHKLZ��[OL�*OPULZL�NV]LYUTLU[�OHZ�WYPVYP[PaLK�
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, 
L[OUPJ��YLSPNPV\Z��HUK�J\S[\YHS�IHJRNYV\UKZ��/V^L]LY��[OL�\IPX\P[`�VM�
racism in the U.S. guarantees policies deeply entrenched in white 
supremacist perspectives and values. In mental health settings, non-
^OP[L�JVTT\UP[PLZ�HYL�\UKLYYLWYLZLU[LK��JSPUPJPHUZ�SHJR�WYVÄJPLUJ`�PU�
culturally humble practice, and academic and training institutions fail 
[V�HKLX\H[LS`�PU[LNYH[L�J\S[\YHSS`�H[[\ULK�WLKHNVN`��.VWHSRYPZOUHU��
�������4LU[HS�OLHS[O�YLZV\YJLZ�HYL�KPZ[YPI\[LK�\ULX\HSS`�HUK�[YHKP[PVUHS�
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 

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



94  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

[OLPY�Z\ɈLYPUN�JH\ZHSS`�[V�ZPU��:\JO�WYHJ[PJLZ�KH[L�IHJR�[V�7YV[LZ[HU[�
traditions that determined the worth of and punished those in poverty. 
(Z�H�YLZ\S[��WLVWSL�^P[O�TLU[HS�OLHS[O�JOHSSLUNLZ�Z\ɈLYLK�PUO\THUL�
JVUÄULTLU[�HUK�JVU[PU\LK�Z[PNTH[PaH[PVU��-SV`K����� "�(UNSPU�L[��HS��
2006). Until the emergence of mental health institutions, families often 
sent relatives with mental health challenges to almshouses: residential 
HJJVTTVKH[PVUZ�ILSVUNPUN�[V�JOHYP[`�VYNHUPaH[PVUZ��>PSZVU���������0U�
the mid-1800s, the federal government responded to ongoing advocacy 
LɈVY[Z�I`�ZL[[PUN�\W����Z[H[L�WZ`JOPH[YPJ�OVZWP[HSZ��/V^L]LY��[OLZL�
OVZWP[HSZ�^LYL�VM[LU�\UKLYZ[HɈLK�HUK�\UKLYM\UKLK��Z\IQLJ[PUN�WH[PLU[Z�
to human rights violations including a severe lack of informed consent, 
\UJSLHU�SP]PUN�X\HY[LYZ��THS[YLH[TLU[��HUK�HI\ZL��4MVHMV�4»*HY[O`�

�/\SZ���������0U�YLZWVUZL��HK]VJH[LZ��PUJS\KPUN�ZVJPHS�^VYRLYZ��
collaborated with policymakers to establish more humane mental 
OLHS[O�ZLY]PJLZ��\S[PTH[LS`�KLPUZ[P[\[PVUHSPaPUN�WZ`JOPH[YPJ�OVZWP[HSZ�HUK�
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 
J\S[\YHS�HUK�ZVJPHS�JSHZZ�KPɈLYLUJLZ�HJYVZZ�YHJPHS�HUK�L[OUPJ�NYV\WZ��
Gambrill’s work has supported this argument, asserting that the 
+PHNUVZ[PJ�HUK�:[H[PZ[PJHS�4HU\HS�VM�4LU[HS�+PZVYKLYZ��+:4��������
KLO\THUPaLZ�PUKP]PK\HSZ�I`�Z[YPWWPUN�[OLPY�SP]LK�L_WLYPLUJL�HUK�[YH\TH�
from environmental (social, political, and economic) context.

In addition, mental health clinicians in the U.S. are disproportionately 

WHITE SUPREMACY IN MENTAL HEALTH PRACTICE



COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   95   

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 
WH[PLU[Z�HYL�VM[LU�VU�[OL�YLJLP]PUN�LUK�VM�[OLZL�\UKLY�X\HSPÄLK�
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 
SPRLS`�[V�JVUJLW[\HSPaL�UVU�^OP[L�TLU[HS�OLHS[O�JOHSSLUNLZ�HZ�YVV[LK�PU�
PUKP]PK\HS�ZOVY[JVTPUNZ�YH[OLY�[OHU�ZVJPHS�Z[Y\J[\YHS�PULX\P[PLZ��@LHNLY�
et al., 2013). 

 Tendencies favoring white supremacist views on mental health 
JOHSSLUNLZ�OH]L�KLSL[LYPV\Z�LɈLJ[Z�VU�[OL�TLU[HS�OLHS[O�V\[JVTLZ�
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 
JVTT\UP[PLZ�[V�SVZL�JVUÄKLUJL�PU�TLU[HS�OLHS[OJHYL�ZLY]PJLZ��

Though mental health treatment has continued to improve, about one 
PU�Ä]L�(TLYPJHU�HK\S[Z�Z\ɈLY�MYVT�TLU[HS�OLHS[O�JOHSSLUNLZ�LHJO�`LHY�
and about 1 in 20 experience serious mental health challenges. Despite 
[OLZL�HSHYTPUN�Z[H[PZ[PJZ��VUS`�����^P[O�TLU[HS�OLHS[O�JOHSSLUNLZ�HUK�
����^P[O�ZLYPV\Z�TLU[HS�OLHS[O�JOHSSLUNLZ�YLJLP]L�[YLH[TLU[�PU�H�NP]LU�
year (Mental Health by the Numbers, 2020). Additionally, as of 2020, 
HWWYV_PTH[LS`�����TPSSPVU�(TLYPJHUZ��e�����SP]LK�PU�HYLHZ�^P[O�ZJHYJL�
access to mental healthcare, highlighting an urban-rural resource divide 
�4LU[HS�/LHS[O�I`�[OL�5\TILYZ���������0U�[OL�ZHTL�`LHY������VM�<�:��
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.  

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



96  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

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 
PZ�ZTHSS�HUK�SHYNLS`�WYPVYP[PaLZ�UVUJVTT\UPJHISL�KPZLHZLZ��5*+Z���
^OPJO�HYL�YLZWVUZPISL�MVY�����VM�KLH[OZ�^VYSK^PKL��5*+Z�KV�UV[�
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, 
^OPJO�WYV]PKLZ�JV]LYHNL�MVY� ���VM�P[Z�JP[PaLUZ��5PNLYPH»Z�UH[PVUHS�
PUZ\YHUJL�JV]LYHNL�VUS`�JV]LYZ�HIV\[����VM�[OL�WVW\SH[PVU��^P[O�
minimal coverage for mental health conditions (Finch, 2013). Although 
community-based insurance schemes and state and local social welfare 
PU[LY]LU[PVUZ�L_PZ[��TVZ[�TLU[HS�OLHS[O�[YLH[TLU[�YLX\PYLZ�V\[�VM�WVJRL[�
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, community-
based 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 
JLU[YHSPaLK�NV]LYUTLU[��*OPUH�OHZ�IV[O�WYP]H[L�HUK�W\ISPJ�OLHS[OJHYL�
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 
VM�� ������WLY�PUKP]PK\HS�HUK�����VM�[OVZL�^P[O�ZL]LYL�TLU[HS�KPZVYKLYZ�
PU�*OPUH�^LYL�\UHISL�[V�HɈVYK�[OL�ULJLZZHY`�[YLH[TLU[��HZ�[OL`�SP]LK�
below the poverty line of $1.00 per day (Liang et al., 2017). 

6IZ[HJSLZ�[V�JHYL�PU�*OPUH�HYL�L_HJLYIH[LK�I`�[OL�NHW�IL[^LLU�[OL�
magnitude of mental health needs and available treatment. Close to 
 ���VM�*OPULZL�JP[PaLUZ�YLWVY[�UL]LY�OH]PUN�YLJLP]LK�TLU[HS�OLHS[O�JHYL�
(Liu et al., 2011). With psychiatric hospitals receiving a majority of the 

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COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   97   

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 
X\HY[LY�VM�[OL�U\TILY�VM�WZ`JOPH[YPJ�WYV]PKLYZ�[OL�<�:��OHZ��HUK�]PY[\HSS`�
no counselors or social workers, as “social work” constitutes an entirely 
KPɈLYLU[�ÄLSK�PU�*OPUH�[OHU�PU�[OL�<�:���-HUN�L[�HS����������

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 
WZ`JOV[YVWPJ�TLKPJH[PVU�YH[OLY�[OHU�OVZWP[HSPaH[PVU��HKKYLZZPUN�[OL�
symptoms of mental illness but failing to address its root causes. U.S. 
TLU[HS�OLHS[O�[YLH[TLU[�OHZ�SHYNLS`�ILLU�I\PS[�HYV\UK�Z\JO�¸X\PJR�
Ä_LZ�¹�PUKP]PK\HS�[YLH[TLU[��HUK�OPNO�TLKPJH[PVU�JVZ[Z��3HYZVU���������0U�
������HWWYV_PTH[LS`� ���VM�(TLYPJHUZ�OHK�LP[OLY�W\ISPJ�VY�WYP]H[L�
OLHS[O�PUZ\YHUJL��2LPZSLY�:[HYRL`�L[�HS����������/V^L]LY��VUS`�����VM�
psychiatrists in the U.S. accept commercial insurance, and government-
ZWVUZVYLK�PUZ\YHUJL�WSHUZ�SPRL�4LKPJHYL�VUS`�JV]LY�HIV\[�����VM�
psychiatrists (Leonhardt, 2021). This phenomenon renders mental health 
treatment only accessible to those with economic means.

0U�[OL�<�:���KPɈLYLU[PHS�HJJLZZ�[V�[YLH[TLU[�VM[LU�PU[LYZLJ[Z�^P[O�YHJPHS�
identity. Systemic oppression inhibits many Americans of color, most 
UV[HIS`�)SHJR�(TLYPJHUZ��MYVT�HJJLZZPUN�LɈLJ[P]L�TLU[HS�OLHS[OJHYL�
(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. 
Further indicating the extreme need for increased access to mental 
healthcare, a study published in 2018 revealed the staggering statistic 
[OH[��������VM�(TLYPJHUZ�^P[O�TLU[HS�OLHS[O�JOHSSLUNLZ�^PSS�IL�
PUJHYJLYH[LK�PU�[OLPY�SPML[PTL��3HYZVU���������*VTWHYH[P]LS �̀�����VM�
people in state and federal prisons have been diagnosed with a mental 
illness (Prison Policy Initiative, 2022). These statistics demonstrate the 
ZLYPV\Z�YPZR�[OH[�\UPUMVYTLK��PUHKLX\H[L�TLU[HS�OLHS[O�JHYL�WVSPJ`�JHU�
pose to the lives of individuals in the United States. 

 When compared to the U.S., Nigeria and China experience a greater 

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



98  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

ZOVY[HNL�VM�YLZV\YJLZ��>OPSL�5PNLYPH�SHJRZ�HU�HKLX\H[L�U\TILY�VM�
TLU[HS�OLHS[O�JSPUPJPHUZ��*OPUH�Z[Y\NNSLZ�^P[O�[OL�Z[PNTH[PaH[PVU�VM�
[OL�WYVMLZZPVU�HZ�H�^OVSL��THRPUN�WLVWSL�OLZP[HU[�[V�LU[LY�[OL�ÄLSK�VM�
mental health (Zhou et al., 2019). Across all three countries, an extreme 
disparity in access to care exists between urban and rural areas. 

6UL�LSLTLU[�\UPX\L�[V�5PNLYPH�PZ�[OH[��HJJVYKPUN�[V�P[Z�JVUZ[P[\[PVU��
mental health treatment is seen as a right and a social justice issue 
(Abdulmalik et al., 2016). The Nigerian government acknowledges that 
TLU[HS�OLHS[O�JOHSSLUNLZ�VM[LU�PU[LYZLJ[�^P[O�KPZHIPSP[`�[V�PTWHJ[�X\HSP[`�
and length of life. Conversely, the Chinese government has not deemed 
TLU[HS�OLHS[OJHYL�H�YPNO[�HUK�]PL^Z�PU]VS\U[HY`�OVZWP[HSPaH[PVU�HZ�H�
WHY[�VM�WH[PLU[�JHYL��5PNLYPH��I`�JVU[YHZ[��JVUZPKLYZ�Z\JO�OVZWP[HSPaH[PVU�
a human rights violation; Abdulmalik et al., 2016). Finally, though 
VYNHUPaH[PVUZ�SPRL�[OL�(7(�PU�[OL�<�:��OH]L�YLJVNUPaLK�TLU[HS�OLHS[O�
HZ�H�O\THU�YPNO[��[OL�<�:��NV]LYUTLU[�OHZ�`L[�[V�YLJVNUPaL�OLHS[O�HZ�H�
human right, let alone mental health (Gerisch, 2018). 

CURRENT GLOBAL INITIATIVES

4\S[PUH[PVUHS�VYNHUPaH[PVUZ�Z\JO�HZ�[OL�<UP[LK�5H[PVUZ��<5��HUK�[OL�
>/6�OH]L�KL]LSVWLK�PUP[PH[P]LZ�ZWHUUPUN�T\S[PWSL�JVU[PULU[Z�[V�Z\WWVY[�
the expansion and development of mental health policy (Department 
VM�,JVUVTPJ�HUK�:VJPHS�(ɈHPYZ, 2015; MHAP���������0U�������[OL�>/6�
initiated a Global Mental Health Action Plan (MHAP) to be completed 
in 2020 with the purpose of guiding nations to increase the availability 
HUK�X\HSP[`�VM�TLU[HS�OLHS[OJHYL��MHAP, 2013). Dr. Margaret Chan, 
+PYLJ[VY�.LULYHS�VM�[OL�>/6��Z[H[LK�[OH[�¸[OPZ�JVTWYLOLUZP]L�HJ[PVU�
WSHU�YLJVNUPaLZ�[OL�LZZLU[PHS�YVSL�VM�TLU[HS�OLHS[O�PU�HJOPL]PUN�OLHS[O�
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 

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COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   99   

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 
LɈVY[Z�[V^HYK�WV]LY[`�YLK\J[PVU�HUK�KL]LSVWTLU[�Z[YH[LNPLZ�HUK�
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, 
W�������;OPZ�WYHJ[P[PVULY�PUJS\ZPVU�HJRUV^SLKNLZ�[OL�ZPNUPÄJHUJL�VM�
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 
LU]PZPVU�H�^VYSK�^OLYL�LX\P[HISL�HJJLZZ�[V�JHYL�PZ�[OL�UVYT��=V[Y\IH�
L[�HS����������0U�VYKLY�[V�HJOPL]L�[OPZ�NSVIHSS`�PUJS\ZP]L��LX\P[HISL�
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 
LɈLJ[P]L��X\HSP[`�OLHS[O�JV]LYHNL��=V[Y\IH��L[�HS����������;OL�<5�HSZV�
JHSSLK�MVY�JVSSHIVYH[P]L�HWWYVHJOLZ��LUJV\YHNPUN�5.6Z�HUK�JP]PS�ZVJPL[`�
VYNHUPaH[PVUZ�[V�^VYR�^P[O�UH[PVUHS�NV]LYUTLU[Z�[V�KL]PZL�LX\P[HISL�
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 
UVYTHSPaPUN�[YHKP[PVUHS�Z`Z[LTZ�VM�WYHJ[PJL�HUK�JHYL��;V�HKKYLZZ�NSVIHS�
TLU[HS�OLHS[O�JHYL�PULX\P[PLZ�TVZ[�LɈLJ[P]LS �̀�TLU[HS�OLHS[O�LK\JH[PVU�
and treatment should integrate traditional and Western practices in a 
fashion that best supports the mental and social liberation of those 

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



100  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

ILPUN�ZLY]LK��-VY�T\S[PUH[PVUHS�HWWYVHJOLZ�[V�LɈLJ[P]LS`�PTWYV]L�
TLU[HS�OLHS[OJHYL��P[�PZ�PTWLYH[P]L�[OH[�[OL`�LTWOHZPaL�KP]LYZP[`�VM�
WYHJ[PJL��SLNP[PTHJ`�VM�[YHKP[PVUHS�JHYL��HUK�KPZY\W[PVU�VM�PUZ[P[\[PVUHSPaLK�
oppression and social stigma across the globe. 

POLICY ALTERNATIVES

;V�YLZWVUK�[V�[OL�PUÅ\LUJLZ�VM�JVSVUPaH[PVU��>LZ[LYUPaH[PVU��^OP[L�
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, 
YLX\PYPUN�H�NV]LYUTLU[HS�JVTTP[TLU[�[V�SVUN�[LYT�M\UKPUN��LZWLJPHSS`�
in lower-to-middle income countries like Nigeria.

Increased home- and community-based services, commonly found 
[V�IL�JVZ[�LɈLJ[P]L��PZ�HSZV�LUJV\YHNLK��5L^JVTLYL[�HS����������6UL�
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 
WYV]PKL�JVZ[S`�PUWH[PLU[�JHYL!�SLNPZSH[PVU�HSSVJH[PUN�Z\ɉJPLU[�M\UKZ�^V\SK�
be necessary. 

Given these policy alternatives, a policy recommendation is proposed 
to address a combination of the outlined global needs. We recommend 
[OH[�H�OLHS[O�MVJ\ZLK�T\S[PUH[PVUHS�VYNHUPaH[PVU��Z\JO�HZ�[OL�<5�VY�[OL�
>/6��PU]LZ[�PU�HU�L]PKLUJL�IHZLK�YLZV\YJL�Z`Z[LT�HSSV^PUN�JV\U[YPLZ�
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. 

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COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   101   

;OPZ�WVSPJ`�YLJVTTLUKH[PVU�^V\SK�YLX\PYL�TLU[HS�OLHS[O�L_WLY[Z�VM�
diverse identities to collaboratively gather baseline evidence on needed 
JV\U[Y`�ZWLJPÄJ�YLZV\YJLZ��5LLKZ�^V\SK�[OLU�IL�JH[LNVYPaLK�HJJVYKPUN�
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 
HKKYLZZ�IHZLSPUL�TLU[HS�OLHS[O�PZZ\LZ��*V\U[YPLZ�^OV�OH]L�WYPVYP[PaLK�
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 
IL�PUJLU[P]PaLK�[V�PUZ[P[\[L�TVYL�LɈLJ[P]L�TLU[HS�OLHS[O�[YLH[TLU[�
HTVUN�[OLPY�JP[PaLUZ�[V^HYK�[OL�NVHS�VM�WYL]LU[PUN�M\[\YL�HUK�SVUN�[LYT�
healthcare costs associated with mental health disorders and their 
YLZ\S[PUN�WO`ZPJHS�ZPKL�LɈLJ[Z��;OYV\NOV\[�PTWSLTLU[H[PVU�P[�^PSS�IL�
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 
JYP[LYPH�PUJS\KLK�PU�[OL�+:4��0[�PZ�LZZLU[PHS�[OH[�THYNPUHSPaLK�WVW\SH[PVUZ��
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 
PU�KPɈLYLU[�J\S[\YHS�JVU[L_[Z��

The proposed system will need to be nimble and responsive to global 
population shifts and constantly changing mental health issues and 
WYPVYP[PLZ��;OPZ�WVSPJ`�YLJVTTLUKH[PVU�VɈLYZ�H�WV[LU[PHS�ZVS\[PVU�
LUJVTWHZZPUN�H�KLJVSVUPaH[PVU�MYHTL^VYR�^OPSL�THPU[HPUPUN�H�Z[YVUN�

KRISTEN M. FOLKERTS, ISRA MERCHANT, CHENXI YANG



102  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  

sense of cultural humility in its approach. The result would be a global 
TLU[HS�OLHS[O�LX\P[`�[VVS�[OH[�LZ[HISPZOLZ�WYHJ[PJHS�[YLH[TLU[�HUK�HJJLZZ�
to plans for individual populations.

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