Category Archives: race and mental health

Diabetes and Mental Health

37.3 million Americans—about 1 in 10—have diabetes.

About 1 in 5 people with diabetes don’t know they have it.

96 million American adults—more than 1 in 3—have prediabetes.

More than 8 in 10 adults with prediabetes don’t know they have it.

For the past three years, approximately 1.5 million new cases of diabetes were diagnosed each year. Many more go undiagnosed.

For people aged 10 to 20 years, new cases of type 2 diabetes increased for ALL racial and ethnic minority groups, especially Black teens.

This past week, the House of Representatives passed a bill capping the cost of insulin on Thursday night with unanimous Democratic support, a mere 12 Republicans voted for the legislation, with 193 voting against it (five didn‘t vote at all). The House (Democrats) voted to cap the price of insulin at $35. (The bill will go to the Senate after Easter).

FACT: The cost of insulin for patients WITH insurance ranges from $334 to $1,000 a month.
FACT: The manufacturing cost for a vial of insulin is approximately $10.
FACT: Many diabetes patients ration their medicines or discontinue them because of the cost.


  • uncontrolled diabetes is implicated in a threefold increase in vascular dementia
  • uncontrolled diabetes drastically increases the chance of stroke, which also brings an entire set of cognitive and physical consequences
  • untreated diabetes and prediabetes results in impaired attention and concentration, brain fog, fatigue, headaches, learning problems, and lethargy
  • diabetics have a much higher level of clinical depression and anxiety, medical related worries, financial hardship, and overall stress
  • diabetics are at higher risk for secondary events, such as car accidents, work disability, and falls
  • people with prediabetes are at far greater risk for long-term cognitive decline and memory problems because they most often walk around without any diagnosis or treatment
  • most people will have/will have a loved one, family member, colleague, or friend who suffers from diabetes and related sequela in their lives. As such, diabetes affects everyone
  • BIPOC individuals have a significantly higher rate of diabetes, with the highest group being Black men, women, and children
  • diabetic medical consequences that affect daily life include vision problems, neuropathy, chronic pain, kidney problems and possible renal failure, memory weakness, increased risk of hypertension, sexual dysfunction, tooth/gum problems, and foot/mobility problems
  • individuals with diabetes have a much higher chance of long-term consequences from COVID-19
  • the consequences of untreated or undertreated diabetes will create an added strain on the medical and mental health system, which is already under severe pressure. This, in turn, has a trickle-down effect on treatment of other conditions
  • as a psychologist, management of diabetes, medication regimen, diabetic self-care, nutrition, and related stressors are often a focus of treatment

(Data sources: Kaiser Health, WebMd 4/22, CDC, 1/22)

Black History Month, Heroes in Psychology

Olivia Hooker, PhD (1915-2018)
As a child, Dr. Hooker survived the Tulsa race massacre of 1921. She and her siblings hid behind a kitchen table while watching the destruction. She described the trauma as life-long, but it didn’t hold her back. Dr. Hooker was the first Black woman to enlist for active duty (Coast Guard) and the only Black woman in her Ph.D. class at the University of Rochester, graduating with honors.  She previously attended TC at Columbia University, where she obtained her master’s in psychology. She was told she was ‘not intelligent enough’ to proceed to the doctoral program, and subsequently transferred to the University of Rochester for her doctorate.

She began her mental health career at a prison in New York, counseling and supporting women with learning disabilities. For decades, she continued to work with neurodivergent people who had intellectual and developmental disabilities and established Division 33 of the American Psychological Association, which focuses on neurodiversity. She was also a distinguished professor of psychology at Fordham University, where she was a mentor to both students and faculty. She was a tireless voice for justice and equality, especially for neurodivergent individuals. Dr. Hooker died in 2018 at the age of 103.

Microaggressions are a public health crisis

In clinical psychology, microaggressions are defined as brief and relatively commonplace daily verbal, behavioral, or environmental indignities and incidents, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color.

Individuals may engage in acts such as avoiding eye contact on the street or making assumptions about someone’s intelligence or mental state. This ‘subtler’ type of discrimination negatively impacts health outcomes. Microaggressions have been described as “death by a thousand cuts.”

Microaggressions tend to be harder to identify than overt racism, more difficult to confront or address, or both, because victims of microaggressions may have different perceptions and racial realities than those who enact them.

An emerging body of research has found that people of color experience an array of microaggressions, ranging from being assumed to be a criminal, being presumed to be cognitively inferior, being exoticized, or being treated as a second-class citizen. From locking of a car door when approached, to stepping away from someone in an elevator, being singled out by security at an airport, a supercilious tone of voice from those in authority positions, to being trailed around the store while shopping… these actions are injurious to the mental health of those who are being aggressed against and they have a cumulative affect on medical and mental health.

The connection between microaggressions and health
An alarming set of data shows that perception of racial discrimination from doctors is associated with reduced trust in mental health professionals/physicians, as well as reduced adherence to treatment regimens among Black American adults suffering from chronic disease. In fact, individuals who perceive their doctors as engaging in microaggressions generally do not return to treatment. With anyone.  See Dr. Siddique’s series of seminars: Minority Mental Health: Everyday Traumas and Microaggressions

Lack of trust in providers due to discrimination is also related to lower levels of screening for cancer, heart disease, and diabetes in Black Americans. Racial discrimination is linked to unhealthy behaviors such as overeating, consumption of fatty and fast foods, and decreased exercise. Repeated exposure to discrimination has also been linked to substance use, including marijuana, alcohol, and tobacco among Black American teens and adults.

The connection between microagressions and mental health
Research on microaggressions provides strong evidence that they lead to elevated levels of depression, anxiety, and trauma among minorities. In several large studies, depressive symptoms were the link in the relationship between racial microaggressions and thoughts of suicide.

Finally, one recent study showed that Native/Indigenous Americans diagnosed with type 2 diabetes experienced racial microaggressions from their mental health care and medical providers. Among those sampled in the study, a correlation was found between microaggressions and reported histories of heart attack, depressive symptoms, and hospitalizations.

What to do?
So, as professionals in health care, how can we work to minimize the physical and psychological harm of overt racism and microaggressions? First, workplaces and health care training programs (such as medical and clinical psychology training programs and nursing schools) can provide better training to employees and students. Such training must include information on the impact of racism and microaggressions on health outcomes and should also increase awareness of one’s own biases. Training should include dialogues and language designed to promote mutual understanding.

This should be facilitated by training experts and focus on the impact of overt racism and microaggressions. Supervision matters, with peer groups, clinical directors, instructors, and program heads. As I have spoken and written about elsewhere, intake processes for new patients very rarely assess for contextual and racism factors in the past.

Active inquiry about microaggressions in the daily and overall life of our patients is mostly missing and absolutely crucial.

Second, health care institutions can create online resources for employees, students/interns, and patients. For example, The New School University’s Health Services created a microaggressions site that assists students with understanding the nature and impact of microaggressions.  As a student, intern, and resident of several excellent programs, I received no training in this area. I had to cobble it together and seek at my own mentors. This should become absolutely mandatory for training and continuing education requirements.

Third, policymakers should consider creating policies that address IRL microaggressions. Similar to sexual harassment policies, racial microaggressions policies can be created to protect individuals/students/employees from experiencing micro-aggressions.

The Psychological Importance of Juneteenth

Juneteenth not only celebrates the freedom of Black Americans from slavery, but it also is a time when achievements are noted and continuous self-development is encouraged.

People dress with pride to show spirit, sometimes in African garments. This day of national pride is celebrated with food, music, games, and other activities to promote cultural awareness and community cohesiveness. Memories are shared for passing down to generations.

Black Mental Health and Juneteenth
From the clinical psychology research on Black mental health: (1) messages focused on instilling a sense of pride and learning about the history of one’s racial group (i.e., cultural socialization); and (2) messages focused on increasing youth’s awareness of racial discrimination and skills to manage it (i.e., preparation for bias) are BOTH powerful psychologically.

Overall, cultural socialization messages are associated with positive psychological and academic outcomes for youth. Preparation for bias messages are sometimes linked with positive outcomes, but there are mixed findings indicating these messages in isolation may not be consistently helpful for youth. One reason for these mixed findings may be because youth need a combination of messages that prepare them for racial discrimination along with messages that instill racial self esteem and pride. For example, if parents only provide messages about racial bias without messages focused on pride, it may lead youth to feel worried or hopeless. A combination of racial pride and knowledge and conversations about racial bias led to stronger mental health outcomes.
(For a great review on the research, see  Umaña-Taylor & Hill, Journal of Marriage and Family, 2020).

Additional ways to celebrate Juneteenth:
Every time, every election.

Buy Black.
By buying black, people are also assisting in strengthening local economies and positive effects like the creation of more jobs.

Promote Black images and experiences in advertising, social media, movies and shows, podcasts, and webinars.

Share resources.
Share information about housing, job opportunities, banking and loans, medical resources and clinics, agencies, and educational opportunities.

Intergenerational conversations.
Build relationships and communication between younger and older adults.

Destigmatize mental health.
Black people are far less likely to seek mental health care. Statistics show that about 25% of Black Americans seek mental health care, compared to 40% of white Americans. Unequal access to health care is one major contributor to this disparity. The lack of cultural sensitivity by health care professionals, feeling marginalized, a history of exploitation by the medical field, the reliance on family, community, and spiritual support instead of medical or psychiatric treatment are others.

Culturally responsive mental health treatment is one way of addressing the disparities in psychological wellbeing in the Black community. Finding and sharing information about culturally informed and responsive mental health professionals and agencies is vital. Also see Racial Trauma and Mental Health.

Strengthen Community.
Conversation around what people can do together that they cannot do apart should be mindful, intentional and strategic.

Racial Trauma and Mental Health

Meta-analysis reviews of racial trauma research unequivocally demonstrate symptoms that mirror post-traumatic stress disorder (PTSD):

  • Mental Health.
  • Psychologically, racial trauma can cause symptoms of post-traumatic stress disorder (PTSD).
  • Arousal: higher reports of somatization when distressed (e.g., stomach aches, headaches, rapid heartbeat).
  • Anger and disruptive behavior: more behavioral problems in children and teens
  • Chronic Stress: depression, anxiety, low motivation.
  • Hypervigilance: reduced ability to trust or form social connections.
  • Avoidance: less willingness to take academic risks, higher school drop-out rates after racial discrimination is perceived.

These negative psychological outcomes are not only present in adults, but have been found to appear as in children as early as 12 years of age. However, the toll of racial trauma and stress is not limited to psychological outcomes. The negative effects of racial trauma also affects physical health outcomes. These symptoms are often exacerbated by lack of access to adequate medical services.

Physical symptoms can include:

  • Physical pain
  • Cardiovascular Disease
  • Hypertension, with spikes in blood pressure following exposure to racist stimuli; blood pressure remains elevated after.
  • Respiratory Complications
  • Higher Allostatic Load (the wear and tear of the body caused by chronic stress) When the body is in a state of distress, it activates the stress response system, which helps us fight or get out of the stressful situations (a.k.a. fight, flight, or freeze). However, when experiences of stress are consistent and chronic, the stress response system becomes taxed and hormones can be unbalanced, exacerbating the physical illnesses and conditions listed above.
  • Digestive issues

APA (American Psychological Association) Guide on the Effects of Stress on the Body
Racism, racial discrimination, and trauma: a systematic review of the social science literature, K.Kirkinis, August 2018. 
Mental Health and Black Patients: Survival and Stigma

Systemic Racism and Mental Health

Currently participating in the Maryland Psychological Association(MPA) annual Ethics Conference. I was able to speak about systemic racism and mental health. With clients: nurturing diversity awareness gently, but also insisting on it.

Takeaways from Dr. Siddique:

  • It is our obligation as mental health professionals to speak about systemic oppression, environmental context, and racism as an integral part of our intake process and treatment planning. This is a required need of our ethical guidelines, as recently endorsed by the American Psychological Association.
  • Microaggressions by clinicians can be a negative part of the psychotherapy process, without training and awareness. The research shows that BIPOC patients who experience their therapist as invalidating generally do not return to treatment. Ever.
  • We must get supervision from peers, consultants, and our own therapy in order to help others and to get a true understanding. Don’t assume that you know.
  • Developing psychological rapport and alliance is the most important way for us to work with our clients, as shown by psychotherapy research.

Coping with Racial Trauma
BlackLine provides a space for peer support and counseling, reporting of mistreatment, and affirming the lived experiences to folxs who are most impacted by systematic oppression with an LGBTQ+ Black Femme Lens.

My Personal Readings to Challenge Oppression.
DiAngelo, Robin (2018). White Fragility: Why It’s So Hard for White People to Talk About Racism Beacon Press: Reprint Edition.
Helms, Janet E. (2019). A Race is A Nice Thing to Have: A Guide to Being a White Person or Understanding the White Persons in Your Life. Cognella Academic Publishing.
Kendi, Ibram X. (2019.) How to Be an Antiracist. One World Publications.
Nadal, Kevin L. (2018). Microaggressions and Traumatic Stress: Theory, Research, and Clinical Treatment. American Psychological Association.

A Tribute to Psychologist Dr. Mamie Phipps Clark

Dr. Mamie Phipps Clark was born in Arkansas to a physician father and a homemaker mother who also ran the office practice. She was an exemplary student, and graduated with honors, winning scholarships to Howard University and Fisk University. She attended Howard University in Washington DC, where she majored in math and physics, before she fell in love with psychology.

Primarily, Dr. Clark investigated and analyzed the development of racial identification in black children and how that relates to self-esteem. After completing her undergraduate studies, and influenced by her work with children in an all-Black nursery school, Clark completed her master’s thesis, “The Development of Consciousness of Self in Negro Pre-School Children.”

Essentially, she wondered when and how children develop the idea that they are Black, and what that means to them on a personal level and social level.

She moved to New York with her husband, the psychologist Dr. Kenneth Clark, where she started her doctoral studies at Columbia University. Their combined research resulted in the famous “doll experiments.”

The Doll Experiments and Black Psychology
Dr. Clark completed the doll experiments with her husband, research which played a key role in the Brown v. Board of Education Supreme Court decision.  It was also the first psychology research to be submitted as hard evidence in the Supreme Court’s history.

The study used four dolls identical in all ways except skin color and asked 260 Black children, ages 3 to 7, to rate them for liking and overall attractiveness. Over two thirds of the participants indicated a preference for the white doll, saying it was the ‘best’.  Further, 60 % of the participants indicated that the brown doll “looks bad.” The tendency to believe that the brown dolls were inferior was consistent, even in three-year old children. The study showed that segregation had significant negative mental health effects on the self-esteem and self-perception of black children.

She gave back to her community
Inspired by her volunteer work at the Riverdale Home for Children, where she conducted psychological testing with homeless Black girls, Dr. Phipps Clark founded the Northside Center for Child Development, in NYC, in February 1946. Launched with a $946 personal loan by her father, the Center was housed in the basement of the Paul Lawrence Dunbar apartments, where her family lived. The first of its kind, the Center provided therapy for children in Harlem, parent training and consultation, and provided support to families needing housing assistance. Dr. Phipps Clark remained active as the director of the Center until she retired in 1979. Today, it continues to support the community with remedial reading and math tutoring services, nutritional workshops, and psycho educational programs. The Clarks also collaborated on various other community projects, including the Harlem Youth Opportunities Unlimited project (HARYOU), to provide job training and employment opportunities for Black youth.

She faced racism head-on
Dr. Phipps Clark earned her Ph.D. in psychology in 1943 from Columbia University. Her doctoral dissertation advisor was Dr. Henry Garrett, an openly racist professor and social scientist, outspoken in his writing and lectures. Dr. Clark later testified against him in a prominent Virginia desegregation case, rebutting his support of inherent racial differences in the ability and cognition of Blacks. Dr. Clark wrote extensively about experiencing pervasive frustration in her career. She attributed this to the “unwanted anomaly” of a Black female presence in a field dominated by White males.

Also see The Pioneers and Black History Month.

The Pioneers: Psychology and Black History Month

Dr. Sumner was the first African American to receive his Ph.D. in Psychology. He was a founder of the psychology department at Howard University,  the first renowned department at a historically black college. Dr. Sumner completed a vast amount of research which delineated racism and bias in psychological studies of African Americans, including in research, testing, and clinical work. Some of his students went on to becoming leading psychologists in their own right, including Dr. Kenneth Clark (below).

Dr. Prosser was the first African American woman to receive her Ph.D. Her dissertation examined the academic development of African American children in mixed and segregated schools. Her findings showed that African American children fared better socially and academically in segregated schools. Specifically, she found that African American children from integrated schools experienced more social maladjustment and more bullying, and felt less secure, a barrier to their learning.  Her research findings were used in the Brown versus Board of Education Supreme Court ruling, in 1954. She spent the last seven years of her life teaching at historical Black colleges, before she was killed in a car accident in Louisiana, in 1934.

Supremely gifted psychologist, Department of Psychology, at Howard University in Washington DC. In the famous “Bobo Doll Study” he studied the responses of Black children who were given a choice of white or brown dolls. His findings illustrated that children showed preference for white dolls from as early as three years old. He concluded segregation was psychologically damaging, which played a role in the Supreme Court decision in outlawing segregation. He was also the first black president of the American Psychological Association (APA).

Dr. Clark graduated from her segregated high school in Arkansas, at age 17, with honors. She subsequently attended Howard University in Washington DC, where she originally intended to major in math. It was at Howard that Mamie Phipps would meet her future husband, Kenneth Clark, in 1934 (they married four years later).  After struggling with misogyny in the math department, she was persuaded by Kenneth Clark to join the psychology department.

After completing undergraduate and Master’s studies at Howard University, the couple enrolled in the psychology doctorate program at Columbia University, where Clark challenged herself by studying under Henry E. Garrett, a prominent statistician, and unabashed racist and eugenicist. Despite his discouragement, she completed her doctoral thesis work on intellectual development in children. She and her husband became the first black recipients of psychology doctorates at Columbia University, in 1943.

Her work with children showed that African American children became aware of their racial identity as early as three years old. Many of the children she studied began to reflect and internalize the views that society held about them. These findings lead to the later Bobo doll studies conducted with Dr. Kenneth Clark, where both black and white children significantly preferred white dolls over dolls of color, rating them as more attractive and intelligent.

Mental Health and Black Patients: Survival and Stigma

The Black community suffers from a high rate of mental health concerns, including anxiety, PTSD, and depression. Black people experience direct traumatic stressors (including being heavily policed or being the victims of physical and verbal attacks), indirect stressors (such as the effects of viewing the video of the killing of George Floyd and others), and intergeneration-ally transmitted stressors (from traumatic stress passed from one generation to the next).

Access and availability of mental health care
Despite these challenges, however, Black people are far less likely to seek care. Statistics show us that about 25% of African Americans seek mental health care, compared to 40% of white Americans. Unequal access to health care is one major contributor to this disparity. The lack of cultural sensitivity by health care professionals, feeling marginalized, and the reliance on family, community, and spiritual support instead of medical or psychiatric treatment are others.

The incidence of psychological difficulties in the Black community is related to the lack of availability and access to appropriate and culturally responsive mental health care, prejudice and racism inherent in the daily environment of Black individuals, and historical trauma enacted on the Black community by the medical field. Moreover, given that the Black community exists at the intersection of racism, classism, and health inequity, mental health needs are often exacerbated and mostly unaddressed and unfulfilled.

History of exploitation and stigma
In Black communities, reluctance to seek both physical and mental health care can often be attributed to a general distrust of the medical establishment. This distrust is not without merit: historically, African Americans have been misdiagnosed at higher rates than white patients, and black communities have been exploited by the U.S. government and medical community in the name of medical research. Seeking mental health care is often viewed as a weakness, running counter to possibly a survivalist mentality born from systemic oppression and chronic racism.

Dr. Martin Luther King, Jr. suffered from bouts of severe depression from his teenage years throughout adulthood. He attempted suicide three times, but refused to go into long-term treatment, even though urged to do so by his inner circle of friends and advisers. He stated that he did not want the Civil Rights movement and his work to be tainted by the stigma of mental health problems. Today, the mental health stigma remains.
Culturally responsive mental health treatment

Culturally responsive mental health treatment is one way of addressing the disparities in psychological wellbeing in the Black community. Culture, a person’s belief, norms, values, and language, plays a vital role in every aspect of our lives, including mental health. Being culturally responsive is a mental health provider’s ability to recognize and understand the role of culture, both the client and clinician’s and the ability to adapt the treatment to meet the client’s needs within their cultural framework.

When meeting with mental and medical health providers, it is essential for clients to ask questions to gain a sense of their level of cultural sensitivity. Many people often feel nervous or guilty about asking these hard questions, but providers usually expect and welcome questions as this helps them better understand the patient and what’s important to them. If they become defensive, that provides important information as well. 

Here are tips Black clients could do to seek out culturally responsive providers:
Experience and training
Ask the provider questions about their treatment approach and if they provide care that is culturally sensitive.

Awareness of intersections
Seek attention from someone who is aware and affirming of your intersecting identities (social categorizations such as race, class, and gender, that are overlapping and interdependent systems of discrimination or disadvantage) and your cultural background.

Ability of the provider to ask questions and be mindful of their own gaps in knowledge and experience

Sidebar: I have to note another statistic that I frequently discuss when I am teaching seminars on this topic. The stats are that Black clients enter therapy with a sense of optimism. Microaggressions can occur in the very context of the therapeutic space. If they remain unaddressed, most often clients will just go away rather than complain. Research also shows that people who drop out of therapy are much less likely to go back.

Additional information on research on developmental psychology and microaggressions can be found here.

(Stats included are from Department of HHS 2017; APA 2019; Mental Health America).

Is extreme racism a form of mental disorder?

This question was recently sent to me via one of my psychology blogs:

Is extreme racism a form of mental disorder? 

My answer:
The American Psychological Association has never officially recognized extreme racism as a mental health problem, although the issue was raised more than 30 years ago. After several racist killings in the civil rights era, a group of black psychiatrists sought to have extreme bigotry classified as a mental disorder. At that time, the question was posed to the American Psychiatric Association, a related medical association that is separate from mental health counseling/psychology.

This professional association rejected the recommendation, arguing ‘that because so many Americans are racist, even extreme racism in this country is normative; a cultural problem rather than an indication of psychopathology’.

The psychiatric profession’s primary index for diagnosing psychiatric symptoms, the Diagnostic and Statistical Manual of Mental Disorders (DSM), does not include racism, prejudice, or bigotry in its text or index.

Therefore, there is currently no statistical support for including extreme racism under any diagnostic category. This leads psychiatrists to think that it cannot and should not be treated in their patients.

Others in the profession have argued that to continue perceiving extreme racism as normative and not pathologic is to lend it legitimacy. Clearly, anyone who scapegoats whole groups of people and seeks to eliminate them to potentially resolve internal conflicts meets criteria for a delusional disorder, a major psychiatric symptom of illness.

Extreme racists’ violence could be examined in the context of behavior described by clinical psychologist Gordon Allport in the classic text, The Nature of Prejudice.

Allport’s 5-point scale categorizes increasingly dangerous acts: It begins with verbal expression of antagonism, progresses to avoidance of members of disliked groups, then to active discrimination including segregation, financial, and, social; to physical attack, and finally to extermination (lynchings, massacres, genocide).

Based on these theories, using the DSM’s structure of diagnostic criteria for a diagnosis of delusional disorder, the following subtype of delusional disorder has been suggested:

Delusional Disorder, Prejudice type: A delusion whose theme is that a group of individuals, who share a defining characteristic have a particular and unusual significance to the (psychiatric) patient. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. When these delusions are extreme, the person may act out by attempting to harm, and even murder, members of the despised group(s). Based on our Allport’s work, individuals suffering delusions usually also have overall serious social dysfunction that impairs their ability to work with others, have healthy interpersonal relationships, and maintain employment.

While psychiatric classification may be a useful tool, other researchers believe behaviors stemming from prejudice/hatred may not necessarily be pathological, and these acts are certainly not generic. Where is the line between societal ‘normal,’ and not? If racism has normative foundations, is it a disease, or an internalization of expectations? Is racism part of intergenerational trauma, as suggested by James Baldwin?

In my forensic work, intent, perceived goals, ability to understand right and wrong, cognitive ability, overall comprehension, and consequences, are all considered when somebody is deemed mentally incompetent. If somebody is aware of all of these factors and fully cognizant of their behavior, is it a mental illness?

We have a lot to study. And we must.

Embolden Psychology

Embolden offers the ADOS-2, the gold standard assessment for kids on the spectrum.

Combined with psychoeducational testing, it helps provide comprehensive information and recommendations to help children and teens six and up.

Thank you for contacting us.