Tag Archives: black mental health

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).

Racism and Mental Health

I was recently interviewed for a mental health blog by a psychiatrist/professor/writer from Georgetown
on the topic of Racism and Mental Health.

Here’s our conversation:
How did you get interested in racism and mental health?

When I was growing up, my father was head of the English department at a historically black college. One of the classes he taught was Race Relations. These conversations were part of my childhood even though my family was not black. Other children would hang posters of musicians and actors in their rooms, and for my birthday I would get Martin Luther King and Malcolm X.

I went on to study genetics, microbiology, and clinical psychology. In addition to practices in Northern Virginia and Montgomery County, I have been Clinical Director at a community health clinic in DC for 18 years, where half my patients have been from communities of color. I have listened and learned a lot from my patients.

What is an example of a case you have seen in your practice that involves racism affecting mental health?
A case that comes to mind I think illustrates what can happen. I was treating a woman who was high functioning with a good job. Her supervisor held her back from promotions and would cut her off in meetings when she tried to express herself. This can happen to all women but especially to minority women. Under this supervision, she deteriorated to the point that this high functioning individual was not able to function. These microaggressions can have a cumulative effect. When this occurs in an area such as your job, these repetitive traumas can accumulate and affect your livelihood.

What are some important findings on racism and mental health?
Some research has found that in patients with a history of discrimination and racism, there can be an overactive amygdala, a similar finding to that in brains of individuals with Post-Traumatic Disorder (PTSD). Also, Dr. Monnica Williams at Louisville discusses race-based PTSD or racial trauma which she describes as PTSD symptoms as a result of racism. The diagnosis of PTSD is a group of symptoms that occur after a single traumatic event. But complex PTSD occurs after repeated trauma in which a number of traumas pile on to one another. Race based stress can be a lifetime of psychological effects and not necessarily something you can leave or get away from. In a recent study, when children were exposed to racism through their lifetime, by the age of 12, there were higher rates of substance abuse and decreased self esteem.

What are your thoughts about the recent events in our country?
One of the hard things about the current events from the wrongful deaths of civilians to the pepper spray of peaceful protesters is the vicarious trauma it is producing for individuals miles away. People see these things and it can feel like it is happening to them. There is intense grief and anger it produces on top of a history of discrimination for many.

The inequities in housing, education, health care, and rental approvals have been longstanding. We all need to listen with an open ear so that people feel seen and heard. As clinicians we need to be careful to not overdiagnose. Someone feeling like the world is out to get them or that they can’t walk down the street might not be simply exhibiting paranoid ideation, but this may be their sense of reality.

How can the medical profession help?
In a number of instances, the medical profession experimented on black women as their scientific subjects. J. Marion Sims, The Father of Gynecology, believed their sensory nerves to be different so they would not feel pain. There is sometimes still a lack of trust in scientists and doctors. As clinicians, we need to be careful in how we interpret and how we understand these complex situations. Psychotherapy research shows that Black Americans begin therapy with optimism, but within a few sessions, they become less optimistic and drop out at higher rates and are unlikely to return. Patients can sometimes feel misheard, misinterpreted, blamed. Race and the experience around this should be part of clinical intakes routinely. Listening with an open ear is crucial to the doctor-patient relationship.

Black Mental Health

Black history month and psychology:

A quick look at research into disparities in need for services and access to mental health treatment.

1946
In the 1940s, psychologists Kenneth and Mamie Clark designed and conducted a series of experiments known colloquially as “the doll tests” to study the psychological effects of segregation on African-American children. Drs. Clark used four dolls, identical except for color, to test children’s racial perceptions. Their subjects, children between the ages of three to seven, were asked to identify both the race of the dolls and which color doll they prefer. A majority of the children, BOTH black and white, preferred the white doll and assigned positive characteristics to it. The Clarks concluded that “prejudice, discrimination, and segregation” created a feeling of inferiority among African-American children and damaged their self-esteem.  The findings were presented to the American Psychological Association about the crisis in mental health for Black children.

2016
In a study published in June 2016, in the Journal of Health and Social Behavior, Princeton doctoral graduate student Heather Kugelmass used voice actors to record phone messages for 320 New York City-based psychotherapists, each asking for a new patient appointment. The psychotherapists, all of whom had doctoral degrees and were selected from the directory of a large HMO, each received calls from one black middle-class and one white middle-class caller, or from one black working-class and one white working-class caller. Each caller mentioned symptoms of depression, mentioned that they were covered by the HMO health insurance plan, requested a weekday evening appointment, and asked the therapist to call back with possible appointment times. Kugelmass varied the names, wording and accents of the callers to suggest race and class. Overall, she found that 44 percent of the voice messages were returned, and that 15 percent elicited a clear appointment offer from the therapist.  Importantly, offer rates varied by race and class—the therapists offered appointments to 28 percent of white middle-class callers but only 17 percent of black middle-class ones. Among working-class callers, only 8 percent of both black and white appointment-seekers received offers.

Current status
According to the federal Health and Human Services Office of Minority Health, African Americans are 10% more likely to experience serious psychological distress.

However, only 30% of Black Americans are likely to seek any form of treatment, when experiencing significant psychiatric symptoms, compared to 45% of white Americans.  In 2017, suicide was the second leading cause of death for African Americans, ages 15 to 24.

Making treatment more affordable
The cost of treatment may be prohibitive for many, especially among those without insurance coverage. Many low-income individuals can find help in the community health system, but such systems may suffer from a lack of clinicians able to treat complex and less common conditions. It can be especially difficult to find care for those who lack any sort of insurance, have an unstable living situation, or who must contend with the inability to make appointments due to overcrowding.  Individual practices and treatment centers can help by publicizing effective low-cost treatment options (i.e., practicum students/interns, sliding-scale slots, etc.)

Increasing awareness of mental disorders and treatment options
Education about mental disorders and the treatment process is critical to reducing barriers to treatment among the African American community. Suggestions for overcoming this barrier include public education campaigns (e.g., mass media), educational presentations at community venues (e.g., black churches), and open information sessions at local mental health clinics. In fact, many black churches are taking the treatment to where the people are and hiring licensed therapists to work with their flock.

Transparency
For those who do start treatment, the first clinical encounter presents an important opportunity to address skepticism about the usefulness of mental health treatment. It’s the clinician’s responsibility to demystify the process and explain the benefits of staying the course. Without this knowledge, the participant may only assume what he or she may encounter and base their decision to follow through on incorrect assumptions. If the expected outcomes, number of sessions, and potential goals are clearly outlined in advance, there is lesser chances of feeling misled or not in control.

Making mental health a priority
Treatment has the potential to conflict with many daily activities or commitments for busy people. Many individuals take second and third jobs to make ends meet. Whether the individual feels treatment is a necessary priority despite prior engagements, transportation, or scheduling issues is an important positive step.

Including the family
Actively incorporating the family is another crucial measure in overcoming barriers to treatment. By gaining familial support, the client may start to lose the fear of being outcast or stigmatized. In addition, with the family’s acceptance, making time for treatment becomes easier and priorities may be put into perspective. Utilizing the family to emphasize the importance of good mental health creates more allies to emphasize the relationship between improved functioning and greater success at home, community, and work.

Reducing fears about therapy and stigma
Making psychotherapy less intimidating may be one of the most important ways of improving help-seeking. Careful use of language can help to reduce some discomfort surrounding mental health care. For example, many clients are more comfortable with the term “counseling” over “psychotherapy” (Thompson et al., 2004), and this should be considered in advertising and conversational exchanges. Another practical way to reduce fears is to offer free initial  assessments, screening/intakes, and phone consultations, which will help familiarize potential patients with the clinic, clinician, and treatment. Clinicians might use initial contacts to address fears of being involuntarily hospitalized by explaining the difference between typical mental health challenges and “being crazy,” which has often been brought up as a concern.

Provider Bias And Inequality Of Care
Conscious or unconscious bias from providers and lack of cultural competence result in misdiagnosis and poorer quality of care. Black Americans, especially women, are more likely to experience and mention physical symptoms related to mental health problems. For example, you may describe bodily aches and pains when talking about depression. A health care provider who is not culturally competent might not recognize these as symptoms of a mental health condition.

Statistics: NAMI (National Alliance on Mental Illness), 2017.

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

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