Initially, I struggled with writing this piece. After a couple of weeks of writing, rewriting and tossing, I finally locked in on my block. The issue is this: it is nearly impossible to write a short blog piece about the black experience in mental health. This goes for both my perspective as a black physician and the perspective of the black patient. I worried about being reductionistic with an incredibly important and deeply layered topic.
There is no simple way to condense the experience of being black in any context. As I considered the different factors that influence the black experience in mental health care, I realized that the histories of discriminatory practices, unethical research, denial of care, racially biased diagnosis and treatment, and poor representation among mental health care providers each deserve volumes of exploration.
That being said, I know that discussing the foundation of racism and discrimination in mental health care is a start. This is the legacy upon which many black patients sit when they come to our offices each day. Three issues in particular have been substantial barriers to my own patients’ seeking care: lack of resources, distrust, and mental illness stigma.
Lack of resources
Jared, a 20-year-old black male, arrived at my office with his mom. Jared, who was living with his mom and younger sister, was unemployed and spent most of his time in his room. They had traveled nearly an hour to see me, as there were limited mental health resources in their community. Jared wanted to see a black psychiatrist but struggled to find any in his city.
Low-income communities and communities of color typically have the fewest mental health resources. To find care, residents often travel far outside of their communities, creating an unnecessary burden. For those with limited finances, arranging transportation, time off from work, and childcare can make access difficult.
When resources aren’t available, information and education aren’t brought into these communities. Mental health practices and clinics not only provide clinical services, but often are the center of knowledge about mental illness and support for those dealing with these conditions. When those resources are absent, members of a local community may not understand their conditions or their options for care and support.
Also absent from the black community are black mental health professionals with a similar lived experience and background. Many black individuals are interested in working with a black therapist or psychiatrist. However, only 4% of psychologists and less than 4% of psychiatrists are black. Non-black mental healthcare providers are less likely to provide racially sensitive and culturally competent care. Black providers are more likely to understand how blackness has impacted the black mental healthcare experience. There’s no need to explore the racial differences between the provider and patient. The focus can be on the reason the individual is seeking care. More importantly, black providers are more likely to understand and be sensitive to the problems black clients experience accessing mental health services.
For some patients and clients, there is a sense of pride in seeing one’s own people successfully navigate the training and career pathway involved in becoming a therapist or psychiatrist. Many black patients feel strongly connected to the success and accomplishments of other members of the black community.
Distrust
Dustin, a 24-year-old black male, had recently moved to Austin. He had dealt with anxiety since childhood. Now living with his aunt, he struggled to go to work each day and rarely socialized. After a long discussion, we agreed to start a low dose SSRI. He missed his first follow-up appointment. He came to his next appointment only to disclose that he had not started his medication and didn’t believe that it would help.
The history of medicine in the United States is fraught with racially discriminatory practices against black people. From non-consensual sterilization to the syphilis experiments, black people have been dehumanized and harmed by unethical medical practices. On the flipside, more recent medical research often fails to include representative black populations and often underrepresents the impact of disease and treatment in the black community.
In mental health, studies have consistently shown bias in diagnosis in black patients. Black patients are more frequently diagnosed with schizophrenia rather than mood disorders when compared with white patients presenting with the same symptoms. Even when a correct diagnosis is made, black patients are less likely to receive evidence-based care than their white counterparts.
These deeply embedded practices and history have cultivated a mistrust, and at times a fear of health care and mental health care institutions in the black community. There is legitimacy in the black community’s concern about misdiagnosis and inappropriate care. Unfortunately, some have chosen not to seek care when needed.
Mental Health Stigma
Erica, a mid-30’s black woman, presented with depression for most of the past year. Raised by two loving parents, she had attended graduate school after college and now worked as an assistant professor at a local university. She had never sought professional help for her mood symptoms, but worried that they were interfering with her work and home life.
Stigma surrounding mental illness is pervasive in the black community. When Erica opened up to her mother about her mood concerns, her mother advised her to talk to her pastor. She discouraged her from seeking professional help worried that people might think she was “crazy.”
Mental health stigma and misinformation has created a reluctance for many in the black community. Holding shame around mental illness means that individuals are less likely to seek appropriate care. When they do look for help, black individuals are more likely to seek counsel from places of worship or family and friends. Unfortunately, their help-seeking often stops there.
Culturally sensitive care recognizes these issues and makes space within the therapeutic relationship for these issues to be acknowledged honestly to the degree that each individual needs.
File under: The Art of Psychotherapy
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There is no simple way to condense the experience of being black in any context. As I considered the different factors that influence the black experience in mental health care, I realized that the histories of discriminatory practices, unethical research, denial of care, racially biased diagnosis and treatment, and poor representation among mental health care providers each deserve volumes of exploration.
That being said, I know that discussing the foundation of racism and discrimination in mental health care is a start. This is the legacy upon which many black patients sit when they come to our offices each day. Three issues in particular have been substantial barriers to my own patients’ seeking care: lack of resources, distrust, and mental illness stigma.
Lack of resources
Jared, a 20-year-old black male, arrived at my office with his mom. Jared, who was living with his mom and younger sister, was unemployed and spent most of his time in his room. They had traveled nearly an hour to see me, as there were limited mental health resources in their community. Jared wanted to see a black psychiatrist but struggled to find any in his city.
Low-income communities and communities of color typically have the fewest mental health resources. To find care, residents often travel far outside of their communities, creating an unnecessary burden. For those with limited finances, arranging transportation, time off from work, and childcare can make access difficult.
When resources aren’t available, information and education aren’t brought into these communities. Mental health practices and clinics not only provide clinical services, but often are the center of knowledge about mental illness and support for those dealing with these conditions. When those resources are absent, members of a local community may not understand their conditions or their options for care and support.
Also absent from the black community are black mental health professionals with a similar lived experience and background. Many black individuals are interested in working with a black therapist or psychiatrist. However, only 4% of psychologists and less than 4% of psychiatrists are black. Non-black mental healthcare providers are less likely to provide racially sensitive and culturally competent care. Black providers are more likely to understand how blackness has impacted the black mental healthcare experience. There’s no need to explore the racial differences between the provider and patient. The focus can be on the reason the individual is seeking care. More importantly, black providers are more likely to understand and be sensitive to the problems black clients experience accessing mental health services.
For some patients and clients, there is a sense of pride in seeing one’s own people successfully navigate the training and career pathway involved in becoming a therapist or psychiatrist. Many black patients feel strongly connected to the success and accomplishments of other members of the black community.
Distrust
Dustin, a 24-year-old black male, had recently moved to Austin. He had dealt with anxiety since childhood. Now living with his aunt, he struggled to go to work each day and rarely socialized. After a long discussion, we agreed to start a low dose SSRI. He missed his first follow-up appointment. He came to his next appointment only to disclose that he had not started his medication and didn’t believe that it would help.
The history of medicine in the United States is fraught with racially discriminatory practices against black people. From non-consensual sterilization to the syphilis experiments, black people have been dehumanized and harmed by unethical medical practices. On the flipside, more recent medical research often fails to include representative black populations and often underrepresents the impact of disease and treatment in the black community.
In mental health, studies have consistently shown bias in diagnosis in black patients. Black patients are more frequently diagnosed with schizophrenia rather than mood disorders when compared with white patients presenting with the same symptoms. Even when a correct diagnosis is made, black patients are less likely to receive evidence-based care than their white counterparts.
These deeply embedded practices and history have cultivated a mistrust, and at times a fear of health care and mental health care institutions in the black community. There is legitimacy in the black community’s concern about misdiagnosis and inappropriate care. Unfortunately, some have chosen not to seek care when needed.
Mental Health Stigma
Erica, a mid-30’s black woman, presented with depression for most of the past year. Raised by two loving parents, she had attended graduate school after college and now worked as an assistant professor at a local university. She had never sought professional help for her mood symptoms, but worried that they were interfering with her work and home life.
Stigma surrounding mental illness is pervasive in the black community. When Erica opened up to her mother about her mood concerns, her mother advised her to talk to her pastor. She discouraged her from seeking professional help worried that people might think she was “crazy.”
Mental health stigma and misinformation has created a reluctance for many in the black community. Holding shame around mental illness means that individuals are less likely to seek appropriate care. When they do look for help, black individuals are more likely to seek counsel from places of worship or family and friends. Unfortunately, their help-seeking often stops there.
Culturally sensitive care recognizes these issues and makes space within the therapeutic relationship for these issues to be acknowledged honestly to the degree that each individual needs.
***
Consider all the spoken and unspoken concerns that accompany your clients or patients into your office. The basics of accessing care, trusting the intentions and guidance of care providers, and trusting the legitimacy of their own health concerns complicate the black experience in mental health care. Psychiatrists and therapists should examine their own beliefs about and around issues of race. Understand what influences your practice and informs how you bring cultural sensitivity into your patient or client interactions.
File under: The Art of Psychotherapy