“COVID-19 has given the Black community permission to seek therapy as the world tries to process this pandemic. There’s a decrease in the stigma and an increase in Black clients reaching out. We are collectively grieving the loss of our loved ones, our jobs, our way of life, and dealing with feelings of uncertainty and isolation.” ~  Vladimire Calixte, LMHC, founder of Therapy For Black Men

Racial or ethnic disparities within the mental health care system are well documented. Black and minority ethnic communities are disproportionately impacted by social factors that are associated with mental disorders and mental health care. 

Research has highlighted that a disproportionate number of black Americans face risk factors associated to mental illness, including cultural stigma, discrimination, poverty, homelessness, and violence, as well as challenges in accessing mental health care and receiving adequate treatment.[1] Data released in 2019 from the National Institute on Minority Health and Health Disparities (NIMHD) stated that Black Americans are 20% more likely than white Americans to suffer from a serious mental health disorder. [2]

A 2020 review by the Race & Equality Foundation conducted a literature and evidence review of Racial Disparities in Mental Health and found that people who are black, indigenous, or of color (BIPOC) are:[3]

• Less likely to have access to mental health services
• Less likely to seek out services
• Less likely to receive needed care
• More likely to receive poor quality of care
• More likely to end services prematurely

This level of imbalance is perhaps surprising considering the recent acknowledgement of and focus on establishing racial equality.  However, despite ongoing efforts, racial disparities are prevalent.  This article addresses the various factors placing ethnic groups at risk. Established barriers for BIPOC include:

• Cultural perceptions and stigma around mental illness
• Racism and discrimination
• Access barriers
• Fear and mistrust of treatment

Cultural  Stigma

Stigma is largely a psychological and social phenomenon. It can be defined as the process whereby labelling, stereotyping, separation, status loss and discrimination co‐occur in the context of power. [4]  The associated components can lead to rejection, devaluation, and exclusion amongst peers which contributes to social disadvantage and a continuation of the fears associated with stigma.

Stigma is generic to all communities as regards to mental disorders, but research has shown that some groups are less likely to seek help than others.  A study on African men and women’s attitude towards mental health found that they are not open to acknowledging their mental health issues and are very concerned about the cultural stigma associated with seeking out treatment, preferring help in a religious setting.[5]  Black African men are particularly concerned about stigma. In 2018, 50% of black African Americans with a serious mental illness did not receive mental health treatment, in part due to their concerns around peer perception. [6]

Cultural stigma is perpetuated through a cycle of low confidence and poor communication around mental health issues that passes from generation to generation.  

There are two key types of stigma:

• Self-Stigma involves the perceptions and experiences of those who possess stigmatized attributes. Those with stigmatized characteristics, such as mental illness, are led to believe that they are a devalued member of society. This, in turn, can lead to negative, destructive or maladaptive behaviors. Within black African American communities, mental health disorders are spoken about in terms of “shame,” or its being a “curse,” “insanity,” a “moral failing” or associated with negative behavioral traits such as violence and anger.[7]
• Social Stigma is created by the collective beliefs of dominant aspects within society, which define acceptable behaviors within a group. This can lead to the ostracization of “unfit” members of the group or the need to coerce others into changing their behavior in order to be acceptable. Within these communities, it is not uncommon for there to be rejection from the family or social group. [8]

Stigmatized responses such as these to mental health disorders not only isolate the sufferer but can also be detrimental to their treatment and lead to an escalation of their condition.  Education amongst these communities is key to enabling change.

Accessibility

Ethnic minorities are vulnerable to a number of factors which prevent them from accessing mental health care services. High financial costs, insurance restrictions and communication barriers can make accessing appropriate treatment a significant challenge.

Recent figures show that around 23% of Black Americans live below the poverty level, compared to 10% of white Americans, and the rate of unemployment for the aforementioned was 9.5 percent and 4.2 percent, respectively.[9]  The U.S. Census reported that nearly 11% of Black Americans were uninsured compared to 6% of White Americans.[10]

Communication barriers for those for whom English is not their first language can result in a lack of awareness and knowledge of mental health issues and a lack of confidence in expressing their needs, and these ethnic minorities are less likely to have a relationship with their healthcare practitioner or community health or support services. This can pose a substantial challenge when requiring mental health support and can lead people to turn inwards to their own community for non-expert advice and help. [11]

Racial inequalities in employment, education, and finances have led to societal and environmental conditions that mean ethnic minorities have a need for individuals to focus on and prioritize their daily survival over their mental health. [12] Therefore, these disparities result in ethnic minority groups being unable to access treatment and, as such, have a reduced choice in treatment modalities and therapeutic approaches, resulting in a reduction in quality care.

Discrimination and Biased Practices

There is significant research to indicate that systemic racism and ethnic bias have a profound effect on ethnic minorities’ mental health and subsequent treatment.  

Clinicians can be at risk of displaying ethnic bias when diagnosing emotional or mental health issues in ethnic minority patients, which could lead to improper treatment, incorrect prescriptions and an escalation of patient symptoms.[13] Due to the aforementioned issues with accessibility to health care, ethnic minorities may be especially vulnerable to malpractice, as they cannot afford to choose clinicians with an understanding of their cultural and societal challenges and who have a higher degree of training and experience. This is partly due to the lack of diversity in the American mental health field, as in 2015, 86% of psychologists in the United States were white, and by 2018, only 7% of psychiatrists were Black.[14] It has been found that black and minority ethnic people are more likely to be medicated for their mental health disorders rather than referred to talking-therapies or further holistic treatment programs. In particular, black Americans are less likely than white Americans to be offered treatment, and black teens are less likely to be referred to treatment when presenting with eating disorder symptoms, even though they are 50% more likely than white teens to show bulimia behaviors.[15]

There is a long-standing historical context whereby systemic racism has meant that signs of mental illness in black Americans is often interpreted as aggressive, violent, or criminal behavior. This view has resulted in black Americans who are suffering with mental health disorders being more likely to be incarcerated than being referred to community-based treatment programs. [16]  For example, a 2019 study found that African-Americans with severe depression are more likely to be misdiagnosed as having schizophrenia.[17] This is not a new issue. Prior to the Civil Rights Movement, schizophrenia was considered a largely white condition, which from the 1920s to the 1950s became attached to middle-class housewives alongside diagnoses of “neurosis.” In the 1960s, the American scientific community and the public began to increasingly see schizophrenia as a violent social disease, “manifested by rage, volatility and aggression, and was a condition that afflicted ‘Negro men’.” [18]

Additionally, we are gaining a greater understanding of how racism itself affects an individual’s mental health. There is a wealth of current research taking place with respect to racial injustice and inequality against Black people in America that has caused intergenerational trauma and consequent mental health disorders.[19] Ethnic inequalities that result from racial discrimination can lead to the progression of severe, chronic health issues such as depression, anxiety, PTSD and also, through physical trauma, responses such as high blood pressure and chronic pain.[20]

Conclusion

Ethnic minorities’ mental health disorders and health care quality and access will not improve without further education and more resources provided to improve living conditions and balanced economic inequalities. All Americans must reflect on their contribution to ethnic bias and consider how systemic racism contributes to racial discrimination in our health care system.

If you are concerned about any issues discussed in this blog, please contact Heather R. Hayes & Associates – call 800-335-0316 or email info@heatherhayes.com today.

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[1] “African Americans Have Limited Access To Mental And Behavioral Health Care”. Https://Www.Apa.Org, 2017, https://www.apa.org/advocacy/civil-rights/diversity/african-american-health.

[2] “Mental Health Snapshot Of African American Men”. Nimhd.Nih.Gov, 2019, https://www.nimhd.nih.gov/docs/byomm_factsheet02.pdf.

[3] Bignell, Tracey et al. “Racial Disparities In Mental Health Literature And Evidence Review”. Raceequalityfoundation.Org.Uk, 2020, https://raceequalityfoundation.org.uk/wp-content/uploads/2020/03/mental-health-report-v5-2.pdf. Accessed 17 Feb 2021.

[4] “Mental Illness-Related Structural Stigma:”. Mentalhealthcommission.Ca, 2013, https://www.mentalhealthcommission.ca/sites/default/files/MHCC_OpeningMinds_MentalIllness-RelatedSructuralStigmaReport_ENG_0_0.pdf.

[5] Ward, Earlise C. et al. “African American Men And Women’S Attitude Toward Mental Illness, Perceptions Of Stigma, And Preferred Coping Behaviors”. Nursing Research, vol 62, no. 3, 2013, pp. 185-194. Ovid Technologies (Wolters Kluwer Health), doi:10.1097/nnr.0b013e31827bf533. Accessed 18 Feb 2021.

[6] “Black And African American Communities And Mental Health”. Mental Health America, 2018, https://www.mhanational.org/issues/black-and-african-american-communities-and-mental-health.

[7] Mantovani, Nadia et al. “Exploring The Relationship Between Stigma And Help-Seeking For Mental Illness In African-Descended Faith Communities In The UK”. Health Expectations, vol 20, no. 3, 2016, pp. 373-384. Wiley, doi:10.1111/hex.12464. Accessed 18 Feb 2021.

[8] Mantovani, Nadia et al. “Exploring The Relationship Between Stigma And Help-Seeking For Mental Illness In African-Descended Faith Communities In The UK”. Health Expectations, vol 20, no. 3, 2016, pp. 373-384. Wiley, doi:10.1111/hex.12464. Accessed 18 Feb 2021.

[9] “Black/African American – The Office Of Minority Health”. Minorityhealth.Hhs.Gov, 2017, https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61.

[10] Bureau, US. “Health Insurance Coverage In The United States: 2017”. The United States Census Bureau, 2017, https://www.census.gov/library/publications/2018/demo/p60-264.html.

[11] Memon, Anjum et al. “Perceived Barriers To Accessing Mental Health Services Among Black And Minority Ethnic (BME) Communities: A Qualitative Study In Southeast England”. BMJ Open, vol 6, no. 11, 2016, p. e012337. BMJ, doi:10.1136/bmjopen-2016-012337. Accessed 18 Feb 2021.

[12] “African Americans Have Limited Access To Mental And Behavioral Health Care”. Https://Www.Apa.Org, 2017, https://www.apa.org/advocacy/civil-rights/diversity/african-american-health.

[13] Swift, Samuel L. et al. “Racial Discrimination In Medical Care Settings And Opioid Pain Reliever Misuse In A U.S. Cohort: 1992 To 2015”. PLOS ONE, vol 14, no. 12, 2019, p. e0226490. Public Library Of Science (Plos), doi:10.1371/journal.pone.0226490. Accessed 18 Feb 2021.

[14] “How Diverse Is The Psychology Workforce?”. Https://Www.Apa.Org, 2018, https://www.apa.org/monitor/2018/02/datapoint#:~:text=In%202015%2C%2086%20percent%20of,from%20other%20racial%2Fethnic%20groups

[15] “People Of Color And Eating Disorders”. National Eating Disorders Association, 2016, https://www.nationaleatingdisorders.org/people-color-and-eating-disorders.

[16] “Impact Of Disproportionate Incarceration Of And Violence Against Black People With Mental Health Conditions In The World’S Largest Jail System”. Tbinternet.Ohchr.Org, 2014, https://tbinternet.ohchr.org/Treaties/CERD/Shared%20Documents/USA/INT_CERD_NGO_USA_17740_E.pdf.

[17] “African-Americans More Likely To Be Misdiagnosed With Schizophrenia, Study Finds: The Study Suggests A Bias In Misdiagnosing Blacks With Major Depression And Schizophrenia”. Sciencedaily, 2019, https://www.sciencedaily.com/releases/2019/03/190321130300.htm.

[18] “The Historical Roots Of Racial Disparities In The Mental Health System – Counseling Today”. Counseling Today, 2020, https://ct.counseling.org/2020/05/the-historical-roots-of-racial-disparities-in-the-mental-health-system/.

[19] “Mental And Behavioral Health – African Americans – The Office Of Minority Health”. Minorityhealth.Hhs.Gov, 2017, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24.

[20] Bhui, Kamaldeep et al. “Making A Difference: Ethnic Inequality And Severe Mental Illness”. The British Journal Of Psychiatry, vol 213, no. 4, 2018, pp. 574-578. Royal College Of Psychiatrists, doi:10.1192/bjp.2018.148. Accessed 18 Feb 2021.