Mental Health and The Black/African American Community

Grounded, in part, in historically marginalizing experiences with healthcare and mental healthcare providers specifically, the stigma surrounding mental illness in the Black community is a general deterrent to seeking and accessing therapy. Black/African Americans can continue to feel overlooked, underserved, and misunderstood by the mental health community.

To better understand mental health and the Black community, we’ll discuss nine essential topics: (1) the role of race and mental health, (2) a brief history of the changing mental health diagnostic factors, (3) shifting attitudes and practices to account for cultural context, (4) cultural factors affecting mental health, (5) mental health stigma in the Black community, (6) the financial burden of treatment, (7) challenging the mental health stigma, (8) treatment issues among African Americans, and (9) the need for cultural diversity in the field of psychology.

The Development of Mistrust: The Role of Race, Culture and Mental Health (mis)Diagnosis in the Black Community

Big picture, according to the National Alliance on Mental Illness, “African Americans are no different when it comes to the prevalence of mental health conditions when compared to the rest of the population.” However, there are differences when it comes to mental health and the Black community.

For example, African Americans (alarmingly, of all ages) are much more likely to face violent crime than White Americans. This increases susceptibility to developing Post Traumatic Stress Disorder (PTSD), which is one of the most common mental health concerns among all races and ethnic groups. This confluence of the increased likelihood of experiencing violence due to one’s race and mental health struggles, as a result, is a starting point for a broader discussion. It speaks to the role of life experiences, culture, and overt and institutional racism and its impact on mental health in the Black Community.  

Historically, African Americans have been more likely to be diagnosed with schizophrenia. In fact, “African Americans are almost five times more likely to be diagnosed with schizophrenia compared with Euro-Americans admitted to state psychiatric hospitals.” That is an alarmingly disproportionate difference in diagnosis rates that begs further scrutiny. Can it indeed be that Black Americans are that much more likely to suffer from such a relatively rare and debilitating severe mental illness, or is something else going on?   

From our perspective, it’s likely the latter. There is strong evidence to suggest that a patient’s race plays a role in the diagnoses assigned to people. A review of diagnostic disparities among different groups showed that Black and Hispanic patients are more likely to be diagnosed with schizophrenia, even when measures of psychopathology do not indicate that diagnosis is justified.

A History Lesson of Changing Diagnostic Criteria, Culture, Society, and Race

We won’t fully delve into the shameful ways that mental health labels and diagnoses have been used for centuries to silence dissent and to further marginalize groups, such as women, LGBTQ persons, and other minorities. However, rates of diagnosis of schizophrenia among Black men is a striking example of how this impacted African Americans.

As recounted on PsychologyToday, the second edition of the Diagnostic and Statistical Manual (DSM) was published during the social, racial, and political upheaval of the 1960s. In the first edition of the DSM, schizophrenia was narrowly conceived of as a splitting of the typical functions of one’s personality. The best thinking at that time was that this splitting results in the delusions, hallucinations, and paranoia that often accompany schizophrenia. With the advent of the 2nd edition of the DSM, new diagnostic criteria of the paranoid type of schizophrenia included the presence of hostility and aggressiveness.

So given these new criteria, there was an expanded view of the paranoid subtype of schizophrenia. Pair that with a situation where many Black men were arrested in the late 1960s for participation in protests. Their behavior was often labeled as defiant, hostile, aggressive, and also paranoid. Given their attitudes and behavior, many were then ultimately diagnosed as schizophrenic at astoundingly higher rates than the rest of the US population. Given the vast difference in rates of diagnoses between Black and White men, there’s an excellent reason to believe that many diagnoses of schizophrenia were inaccurately made for Black men.

We want to point out that the overwhelming number of white mental health providers of the time were likely motivated by a sincere desire to help. Yet, it would appear that they lacked knowledge as to the legitimate reasons that many Black women and men had for feeling angry, hostile, and appropriately wary. So, from their uninformed perspectives, they assigned labels of mental illness, instead of healthy and appropriate reactions to a life full of oppression and racism.  

The Rise of Cultural Context and Better Understanding African American Mental Health

There was a shift decades ago to the prevailing medical and psychological assumptions about LGBTQ persons. Similarly, there has been a shift towards better accounting for cultural context.  It has improved understanding and accuracy of diagnosis when it comes to Black people’s experiences with mental illness and well-being.

As an example of that better understanding let’s revisit the concept of paranoia. According to Mental Health America, these are the signs of paranoia:

“…intense and irrational mistrust or suspicion, which can bring on a sense of fear, anger, and betrayal. Some identifiable beliefs and behaviors of individuals with symptoms of paranoia include mistrust, hypervigilance, difficulty with forgiveness, defensive attitude in response to imagined criticism, preoccupation with hidden motives, fear of being deceived or taken advantage of, inability to relax, or argumentative [behavior].”

It is difficult to conclude that signs of paranoia in the black community are indeed pathological (as compared to adaptive) without consideration of their context, especially in the face of racism and oppression. For a straightforward example, when faced with hostility and hate, it would seem that most prudent individuals or even entire populations be wary and vigilant about their surroundings and the people near them. Moreover, as for fear, anger, and a sense of betrayal? How is one supposed to react to injustice? Those reactions seem like a legitimate and self-protective place to begin.

So, how do we begin to understand the concept of heightened wariness and “paranoia” when contextualized within that social and cultural period? To get to the heart of it, two pioneering Black psychiatrists coined a term in 1968: Cultural Paranoia. Simply put, cultural paranoia (sometimes also called healthy paranoia) is an adaptive response by African Americans to the lived experience of being subjected to racially motivated oppression and discrimination. It’s an adaptive and useful response to one’s hostile surroundings.

The introduction of the concept of cultural paranoia and other similar ideas (e.g., racial trauma and minority stress) and a growing focus on multiculturalism in psychological research and practice has contributed to an emphasis on training culturally informed therapists.  Therapists with multicultural awareness and training can more effectively understand and navigate the unique needs of Black patients and other individuals holding marginalized identities.

Contextually and Culturally Appropriate Diagnostics

Even when diagnoses are made legitimately due to clear indications of mental illness, the importance of understanding the cultural factors that might cause psychological distress cannot be overstated. Overviews of research in the US show that racism can affect mental health, and this can be due to three key reasons:

• “Racism in societal institutions can lead to truncated socioeconomic mobility, differential access to desirable resources, and poor living conditions that can adversely affect mental health.”
• “Experiences of discrimination can induce physiological and psychological reactions that can lead to adverse changes in mental health status.”
• “In race-conscious societies, the acceptance of negative cultural stereotypes can lead to unfavorable self-evaluations that have deleterious effects on psychological well-being.”

Researchers have also found that encounters with racism have led to psychological symptoms such as trauma, general psychological distress, cultural mistrust, poor quality of life, less life satisfaction, and depression. This provides evidence that a person’s racial identity and life experiences must be considered when understanding race-related stress and mental health.

Given these findings, it’s evident that there are specific mental health factors that affect the African American community, and race should be considered when treating patients as a result.

Treatment Issues Among African Americans

There are many obstacles to treatment among African Americans for mental illness.

Historically, African Americans have received “worse access to care, lower quality of care, and poorer health outcomes” than the rest of the country. This means they are more likely to die from treatable health conditions than anyone else. This was one of the compelling reasons for the implementation of the Affordable Care Act. It was an effort to “close the equity gap for Black Americans.”

Another issue of treatment is the underrepresentation of African Americans in the mental health workforce. Less than two percent of the members of the American Psychological Association are Black, which could cause hesitation among Black Americans seeking help. Many clients will state a preference for therapists who share a personal understanding of their culture or specific issues. Moreover, many therapists have little or no personal experience to understand of how racism can affect a minority or the traumatic implications it can have, which can come across as insensitive or dismissive, despite therapists’ best intentions.

The Cost of Treatment

The cost of treatment for mental health issues can be daunting among the Black community, where income inequality is a real concern. Like many other minorities, the financial considerations of treatment are an obstacle African Americans face when considering mental health treatment.  Insurance is also a lagging factor in the Black community. While the Affordable Care Act did help, African Americans continue to have a higher uninsured rate than whites and Asian Americans. Increasing insurance coverage for this population is crucial in expanding treatment possibilities for mental health issues.

Added to this are other factors that include:

• much confusion around using insurance benefits for mental healthcare,
• seemingly illegal practices by insurance companies to deny mental health care, and
• lack of enforcement of federal law requiring health insurance companies to cover the costs of mental health care at the same rates as physical health care.

Mental Health Stigma and the Black Community

Mental illness has long been somewhat of a “taboo subject” within the Black community. The cause for that is multifaceted.

As elaborated upon earlier, historically negative encounters with healthcare systems have led to intergenerational mistrust. These experiences include well-publicized events such as the Tuskegee Study, and the experiences of Henrietta Lacks to more every day, systemic disparities in treatment and diagnosis, which affects the routine care that African Americans receive.

According to podcaster Hafeez Baoku, the main reason for the stigma is culturally embedded. Within the African American community, many forms of community-based healing such as a reliance on elders, or the ability to confide in religious leaders, may be prioritized over working with a relative stranger.

A lack of culturally relevant research on the mental health experiences of African Americans might also result in a lack of information. This lack of information may lead people to feel that mental illness is a weakness. It could also mean that treatment providers and potential African American patients alike are less able to recognize culturally-specific manifestations of symptoms of mental illness. If people don’t understand symptoms, they may be less likely to seek help.

That is, people might assume a particular emotional or behavioral experience is “just life” and would, therefore, not even consider therapy or any help to change it.

Challenging the Stigma

Baoku is not alone in his quest to fight the stigma associated with mental illness in the Black community. In recent years, celebrities and prominent members of the Black community have been brave enough to come forward and share their experiences and struggles. These acts of openness and bravery in the face of stigma are starting to change the landscape of discussion of mental illness and mental health awareness, but the battle is far from over.

In 2018, renowned pop singer Janet Jackson came forward to discuss her struggle with depression. She said her biggest battle was in her late 30s. During this time, she felt the effects of low-self esteem and recognized feelings of inferiority based on experiences from her childhood. She also attributes racism and sexism to her bouts of self-doubt and unhappiness.

Iconic celebrity Mariah Carey is another public figure who recently broke her silence on mental health struggles. She revealed that she was diagnosed with bipolar disorder in 2001, and has been very open about the struggles she has faced because of it. She admitted that her hesitation to reveal her diagnosis was mainly due to the stigma and ridicule she feared she might suffer as a result.

Relatedly, former First Lady Michele Obama shared that she and Barack sought marriage counseling to gain tools for their relationship and to better understand one another.

The Need for Cultural Diversity in the Field of Psychology

Because African Americans only make up about 2 percent of the American Psychological Association, there is a striking underrepresentation of their perspectives and voices in the field. This is a recognized problem.

The Association of Black Psychologists (ABPsi) was created to encourage more Black people to enter the profession and build upon their shared expertise and commitment. Their mission is to train their psychologists to serve the Black community by offering Black/African-centered psychology. This method’s definition includes considering African “realities, cultures, and epistemologies” to treat patients.

The real question is, “How do we increase the number of Black psychologists in America, and how do we entice the Black community to seek help when they need it?”

The answer to the second question may lie within the first. Increasing the number of African American Therapists in the field might increase a sense of comfort for African Americans seeking treatment. In tandem, enhancing the cultural competency and sensitivity of licensed psychologists in the field will lead to more accurate diagnoses, more appropriate care, and a lessening of the historically-based hesitation to seek mental healthcare for people of color.

As mental health professionals at the Therapy Group of DC in Washington DC and Therapy Group of NYC in New York, we place significance on multicultural and racial competence. We recognize and wholeheartedly believe that understanding the experiences of many minority groups is the bedrock of providing compassionate, warm, and effective care.