Regardless of race, we all share one thing in common. Mental Health. We all suffer from mental health difficulties such as anxiety, depression, or schizophrenia. However, growing up in a mixed-race household, I know that black people often deter from seeking treatment, or even acknowledging that their difficulties are due to mental health issues. There are a number of barriers that come up, such as stigma, the psychologist, and racial bias which can prevent treatment. This is not a comprehensive list; there are limitations in education and services, as well as, doctor-patient communication that can further lower the percentage.
We cannot get through them all but here is a start.
*This is mainly research from Black and Asian minority groups in the UK, and partially in America.*
Stigma can be defined as ‘an attribute that is deeply discrediting’ (Goffman, 1963). It has been a prevalent issue in the mental health community for centuries, with women suffering from mental health difficulties once being known as having ‘wandering womb’ syndrome. This is the idea that exclusively women (since they are so weak and easily influenced) suffer from a type of ‘hysteria’ because of a displaced uterus, a theory that dates back to 2 AD and lasted to around the 19th century (Tasca et al., 2012).
In terms of black and minority ethnic (BME) groups, Alvidrez et al., (2008) found that 1/3 of black participants suffering from anxiety and depression reported that they would be considered “crazy” in social circles. Unsurprisingly, there is a strong desire to avoid this label. Therefore, they avoid going to the GP and receiving treatment, in the fear of being given a label (Connor et al., 2010). It is important to note that the majority of research focuses heavily on the black community, especially in America, where they find that this cultural stigma towards mental health and therapy is the most prevalent, compared to any other ethnic group (Anglin et al., 2006).
It is not a surprise that BME groups then avoid receiving treatment for fear of stigmatisation. Unlike white people, BME groups are already stigmatised due to their colour. Those who grow up in Western cultures, such as the UK or the USA, suffer from structural racism on a daily basis. The idea of accepting that they have a mental illness would be accepting the adoption of another stigma (Campbell & Mowbray, 2016). It pushes them further into the margins.
In terms of depression and anxiety, for a long time, the majority of research and examples were about white women. Therefore, the idea of therapy and mental health difficulties has been seen as a “white problem” in the BME community, specifically a white woman problem. By using this language to describe mental health, they exclude the idea that they could even have an illness in the first place as they don’t fit into that category (Campbell & Mowbray, 2016).
Removing the stigma could aid in encouraging more individuals from BME backgrounds to seek help
The Race of the Psychologist
Like so many fields in the past, psychology has been dominated by white men. This skews the idea of what a real community psychologist looks like, to those not in the psychology field. Thompson et al., (2004) found that BME communities reported that their view of a psychologist was an older, white man that would be insensitive to their social and economic difficulties.
I do not believe that white psychologists can’t give effective treatment to those in BME groups, but research has shown black patients feel a greater comfort with black therapists.
Goode-Cross and Grim (2014) found that black therapists form a greater, more innate connection, due to less of the feeling of cultural mistrust. They do report that not all black therapists are the same (of course) and therefore how a patient responds does differ. They also made an interesting point that this innate connection can cause issues in terms of boundaries with patients, and argue for an increase in more black supervisors that can improve the training for these black therapists.
We need to have more BME therapists as not only is it representative of the community we live in today, it can increase the chances of black patients seeking treatment and reduce dropouts.
However, we cannot say that the reason black people do not seek treatment is simply due to their own cultural restrictions. We must also address the institutional racism inside the mental health system that leads to racial bias. Discussions have focused on the number of minorities in psychiatric institutions, the quality of their mental health services, and the implicit biases held by the therapists and doctors they meet. For example, Sabshin et al., (1970) found racial stereotyping within therapists, who claimed black patients were “hostile and unmotivated for treatment”. If one holds this bias, they will less willing to offer them access to services or give up on them sooner. While this study was held in the 1970’s, in a more racially-aggravated time, it cannot be said to be gone. Hoffman et al., (2016) found racial bias was present within pain assessment of black patients. In their second study, they found 50% of white medics held false beliefs regarding biological differences between black and white people. A common one is that black people “have thicker skin” compared to white people. This bias influences their treatment recommendations, with medics less likely to give black patients pain medication, and if they do, it is at a lower dose. Removing these implicit biases, or raising awareness of them, can help black patients feel more comfortable in their environment. Mental health is a very vulnerable thing, and we have to do everything to ensure each patient feels equal and valid.
A common solution is that therapists should be ‘colour-blind’, that race does not matter and we should treat everyone equally. While, that sounds lovely, by refusing to acknowledge a patients race, you fail to recognise the difficulties that are exclusive to those in the BME community. Burkard and Knox (2004) found that once controlling for social desirability, therapists who scored higher for colour-blindness had lower empathy for both white and black patients. Therapists, regardless of race, that is willing to acknowledge the impact of someone’s race in their lives, have greater empathy and therefore, can connect more with their patients. By accepting this bias, we become more open-minded and empathetic, which encourages all patients to open up. One bad experience with a therapist can deter BME groups from returning, trying another therapist, or even seeking help in the first place.
The reason for BME groups not going to therapy is multi-factorial. There are issues at an individual, cultural, and institutional level which reduce the likelihood that these groups will seek therapy.
More research should go into focusing on the effectiveness of therapy on BME groups, working on initiatives that encourage everyone to seek more help and training all psychologists on BME difficulties.
This post was inspired by the book: Why I’m no longer talking to White People about Race by Reni Eddo-Lodge
On the road to feeling less,
Anxious and Hungry
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York, NY: Simon & Schuster, Inc.
Tasca, C., Rapetti, M., Carta, M. G., & Fadda, B. (2012). Women and Hysteria In The History Of Mental Health. Clinical Practice and Epidemiology in Mental Health : CP & EMH, 8, 110–119. http://doi.org/10.2174/1745017901208010110
Alvidrez, J., Snowden, L. R., & Kaiser, D. M. (2008). The experience of stigma among Black mental health consumers. Journal of Health Care for the Poor and Underserved. 19, 874– 893. doi:10.1353/hpu.0.0058
Conner, K. O., Copeland, V. C., Grote, N. K., Rosen, D., Albert, S., McMurray, M. L.,. . . Koeske, G. (2010). Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults. Aging & Mental Health, 14(8), 971–983. doi:10.1080/13607863.2010.501061
Anglin, D. M., Link, B. G., & Phelan, J. C. (2006). Racial differences in stigmatizing attitudes toward people with mental illness. Psychiatric Services, 57(6), 857–862. doi:10.1176/ ps.2006.57.6.857
Campbell, R., and Mowbray, O., (2016). The Stigma of Depression: Black American Experiences. Journal of Ethnic & Cultural Diversity in Social Work. 25:4, 253-269, DOI: 10.1080/15313204.2016.1187101
Thompson, V. L. S., Bazile, B., & Akbar, M. (2004). African Americans’ perceptions of psychotherapy and psychotherapists. Professional Psychology: Research and Practice, 35(1), 19–26. doi:10.1037/0735-7028.35.1.19
Goode-Cross, D., and Grim, K., (2014). “An Unspoken Level of Comfort” Black Therapists’ Experiences Working with Black Clients. Journal of Black Psychology. 42(1). 29-53.
Sabshin, M., Diesenhaus, H., & Wilkerson, R. (1970). Dimensions of institutional racism. American Journal of Psychiatry, 127, 787-793.
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296–4301. http://doi.org/10.1073/pnas.1516047113
Burkard, A., and Knox, S., (2004)., Effect of Therapist Color-Blindness on Empathy and Attributions in Cross-Cultural Counselling. Journal of Counselling Psychology, Vol. 51, No. 4. 387-397