Mental Health and Racism
Mental Health and Racism
BARRIERS TO EFFECTIVE MENTAL HEALTH SERVICES
President Bill Clinton’s 1997 Initiative on Race identified racism as one of the most toxic forces in society, with detrimental consequences on racial and ethnic minorities in education, employment, income, housing, and access to health care. Within the field of mental health, the deleterious effects of racism for people of color have been well documented. A survey of studies examining racism and mental health concluded that racism is a major cause of unhappiness, lower life satisfaction, poor self-esteem, and feelings of powerlessness (Williams, Neighbors, and Jackson 2003). African Americans and Latino/Hispanic Americans report higher levels of global stress, experience greater physiological distress, and have more trauma-related symptoms than do white Americans. Racism has also been found to be associated with depressive symptoms and stress for Asian Pacific Americans as well. Racism not only predisposes an individual to socio-emotional disorders, but it can also result in a depletion of cognitive and emotional resources. The inevitable conclusion is that racism is a social risk factor for mental illness among people of color.
UTILIZATION PATTERNS
Unfortunately, racism not only causes emotional distress for people of color, but it may infect the delivery of mental-health services as well. Significant racial and ethnic disparities in health care for racial and ethnic minorities, when compared to their white counterparts, are remarkably consistent in studies (Smedley and Smedley 2005). In brief, racial minorities (1) receive an inferior quality of health care across many diseases, including mental disorders, (2) receive less desirable services, (3) are more likely to receive an inaccurate diagnosis, and (4) suffer higher mortality. In a major report, Mental Health: Culture, Race, and Ethnicity (2001), the U.S. surgeon general concluded that major disparities in the delivery and utilization patterns of mental-health services for people of color were due to bias and cultural insensitivity.
In one study cited in this report, only 16 percent of African Americans with a diagnosable mood disorder saw a mental health professional, and less than one-third saw a health provider of any kind. When sociodemographic factors such as income and insurance coverage were controlled for, the percentage of African Americans receiving any mental-health treatment was half that of whites. Less than 25 percent of Asian Americans who experienced symptoms of a mood or anxiety disorder, and 32 percent of Native American/Alaska Natives with a diagnosable mental disorder received treatment from a mental-health professional. Among Latino/Hispanic Americans, only 11 percent with a mood disorder and 10 percent with an anxiety disorder utilized mental-health services.
However, although minimal numbers of racial and ethnic minorities seek mental health treatment from private providers and treatment centers, they are often overrepresented in public mental health treatment facilities, such as hospital emergency rooms. Perhaps this is due to ease of accessibility or because the person waited to treat a problem due to mistrust of mental health providers until it was unavoidable. Because African Americans are significantly more likely to have inpatient psychiatric care than are whites, and because African Americans and Native Americans are more likely to receive emergency care, these groups are greatly overrepresented in inpatient settings. Ironically, among the small numbers of African Americans, Asian Americans, Latino/Hispanic Americans, and Native Americans who do seek mental-health services, the majority are more likely to prematurely terminate treatment than are whites. This high drop-out rate can be directly attributed to the person of color’s experience of mental-health care, which is often invalidating and antagonistic to their life experiences and cultural values.
Societal, community, and organizational biases often make mental-health services unavailable and inaccessible to people of color. For example, in rural communities inhabited by many Native Americans and Alaska Natives, there is a dearth of mental-health services. In addition, psychologists and psychiatrists in private practice tend to be inaccessible to those in lower socioeconomic classes, due to high hourly rates and a tendency not to accept government-funded programs such as Medicare. Further, people of color are significantly less likely to have adequate insurance than whites.
Not only is treatment less available to many people of color, but research supports the idea that mental-health services for people of color are often inferior to the treatment received by whites. For example, many African Americans and Latino/Hispanic Americans feel that providers have judged them unfairly or treated them with disrespect because of their race or ethnic background. African Americans were found to be less likely to receive appropriate care than whites for depression and anxiety and African Americans and Latino/Hispanic Americans experiencing a mood or anxiety disorder are less likely to receive good guideline-adherent treatment.
The prescription of psychotropic medication is also distributed unevenly among whites and people of color. In a trial study of Medicare recipients, African Americans were less likely than whites to be prescribed an antidepressant medication, and African Americans were significantly more likely to be prescribed antipsychotic drugs, even when indications for this treatment did not exist. Misdiagnosis of people of color is a pervasive issue in mental-health-care settings. Oftentimes, the mental-health provider will mistakenly see differences in cultural determined behaviors as pathology. Clinicians have been shown to be predisposed to diagnosing African Americans as schizophrenic, whereas widely held stereotypes of Asian Americans as the “model minority” may prompt clinicians to overlook their mental-health problems.
BARRIERS TO EFFECTIVE MENTAL HEALTH SERVICES
Various factors act as barriers to mental-health treatment for people of color. The culture-bound and class-bound values of therapy may work against minority clients from seeking such treatment. For example, researchers have shown that the under-utilization of mental-health resources by Asian Americans can be attributed to a mismatch between Asian cultural values and the values inherent in Western mental-health services. In particular, Asian Americans were significantly less likely than whites to discuss their mental-health problems with a mental-health specialist because of the shame and stigma associated with disclosing family and personal issues. African Americans have described such a stigma and the “cold,” “detached,” and objective manner of professionals as affecting their willingness to seek help. Indeed, therapists who are unaware of how cultural values influence the helping process are likely to misinterpret and misdiagnose racial and ethnic minorities in a pathological manner.
Cultural mistrust is also a major barrier to mental-health treatment. Mistrust of white clinicians by people of color derives from historical persecution and continuing experiences of racism. The field of psychology has a history of exploiting people of color and utilizing racist and culturally ignorant practices. The alienation and lack of trust felt by people of color toward mental-health services is well documented and is considered to be compounded by cultural misunderstanding (Sue 2003). Clients of color are likely to approach the helping professional with a healthy suspiciousness about whether the clinician’s biases, preconceived notions, and lack of cultural understanding will prevent them from obtaining the help needed. Unfortunately, they often conclude that they will not receive the help they need and fail to return for sessions.
The heavy reliance on the use of Standard English and “talking” may also serve as barriers to mental-health services for people of color. It is estimated that access to mental-health care is limited for approximately half of the Asian-American population due to lack of English proficiency, as well as to the shortage of providers who have the necessary language skills. Among Native Americans and Alaska Natives, cultural differences in the expression of distress often compromises the ability of both clinicians and assessment tools to capture the key signs and symptoms of mental illness. For example, the words “depressed” and “anxious” do not exist in some American Indian and Alaska Native languages. Further, many cultural groups rely heavily on nonverbal rather than verbal communication to transmit information about themselves and their problems. A culturally unaware provider may miss or misinterpret important nonverbal messages being imparted by the client.
The limited availability of mental-health professionals who can be ethnically matched with clients is problematic, especially as it often relates to language barriers. For example, there are very few African American, Latino/Hispanic American, Native American/Alaska Native, and Asian American mental-health professionals, so making an ethnic match between therapist and client is difficult at best. Studies have shown that both an ethnic match between therapist and client and services that respond to the cultural needs of the client can prevent early termination of treatment and lead to better outcomes for racial and ethnic minorities.
In conclusion, there is overwhelming evidence supporting the notion that racism is a risk factor for mental illness among racial and ethnic minorities. Unfortunately, research also suggests that mental-health systems are often inappropriate, antagonistic, inferior, and inaccessible to populations of color and may only serve to marginalize them. Only if society and the mental-health professions begin to address these disparities in a serious way will we be a be to improve the mental health of populations of color and provide culturally relevant services. In general, it is important for mental-health professionals to acknowledge the insidious effects of racism in their profession and themselves. No helping professional is free from racial or ethnic bias, and only if racism is honestly acknowledged and confronted will the profession begin to minimize the psychological harm of racism, enhance physical and psychological well-being, and increase access to health care for all minorities.
SEE ALSO Health Care Gap; Medical Racism; Model Minorities.
BIBLIOGRAPHY
President’s Initiative on Race. 1998. One America in the Twenty-First Century: The President’s Initiative on Race. Washington, DC: U.S. Government Printing Office. Available from http://www.ncjrs.org.
Smedley, Audrey, and Brian D. Smedley. 2005. “Race as Biology Is Fiction, Racism as a Social Problem Is Real.” American Psychologist 60 (1): 16–26.
Sue, Derald W. 2003. Overcoming Our Racism: The Journey to Liberation. San Francisco, CA: Jossey-Bass Publications.
U.S. Department of Health and Human Services. 2001. Mental Health: Culture, Race and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office. Available from http://www.surgeongeneral.gov.
Williams, David R., Harold W. Neighbors, and James S. Jackson. 2003. “Racial/Ethnic Discrimination and Health: Findings from Community Studies.” American Journal of Public Health, 93(2): 200–208.
Christina M. Capodilupo
Derald Wing Sue