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A Look at Black History Through the Lens of Mental Health

by Courtney Reyers, NAMI Communications Manager

February is when we, as a nation, celebrate Black History Month. African American history is bittersweet: filled with glorious victories, but also rife with tragedy and pain.

Mental illness in the African American community is just one of the many areas touched by this painful history. NAMI spoke with an African American psychiatrist and an African American psychologist to discuss the challenges and disparities in care they have faced when it comes to mental health treatment for African Americans in our country today.

Dr. Annelle Primm, M.D., M.P.H., is the deputy medical director of the American Psychiatric Association, where she also serves as the Director of Minority and National Affairs (OMNA). She produced Black and Blue, a film about depression in African American communities, in 2001. She also maintains a small private practice and is a past psychiatric consultant to On Our Own, a drop-in center for adults with mental illness in Baltimore. Dr. BraVada Garrett-Akinsanya, Ph.D., L.P., is a psychologist and executive director at the African American Child Wellness Institute in Minneapolis. She is a recognized leader in multiculturalism, and was the first African American to serve as president of the Minnesota Psychological Association.

What is the role of faith in the African American community in terms of coping with mental illness?

AP: Faith is an important strength from which people derive hope. Resilience is very prevalent in the African American community; despite adverse living circumstances, people find ways to keep on keeping on, survive and thrive. And research shows that people of faith who participate in various religious activities and services receive good health benefits—both physical and mental.

It can be a challenge when people who are experiencing a mental illness try to achieve wellness by using faith alone. It’s not always sufficient enough to deal with serious mental illness. Perhaps, with stress or a mild mental health issue, prayer and support from your faith community could be sufficient. However, when people are dealing with a mental illness, ideally, services from a mental health professional should be added to faith beliefs.

Many of us in the mental health community have seen the great importance of developing relationships with faith communities, so we can be supportive of their efforts. Clergy leaders who provide counseling to members of their congregation often discover that someone may need mental health services, so it’s good for faith community leaders to know that they can make referrals to mental health professionals.

It’s important that a person of faith know from his or her religious leader that they are not turning their backs on their faith by seeking mental health services. There is a line from Black and Blue that I think really speaks to this point: “I wouldn’t say don’t pray… I would say don’t JUST pray.” Reach out and get the mental health services you need and also stay in prayer.

Strong religious ties can coexist very well with seeking mental health services. Partnerships between mental health practitioners and faith communities around the country are growing. These kinds of collaborations can pave the way for providing culturally competent mental health services for people of faith.

BG: A lot of people don’t understand what a psychologist does; they think it’s a white profession. I have to educate a lot of people. The first group I had to educate was the clergy, because the preacher will say go to the Lord, not to psychology. Black people feel that if they go see a psychiatrist, they are turning their backs on God. I have to partner with the clergy, and now some of my biggest referral sources are the clergy. There are two churches in Minneapolis—they keep my appointment book full. We often do co-therapy with the minister or the deacons.

What are some general differences in the way African Americans experience the health care system—communication styles, expectations about roles or outcomes—compared with Caucasian patients?

BG: In our community, one of the biggest issues around mental illness and African Americans is stigma. We know from the U.S. Surgeon General’s report that African Americans wait longer than whites before they report any problems—largely because of that stigma. Many times, African Americans have strong roots in spirituality and believe in demon possession. Black parents will say their child has a “bipolar demon” or “ADHD demon.” Our culture is steeped in the belief that if you have mental illness, you’re possessed by the devil. There is a belief that you can pray away illnesses.

We rely on doctors who “know” things and make us feel like we don’t have any sense, or the doctors say things that we don’t understand.

AP: There is a tendency to assume that the health care provider is all-knowing and to give them all the power. This stems from not being aware of the importance of personal input and participation in one’s own health care. Those of us in the advocacy world should encourage people to feel more empowered in their mental health care encounters and to be prepared with questions, to make sure to understand their illness, what to do about it and why.

There are studies that show that African Americans, as well as other people of color, are more likely than whites to feel as if they’re being disrespected or looked down upon in health care provider/patient relationships. Practitioners should communicate clearly and make sure that their patients understand, and be respectful of cultural differences.

BG: Right. We don’t use the same words to articulate our needs. We don’t know how to own or care for our bodies because we didn’t own them for 200 years in the U.S. African Americans were traded as animals, and we still have that livestock mentality due to slavery; we don’t fully claim our bodies. When people don’t understand that they own their bodies, they will abuse them, they don’t take care of them.

AP: This really is an extension of the experience that African Americans have had in this country emanating from historical realities such as the middle passage and slavery, Jim Crow Laws, segregation and certain disadvantages in terms of opportunity structures related to employment, housing, education, etc. African Americans encounter individuals of other racial backgrounds with whom they may have had negative experiences in the past—bias, discrimination—that result in distrust. How are they going to be treated? Will they be looked upon as inferior? These are some of the stereotypes that do exist, and it would be naïve of us to think that some of those stereotypes wouldn’t find their way into a health or mental health care encounter.

The Institute of Medicine’s 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, showed that bias and stereotyping played a role in disparaties of care regardless of socioeconomic status. One of the most famous studies highlighted in this report was an article in the New England Journal of Medicine showing that African Americans were less likely to get standard treatment for chest pain—black women in particular.

BG: Na’im Akbar (a clinical psychologist at Florida State University) has done a lot of work around mental illness in the black community; he coined the term “alien self-disorder,” which is where you don’t even recognize who you are anymore. There are a lot of ideas around why we are in constant recovery of our selfhood. We are struggling. That impacts your mental health: the stress of not knowing who you are, or being who you are in a society that marginalizes and discounts you.

In the African American community, there is a propensity to stick with a bad situation because you don’t feel like you have the right to ask—that you should be grateful, even if it’s mistreatment—and hope and pray that it will change, instead of saying, “You know, I don’t have to take this.”

What are some other hurdles when it comes to mental health, treatment and recovery for African Americans or other ethnic groups?

BG: Most of them are financial: Many clients can’t afford co-pays. Transportation is a huge issue; many mental health centers are outside of their neighborhoods. There are also the issues of compliance, understanding that they have power to say if something is not working. Also ethno-pharmacology: We require a lesser dosage to get the benefit out of a medication.

Much of my work is trying to teach people that they have a right to be well. We have to teach our community to fight for that—and sometimes you have to fight for yourself.

How does the legacy of the Tuskegee syphilis experiment continue to affect African Americans’ utilization and trust of health care, and how can we try to counteract this history?

BG: It’s hard to get African Amercians to get flu shots or to take any kind of pill because we feel like we’re getting experimented on. Doctors tend to make more harsh diagnoses with negative prognoses for African Americans as opposed to whites.

Counteracting this history would involve having more providers that look like the clients, but, if you remember, the vehicle they used in the Tuskegee experiment had a black driver and a black doctor. So simply having black providers is not enough. They have to see black people in charge of the system.

AP: Knowledge is power. Providing information and educational opportunities around mental illness and mental health is very important. It is similar to what we need to do for everyone, but at the same time, whenever we can, tailor that communication so that it’s culturally translated in ways to which African Americans or members of other ethnic communities can relate. Culturally tailored approaches can open doors to greater trust and understanding.

Have you experienced resistance in your professional role from peers or patients?

AP: I do think that there is some resistance, and again I will say that the field of psychiatry is also heterogeneous; there are many psychiatrists who, I believe, understand the importance of addressing culture in their interactions with patients. There are others who feel that they were trained to provide care and that should be applicable to any person that they serve and don’t see a need to focus on a person’s cultural background.

There are differences of opinion about this, but we need to look at some of the trends around the country. In New Jersey, practitioners are required to have cultural competence training and education in order to renew or receive medical licenses. California has requirements that all continuing medical education programs need to have components focused on cultural care. Hopefully, over time, this will catch on throughout the nation so that people can have some confidence that providers will be cognizant about considering culture in their care.

BG: When I worked with interns, I could see the shock on their faces when I walked in on the first day, because they were expecting a white man. I’ve actually had people ask for a different therapist when they saw that I was black—and they were black.

But new generations see that we are alike and the differences we have are respected. Things are getting better with each new generation. They are more comfortable with difference. Young people nowadays, they are so different in the way they look at the world, and it gives me so much hope.

Every human being on this earth has a right to be well. I have a bill of rights I give my clients, rights to all kinds of wellness: spiritual, health and academic wellness. When we work together, we should fight for those rights.