Some Thoughts Regarding Stigma: The Often Silent Obstacle to Mental Health and Substance Care Among African Americans

The term stigma according to the Merriam Webster dictionary is Greek or Latin and indicates “a mark of shame or discredit.” It most often refers to “a set of negative and often unfair beliefs that a society or group of people have about something.” When addressing the concept of stigma within mental health, specifically within the African American community, one has to examine the historical factors that contribute to our mistrust of medical and behavioral health systems, the over-pathologizing of mental health within our community, and cultural beliefs about emotional wellness and where healing can come from. In addressing these causes of stigma around mental health and help-seeking behaviors, we can begin to effectively provide mental health services to those within a traditionally underserved community that has a demonstrated need for mental health services.

Young African American couple with a mental health therapist

Essential Historical Facts Regarding African Americans and Stigma

History has justified the mistrust African Americans have for physical and mental health systems whose missions were allegedly to “do no harm.” These experiences have understandably resulted in a weariness around seeking services and, even when services are sought within the mental health field, mental health practices have been used to demonize and pathologize their experiences. (Bailey et al., 2017; APA, 2021.)

Beginning with the enslavement of Africans, the United States sought to pathologize African Americans and their understandable response to the inhumanity of slavery and to justify such treatment within society. During the 1840 census for example, so called researchers noted increased rates of insanity among freed Blacks in the north. This “research” was utilized to substantiate the need for African Americans to be enslaved reasoning freedom caused insanity among freed African Americans (Jackson, V., 2002). In 1851, Louisiana physician Dr Samuel Cartwright identified a mental disorder among slaves he called “Drapetomania, a disease causing Negroes to run away from their slave owners.” Further, he felt the treatment intervention for slaves evidencing this so-called disorder was whipping (Ibid).

Under the guise of receiving medical care or advancing the field of medicine, African Americans have suffered from the Tuskegee Experiment in which African American males were deceived into not being treated for syphilis in order to study the disease’s progression to the unlawful and immoral use of the uterine cells belonging to Henrietta Lacks and the fact that she too was denied informed consent and adequate compensation for the use of her cells (www.hopkinsmedicine.org).

Current Experience of African Americans and Accessing Mental Health Care

According to the Centers for Disease Control, in 2019, suicide was the second leading cause of death for Africans Americans ages 15 to 24. In addition, research indicates that adult Blacks and African Americans are more likely to have feelings of sadness, hopelessness, and worthlessness than their Caucasian counterparts (CDC. 2019). Coupled with the disproportionate emotional and financial impact of the COVID-19 pandemic on Black and other marginalized communities, the need for mental health services by those within the Black community are not in question. However, only 37% of African Americans with mental health concerns receive treatment (www.nami.org/mhstats).

Obstacles to Seeking Mental Health Care Within the Black Community

We must not neglect the extent to which African Americans engage in self-stigmatizing with respect to accessing mental health and substance abuse services. We have heard common statements such as: “It’s just the blues. We don’t do therapy. Seeing a therapist is a sign of weakness. It will look bad on my record if I saw a therapist and that prevents me from getting a job. It is a poor reflection on my family. Remember Tuskegee and Henrietta Lacks.”

Many African Americans who may be suffering from major depression describe their symptoms simply as being “down” while experiencing debilitating symptoms such as despair, sadness, insomnia, hopelessness, helplessness, guilt and for others, anger, agitation, and physical symptoms such as physical pain and headaches. Some seek relief by self-medicating leading to addiction to alcohol and other substances.

For many who are religiously or spiritually focused, the concept of church/faith being a place for healing cannot be ignored (McRae, 1998). There is a false belief that seeking mental health services somehow indicates a lack of faith.

For other African Americans there is a misalignment of mental health and wellness as being “crazy.” Research indicates that depictions of negative stereotypes related to mental illness shown within the media does not help this erroneous perception (Rossler, 2016). Even more recently, the attribution of school shootings and other violent acts to “mental illness” likely reinforces this belief.

When addressing concepts of emotional health/wellness within the community, there is a belief that seeking mental health services is only for those whose mental health concerns are keeping them from functioning at an optimal level. Even in this definition of optimal, the belief of “pushing through” can contribute to minimizing significant difficulties in functioning.

As a nation, as we become clear in our understanding of what traumatic experiences exert in our mind, body and spirit, African Americans may have the tendency to deemphasize childhood experiences of sexual, physical, and experiences of neglect and maltreatment. The insistence of “resiliency” in the face of trauma often does not permit “time” or understanding in addressing trauma through therapy.

Although African Americans would benefit from receiving mental health services, there are several access barriers to good mental healthcare in addition to those related to stigma. These barriers include the following:

  1. The lack of mental health professionals who are of color
  2. The lack of mental health professionals who are culturally informed and practice from a cultural humility perspective
  3. The lack of community focused mental health care, including an end to the Community Mental Health model of care
  4. Lack of access to services due to no or inadequate insurance coverage among African Americans as well as failure of services to be located within their communities
  5. A tendency to over-pathologize the mental health presentation of People of Color within the field. (Bell CC et al., 2015), which can contribute to ineffective interventions/poor outcomes

Where Do We Go From Here?

To better serve the needs of African Americans seeking mental health services, consider the following:

  1. Stigma associated with mental health services must be addressed at all levels, including policy, Mental Health Associations, local government, community, and much more.
  2. Increase mental health literacy and awareness by providing accurate and culturally informed knowledge about mental illness, preventions and recognizing signs and symptoms. Consider Mental Health First Aid Training in a variety of community venues. It demystifies mental and substance abuse challenges.
  3. Ensure that treatment interventions being used have been demonstrated to be effective with the community being served. There is enormous heterogeneity in the Black community. Although rooted in African American cultural and healing practices, interventions must still be diverse and incorporate client needs at all intersections of their identities.
  4. Engage in ongoing required training of clinicians, supervisors, agency leadership, Boards, etc. to increase their cultural understanding while practicing cultural humility.
  5. Provide services with their community in collaboration with systems/organization they trust, i.e., churches, social and civic organizations. This includes addressing the concept of “God and a therapist” as being beneficial versus mutually exclusive concepts.
  6. Identify barriers to accessing services by making mental health services affordable, multidisciplinary, and available.

Tyffani Dent, PsyD, is Senior Director of Learning and Program Strengthening and Lorna Hines-Cunningham, LCSW/R, ACSW, is Consultant, Technical Advisor, and Psychotherapist, at Black Women’s Blueprint. For more information, email Dent-Education@Blueprintny.org, Hines-Cunningham-lornahc876@optonline.net, and visit www.blackwomensblueprint.org.

References

Apology to People of Color for APA’s Role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Hierarchy in U.S. (2021) https://www.apa.org/about/policy/racism-apology,. Downloaded 6/16/2022

Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 Apr 8;389(10077):1453-1463. doi: 10.1016/S0140-6736(17)30569-X. PMID: 28402827.)

Centers for Disease Control (2019) Summary Health Statistics: National Health Interview Survey: 2017. Table A-7 Retrieved from https://www.cdc.gov/nchs/nhis/shs/tables.htm
Jackson, Vanessa (2002), ” An Early History-African American Mental Health” https://academic.udayton.edu/health/01status/mental01.htm

Bell CC , Jackson WM, Bell BH. Misdiagnosis of African Americans with Psychiatric Issues-Part ii. Natl Med Assoc. 2015 Mar; 107 (3): 35-41. Doi: 10.1016/S0027-9684 (15) 30049-3.Epub 2015 Dec 2. PMID 27282721.)

McRae, M. B., Carey, P. M., & Anderson-Scott, R. (1998). Black Churches as Therapeutic Systems: A Group Process Perspective. Health Education and Behavior25(6), 778-789. https://doi.org/10.1177/109019819802500607

Rossler, W (2016). The stigma of mental disorders: a millennia long history of social exclusion and prejudices. EMBO Reports, 17) (9) 1250-1253

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