Stigma and judgment
In places like Los Angeles and New York, everyone and their pet has a therapist, yet even among the wealthy and elite, many African Americans continue to hold stigmatizing beliefs about mental illness. For example, a qualitative study by Alvidrez et al., (2008) found that among Blacks who were already mental health consumers, over a third felt that mild depression or anxiety would be considered "crazy" in their social circles. Talking about problems with an outsider (i.e., therapist) may be viewed as airing one's "dirty laundry," and even more telling is the fact that over a quarter of those consumers felt that discussions about mental illness would not be appropriate even among family.
In a study I recently completed, one African American gentleman noted, "I was just embarrassed. Getting this type of help has, and continues to be, like a sore thumb in the African American community. Unfortunately, I don't have insurance, so my fear was that if I sought help, it would not be good because I couldn't afford it."
Likewise, African Americans may be resistant to seek treatment because they fear it may reflect badly on their families–an outward admission of the family's failure to handle problems internally. Something I found in my own studies, is that even among African Americans who suffered greatly from mental disorders, many held negative attitudes about people who obtain mental health care. No matter how impaired they were, they didn't want to be one of "those people."
Many African Americans with mental disorders are unaware that they have a diagnosable illness at all, and are even less aware that effective psychological treatments exist for their specific problem. Because of the taboo surrounding open discussion about mental illness, African Americans often have little knowledge of mental health problems and their treatments.
Concerns about therapist or treatment process
Many African Americans also have concerns about treatment effectiveness, which may be due to both lack of education and cultural misgivings. Apprehension about clashing with the values or worldview of the clinician can cause ambivalence about seeking help, and this may be especially true for the many who believe that mental health treatment was designed by White people for White people. African Americans view the typical psychologist as an older, White male, who would be insensitive to the social and economic realities of their lives (Thompson et al., 2004). In actuality, however, even though African Americans are underrepresented as psychologists, they are well-represented among mental health providers in general, and can be found among the ranks of master's level clinicians, such as professional counselors and clinical social workers. These types of therapists can be very useful for many sorts of difficulties, including family problems and many mental health needs.
Many African Americans avoid treatment even when needed.
Anxiety about therapy may also be related to a lack of knowledge about what to expect from the treatment itself. Indeed, many African Americans with mental disorders express fears about being involuntarily hospitalized, and are unwilling to share their symptoms for fear of being "locked up" or "put away."
Yet even those who are willing to brave treatment may not place therapy among their priorities. Work, family responsibilities, commitments, and transportation issues all can overshadow the need for therapy, which may be viewed as a luxury endeavor when there are kids to drive to little league and dinner to make at home. This troublesome reality suggests that despite struggling for years with a mental disorder, many are reluctant to take time for themselves to get better.
Cost of treatment and lack of insurance coverage
The financial burden of mental health treatment is a barrier that affects everyone, but disproportionally affects African Americans due to lower incomes and reduced employment opportunities. In my own research, I found that those most concerned about cost are more likely to be uninsured; their incomes are not low enough to qualify for publicly provided services but not high enough to afford a private insurance plan.
Increasing treatment participation
All of the issues described thus far can create a difficult uphill battle when trying to increase treatment participation within the African American community. But there are many practical approaches that can reduce this mental health disparity.
Making treatment more affordable
The cost of treatment may be prohibitive for many, especially among those without insurance coverage. Many low-income individuals can find help in the community health system, but such systems may suffer from a lack of clinicians able to treat complex and less common conditions. It can be especially difficult to find care for those who lack any sort of insurance, have an unstable living situation, or who must contend with the inability to make appointments due to overcrowding.
Individual practices and treatment centers can help by publicizing effective low cost treatment options (i.e. practicum students, sliding scale slots, etc.) Another cost-effective option is stepped-care. For example, one model proposed by Tolin, Diefenback, Maltby, and Hannan, (2005) for the treatment of OCD involves bibliotherapy (self-help books), followed by clinician-guided self-treatment as needed, as well as traditional exposure and ritual prevention for non-responders. In this way, the most expensive treatment is provided to those who need it most, while others may benefit from a lesser approach. Nonetheless, it is important to be aware that the cost of treatment is a larger problem that involves many aspects of our society, including the politics of health care and social inequalities.
Increasing awareness of mental disorders and treatment options
Education about mental disorders and the treatment process is a critical to reducing barriers to treatment among the African American community. Suggestions for overcoming this barrier include public education campaigns (e.g., mass media), educational presentations at community venues (e.g., Black churches), and open information sessions at local mental health clinics. In fact, many Black churches are taking the treatment to where the people are, and hiring licensed therapists to work with their flock.
For those who do start conventional treatment, the first clinical encounter presents an important opportunity to address skepticism about the usefulness of treatment. It's the clinician's responsibility to demystify the process and explain the benefits of staying the course. Without this knowledge the participant may only assume what he or she may encounter and base their decision to follow through on incorrect assumptions. If the expected outcomes, number of sessions, and potential goals are clearly outlined in advance, there is little chance of feeling misled or not in control. The client-patient bond may be strengthened with this extra attempt at transparency.
Making mental health a priority
Treatment has the potential to conflict with many daily activities or commitments for busy people. In the current economy, many take second and third jobs to make ends meet. Whether the individual feels treatment is a necessary priority despite prior engagements, transportation, or scheduling issues is an important positive step. Moreover, incorporating the family is another crucial measure in overcoming barriers to treatment. By gaining familial support the client may gain peace of mind as well as lose the fear of being outcast or stigmatized. In addition, with the family's acceptance, making time for treatment becomes easier and priorities may be put into perspective. Utilizing the family to emphasize the importance of good mental health creates more allies to emphasize the relationship between improved functioning and greater success at home and work.
Reducing fears about therapy and stigma
Making psychotherapy less intimidating may be one of the most important ways of improving help-seeking. Careful use of language can help to reduce some discomfort surrounding mental health care. For example, African Americans are more comfortable with the term "counseling" over "psychotherapy" (Thompson et al., 2004), and this should be considered in advertising and conversational exchanges. Another practical way to reduce fears is to offer free assessments and phone consultations, which will help familiarize potential patients with the clinic, clinician, and treatment. Clinicians might use initial contacts to address fears of being involuntarily hospitalized by explaining the difference between typical mental health challenges and "being crazy," including the role of insight and self-efficacy.
However, it is important to note that reservations against treatment may be rooted in actual experiences of racism and encounters with medical professionals lacking cultural awareness. Treatment is a partnership that can only be successful with mutual respect, and for this to occur it remains the duty of the therapist to become culturally competent and sensitive to disparities, and in turn, communicate support and understanding to the patient. African Americans look for subtle cues to determine if a therapist holds racist attitudes, as many are afraid of being mistreated due to their race or ethnicity. These concerns are not unfounded, as a lower social status makes African Americans more vulnerable to abuse, particularly in a medical setting, where the clinician is considered the authority figure. A recent study by Snowden et al. (2009), found that after controlling for severity of mental illness and other variables, African Americans are more than twice as likely to experience a psychiatric hospitalization than Whites, an indication of continued bias among clinicians when faced with Black patients in need of mental health services.
To completely eliminate mental health disparities, clinicians must be willing to undertake an honest self-examination of their own conscious and unconscious attitudes about race, including preconceived notions about who would be a good client. By increasing the cultural competence and social awareness of all clinicians, the mental health system can begin to shed its bias against ethnic minorities. This would result in greater understanding and empathy for the patient's experience, improved treatment outcomes, and more African Americans willing to take a chance with mental health care.
Alvidrez, J., Snowden, L. R., and 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.
Suite, D.H., La Bril, R., Primm, A., et al. (2007). Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color. Journal of the National Medical Association, 99(8), 879-8.
Thompson, V.L., Bazile, A., & Akbar, M. (2004). African Americans' perceptions of psychotherapy and psychotherapists. Professional Psychological Research and Practice, 35(1), 19-26.
Tolin, D.F., Diefenbach, G.J., Maltby, N., Hannan, S., (2005). Stepped care for obsessive-compulsive disorder: A pilot study. Cognitive and Behavioral Practice, 12, 4, 403-414.