We know that people of all ethnicities and cultures experience mental health conditions, and that Black individuals experiences mental health challenges at rates like other groups. Black History Month can be a great reason to reflect on some things.
However, when considering the mental health of Black Americans, it’s important to look at historical and cultural factors, some of which have led to significant disparities. For example, 25% of Black people seek mental health treatment when needed, compared to 40% of white people.
When Christine M. Crawford, MD, MPH, was doing her psychiatric rotation in medical school, she knew psychiatry was her calling. But when she shared that she decided to become a psychiatrist instead of specializing in another field of medicine, the response she received was one of disappointment.
“One person asked why I didn’t want to become a ‘real’ doctor,” Crawford said. “Another asked why I would want to work with ‘those’ people.”
Crawford said it was challenging to hear this from those closest to her—individuals she knew to be compassionate, smart, and supportive to others. Crawford, who is Black, said at that point she truly understood the depth of mental health stigma in the Black community.
“Ironically, as my career as a psychiatrist progressed,” she said, “I came to learn that many who responded most negatively to my career choice were the very people I was dedicating my life to helping—African Americans who silently live with mental illness for fear of being judged.”
Steeped in Stigma
The stigma of mental health isn’t new to the Black community. Martin Luther King Jr. reportedly had severe depression during periods of his life and refused psychiatric treatment, even when urged to seek care by his staff. Unfortunately, that scenario continues to be common today, with African Americans not seeking mental health care because of stigma.
“We can all work together to recognize and address this challenge,” Crawford said. “But to do so, we must understand where it comes from and why it is so ingrained in our culture.”
The root of mental health stigma among Black people can be traced back to slavery.
At that time, it was commonly thought enslaved people were not sophisticated enough to develop depression, anxiety, or other mental health disorders.
“From those historic misconceptions, we learned to ignore mental illness or call it other terms, like ‘stress’ and ‘being tired,’” Crawford said.
Such nuanced descriptions for depression and other mental illnesses—adopted by the Black community and passed on from generation to generation—led to underestimating the effects and impact of mental health conditions. Also, it strengthened beliefs that a psychiatric disorder is a personal weakness.
Crawford explained that “all these factors created a culture that is fearful and uninformed about mental illness.”
Racism, Trauma, and Mental Health
Black Americans develop mental health conditions at a rate equal to anyone else. The Centers for Disease Control (CDC) has declared racism a serious threat to public health that has placed communities of color at greater risk for poor health outcomes.
When considering the mental health of Black Americans, it is important to view their experience through a historical and cultural lens. The Black community has shown resilience in the face of adversity for centuries.
Starting in the 1600s in the United States, Black people faced oppression in the form of the enslavement of Africans and their descendants. The fact that a group of people were once considered property and not human beings, and the effects this has on people of African descent, cannot be underestimated.
Through 1965, U.S. laws were used to justify abuse of Black people. In the years after the American Civil War, Black people faced oppression in the form of sharecropping: farm labor that severely restricted economic mobility. They faced segregation: enforced and legalized separation from housing, health care, and other services.
Racism today is often more hidden, but it is still dangerous. It exists in the form of reduced access to housing, health care, and education and in increased incarceration.
The social, economic, and emotional toll continues for Black Americans.
According to the American Psychological Association, racial trauma can result from direct experiences of racism, as well as insidious occurrences that add up over time.
Major experiences of racism include physical and verbal attacks, while indirect stressors include seeing videos of police brutality on social media or being the target of subtle putdowns. Racial trauma can also result from intergenerational trauma: traumatic stress passed from one generation to the next.
Stress reactions to trauma are normal responses to abnormal situations. A person’s response to a trauma depends on the individual, the type of trauma, the meaning of the trauma, as well as cultural factors.
People who have experienced multiple traumas throughout their lives are at greater risk for experiencing another trauma. They also experience more severe symptoms and longer lasting effects.
Researchers believe that racial trauma is one of the reasons Black people in some communities have higher rates of PTSD (8.7%) compared to white people (7.4%).
Studies also show that African American youth are at risk of developing PTSD: Nearly 65% of African American youth report traumatic experiences, compared to 30% of their peers from other ethnic groups.
Since treatment shortly after a traumatic event is a major factor in recovery, lack of access to health care may contribute to the higher rates of trauma symptoms and PTSD among African Americans.
Transmitted Stressors: Intergenerational Trauma
Researchers are learning more about the health effects of intergenerational trauma.
Trauma can be passed down through genes in a process called intergenerational transmission. Stress can cause changes to reproductive cells, as well as to the uterine environment where a fetus develops.
Because of this, people whose ancestors experienced trauma may be vulnerable to mental health conditions. Even individuals who did not experience a trauma directly may have inherited trauma symptoms, such as anxiety and mood dysregulation.
This has mental health implications for descendants of people, including Black Americans, who have experienced oppression and violence.
The Mental Health Impact of Systemic Racism
The effects of racism lead to higher poverty rates, increased incarceration, and reduced access to health care and housing.
Racism also appears in less obvious forms. Like other marginalized populations, African Americans experience microaggressions. These subtle, indirect, and sometimes unintentional putdowns from people point to one’s “otherness” or assume racial stereotypes.
Examples of microaggressions include a white professor failing to call upon Black students in a classroom, or a clerk following a Black customer around a store.
Microaggressions are a form of racial trauma. Due to their frequency, subtlety, and harm, they can chip away at a person’s identity and sense of self-worth, potentially impacting their mental health.
Black Americans Are Less Likely to Seek Mental Health Care
Black people are far less likely to seek care. Statistics tell us that about 25% of African Americans seek mental health treatment, compared to 40% of white Americans.
Unequal access to health care is one major contributor to this disparity. Nearly 10% of Black people in the U.S. do not have health insurance, compared to 5.2% of non-Hispanic white people.
When members of the Black community do seek mental health care, they are more likely to receive it from an emergency department than from a mental health specialist.
According to Crawford, other reasons Black Americans receive less care include “the lack of cultural sensitivity by health care professionals, African Americans feeling marginalized, and the reliance on family, community, and spiritual support instead of medical or psychiatric treatment—even when it is critically necessary.”
Black people can also face prejudice from health care providers. Communication between providers and patients can differ for African American patients compared with white patients.
In one study, physicians working with Black patients were 33% less likely to engage in patient-centered communications than they were with white patients. Such discriminatory practices have been connected to patients’ increased psychological distress.
Barriers to Treatment
One barrier to treatment for African Americans may be an understandable mistrust in the medical and mental health systems.
For example, research studies are less likely to include members of the Black population. There are also historical cases, such as the Tuskegee syphilis experiment (1932-1972), in which Black people were subjected to medical experiments without their permission.
Another obstacle? Mainstream psychotherapy has its roots in Western Europe. The founders of psychoanalysis and other early treatments were white men.
According to the work of psychologist Nancy Boyd-Franklin, early models of mental health care and family therapy were established to treat white middle-class families. These forms of therapy pathologized Black families that were structured differently from white families in any way.
Boyd-Franklin states that such models overlooked the strengths of Black families, which include extended kinship ties, an openness to taking on different family roles (for example, an aunt serving as a nephew’s primary caregiver), and an emphasis on spirituality—factors that modern psychotherapy now recognizes as fundamentally important to well-being.
Lack of Black Therapists
Because of the history of psychotherapy, as well as the unique challenges faced by members of the Black community, Black patients may prefer seeing Black therapists.
A shared ethnicity does not necessarily guarantee the best therapeutic relationship. Regardless of the identity of the therapist, the most important qualities are compassion and cultural competence.
However, some Black patients may feel that Black therapists can better understand their experiences and identify with their cultural stressors. If this is the case, providers should make every possible effort to match a Black patient with a Black therapist. Unfortunately, only 2% of U.S. psychologists are Black.
The Importance of Culturally Competent Care
In addressing the needs of the Black community, all mental health professionals should provide culturally competent care.
Such care involves effective, compassionate treatment regardless of any ethnic, gender, sexual identity, or other differences between a therapist and a patient.
How Do Therapists Provide Culturally Competent Care?
To provide culturally competent care for African American patients, therapists should acknowledge racism’s harmful effects. When possible, they should attend trainings provided by professional organizations.
Through this process, clinicians can learn about conscious and unconscious biases. As part of their growing cultural awareness, they can consider their own experiences with power and oppression.
To compassionately serve patients, health care professionals should strive to learn more about their patients’ ethnicity, history, as well as any current events that may be impacting them. They should keep in mind that regardless of collective experiences, each patient will be different, and each therapeutic relationship will be unique.
Mental health care professionals who work with Black patients should consider how community, family, and faith play important roles in the lives of many African Americans.
A community care model of treatment may work well for many Black patients. In a community care setting, family, friends, and neighbors form a supportive network.
As part of this system, people have different supportive roles. Some may give the patient rides to health care appointments. Others may deliver meals, or care for children and pets to help the patient through a crisis.
As members of the Black community may have experienced significant trauma, therapists should consider approaching treatment from a trauma perspective. To the greatest degree possible, treatment should be trauma-informed as well as culturally competent.
A 2021 study proposed that African American youth would benefit from the incorporation of racial socialization into trauma-focused cognitive behavior theory.
Racial socialization involves messages of support and guidance around African American cultures, attitudes, and values. The treatment focuses on African American heritage, the existence of discrimination, and how African American youth can manage complex interactions with the majority culture.
The African American community has experienced oppression and trauma throughout the history of the United States. This community has shown great strength in the face of incredible hardships.
Members of the Black community often find support in family and through community and spirituality. They also deserve professional, respectful mental health care that understands their needs from a cultural perspective.
We can all work to:
- Bring awareness to the use of stigmatizing language around mental illness
- Educate family, friends, and colleagues about the unique challenges of mental illness within the Black community
- Become aware of our own attitudes and beliefs toward the Black community to reduce implicit bias and negative assumptions
Each one of us can make a difference in the lives of those who need mental health support.
“By recognizing that the Black community has unique experiences when it comes to mental illness, we—as citizens of the world—are beginning to chip away at the stigma that permeates through culture,” Crawford said.
We live in a diverse world, and each day we interact with people of a variety of backgrounds. The more we understand differences that make us distinct, the more we’ll understand there is no shame in having a mental illness—regardless of our culture and background.