Traditionally, many black people have viewed participating in mental health treatment as inconsistent with their cultural behaviors, attitudes, beliefs and social practices. Going to therapy is “something white people do” and telling your problems to strangers is close to criminal.
As a clinical psychologist and assistant professor in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University, I conducted an analysis of data from the National Epidemiologic Study of Drug and Related Conditions of 6,587 non-institutionalized black adults with psychiatric conditions nationwide and found that those who more strongly identified with being black were less likely to receive mental health services.
Strength and resilience are virtues held in the highest regard in the black community. The belief that you should be able to effortlessly handle work, family and societal demands is a cultural norm and expectation that is often taken for granted. Seeking mental health treatment is admitting weakness and defeat.
Failure to seek needed mental health treatment is not a problem not of personal weakness, but a significant public health concern.
According to the 2014 Substance Abuse and Mental Health Services Administration National Survey of Drug Use and Health, nearly one in five adults in the U.S., or nearly 40 million people, will meet criteria for a diagnosable psychiatric condition in a given 12-month period. An estimated 40 percent do not receive treatment.
Those adults with fewer years of education, less income and no insurance are less likely to receive treatment. Those who are sicker - have more chronic and severe symptoms, multiple medical comorbidities and impairments in functioning at work and home are also less likely to receive treatment. black people are 50 percent less likely than whites to receive treatment.
Some black people may be more likely to turn to church and faith in God, rather than therapy, to cope with hard times and suffering. Historically, the church has been the epicenter of the black community and an invaluable source of emotional, social and material support.
Dr. Lisa Cooper of the Johns Hopkins University School of Medicine and colleagues conducted a survey of black and White adults in primary care and found that Blacks were three times more likely than Whites to rate spirituality as an extremely important aspect of their depression care. This is a fact that healthcare providers often fail to consider.
Certainly for many, the church is important in instilling hope, giving people the tools to reframe negative thoughts that can fuel symptoms of depression and anxiety. The church also provides a sense of community. However, a conflict arises when the church is positioned as in opposition to mental health treatment, rather than a means to providing complimentary wraparound care to the individual and family.
In general, many do not identify themselves as having a problem in need of mental health treatment. They may acknowledge stress, but believe that the problem “isn’t that bad” and will get better on its own.
In the black community, the threshold that is used to define treatment as necessary is exceedingly high. For instance, some believe that you must be on the brink of a “nervous breakdown,” hearing voices or contemplating suicide before seeking outside treatment
These inaccurate representations of mental illness and treatment can delay treatment, allowing time for symptoms to progress, damaging work and family relationships and compounding negative impacts on physical health.
The concerns of what to expect in therapy can be insurmountable. Some worry about privacy violations and wonder who will have access to the information. This is especially troublesome for those who have co-morbid substance use issues or child custody cases. They may worry about potential negative consequences related to the information they share.
Many have fears of being misunderstood and judged, particularly if the provider is of another race. There is a fear of potential ramifications of being in therapy such as a fear of being labelled, “locked up” or forced to take medications that may be addictive or have negative side effects.
To be sure, concrete barriers that limit access to care are pervasive. Factors such as lack of available services in community based settings, long wait times to get an appointment, scarcity of diverse providers, lack of culturally appropriate treatments and inflexible hours make it difficult for many to access care. In addition, barriers on the personal level such as lack of childcare, transportation and the need to cope with multiple other health concerns exacerbate problems of access.
The 2016 $1.1 trillion budget bill (HR 2029) included important new investments in mental illness research and services including $85.4 million for research at the National Institute of Mental Health, the largest increase to mental illness research at NIMH since 2012. Additionally it included $50 million more for services at the Substance Abuse and MentalHealth Services Administration and $255 million increase for veterans mental health treatment.
California and New York have been leading the nation in parity through legislation and litigation. Limited availability of services and inadequate insurance coverage to pay for services are key barriers to participation in treatment.
In Illinois where I am based, the Illinois Department of Insurance recently announced it received a $1.3 M federal grant to improve access to mental health and substance use disorder services in this state. This grant will help to implement laws that require insurance plans to cover behavioral health services on par with physical health care.
Yet from 2009 to 2012, Illinois cut $113.7 million in revenue funding for mental health services resulting in two closed inpatient facilities and six of twelve mental health clinics closing as well as the closing of several community health agencies.
In response to these budget cuts, earlier this year, the Cook County Health & Hospitals System established a pilot 24/7 Community Triage Center in the Roseland neighborhood to provide early intervention services for individuals at risk of detention or hospitalization due to mental illness.
The Cook County system received a grant from the Otho S.A. Sprague Memorial Institute for initial planning of the CTC and will invest an additional $3 million to operationalize the center. This investment in mental health and substance use disorders services is a critical step in reducing healthcare disparities.
Illinois is not alone as a state in this country with these challenges. Wyoming, North Carolina and Alaska have had budget cuts every year from 2012 to 2015.
It is important to take a multi-pronged approach to improve access and engagement in high quality, evidence-based mental health and substance use treatment in every city in every state. The approach must address both concrete and psychological barriers to care.
Regardless of race and socio-economic status, all people need easy access to accurate information about the signs and symptoms of mental illness and available evidence-based treatments. Mental health providers need to collaborate with community organizations such as community centers, health clubs and churches to provide preventative and supportive care.
Historically mental health treatment has been the step child of healthcare. But in order to benefit the most people, we must shift our approach to thinking about comprehensive, integrative care that is inclusive of mental health.
In order to reduce stigma and normalize participation in mental health treatment we must be mindful of the language that we use discussing mental health issues. The reality is that mental illness effects people of all race/ethnicities and socio-economic statuses and it is critical that people of all backgrounds have equal access to treatment.
Inger E. Burnett-Zeigler is a clinical psychologist and assistant professor at Northwestern University, Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences. She is an NU Public Voices Fellow with The OpEd Project.