Best Practice Highlights African Americans/Blacks Prepared by Rahn K. Bailey, M.D.
The Black Population
The term “Blacks” encompasses both African Americans and more recent African and Caribbean immigrants. 13.2% of the U.S. population, approximately 42 million people, identify themselves as Black and another 1% self-identify as multiracial.
Frequently, due to issues of stigma and lack of access Blacks are seen in crisis and, hence, in the acute care settings. This may explain why adult Blacks are 20% more likely to be reported as having serious psychological distress than adult Whites. They are also more likely to have feelings of sadness, helplessness and worthlessness compared to adult Whites. And while Blacks are less likely than Whites to die from suicide as teenagers, Black teenagers are more likely to attempt suicide than are White teenagers.
Social determinants, can affect mental health. For Blacks, class and poverty are two impactful factors. For example, adult Blacks living below poverty are two to three times more likely to report serious psychological distress than those living above poverty.
Blacks of all ages are more likely to be victims of serious violent crime than are non-Hispanic Whites, making them more likely to meet the diagnostic criteria for post-traumatic stress disorder (PTSD).
Significant History – Events which influenced the community and contextualize assessment and Treatment
Historical adversity, for example, slavery, sharecropping, and segregation, along with other means of race-based exclusion from health, educational, social and economic resources, has led us to socioeconomic disparities experienced by Blacks in America today. In spite of progressive gains and reform in our society, racism lingers
and continues to influence the mental health of Blacks. Damaging stereotypes and attitudes of rejection have diminished in many ways, but their continued occurrence points to a tone within our culture that has quantifiable adverse consequences.
Health Disparities and stigma that surround mental health create barriers for patients and impede treatment. Within Black communities, attitudinal barriers can prevent patients from even seeking treatment in the first place. Some of this apprehension is born from cultural mistrust that can be linked to the Tuskegee project. This U.S. government funded project continues to be a factor negatively influencing Blacks’ willingness to enter research studies, leading to underrepresentation. Perhaps more damaging, it can lead some Blacks to be resistant to pharmacological therapies.
The fact that Blacks are overrepresented in prisons, 1 million of the total 2.3 million people incarcerated in the United States, is another barrier we face. A current major national concern, people of color account for 60% of the prison population, and while Blacks only represent 14% of drug users, they account for 37% of drug arrests. This incarceration could contribute to mental health issues of Black people and raises questions surrounding the delivery of the mental health services in prisons. This reality leads to real issues in health care regarding access, mental health, and quality care/ treatment.
Treatment issues that must be addressed include the fact that Blacks are overrepresented in inpatient treatment and underrepresented in outpatient treatment, highlighting the need for more early education and intervention. This can be attributed to misdiagnosis and other issues like access of care. Access is a central point of contention when thinking about the care of Black psychiatric patients. Often communities are not equipped with adequate facilities and services. Having to seek treatment outside of the place where you live is an added barrier and provides for another layer of issues related to time, work, and transportation.
13.2% of the U.S. population, approximately 42 million people, identify themselves as Black and another 1% self-identify as multiracial.
- Proper screening and follow through with quality assessments that utilize a bio-psychosocial model will help practitioners gather unabridged evaluations of their patients. This, in turn, will enable them to find the most appropriate diagnosis for their patients.
Keeping talk therapy the center of all treatment paradigms, from the start, and then providing consistency in care should always be fundamental considerations for providers.
- Be aware of microagressions, a term coined by Chester Pierce, M.D. a leading Black psychiatrist to describe the ongoing experience of Blacks in the post-civil rights movement era. A cumulative burden of a lifetime of “microagressions” can contribute to physical illness and mental health. In the context of psychotherapy, microagressions by providers can disrupt therapeutic rapport. Know your own cultural influences and those of the people with whom you work.
- Perceived discrimination may be related to mental and physical health outcomes. These effects are felt to be due to stress response and health behaviors. Existing literature suggests social support, active coping styles and group identification serve to be a protective function in these stress pathways.
- Be aware of idioms of distress, or ways that people cope, be it constructive or destructive, with pain or struggle. Here are a few common idioms of distress:
- Be aware of the role of extended family for Blacks in caring
for children, supporting mothers, serving as role models, and supporting family members in their health and preventing fatal diseases and mental health illness.
- To avoid misdiagnosis, a chronic problem in the treatment of
Black patients, integrate the culture, context, persona, and family history into your conceptualization. Address the significance of the patient’s race.
- Focus on strengths and affirmation. The emphasis on the patient’s assets including intrapersonal and social has been found effective in prevention and creating family cohesion. Offering an integrated care model that includes wraparound services is important in the holistic treatment of Black psychiatry patients, many of whom find support within family, churches, and the community.
- Though more research is needed, be aware of ethnopsychopharmacological issues affecting Black patients. For example, evidence suggests the physician should consider starting with lower doses of many antipsychotic agents. Most importantly, establish a firm rapport before prescribing medications.
Looking ahead, while Black patients may prefer Black physicians, only about 2 to
4 percent of mental health providers identify as Black. This means Black patients are likely to be seen by a provider from a different cultural
and ethnic background than their own. Similarly in research, there is a paucity of Black researchers and Black patients participating in research – which is problematic as research is the basis for our evidence- based clinical practices.
Finally, it is imperative that we continue to improve our screening and assessment processes; we have to take cultural issues into account while still providing a general level of consistency between our patients. Early and accurate assessments and diagnosis simply lead to better outcomes for patients. We must consider the saliency of our treatment models and their relative effectiveness for clients with respect
to cultural differences