Rachita Sharma, PhD, CRC, LPC-S
Clinical Assistant Professor
Department of Rehabilitation & Health Services
Clinical Director UNTWELL
University of North Texas
Chandra Donnell Carey, PhD, CRC, FNAMRC
Academic Associate Dean
College of Health & Public Service
Co-Founder, Center for Racial and Ethnic Equity in Health and Society
University of North Texas
Between a Rock and a Very Hard Place: Mental Health in Minoritized Communities
The year 1999 brought widespread fear and anxiety about the world going “offline” due to an alleged internet clock glitch. Y2K never happened, but in that same year the Office of the Surgeon General Report on Mental Health included a historically notable supplement, Mental Health: Culture, Race and Ethnicity (USDHHS, 1999b). While this report didn’t incite widespread fear, it did heighten awareness and instigated nationwide discussion about mental health in communities of color. This seminal report provided one of the first comprehensive overviews of mental health and mental illnesses from a cultural perspective. It ushered our nation into a dialogue examining disparities within relevant historical and cultural contexts. This report exposed the reality of disparities for racial/ethnic minorities and amplified the issues seen by some practitioners and experienced within communities of color for decades.
While we know that mental illnesses can affect persons of any age, race, religion, or income and that they are not the result of personal weakness, lack of character, or poor upbringing, there was still little discussion in the community or in the literature about the disparate impact a diagnosis could have. In 2000, we knew and understood less about the disparities in treatment, availability of services and utilization of services within minoritized and marginalized communities. Twenty-one years later, we know more, yet the disparities persist.
Let us pick depression as an example to highlight these disparities. While rates of depression in the African American and Latino(a) population are typically lower than what we see in the White, non-Hispanic populations, we also know that the rate of seeking treatment is less amongst these populations. While that prevents us from having accurate data from these populations that could lead to targeted treatment interventions in their home communities, the gaps in these numbers could also indicate that individuals from these groups are lacking the necessary treatment that can promote a healthy recovery process. The Agency of Healthcare Research and Quality (AHRQ) reports that in the U.S., racial and ethnic groups are less likely to have access to mental health services, less likely to use community mental health services, more likely to use emergency departments as a first point of mental healthcare service, and are more likely to receive a lower quality of care. What you might find is that despite the existence of effective treatments, disparities in the availability, accessibility and quality of mental health services for racial and ethnic minorities further exacerbate the negative effects of mental illnesses. Added to these are culture-specific attitudinal barriers that impact the view of mental illness and keep individuals from seeking help. We will present an overview of these attitudinal barriers later in this blog.
First, in a discussion about disparities in mental health care, we have to acknowledge that inequities in education, insurance coverage, and English-language proficiency are linked to difficulties in accessing mental health services and receiving quality care. These disparities are particularly impactful for racial-ethnic and linguistic minorities. The dearth of cultural and linguistic diversity in the behavioral health workforce creates a critical shortage of providers who possess culturally relevant knowledge, training, and skills to serve people who speak languages other than English or of racial/ethnic minority populations (Hogg Foundation for Mental Health, 2011). Understanding these factors, being culturally responsive, and demonstrating cultural humility in practice from intake through treatment and especially at closure or termination of services, can make a substantial difference in those who choose to seek treatment, those who stay in treatment and those who might return at some point later.
The emergence of the COVID-19 pandemic further impacted healthcare disparities due to its convergence with existing systemic structural racism thereby bringing renewed and heightened attention to disparities and inequities in health outcomes that exist for US residents who are most commonly oppressed and marginalized in US society. Racist incident-based trauma, intergenerational trauma, and race-based stress have been discussed in the counseling and mental health literature with increasing intention over the past 15 years (Bryant-Davis, 2007), but the events surrounding the murders of George Floyd, Breonna Taylor and Ahmad Aubrey, boiled these issues right back to the surface and left most of us scarred and raw. Clinicians and researchers of color recognized the effects of race-based traumatic stress in ourselves. Knowing that race-based traumatic stress can potentially impact anyone who has experienced sudden, emotionally upsetting and uncontrollable racist incidents. So, in addition to COVID-19, systemic racism and systems of white supremacy in the United States made experiences of racism, discrimination, microaggressions and other race related traumatic events even more debilitating for people of color (Williams et al., 2018).
As the U.S. population has become increasingly ethnically, linguistically, and culturally diverse, its mental health professionals must be knowledgeable of the needs of client populations. An individual's attitudes, values, ideals, and beliefs are greatly influenced by the culture (or cultures) in which he or she operates. Thus, an individual’s multicultural experiences and backgrounds become salient aspects of his/her self-identity. In 1973, anthropologist and cross-cultural researcher Dr. Edward T. Hall, stumbled upon one of the greatest secrets of culture which he later shared in his famous book The Silent Language. Dr. Hall succinctly identified the paradox of cross-cultural sensitivity by stating Culture hides more than it reveals, and strangely enough what it hides, it hides most effectively from its own participants. Since then, countless researchers have emphasized the importance of acknowledging that illnesses and health, including mental health, are perceived differently across cultures (Gopalkrishnan, 2018). Almost half a century later, Edward Hall’s words still ring true as psychologists and mental health counselors become more aware of the cultural attitudes and barriers that prevent people from seeking support when struggling with mental health concerns.
Decades of research in this important area has suggested that the cultural conditioning that a person experiences in childhood contributes to his/her patterns of behavior, emotional responding, and management of stress as an adult. In 2013 the World Health Organization (WHO) sponsored a large study where researchers interviewed over 60,000 people with mental health disorders across 24 countries to assess the barriers that kept them from initiating or continuing in mental health treatment. These researchers discovered that over 60% of people with mental health disorders believed that they did not need to be in treatment indicating a low perceived need for treatment. Of additional concern was the finding that their personal and cultural attitudinal barriers such as stigma, negative health beliefs, and concerns about consequences of treatment when seeking mental health support kept them from initiating or continuing in treatment. For some people, these attitudinal barriers might take the form of beliefs involving concerns about losing face or a desire to keep things in the family, or to avoid airing dirty laundry in front of a stranger, even when that stranger is a trained mental health professional.
Attitudinal beliefs might also be impacted by the specific culture with which the individual identifies. Closer to home in the US, many researchers such as Tiwari & Wang, 2008 have studied the impact that an individual’s cultural attitudes have on their engagement in mental health treatment. They have found that clients from minority backgrounds typically utilize mental health resources less frequently when compared to their non-minority peers in the community. Other researchers such as Leong & Lau, 2001 have found that clients from minority backgrounds (and especially clients who are first generation immigrants) tend to drop out of mental health treatment earlier than their peers who are Caucasian and US nationals. It is important to note that a person’s level of acculturation to the dominant culture in which they operate (e.g., the mainstream American culture) might impact how closely they adhere, or whether they adhere at all to the attitudinal barriers typically endorsed by their cultural community. Although not every individual will be impacted by their cultural beliefs about mental health concerns to the same degree, many individuals are raised with stigmatizing beliefs about mental health that continue to impact their help-seeking behaviors as adults. Following are some general examples from specific minority populations present in the United Stated.
Asian Americans: Kung (2004) suggests that Asian Americans might consider mental distress a result of malingering negative thoughts towards others, a lack of will power, or a weakness in the person’s personality or self-identity. Thus, the individual might feel ashamed of experiencing mental health distress. Emphasis might be placed on cultivating self-control and individuals might feel inclined to either solve their own problems or seek advice from family/community elders. Many times, individuals in this community might not feel comfortable expressing mental health symptoms; instead, they report physical symptoms that often correlate closely to mental health diagnosis. For example, instead of disclosing their mental health status, an individual who is depressed might seek treatment from a primary care physician for chronic headaches, fatigue or exhaustion, digestive issues, or weight gain, all of which are common symptoms of depression.
Latinos: Attitudinal barriers within the Hispanic community have been studied extensively. When interviewing participants from Hispanic/Latino backgrounds, Caplan (2019) discovered that such individuals might have negative views of mental illness, possibly associating all kinds of mental illness as being “crazy” and violent. Participants in this cultural group indicated that they were socialized from a young age to believe that persons with mental illness were dangerous, out of control, and suffering from an incurable illness that resulted in rejection and ostracism. Consequently, many families might deny the existence of mental illness including depression and anxiety, unless the symptoms significantly interfered with daily functioning or were life-threatening to the individual. The presence of mental illness, including depression might be attributed to lack of religious faith, not praying enough, act of demons, and sinful behaviors of parents. Instead of reaching out for mental health treatment, individuals with mental health concerns might be encouraged to find solace in religious interventions, encouraged to engage in more prayer and to have more faith in God.
African Americans: Researchers Matthews, Corrigan, Smith, and Aranda (2006) conducted targeted mental health research with individuals who self-identified as being African American and discovered that self-reliance was a message often heard within the African American community in the context of mental health support. Similar to other minority communities, individuals expressed high levels of embarrassment, refusal to accept the need for services, concerns about experiencing double discrimination, and stigma associated with mental illness and treatment seeking behaviors. When a person’s inner coping resources were strained, reliance on religious beliefs or spirituality was strongly endorsed as a coping strategy by most participants from this cultural community. African American individuals typically found themselves relying on support from family and friends within the community when struggling with mental health concerns.
American Indians/Alaska Native (AI/AN): When exploring attitudes and barriers towards mental health within this cultural minority, Brave Heart (2011) discovered a relationship between the decades of historical losses (e.g., loss of people, land, culture) suffered by the AI/AN population and their receptiveness towards mental health help-seeking behaviors. Researcher Roh and team (2015) found that this was especially relevant among older individuals within this community who could remember the racial trauma experienced by generations of American Indians, causing them to be mistrustful of providers outside the community. The overall attitudes towards mental health were further impacted by a desire for privacy, reliance on self, and concerns about the quality of care provided by non-community providers.
Where it may be clear to others that seeking treatment is a part of the process to recovery, the aforementioned stigma, stereotypes and tropes regarding strength, faith, and resilience have prompted a denial of the impact of mental health even among those likely experiencing the daily effects of it. Between improper diagnoses, attitudinal barriers, economic barriers, lack of culturally responsive treatment and interventions, and ineffective relationships with service providers, few people who could benefit from mental health treatment receive the appropriate care. This presents a precarious conundrum for practitioners who may be prepared to service these populations, but see disparate rates of utilization of mental health services within communities of color.
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., ... & Kessler, R. C. (2014). Barriers to mental health treatment: results from the WHO World Mental Health (WMH) Surveys. Psychological medicine, 44(6), 1303.
Caplan, S. (2019). Intersection of cultural and religious beliefs about mental health: Latinos in the faith-based setting. Hispanic Health Care International, 17(1), 4-10.
Gopalkrishnan, N. (2018). Cultural diversity and mental health: Considerations for policy and practice. Frontiers in public health, 6, 179.
Kung, W. W. (2004). Cultural and practical barriers to seeking mental health treatment for Chinese Americans. Journal of Community Psychology, 32(1), 27-43.
Matthews, A. K., Corrigan, P. W., Smith, B. M., & Aranda, F. (2006). A qualitative exploration of African-Americans’ attitudes toward mental illness and mental illness treatment seeking. Rehabilitation Education, 20(4), 253-268.
Roh, S., Brown-Rice, K. A., Lee, K. H., Lee, Y. S., Yee-Melichar, D., & Talbot, E. P. (2015). Attitudes toward mental health services among American Indians by two age groups. Community mental health journal, 51(8), 970-977.