GFW PTSD Home | Site Map | Site Search
Gift From Within - PTSD Resources for Survivors and Caregivers
Challenges and Obstacles in Treating Mentally Ill African American Patients
by Carl C. Bell, MD, Henry W. Dove, MD, and Johnny L. Williamson, MD
Posted with Permission from Psychiatric Times
As the United States becomes more culturally, racially, and ethnically diverse, psychiatry will be faced with the necessity to treat more diverse populations. This article focuses on challenges and obstacles encountered when treating African American patients with mental illness. The African American community in the United States is not a monolithic, homogeneous community. The heterogeneity of the community as a function of the African diaspora is complex and deserving of an understanding that goes beyond the phenotypic identification and assignment of individuals to what we believe to be "African American."1 Language, ethnic culture (e.g., Caribbean vs southern born), religious practices, socioeconomic status, immigration or refugee status, and the historical participation, or lack thereof, in the unique American experience of race relations defines how persons experience being "African American" and express mental illness.
The first skill necessary to appropriately treat patients from the African-American community is to avoid stereotyping members of this diverse community.2 Such stereotyping is at the root of behaviors that result in the expression of micro insults and micro aggressions toward members of the African diaspora.3-5 For example, psychiatric services staff need to learn not to automatically ask African-American patients for their "Medicaid cards," but should rather ask, "How does the patient intend to pay for services?" Conversely, gratuitously attempting to overidentify with the African-American culture based on stereotypes is equally detrimental. An example is a white therapist giving an African-American patient an unsolicited "soul" handshake at their first meeting. Alternatively, the supposition that leads a therapist to prematurely inquire about substance abuse prior to eliciting relevant data to support this possibility may be offensive to an African-American patient. It is advisable to establish rapport and elicit data that more directly relates to the presenting problem prior to incorporating this and other more sensitive types of inquiry.
Satcher's Culture, Race, and Ethnicity Report6 is an excellent primer that combats stereotyping by emphasizing the importance of recognizing the diversity that exists within African-American communities. Consideration of the individual patient's social context is important for avoidance of stereotyping and for understanding the context in which the patient's mental illness occurs. Middle class,working class, and poor African Americans have different patterns of family membership; employment and continuity of employment; number of children; family functions; patterns of interaction (egalitarian, paternal, maternal); income and spending patterns; social and leisure activities; involvement in community affairs; education; attitudes toward work; success and self-reliance; etc.7 Despite the myth that all African-American families are matriarchal, middle class African-American families are egalitarian, and those of Caribbean extraction are very patriarchal; therefore, making assumptions about black family structure and function is a potential land mine. Factors that affect levels of cultural identity8,9 among persons of the African diaspora can be further understood by referring to the under used "Cultural Formulation" section of the DSM-IV-TR.
Central to recognizing the diversity within the African-American community, is the development of skills of "cultural sensitivity."6 For example, it is important to recognize and understand that different cultural, racial, and ethnic groups may require different medication prescribing practices.10 For example, because African Americans have higher blood levels they may be more predisposed to tardive dyskinesia given the same dose of a neuroleptic versus a white counterpart.11,12 Simultaneously, while cultural sensitivity is important in the treatment of African Americans with mental illness, it is equally important to recognize that there are universal principles of treatment that should be applied to all patients.13 Clinicians must become astute in their ability to draw from both in their work with African Americans.
Perceptions of racism
Another aspect of cultural sensitivity is recognizing that many African Americans have been subjected to various degrees of racism14 and have varying levels of recognition of this reality. Misconceptions on the part of African Americans may stem from any of the following5:
The first 3 of these areas of confusion can seriously disrupt the establishment of good rapport between the patient and the treatment provider. The American Psychiatric Association's position statement on racism emphasizes the importance of being mindful of the existence and impact of racism and racial discrimination in the lives of patients and their families, in clinical encounters, and in the development of mental health services.16 Additionally, the confusion about locus of control has a potentially tremendous impact on feelings of self-efficacy, making it critically important to discuss these confusions with African-American patients early in treatment.
African Americans may harbor fear, distrust, lack of confidence, and anxiety over the prospects of stigmatization-all born of a historic recognition of failures of the mental health system to adequately address disparities and exploitation (e.g., Tuskegee syphylis experiments).17,18 Additionally, because exposure to trauma is another common issue for African-American patients, they should be asked about their experiences with racism and trauma.6,19
When treating African Americans, it is critical to understand that risk factors are not necessarily predictive factors, since protective factors may intervene. Thus, psychiatrists must actively explore the protective factors surrounding African Americans in risky contexts.20 In general, protective factors are the extent of social fabric surrounding the patient,21,22 the patient's access to state-of-the-art medical technology, the opportunities the patient has had for developing social skills (e.g., the capacity for affect regulation), the patient's sense of self-efficacy and self-esteem,22 the protective shields in the patient's life (e.g., family involvement, church), and the opportunity for the patient to develop a sense of self-efficacy by turning traumatic helplessness into learned helpfulness.23
It is imperative that objective, empiric, evidence-based research guide how best to adapt current practices to mental health issues relevant to the diverse African-American community. Humanistic interventions geared toward using existing community resources and strengths (including family support, ethnic and spiritual values, education, and belief systems borne of tradition) and an understanding of the African-American experience can be used to construct culturally sensitive and effective mental health services and interventions.24
Dr Bell is president and CEO of the Community Mental Health Council and clinical professor in the department of psychiatry at the University of Illinois at Chicago. Dr Dove is interim head of psychiatry and associate professor of clinical psychiatry in the department of psychiatry at the University of Illinois in Chicago. Dr Williamson is a staff child psychiatrist at the Community Mental Health Council. They report that they have no conflicts of interest concerning the subject matter of this article.
1. African Americans. Available at http://encarta.msn.com/encyclopedia_761587467African-Americans.html. Accessed October 23, 2006.
3. Pierce CM, Earls FJ, Kleinman A. Race and culture in psychiatry. In: Nicholi AR, ed. The Harvard Guide to Psychiatry. Cambridge, Mass: Belknap Press of Harvard University Press; 1999:735-743.
4. Shahrokh NC, Hales RE, eds. Psychiatry Glossary, 8th Edition. Washington, DC: American Psychiatric Press, Inc; 2003.
6. US Public Health Service. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Available at http://www.surgeongeneral.gov/library/mentalhealth/cre/. Accessed October 23, 2006.
7. Willie CV. Black Families. Bayside, NY: General Hall; 1981.
8. Carter RT. The Influence of Race and Racial Identity in Psychotherapy. New York: Wiley & Sons; 1995.
11. Lawson WB. Clinical issues in the pharmacotherapy of African-Americans. Psychopharmacol Bull. 1996;32:275-281.
13. Bell CC, Bhana A, McKay MM, Petersen, I. A commentary on the triadic theory of influence as a guide for adapting HIV prevention programs for new contexts and populations: the CHAMP-South Africa story. Soc Work Mental Health. 2006;5:237-261.
14. Feagin J, Sikes MP. Living With Racism: The Black Middle Class Experience. Boston: Beacon Press; 1994.
16. American Psychiatric Association. Resolution Against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health; Position Statement; 2006. http://www.psych.org/edu/other_res/lib_archives/archives/200603.pdf
18. Thomas A, Sillen S. Racism and Psychiatry. New York: Brunner/Mazel; 1972.
19. Dove HW, Anderson T, Bell CC. Mental health and its impact on the health in the U.S. nonwhite population. In: Satcher D, Pamies RJ. Multicultural Medicine and Health Disparities. New York: McGraw-Hill; 2005:295-303.
20. Bell CC, Flay B, Paikoff R. Strategies for health behavioral change. In: Chunn J, ed. The Health Behavioral Change Imperative: Theory, Education, and Practice in Diverse Populations. New York: Kluwer Academic/Plenum Publishers; 2002:17-40.
22. Flay BR, Graumlich S, Segawa E, et al, for the Aban Aya Investigators. Effects of 2 prevention programs on high-risk behaviors among African American youth: a randomized trial. Arch Pediatrics Adoles Med. 2004;158:377-384.
24. Williams K, Johnson V. Eliminating African American Health Disparity via History-based Policy. Harvard Health Policy Review. 2002;3:1-4. Available on line at http://www.hhpr.org/currentissue/fall2002/williams-johnson.php Accessed October 23, 2006.
Harris HW, Felder D, Clark MO. A psychiatric residency curriculum on the care of African American patients. Acad Psychiatry. 2004;28):226-239.
Posted with Permission from Psychiatric Times
Was this helpful to you?
If so, please consider supporting our work.
Addiction | Adoption | Auto Accidents | Chaplains, Police, EMT | Childhood & Adult Sexual Victimization | Compassion Fatigue
Culture, Race, and Ethnicity | Domestic Violence and Sexual Assault | Grief | Journalists, Survivors, and the Media
Male Sexual Abuse & Domestic Violence | Partners & Families | PTSD Treatment & Recovery | PTSD and Health
PTSD and Workplace Issues | Recovery & Self Help | Resiliency | School Disasters
Spirituality & Trauma | Survivor Guilt | Trauma Responses in the Aftermath of Disasters | Veterans & Their Families
Post Traumatic Stress Disorder (PTSD) Home Page | Site Map | Articles | Webcasts | Order Form | DVDs on PTSD and Trauma | Q&A with Dr. Ochberg
Email Pen Pal Support Network | PTSD Etiquette: Finding The Right Words | Meditations | Support Pals Humor Grab Bag
Support Pals Share Inspirational Stories | Support Pals Share Favorite Healing Ideas | Support Pals Book Reviews
Support Pals Finding A Therapist | Support Pals Talk About Living With PTSD | Support Pals Favorite Books & Music
Support Pals Discuss: What PTSD Means To Me | Military Family Resources | Support Groups | Internet Links | Retreats & Respites
Conferences, Workshops and Seminars | PTSD & Trauma Bookstore | Poetry | Art | Music | Survivor Psalm | Memory Shouldn't Be...
Mission Statement | What People Are Saying | Support GFW | Frank Ochberg's Bio | Joyce Boaz's Bio | Board Members | Contact Us
Awards | Band of Angels | What's New | View Our PSAs | Site Search | Guestbook
Copyright © 1995-2014 Gift from Within,Camden, Maine 04843
html Conversion Copyright © 1995-2014 SourceMaine, Belfast, Maine 04915
Content may not be reproduced on websites without express permission. Please link instead.
Page created on 21 December 2006
Last updated by on 9 January 2014