BY KELVA EDMUNDS-WALLER, DNP, RN, CCM
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
Reverend Dr. Martin Luther King, Jr.
As a Black woman and healthcare professional, I struggle with words like stigma used in the same sentence as Blacks, minorities and mental health. When I read this combination of words, I instinctively sense there is an assignment of blame and responsibility to the victims –Black people. The American Psychological Association dictionary defines “stigma,” a noun, as a negative social attitude regarded as a mental, physical or social deficiency that characterizes an individual. The word implies social disapproval that may lead to unfair discrimination against or exclusion of an individual or community. Stigmatization, also a noun, is the process by which a mark or attribute that is culturally accepted or understood as devaluing is recognized or applied to an individual or group by a group of more powerful individuals. The stigmatizing mark serves to separate marked and unmarked individuals. Stigmatization requires action or a lack of action by an individual or group to reduce an individual from a whole person to a single mark based on negative stereotypes, prejudice and racism, and discriminatory behavior with explicit or implicit bias.
July is Black, Indigenous, and People of Color (BIPOC) Mental Health Month (originally known as National Minority Mental Health Month). The month highlights the mental health challenges and needs unique to historically disenfranchised and oppressed racial and ethnic groups in the United States. Throughout the month, the Department of Health and Human Services, Office of Minority Health (OMH), promotes awareness of mental health and the stigma of mental health among racial and ethnic minorities. OMH encourages state and local leaders, healthcare providers, community-based organizations and faith leaders to educate communities and individuals about the stigma surrounding mental health. This month is a great opportunity for state and local leaders, healthcare organizations, providers and practitioners to acknowledge and own their culpability in the stigmatization of black mental health by advancing policy and implementing best practices.
A brief history of mental healthcare for Black Americans
Early Hypothesis
Historically, race-guided views on Blacks’ vulnerability or risk for mental illness emerged from medical physicians and societies in the early 1700s. John Galt, MD, medical director of the Eastern Lunatic Asylum in Virginia, proposed the “immunity hypothesis,” which reasoned that enslaved Africans were immune from mental illness. Enslaved Africans were immune to mental illness because they did not own property, engage in commerce or participate in civic affairs. For nearly 150 years, Galt’s immunity hypothesis primarily assigned the highest risk of “lunacy” to white men with higher emotional exposure to profit-making stress. The 1840 census contradicted Galt’s immunity hypothesis. The census noted higher rates of mental illness among free Blacks in northern cities compared to enslaved southern Blacks. The medical community hypothesized that Blacks could not manage their freedom, and repeated attempts of enslaved Blacks to escape were categorized as pathological. In 1851, Samuel A. Cartwright, an American physician, coined the term “drapetomania” to describe the abnormal psychology of enslaved Africans attempting to flee captivity. Cartwright’s hypothesis centered on the belief that slavery improved the lives of enslaved people. Therefore, only enslaved people with mental illness would desire freedom. Physicians began to pathologize behaviors expected of enslaved people. Fleeing plantation life or experiencing a dull demeanor became abnormal behaviors. Enslaved Blacks demonstrating such behaviors were housed in outdoor quarters or jails and still forced to perform hard labor.
20th-Century Medical Practices
Eugenics Movement
Harmful thinking and practices related to Black mental illness continued into the 20th century.
The eugenics movement in the U.S. began in 1907 and continued into the 1960s. Eugenicists promoted white supremacy and used forced sterilization to limit the birth rates of specific populations. Medical professionals target Blacks experiencing mental illness and persons deemed mentally deficient, deaf, blind, disabled, poor, and “promiscuous” women. State-mandated sterilizations resulted in the forced sterilization of as many as 70,000 Americans in the 20th century.
Psychosurgical Movement
From the 1930s to the 1970s, psychosurgery, a process to surgically remove parts of the brain to treat mental illness, targeted and victimized Blacks in the U.S. Psychosurgeries or lobotomies were a cure for “brain dysfunction,” which two neurosurgeons correlated to urban violence and the political unrest of the 1960s. The false link between civil unrest and mental illness victimized Blacks across the U.S.
Research Studies
In 1932, the U.S. Public Health Service engaged the Tuskegee Institute in a syphilis study involving 600 Black men, 399 with syphilis. The men received free medical exams, meals and burial insurance in exchange for participation. Eleven years later, penicillin was the drug of choice to treat syphilis and had become widely available. Unfortunately, the Tuskegee participants did not receive treatment.
Historical adversity, institutionalized racism, and mistrust of the medical professions have led to disparities in access, diagnosis, and treatment of mental health disorders among Blacks in the U.S. As a result, Blacks are reluctant to seek mental health care.
Blacks are also reluctant to seek physical care. Statistics related to Black mental health are dismal. Blacks are:
- more likely to seek care in emergency departments for mental health symptoms
- more likely to have Medicaid as the primary source of payment for health care services
- more likely to be misdiagnosed with schizophrenia spectrum disorders
- less likely to receive antidepressant therapy despite access to financial resources
- more likely to live in poverty and twice as likely to report psychological distress
Practical solutions to address disparities in the access to care, diagnosis and treatment of mental health disorders in the Black community include the implementation of best practices by the medical community, including recognizing the Black religious community as a partner in raising awareness of mental health in Black communities and as an active provider of mental health services in the Black community. Best practices include:
- Self-assessment of personal biases in care and misperceptions of emotions expressed by Blacks
- Seek to understand core values of Black culture, including spirituality and community, and how these values align or misalign with professional practice
- Actively listen to Black patients without judgment to strengthen the patient-provider relationship
- Properly screen patients for mental health disorders and refer them for further evaluation and treatment
- Connect with Black religious leaders or organizations to learn about mental health ministries and connect Black patients to providers that they trust.
Additional Resources
National Minority Mental Health Awareness Month
https://minorityhealth.hhs.gov/minority-mental-health/index.html
Centers for Disease Control: Prioritizing Minority Mental Health
https://www.cdc.gov/healthequity/features/minority-mental-health/index.html
BIPOC Mental Health Month
https://www.counseling.org/knowledge-center/mental-health-resources/bipoc-mental-health-month
Mental Health America – Racial Trauma
https://www.mhanational.org/racial-trauma
Black Mental Health: A Story of Resistance
https://healthcare.rti.org/insights/black-mental-health
The Role of the Black Church in the South
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447305/
National Alliance of Mental Illness
https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Black-African-American
Mental Health and The Black Church Roundtable
https://www.youtube.com/watch?v=r6xjqi5THPM
References
American Psychological Association Dictionary of Psychology. (2023).
Davis, K. (2018). Blacks are immune from mental illness. Psychiatric News, 53(9), https://doi.org/10.1176/appi.pn.2018.5a18
Office of Minority Health. (2023). Mental and behavioral health – African Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24
Opara, I., Riddle-Jones, L., & Allen, N. (2022). Modern Day Drapetomania: Calling Out Scientific Racism. Journal of General Internal Medicine, 37(1), 225–226. https://doi.org/10.1007/s11606-021-07163-z
Perzichilli, T. (2020). The historical roots of racial disparities in the mental health system. Counseling Today. https://ct.counseling.org/2020/05/the-historical-roots-of-racial-disparities-in-the-mental-health-system/
Peters, Z., Santo, L., Davis, D., & DeFrances, C. (2023). Emergency department visits related to mental health disorders among adults, by race and Hispanic ethnicity: United States, 2018-2020. National Health Statistics Report, 181. https://www.cdc.gov/nchs/data/nhsr/nhsr181.pdf
Schormans, A. (2014). Stigmatization. Michalos, A.C. Encyclopedia of Quality of Life and Well-Being Research. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-0753-5_2871
Stern, A. (2020). Forced sterilization policies in the US targeted minorities and those with disabilities – and lasted into the 21st century. The Conversation. https://ihpi.umich.edu/news/forced-sterilization-policies-us-targeted-minorities-and-those-disabilities-and-lasted-21st#:~:text=Iowa%20and%20Michigan.-,Eugenics,and%20genetics%20to%20human%20breeding
Kelva Edmunds-Waller, DNP, RN, CCM, has nearly 40 years of nursing experience, including over 20 years in leadership roles. She has clinical experience in acute care, home health, infusion therapy, public health, managed care, primary care, and long-term acute care. She earned a DNP degree at Loyola University New Orleans. She completed her undergraduate and graduate nursing degrees at Virginia Commonwealth University in Richmond, VA. Kelva serves as president of the Central Virginia Chapter of CMSA and is a member of the CMSA Editorial Board.
IMAGE CREDIT: ISTOCK.COM/FIZKES
