Culture Clash: The Danger in Downplaying Black Experiences in Mental Healthcare

As a new clinician, Norissa Williams set out to begin her personal journey with mental health through treatment, which led her to the offices of a white woman. Williams found value in her sessions with this clinician, but it didn’t take long for her to also recognize a significant challenge that many clients face while working with mental health professionals – feeling culturally understood.   

“When I talked about anything related to living and being black in America, she couldn’t necessarily relate, and I could see that. So, I had to leave that part of me at the door,” said Williams, who works at NYU Steinhardt’s Applied Psychology Department and serves as a clinical assistant professor for the online master’s in mental health counseling program.

Williams is not alone. In a field that was developed and is primarily staffed by white doctors and clinicians, black experiences and black culture are often overlooked or misunderstood.

Trauma grief and loss counselor Babe Kawaii-Bogue, who has worked in both inpatient and outpatient mental health settings for over a decade said, “When you think about how societal systems are set up in this country to help people (i.e., healthcare, criminal justice, education, housing, workforce systems, etc.), you will notice they are really designed to help a certain group of people.” That group, said Kawaii-Bogue, are “predominantly white or wealthy communities.”

“And if you examine these societal ‘helping’ systems even more thoroughly,” says Kawaii-Bogue, “you will notice they have the opposite effects on the African American community in that these systems work to disenfranchise African Americans, not help them.”

Kawaii-Bogue suggests that this is something that mental health practitioners must understand in order to effectively support African American communities.

The Implications of Stigma and Cultural Bias

In an upcoming paper to be published in Best Practices in Mental Health, Williams and Kawaii-Bogue identify a number of cultural pain points within the mental healthcare field that prevent some African Americans from seeking treatment and from receiving effective care when they seek treatment. Stigma is one of the biggest challenges to getting black people in need of treatment through the door.

Williams pointed out that, while men in general are socialized not to show emotions, black men in particular are required by society to be strong in response to a number of stressors they experience as members of a marginalized and often targeted community. Similarly, black women are included in this phenomenon, which requires them to be strong caretakers for their families and communities at the expense of their own needs. An admission of needing help for both men and women can be viewed as a weakness.

The perceived need to be “strong” is partially a means of preventing society from further stereotyping the black community, added Kawaii-Bogue. Negative portrayals of African Americans in the media, for example, create a stronger desire for black men and women to represent their community as a whole in a more positive light.

However, stigma is also rooted in the past.

“One of the biggest barriers to care is the historical trauma caused by the medical industrial complex and the legacy of that trauma,” said Yolo Akili Robinson, founder and executive director of the Black Emotional and Mental Health Collective (BEAM), an organization dedicated to removing barriers to emotional healthcare through education, training, advocacy, and the creative arts. 

Robinson said the historical mistreatment of black people by the overall healthcare field, as well as the psychiatry and psychology fields, has created a sense of fear and mistrust that can affect help-seeking behaviors. That fear has been passed down through generations.

The danger in stigma and fear is that many black clients wait too long to seek out treatment, and, consequently, their conditions can become more severe.

“It’s not about maintaining everyday health the way white people or more wealthy populations think about it,” Kawaii-Bogue said. “When black people do seek out mental health services, they are more or less saying that there’s something seriously wrong.”

And while stereotypes can play a dangerous role in blocking access to mental health treatment, they can also play a dangerous role inside offices for mental health practitioners.

African Americans and other racial groups do not always present symptoms in the same manner as white clients, which can lead to misdiagnosis. Williams said that a black man, for example, may present depression as anger instead of sadness because he may not be culturally or socially permitted to express sadness. However, a white clinician may diagnose an illness based on how that illness presents in white culture.

“The problem with misdiagnoses and underdiagnoses is that the client is not going to get the correct treatment or any treatment at all,” said Williams.

“The problem with misdiagnoses and underdiagnoses is that the client is not going to get the correct treatment or any treatment at all,” said Williams.

The researchers said mental health practitioners must recognize that African Americans interact with the mental healthcare system differently than white clients, and they have different treatment needs.

“Some white communities are beginning to recognize that living the life of a black person is very different,” said Kawaii-Bogue. “We don’t relate to systems in the same way because they are not set up for us.”  

Many black clients, Williams and Kawaii-Bogue said, question whether clinicians have their best interests in mind, particularly when they enter offices in which nobody looks like them. These experiences can be isolating, which can cause people to put their guard up.

Clinicians, they added, also need to reflect on how their actions contribute to creating these walls. African Americans place a high value on forming interpersonal relationships in treatment, Kawaii-Bogue said. Many practitioners do not take the time to create those relationships. Instead, they diagnose an illness, create a treatment or medication plan, and expect their clients to trust that the plan will work.   

“The empowerment factor is really important especially for black people who want to have some knowledge about what these illnesses are,” Williams said.

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Expanding Representation within the Mental Health Field

The researchers said one important way to better address the mental healthcare needs of the African American community is to recruit more black clinicians and researchers in the field and to invest in the research of communities of color and other underserved communities.

“You have to do a lot of work to recruit in communities of color because you are not going to be drawing from your typical networks,” Kawaii-Bogue said. “You have to know other networks, and you have to know where these communities are.”

According to the Bureau of Labor Statistics, African Americans are underrepresented in the psychology workforce but fare better in the social work and counseling workforces. African Americans made up approximately 6 percent of psychologists, 23 percent of social workers, and 20 percent of counselors employed in the 2016 U.S. workforce. Even so, the overall mental healthcare field faces shortages of workers, which are only expected to worsen.

While increasing the number of black mental healthcare workers can help to bridge the cultural divide between the field and African American clients, practitioners need to be more knowledgeable and culturally responsive than simply being the same race as their client, according to Williams. She encourages practitioners to take the implicit bias association test to help identify their own unconscious biases and to intentionally seek out conversations with all of the communities that they serve in order to increase individual awareness about the unfounded beliefs they may hold.

Both women also emphasize the need to understand how the population already copes with mental health conditions and to find a means to integrate evidence-based practices into these methods. 

Robinson’s BEAM is doing just that.

“Mental health is sustained by all different members of our community,” he said.

In order to eliminate stigma and fear, BEAM hosts training programs and seminars with various leaders within the black community, including teachers, pastors, and activists, to improve their baseline understanding of mental health. By building up the entire community’s understanding and willingness to engage on the topic, Robinson said he believes more people will seek out care.

 “The approach is not to assume that black folks don’t already have coping strategies. We do,” Robinson said. “We aim to highlight the tools the community already has and expand upon the ones that are healthy to further mental health literacy.”

Art, dance, music, and yoga are just some of the creative outlets BEAM is tapping into to promote black healing and wellness. All three experts agree that transformative models of care are the key to providing effective treatment for the black community.     

African Americans “have developed their own methods of treatment,” Kawaii-Bogue said. “But they can’t do it themselves. Nobody can.”

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Citation for this content: Counseling@NYU, the online masters in mental health counseling from NYU Steinhardt.