INDEX: African-American diversity Perceptions of racism Treatment considerations References Evidence-based References Bio

Challenges and Obstacles in Treating Mentally Ill African American Patients by Carl C. Bell, MD, Henry W. Dove, MD, and Johnny L. Williamson, MD Carl C. Bell, MD 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. African-American diversity 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: African Americans' confusion about whether they are being tolerated or accepted by whites. Though some whites truly accept African Americans, others may harbor negative stereotypes and only tolerate them. Rejecting the legitimate goodwill of whites is as big a mistake as trusting a white person who harbors racist attitudes. Many African Americans can rarely tell who's who, and consequently pay the price. A second problem concerns the inability of African Americans to distinguish between the supportive efforts of individual whites and the destructive actions of whites as a collective (e.g., the long-standing and un-addressed health disparities between African Americans and whites). This confusion occurs when an African American is accepted by an white person, and, as a result, mistakenly believes that racism no longer exists. Another problem is knowing when, where, and how to resist oppression, (e.g., micro insults or micro aggressions and overt discrimination) versus when, where, and how to accommodate it. There are occasions when racism should be fought bitterly, but other times when the fight proves more detrimental than beneficial-for example, when a white psychiatrist stereotypes an African-American patient by diagnosing a psychotic spectrum disorder when an affective spectrum disorder is more suitable. Because of the power differentials, the misdiagnosed patient has a difficult choice to make regarding whether to challenge the treating psychiatrist's clinical acumen and power.15 Finally, the African American may be confused as to whether his locus of control is internal or external. An internal locus of control implies that you attribute your successes to yourself and your failures to your lack of effort. An external locus of control implies that you attribute your failures or successes to something outside of your control. A major problem for African Americans is determining when they are in control of their destiny and when there are external factors imposed by racism. If African Americans assume an external locus of control (i.e., "the man" controls everything African Americans do), then African Americans will lack motivation to help themselves, and they will lack feelings of self-efficacy. Conversely, if African Americans don't recognize the toxic external constraints imposed on them, they could erroneously attribute their failure to their own perceived shortcomings. 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. Treatment considerations 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. References 1. African Americans. Available at http://encarta.msn.com/encyclopedia_761587467African-Americans.html. Accessed October 23, 2006. back 2. Pinderhughes CA. Differential bonding: toward a psychophysiological theory of stereotyping. Am J Psychiatry. 1979;136:33-37. back 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. back 4. Shahrokh NC, Hales RE, eds. Psychiatry Glossary, 8th Edition. Washington, DC: American Psychiatric Press, Inc; 2003. back 5. Bell CC. Treatment issues for African-American men. Psychiatric Annals. 1996;26:33-36. back 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. back 7. Willie CV. Black Families. Bayside, NY: General Hall; 1981. back 8. Carter RT. The Influence of Race and Racial Identity in Psychotherapy. New York: Wiley & Sons; 1995. back 9. Spurlock J. Development of self-concept in Afro-American children. Hosp Community Psychiatry. 1986;37:66-70. back 10. Herbeck DM, West JC, Ruditis I, et al. Variations in use of second-generation antipsychotic medication by race among adult psychiatric patient. Psychiatr Serv. 2004;55:677-684. back 11. Lawson WB. Clinical issues in the pharmacotherapy of African-Americans. Psychopharmacol Bull. 1996;32:275-281. back 12. Glazer WM, Morgenstern H, Doucette J. Race and tardive dyskinesia among outpatients at a CMHC. Hosp Community Psychiatry. 1994;45:38-42. back 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. back 14. Feagin J, Sikes MP. Living With Racism: The Black Middle Class Experience. Boston: Beacon Press; 1994. back 15. Baker FM, Bell CC. Issues in the psychiatric treatment of African Americans. Psychiatric Serv. 1999;50:362-368. back 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 back 17. Benkert R, Peters RM, Clark R, Keves-Foster K. Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care. J Natl Med Assoc. 2006;98(9):1532-1540. back 18. Thomas A, Sillen S. Racism and Psychiatry. New York: Brunner/Mazel; 1972. back 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. back 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. back 21. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997;277:918-924. back 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. back 23. Bell CC. Cultivating resiliency in youth. J Adolesc Health. 2001;29:375-381. back 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. back Evidence-based References Harris HW, Felder D, Clark MO. A psychiatric residency curriculum on the care of African American patients. Acad Psychiatry. 2004;28):226-239. 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. challeng.pdf Posted with Permission from Psychiatric Times

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