Since the early 2000s, countless researchers have studied the differences in the prevalence of mental illness and the quality of the American healthcare system concerning race and ethnic groups. These researchers have showcased the existence of significant disparities in mental health and mental healthcare within the United States. However, these disparities exist regarding physical health as well.
History of Disparities in Healthcare
In the early 1980s, researchers utilized area analysis and geographic analytic techniques to demonstrate the practice variability among patients with similar conditions, receiving treatment from clinics in different geographic locations. These findings lead to the 1984, Department of Health and Human Services report. “Health, United States, 1983.” In this report, the United States government documents that there were disparities in, “the burden of death and illness experienced by blacks and other minority Americans as compared with the nation’s population as a whole,” (Gibbons, 2005)
This report forced the secretary of the Department of Health and Human Services to create a task force focused on the health of African Americans and other minorities. The primary purpose of this task force was to conduct a study of health problems among minorities and raise awareness of the disparities that existed in the healthcare system. In 1985, the “Report of the Secretary’s Task Force on Black and Minority Health,” was released (Gibbons, 2005).
The practice variability discovered in the 1980s was linked to substandard care in regions with poor populations. However, these regions receiving substandard care were inhabited by minority patients (Gibbons, 2005). While these disparities could have been based on socioeconomic status, we must ask ourselves, “Why did these regions associated with poor populations have such a large number of minorities residing there?” Disparities in substandard care exist across race, ethnicity, geography, gender, age, and socioeconomic status. But, the greatest disparities exist among race or ethnicity, and socioeconomic status. These two factors strongly correlate. The roots of this correlation between wealth and race, or ethnicity can be found in the late 1400s, 1492 specifically, and have continued to grow and disperse since then.
In 1492 Columbus sailed the ocean blue and ‘discovered’ America. From 1492 to the late 1700s European explorers set sail for America and claimed the land as their own. This ‘colonization of America’ was prompted by political, religious, and economic motives. A large number of settlers came to America to escape religious persecution. The irony in that is that the individuals who were cast out for their differences in opinion persecuted the natives for their differences in beliefs, appearance, and social practices.
Throughout history, we have observed countless civilizations persecute and exploit individuals based on their differences. But, in America, black and indigenous people have been exploited far more than any other race or ethnicity. To emphasize this, BIPOC, or black and indigenous people of color, is used to discuss this exploitation, robbery of culture, and enslavement of these two populations at two separate times during history. The term is also used to explain the mental, social, and physical effects these events have had on these two populations today.
The term BIPOC is utilized to differentiate minorities and people of color from those that have been exploited since America’s founding. Black and indigenous people (Alaskan Natives, Hawaiian Natives, and Native Americans) share common historical experiences.
Upon arrival, Europeans exploited the natives. They stole their resources, culture, and land. These Europeans brutalized natives and forced them to work for the European’s profit. From 1492 to 1880, somewhere between 2 and 5.5 million natives were enslaved. (Brown University) In some cases, the natives were shipped to the Caribbean and in others, they were enslaved in North America. During enslavement, the natives were forced to perform extreme labor, physically abused, raped, and tormented. The Europeans enslaved natives for financial purposes and to acquire their land. Native American slavery resulted in the loss of native culture and traditions for many tribes.
In 1619, twenty enslaved Africans were brought to Jamestown, Virginia. Many historians agree that this was the beginning of chattel slavery in America. From 1619 to 1808, when congress outlawed the slave trade, 12.5 million Africans had been stolen from their homeland and transported across the Middle Passage. (Halliburton) This figure does not include the children born to enslaved mothers. From their arrival, Africans were stripped of their name and dispersed across colonial America. During their enslavement, they were exposed to the same horrors as Native Americans. They were abused, raped, tormented, and forced into strenuous labor. Just like the natives, their culture was ripped from them and in many cases so were their families.
BIPOC in Post-Slavery
The mass enslavement of Native Americans ended around 1750 with the importation of African slaves. Native Americans had no immunity to European disease and illness and many natives died due to these foreign contagions. This factor and the outcomes of various Indian Wars lead to the fall of Native American enslavement. However, the practice continued in southwestern regions under the guise of ‘civilizing the savages’ (Mark, J.J). As the United States expanded west across North America, the native Americans were pushed farther and farther in.
In 1830, Congress passed the ‘Indian Removal Act,’ a plan to relocate over 100,000 natives to a small region west of the Mississippi River. The indigenous people resisted removal but eventually lost the fight in 1836. They were then forced to travel 800 miles on the Trail of Tears. Throughout the journey, masses of indigenous people died from disease, starvation, weather, and exhaustion. These acts were oppressive and unjust. In the European’s effort to ‘civilize’ and develop North America, they forced the natives from their land due to their disinterest in assimilation.
The African slave trade was outlawed in 1808, but their enslavement remained legal for another six decades. Rising tensions lead to a civil war between the north, the Union, and the south, the Confederacy from 1861 to 1865. When the confederates seceded in the spring of 1865, the confederacy was dissolved and slavery was abolished. On December 6th, 1865, the thirteenth amendment was ratified abolishing slavery in the United States. Following this ratification, the United States underwent a period of reconstruction. From 1865 to 1877 the U.S. worked to unify the states and redress inequities caused by slavery.
At the end of this period of reconstruction, southern states began passing what would become known as Jim Crow laws. The supreme court solidified these laws in 1892 with their ruling in the “Plessy vs Ferguson” case. After their ruling was announced, the conditions of African Americans living in the south began to rapidly deteriorate. Across the south, segregation became the new normal. Northern states participated in segregation through separate schools and neighborhoods, ‘whites only’ signs outside of businesses, and the enforcement of laws restricting non-property-owning individuals from voting. This segregation reinforced the idea in the minds of Americans that blacks and whites were not equal. These laws were still enforced in the south until 1968.
When we hear the years; 1492, 1619, and 1865, it is easy to think that these events happened so long ago that they no longer matter. But the segregation, discrimination, and oppression that was forced upon these populations post-slavery still existed in the mid to late 1900s. Consider the lives of these people during these time periods. Their lives were full of fear, stress, trauma, and abuse. These feelings and experiences leave a mental imprint. The stress and trauma that black and indigenous people of color faced were enough to cause PTSD or post-traumatic stress disorder.
We now know that trauma causes symptoms of depression and anxiety. The condition also correlates to substance use disorders. Post-traumatic stress disorder affects relationships, actions, sleep, memory, social engagement, and so many other aspects of our lives. The trauma caused by slavery, segregation, and discrimination has been passed down for 400 years. This is intergenerational trauma or transgenerational trauma and it affects us socially, mentally, emotionally, and biologically. (Halliburton)
Generational trauma or the idea that the effects of an experience can be passed down from generation to generation can be compared to the study of epigenetics. The idea of epigenetics is best demonstrated by reviewing the archives of Norrbotten, Sweden. This small town, north of the arctic circle struggled with inconsistent crop growth. The region would experience years of farming success (feast) and years of farming failure (famine). The town’s archives monitored the life span, reason for death, crop growth, and more.
Upon review, the data suggest that men between the age of 9 and 12 (the slow growth period), living in a time of famine, passed on a health boost to their children. Their children’s and their grandchildren’s life expectancy increased by 30 years and their risk of heart disease and diabetes was reduced by 75%. The starvation of these boys altered their chemical makeup on a molecular level (Miller and Nasser). The slow growth period in boys is a time of sexual development, in which their male reproductive fluid is developing, so the genetic expression was imprinted so deeply that it affected the genetic expression of their future children through the reproductive fluid.
The science of epigenetics can be applied to mental health as well. We know that trauma and adverse childhood experiences leave imprints on the brain. The presence of adverse childhood experiences and chronic stress are huge indicators of future mental illness. Neal-Barnett, a professor at Akron University stated, “Our bodies can be altered in terms of how our bodies interpret or express our genes. Which can lead to higher rates of disease. Our inability to address trauma affects our mental health, which affects our physical health,” (Halliburton)
Studies have shown that mental illness has both nature and nurture causes. Our mental health is affected by both our genes and experiences. The experiences black and indigenous people of color faced during slavery and segregation would have affected their mental health and led to the increased prevalence of mental illness in their communities. The increased prevalence of mental illness in minority communities creates the opportunity for adverse childhood experiences in their children’s lives. This cycle of intergenerational trauma, the genetic imprints that this trauma leaves in the minds of these individuals and their children, and the mental health effects of current experiences in racism and discrimination have led to the disparity in mental health among people of color in America.
Adverse experiences affect our mental health by imprinting our brain cells, altering the way we think and view the world, and causing high levels of stress, fear, and trauma. Adverse experiences can affect someone of any age, race, ethnicity, or gender. These experiences include domestic, community, climate, and cultural experiences. Domestic, community and climate adverse experiences affect us all, but adverse cultural experiences are specific to minorities. Some examples of adverse cultural experiences are slavery, genocide, segregation, racism, and discrimination.
Racism and Discrimination
Consider the society that existed in colonial America. To justify the enslavement of human beings, Caucasians had to differentiate themselves from those they enslaved. To do this, Caucasians developed a social structure in which ‘whiteness’ was at the top and ‘blackness’ was at the bottom. The closer an individual existed to the bottom of this structure, the more justified Caucasians felt in their treatment of them. Enslaving, traumatizing, raping, and abusing another human being is wrong. Separating families is wrong. America created the cultural category of race to dehumanize people of color in the eyes of Caucasians, thus justifying their behavior, social norms, and mistreatment of black and indigenous people of color. (Scott-Jones)
This adverse cultural experience of being dehumanized, reduced to property and lacking control in your own life traumatized these populations. These ideas and practices were passed down from generation to generation and traces of these ideas still exist in the structure, culture, and norms that exist in the United States today. Race has become the basis of the mistreatment of people of color and holds both social and economic significance in our current lives, (Scott-Jones).
The intergenerational trauma, discrimination, racism, and prejudices that exist towards minorities are all the result of the unaddressed historical racial wounds that were never resolved, (Halliburton). The symptoms of this gaping wound, bleeding racism, prejudice, and discrimination across the nation, have resulted in the current mental health crisis and the disparities that exist among people of color today. The greater the amount of racism and discrimination an individual experiences the worse their mental health, (Halliburton).
History of Medical Malpractice
Despite the existence of this mental health crisis among minorities, these populations are far less likely to receive treatment. The treatment rate for non-Hispanic, white individuals with diagnosed mental illness is 51.8%. In comparison, the treatment rate for African Americans living with diagnosed mental illness is 37.1%, (NAMI). . In 2018, Asian Americans were 60% less likely than Caucasians to receive mental health treatment. Hispanic Americans were 50% less likely to receive mental health treatment, (Leblanc). There are several barriers that all Americans face in our mental health care system, these include; access, and availability. stigma, insurance, housing, and cost. Are these barriers more effective in preventing the receipt of effective mental healthcare for minorities? Or- Is there more to consider?
Tuskegee Syphilis Study
One of the greatest barriers minorities, specifically African Americans, face in receiving mental health care is an ingrained distrust in the American health care system. This distrust was birthed from the stories of historical, medical mistreatment. One of the most well-known examples is the Tuskegee Syphilis Study. The study was funded by the United States government and the National Institute of Health in 1932 with the help of leaders at the Tuskegee Institute. 600 men were inducted into the study and informed that they had ‘bad blood,’ (Owens). The incentive for participating in the study was ‘free health care.’
The study went on for 40 years. In the 1940s penicillin was proven to cure syphilis, but the government wanted to understand the effects of syphilis on the African American males’ bodies. Instead of being treated, the participants were given a placebo, (Owens). These men were still living in the Tuskegee community. They unknowingly went on to pass this sexually transmitted disease on to their partners and children. After several pleas for the experiment to stop, a whistleblower notified the press of the conditions in 1972 leading the government to end the study, (Owens). A formal apology was not issued for another 18 years.
Another famous example of medical malpractice in America is the non-consensual harvesting of cells from the dead body of Henrietta Lack in the 1950s. Upon her death, doctors noticed that her harvested cells continued to live on. They appeared to be immortal. In their excitement, the doctors sent samples of the cells to colleagues around the world, (Owens). These ‘HeLa Cells’ allowed companies, universities, and research teams to profit from the medical mistreatment of Henrietta Lack.
Henrietta Lack did not provide consent and her family was uninformed of the discovery. In fact, the family was not informed for decades. In 2021, Henrietta’s family obtained representation to sue the companies that utilized the cells without familiar consent, (Owens).
African American Women
Throughout their enslavement, the bodies of African Americans were used for research, experimentation, and medical practice. Of these practices, one of the most common practices and well-known experiments developed the cesarean section or C-section. Francois Marie Prevost practiced these surgeries on enslaved women in Haiti. He went on to practice on the enslaved women residing in Louisiana. His actions earned him the lauded title of father of the C-Section, (Owens).
These women were again mistreated in the name of medicine once they became ‘free’ women. When African American women of child-bearing ages went to the doctors with a problem, they faced the danger of sterilization and hysterectomies being performed without notice or consent. These stories, along with many other non-fictitious tales, have led to the distrust of minorities in the mental and physical health care system in America.
Major Factors Creating Disparity
Mental health disparity is the concept that there are discrepancies in mental health services, prevalence, and quality of care between different demographics. One of the most prominent disparities that exist in mental health care is concerning minorities, specifically African and Hispanic Americans.
In addition to these specific factors above, people of color face many other barriers to mental health care which contribute to the disparity in quality of care, frequency of care, and prevalence of mental illness within minority communities. Minorities with serious mental illness are more likely to experience the following, (APA.org)
In 2004, in the report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the IOM Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care determined that ethnic disparities do indeed exist that can not be connected to the ability to pay, insurance coverage, or access to care. The committee deemed that disparity existed due to social and economic inequality and discrimination from the past and existing in the present, (Gibbons).
Access to mental health care is a barrier that most Americans face through limited options, lengthy wait lists, and inconsistent scheduling. In rural areas, those seeking treatment often must travel more than an hour to reach a provider. In the age of technology, these issues are becoming less cumbersome. Telehealth offers a more convenient and accessible option. However, African Americans, Hispanics, and other minorities are less likely to have access to a personal computer capable of participating in telehealth services.
In addition to the lack of services and options available, minorities struggle to find mental health professionals that speak their language or understand their experiences. The American Psychological Association suggests that “Primary care that includes mental health screenings and treatments that take into account the patient’s language and cultural background could help address the mental health care disparities among ethnic minorities,” (NCSL). In a study conducted in 2016 on psychiatric services, linguistic and cultural competence in mental health care, especially regarding racial and ethnic minorities greatly increased the quality of care, (NCSL).
Cost and insurance are significant barriers to mental health care for all Americans. The American mental health care system is in desperate need of repair. 30 million Americans live with untreated mental health conditions. A survey conducted by SAMHSA concludes that “service cost or a lack of insurance coverage is the most often reason provided for individuals not receiving mental health services from every ethnic group,” (Leblanc).
African Americans, Alaskan Natives, and American Indians have a high percentage of uninsured individuals when compared to Caucasians. This is partially due to the income disparity between Caucasians and people of color. These groups also tend to face more challenges in pursuing higher education, which results in lower earnings throughout their lives, (Simmons). Uninsured individuals typically receive fewer health services due to out-of-pocket costs. This reduction in health services includes the absence of preventative care, which is often associated with the absence of behavioral health services, (NCSL).
The majority of Americans can admit that we are in the middle of a mental health crisis. Despite this agreement, there is still a stigma associated with mental illness. In African American homes, the concepts of trauma, anxiety, and depression are rarely discussed. 80% of African Americans feel discouraged from seeking mental health treatment due to the associated stigma, (Leblanc). The stigma associated with mental illness and the lack of prioritization of mental health leads many Americans to withdraw from or avoid mental health treatment.
A report by HHS, published in 2021 sites, “Persistent, systemic social inequities and discrimination,” as the reason for heightened levels of stress and mental health concerns in minority populations, (Leblanc).
Systematic racism and law enforcement prejudice has led to the displacement of African Americans from their homes and communities. Black Americans represent 13.6% of the United States population according to the United States Census Bureau, the minority represents 50% of the prison population, 40% of the homeless population, and 45% of the population of children living in foster care, (Leblanc).
This pattern of imprisonment, displacement, and inconsistent living arrangements increases the stress, fear, and anxiety that African Americans already face on a daily basis. Note that these three feelings are strongly correlated with trauma, an issue that is already extremely prevalent in the Black American population. We know that a large amount of the homeless population struggles with mental illness. The same could be said for the United States prison population. Among American youth, somewhere between 50 and 70% of the population in the United States juvenile system meets the criteria for a serious mental illness, (Leblanc).
The disproportionate number of African Americans living in our foster care and prison system is a direct result of structural racism. Structural racism in the United States is a concept that normalizes historical, cultural, institutional, and interpersonal dynamics that are advantageous to Caucasians and adversely affect people of color. (Scott-Jones) Normalized segregation and the disparity in equity of minorities are two examples of structural racism.
Structural racism is traumatizing to people of color. It induces stress and contributes to the disparity in mental illness. For example, African Americans are 20% more likely to experience generalized anxiety disorder and major depressive disorder, (Leblanc). There are three major aspects that structural racism encompasses. These aspects largely contribute to the disparities that exist in access to mental health care, symptom severity, mental health diagnosis, and treatment of mental health issues, (Scott-Jones).
When we learn history in school, we learn a white-washed version of it. We learn about European history, the great wars, and scientific advancements, but these books and the recount of history that they teach us are from the perspective of Europeans and those that descended from them. When February rolls around each year, schools hone in on Black history and claim that they teach a well-rounded curriculum.
American children in these classrooms are told about exceptional scientists, enlightened philosophers, and brave generals. All of them are white and subtly reinforce the idea of white supremacy. State lawmakers might as well say, “These are the people you should inspire to be. These are the stories worth telling.” But, every continent, every country, and every region in the world has its own version of history. The biased version that is taught in public schools contributes to structural racism and gently reinforces white supremacy in the minds of all American children.
White children can look at history and identify numerous people who accomplished something and looked just like them. Then aspire to do something similar. Minorities, including African Americans, Hispanic Americans, Native Americans, and other ethnicities, are limited to the stories their families tell for familiar role models. From a very young age, the idea presented is that their history, their culture, and their pasts are not as important as that of Caucasians.
American culture is difficult to define. We’ve incorporated so many customs, norms, and traditions from various countries across Europe and created the social environment we now live in. Our holidays primarily have European roots and are heavily incorporated into the television, advertising, marketing, and nearly every other aspect of American life. We aspire to an American dream that consists of a white mother, a white father, and two and a half white children living in a white house with a white picket fence.
In America, Jesus is white, Santa is white, our government is primarily white, and anything different is weird. Our culture and society are based on the routines of white families. Minorities see these ideas reinforced everywhere. A constant reinforcement that they are different and don’t belong. For many minorities, this results in a specialized form of ‘imposter syndrome.’ Imposter syndrome is associated with feelings of self-doubt, fear, anxiety, depression, and stress.
The history children are taught and the culture that they grow up in shape their ideas, opinions, and beliefs. When they become adults, these thoughts exist in the back of our minds and subconsciously affect the way that we behave, the things that we say, and how we assess others and the world around us. We carry these subconscious thoughts everywhere we go and they are the basis of institutional racism.
Doctors, lawyers, law enforcement, government officials, financial officers, and every other profession affect the institutions that operate within the nation. If the individuals who create laws, respond to emergencies, assess patients, and decide who is eligible for a loan are behaving in a way that aligns with their subconscious thoughts, they are contributing to structural racism because they were raised in a racist society and they are to some degree racist.
When we hear the word racist, we think of white hoods, racially charged acts of aggression, and outdated ideas. But, that way of thinking is preventing us from looking inside ourselves to uncover our own biases and tendencies. The only way we can restructure our society to be inclusive of all is if we restructure our way of thinking on a personal level.
Structural racism affects the quality of mental health care people of color receive. Due to that, there are significant disparities in behavioral diagnosis dependent on race and ethnicity. African Americans and other people of color are more likely to be misdiagnosed and provided inappropriate treatment, (Milbank).
Our experiences make us who we are. Each of our experiences differs, but there are commonalities to be found in them. These commonalities increase among similar demographics. Women are more likely to have things in common with other women. Young adults have more in common with an individual of similar age, than they do an elder or child. And African Americans will find more commonalities with other African Americans than they would an Asian American, Hispanic American, or Caucasian.
The behavioral health workforce is composed of mostly white clinicians. These clinicians are more likely to find commonalities with a patient who looks like them, talks like them, and acts like them. Therapy has proven to be more effective when there is a strong therapeutic relationship present. This relationship is strengthened by similarities and understanding. Thus, reducing minorities’ access to quality mental health care even further.
The racially charged atmosphere that encompasses America, prevents clinicians from discussing racism with their patients, (Milford). This is a huge issue considering the number of minorities dealing with trauma and other mental health issues caused by racist experiences. The more racism experienced, the worse our mental health, (Halliburton).
Cultural Humility in Mental Health Care
Minorities are more likely to require mental health services, but less likely to obtain access to them, and more likely to receive ineffective, or low-quality mental health care, (Milbank). We’ve already reviewed the primary reasons for this disparity, but how can we address it? We could begin by developing an action plan meant to increase diversity in the mental health workforce and require mental health professionals to complete standard and effective cultural competence and humility training programs.
We currently have a primarily white, male, heteronormative mental health workforce that operates on the assumption that individuals from different ethnicities share common beliefs and experiences stereotypical to the ethnicity and different from their own. However, this approach reproduces stereotypes and is based on racism. When providers work from the perspective that the client, or patient, thinks, behaves, or feels certain things solely based on their ethnicity which is different from the providers it successfully contributes to an ‘us’ vs ‘them’ orientation, (Lekas).
Competency to Humility
When we are competent at something, it infers that we understand the subject enough to be successful. However, it is impossible to develop competency in culture. Culture is not a stationary object, it is an ever-changing system of values, beliefs, and social norms. Various factors contribute to and shift culture every day. If a mental health care provider believes themselves to demonstrate cultural competency, they risk stereotyping the patient, (Lekas). Instead, the mental health care system should aim for cultural humility.
Cultural humility is a patient-centered approach that allows the provider to assess and appreciate the individual and their specific culture. To successfully utilize this approach, the provider will need to be open-minded. They will need to practice self-reflection and acknowledge their own implicit bias and the impacts of their own culture on the client, (Lekas). Doing so will allow mental health care providers to become more interpersonal and respectful of the patient’s experiences, beliefs, and opinions.
When the provider is focused on the patient and dedicated to understanding them as an individual, the relationship between provider and patient is strengthened. This strengthened relationship in addition to the demonstrated respect balances the power in this type of relationship. A healthy power balance and patient-centered approach greatly enhance communication and quality of care, (Lekas).
Appreciate the Individual
The mental health care system, along with the rest of us, needs to develop a love for lifelong learning. With knowledge comes understanding and appreciation. To fully deconstruct institutional racism and address these grave disparities in mental health, we need to be humble. It’s important that we understand what we do not understand. Without experiencing these things ourselves, we can only respect and appreciate the experiences of others.
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