Recently, Fiona Godlee — editor-in-chief at the BMJ — wrote a column in which she called racism “the other pandemic.”
“Racism is suddenly and at last everyone’s business, and acting against it is everyone’s responsibility,” she points out.
Action has been a long time coming. For years, studies from around the world have shown that systemic racism blocks access to healthful lifestyles and appropriate healthcare among consistently marginalized groups — particularly people of color. Despite this, decision makers have done little to address these inequities.
In some of our recent features at ishonest — which are part of an ongoing series about race-related health disparities — we have discussed how and why the COVID-19 pandemic has disproportionately hit Black communities, and how the pandemic is likely to impact the mental health of people of color.
Now, we look at how racism has forever been an obstacle blocking people’s access to appropriate formal mental healthcare among those in marginalized ethnic groups.
We acknowledge that “people of color” is a very general term that encompasses numerous groups and identities, each of which has faced subtly different forms of racist discrimination. The same goes for the term marginalized ethnic groups.
However, the aim of this feature is to provide an introduction to the impact of racism on mental healthcare. Future features will look at how racism has affected health and healthcare access in distinct marginalized groups more specifically.
The impact of institutional racism
Many forms of racism can be very subtle. Microaggressions, such as making assumptions about a person in conversation, often go unnoticed except by the person or people on the receiving end.
In a personal essay called “On Becoming a Psychologist” — which appears in The Colour Of Madness, a book exploring the relationship between people of color and mental health — psychologist Cassie Addai wrote of experiencing such forms of aggression.
“Growing up as a Black girl in a majority-white city, I can vividly recall examples of overt racism including being teased because of my ‘thick lips’ and being told to ‘go back/to where I ‘came from,'” she wrote.
However, although people can identify and call out individual racist remarks more easily and spontaneously once victims and allies become acquainted with the forms it takes, this is more complicated in the case of institutional, or systemic, racism.
As Prof. Hannah Bradby, a sociologist at Uppsala University in Sweden, explains in a 2010 paper in Sociological Research Online:
“The distinction between individual and institutional racism arose with the Black power movement in the U.S. when it was described as subtle and less identifiable compared with individual racism. ‘Respectable’ individuals can absolve themselves from blame for individually racist acts but nonetheless ‘support officials and institutions that perpetuate institutionally racist policies.'”
Institutional racism upholds misconceptions and baseless assumptions about race and ethnicity, and it affects all official institutions, including those that offer mental healthcare.
At the same time, Black individuals were more likely than other community members to receive poor or downright harsh treatment in mental healthcare settings.
“‘Circles of fear’ continue to be experienced by Black service users and communities in relation to mainstream mental health services,” the report notes.
“Treatment is more likely to be harsher or coercive [for Black people] than that received by white service users and characterized by a lower uptake of primary care, therapeutic, and psychological interventions,” it continues.
The same report notes that Black and other marginalized groups consistently found it difficult to access mental healthcare to begin with.
‘Serious, unconscionable disparities’
Similar situations occur in the United States and elsewhere in the world.
“There are serious, unconscionable disparities in access to mental health for people of color in America,” said Nathan Greene, Psy.D., one of MNT‘s expert advisors.
“African Americans, Latinx, and Asian Americans receive treatment of mental health challenges at 50–70% lower rates than white Americans in this country. This is the result of failures on individual and systemic levels,” he added.
A 2019 study in the journal Health Services Research looked at the data of 1,237 Black adults in the U.S. who reported not having received formal support for a mental health issue for which they required support.
Black respondents — particularly those who had been through higher education — reported that they had experienced stigmatization, and that professionals had minimized their mental health symptoms. This resulted in a lack of access to appropriate care.
On May 29, 2020, Daniel H. Gillison, Jr. — the CEO of the National Alliance on Mental Illness — released an official statement acknowledging the extent of mental healthcare disparities in communities of color in the U.S.
“The effect of racism and racial trauma on mental health is real and cannot be ignored,” he said. “The disparity in access to mental healthcare in communities of color cannot be ignored. The inequality and lack of cultural competency in mental health treatment cannot be ignored.”
Stigmatization and cultural barriers
The stigmatization of mental health issues can further amplify the effect of institutional racism on access to healthcare among Black people and other marginalized communities. It is also true that institutional racism can amplify internalized stigma.
In an article for Columbia University, psychologist Thomas Vance, Ph.D., writes about the relationship between institutional racism and the stigmatization of mental health issues, particularly in the context of Black communities.
“The lack of cultural responsiveness from the therapist, cultural mistrust, and potential negative views from the therapist associated with stigma impact the provision of mental health services in the Black community,” Vance points out.
Speaking to MNT, psychologist Riya Patel, Ph.D.* — an assistant professor in the Faculty Research Centre for Intelligent Healthcare at the University of Coventry in the U.K. — further explained the role of stigma associated with mental health issues among communities of color and marginalized ethnic groups.
“The first important [barrier in accessing mental healthcare] relates to how mental health problems are experienced, shared, and supported within diverse minority communities,” she told us.
“Shame and stigma about poor mental health are common across societies, but these experiences may be amplified in some cultural settings and hold people back from reaching out for assistance,” she added.
However, cultural differences can also be barriers, Patel noted. Mental health professionals who do not understand patterns of communication characteristic of certain cultural groups may not understand the issue or provide appropriate support.
“People from different backgrounds experience and describe symptoms of mental ill health in different ways, which do not always fit prevailing models of mental healthcare.”
– Riya Patel, Ph.D.
She added, “People have options within their own communities for getting help and may not perceive a need to access formal services.”
“If people experience systemic discrimination when they do use mainstream services, this can cause secondary victimization, exacerbate their mental health status, and lead to distrust between community members and health providers,” Patel noted.
Anti-racism for lasting change
There is only one solution for these issues: tackling forms of racism and anti- Blackness at their root. To do so, different steps are necessary.
Greene spoke of the importance of funding mental healthcare support programs at the community level as a first step.
“To improve access, we must expand funding for community mental health programs that serve underserved communities and […] train clinicians to be anti-racist so they can recognize bias and discrimination in themselves and in the systems they work within and actively work against those forces,” he said.
However, even more important than this is the need to place Black, Indigenous, and people of color — plus those belonging to other marginalized ethnic groups — front and center, to consult them on their communities’ mental health support needs and promote them as decision makers in healthcare contexts.
“Attention must also be given to improve and expand recruitment, retention, and valuing of clinicians of color at every level of training and practice in order to create a welcoming mental health space that reflects the cultural and linguistic diversity of Americans,” Green emphasized.
“There is a lot of work that needs to be done when working with the diverse minority community groups, but I truly believe our priority should be working more collaboratively with people of color,” Patel also told MNT.
“Mental health providers and organizations that conduct research to inform healthcare […] need to understand what mental well-being and illness look like to individuals from different ethnicities and cultures.”
“What are their current strategies when coping with mental illness, and what does coping look like among these communities? There are a lot of negative narratives surrounding mental health; how can we collaboratively begin to change these narratives and reduce the barriers they pose?”
– Riya Patel, Ph.D.
Advice to white people and allies
We also asked Patel what white people and allies can do to help support and protect the mental well-being of Black people and other people of color around the world.
“Reflecting on recent events globally and the unyielding discrimination that affects members of minority communities across the world is time well spent,” she emphasized.
“Links between inequalities and poor (mental) health must be acknowledged,” she added. “Equally, health systems that are trauma-informed, culturally responsive, and recognize the intersectionality of people’s lives are all imperatives for future healthcare design and delivery.”
Finally, Patel noted: “Change initiatives need leadership by those with lived experience. Above all else, when in doubt, show compassion.”