An Expert’s Advocacy Guide for Minority Mental Health Month
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More than ever, it is important to recognize Minority Mental Health Month. During this unprecedented year-and-a-half, many of us have struggled with isolation, drastic changes to routine, sickness, loss of jobs, death and more. And for many minority groups, the pandemic has been interwoven with a legacy of mistreatment and additional circumstances that have escalated stress, trauma, and other threats to overall mental health.
“The effect of racism and racial trauma on mental health is real and cannot be ignored,” wrote National Alliance of Mental Illness (NAMI) CEO Daniel H. Gillison, Jr. in a statement last year. “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.”
National Minority Mental Health Awareness Month, also known as BIPOC Mental Health Month, was created in memory of mental health champion Bebe Moore Campbell. Her widower Ellis Gordon, Jr. says of his late wife, “First and foremost, Bebe’s crusade was to erase the stigma of having mental illness…She wanted [mental illness] to be viewed as you would view diabetes. It is a health issue; it just happens to be mental health issue. Her philosophy was, ‘When you get your checkup, make sure you get a checkup from the neck up.’”
Culturally competent counseling practitioners have an understanding of the unique worldviews and cultural backgrounds of clients and bring that awareness and sensitivity to their work. As the topic has risen in visibility and in discussions in the psychological world, the American Psychological Association developed Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists, underscoring the “knowledge and skills needed for the profession in the midst of dramatic historic sociopolitical changes in U.S. society, as well as needs from new constituencies, markets, and clients.”
Notably, the standards also acknowledge the “data about the different needs for particular individuals and groups historically marginalized or disenfranchised within and by psychology based on their ethnic/racial heritage and social group identity or membership.”
Meet the Expert: Professor Cristina Leal
Cristina Leal, MA is a tenure track professor of child development at Mission College. She teaches courses in child and adolescent development, psychology, education and family studies from a cultural perspective. She has been teaching undergraduates to approach learning and teaching using a cultural lens for the past 14 years.
She is currently a PhD candidate in Developmental and Psychological Sciences at Stanford University as well as a counseling psychology graduate student, working towards licensure as a Licensed Marriage and Family Therapist (LMFT) with an emphasis on Latinx families. She earned her MA at Stanford University.
As an immigrant and former migrant student and English language learner, she is particularly interested in studying ethnic/racial identity and the protective effects of dual cultural socialization within family systems. She is currently conducting research on the effects of microaggressions and racism on the mental and physical health of emerging adults.
The Data on BIPOC Mental Healthcare
The Centers for Medicare and Medicaid Services defines quality measures as “tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality healthcare and/or that relate to one or more quality goals for healthcare. These goals include effective, safe, efficient, patient-centered, equitable, and timely care.”
In its 2018 National Healthcare Quality and Disparities Report, the Agency for Healthcare Research and Quality (AHRQ) revealed that while some disparities between mental health care for different racial and ethnic groups have lessened in the last two decades, inequalities remain pervasive for the poor and uninsured:
- Blacks, American Indians and Alaska Natives (AI/ANs), and Native Hawaiians/Pacific Islanders (NHPIs) received worse care than whites for about 40 percent of quality measures. Disparities were improving for only four measures for Blacks, two measures for AI/ANs, and one measure for NHPIs.
- Hispanics received worse care than whites for about 35 percent of quality measures. From 2000 to 2017, disparities were improving for five measures for Hispanics.
- Asians received worse care than whites for 27 percent of quality measures but better care than whites for 28 percent of quality measures. Disparities were improving for only two measures for Asians.
Racism’s Effects on Mental Health
The BIPOC community continues to face racism and discrimination in the United States, both overt and cloaked. Race-based stress includes “the experience of daily microaggressions: subtle, everyday interactions directed towards people of color, whether consciously or unconsciously, that send negative messages to those belonging to a racial or ethnic minority group,” says Cristina Leal, professor of child development at Mission College who is researching the effects of microaggressions and racism on emerging adults.
“(Microagressions) can be verbal, like statements or subtle insults, or nonverbal, like dismissive looks, gestures or tones,” says Leal. “They are so commonplace and subtle that the recipient is often left wondering whether something just happened or not. They are often dismissed as innocent or unintentional, but their effect is not harmless. In fact, the experience of discrimination has been linked in youth and adults to post-traumatic stress symptoms including depression, anxiety, hypervigilance, and avoidance. As with PTSD, these persons are at risk for anxiety and depressive disorders as well as substance use disorders and poor health outcomes.”
Recent acts of racism and discrimination have opened simmering mental health wounds and further amplified the stress minorities face on a daily basis. The Unite the Right rally in Charlottesville, George Floyd’s brutal moder, and anti-Asian hate crimes proliferating during the pandemic are just a few examples. Leal points out that this constant state of stress and hypervigilance is not anything new for racial minorities.
“It’s traumatizing to be a person of color in the United States right now—to watch members of your community be targeted and even killed, and then to hear the media report that the shooter was ‘having a bad day,’” says Leal. “Closer to (my) home, the Gilroy Garlic festival shooting in 2019 targeted the Latinx/e community. The recent public acknowledgments of Indigenous children’s remains found at residential schools and unmarked graves on church properties remind our Indigenous communities of the pain of forced separation of families, the deliberate erasure of their language and cultures, and the genocide that has been perpetrated on them for centuries. Investigations of boarding schools and church grounds are now ensuing all over the U.S., but elders have been telling these stories for years of children and families taken and lost, and we are now just beginning to listen.”
The Black and African American Community
Mental Health America reports that 6.8 million African Americans live with mental illness, which represents 17 percent of the population. There are multiple reasons that this demographic is at higher risk, and the American Psychological Association identifies the following:
- Forty percent of youth in the criminal justice system and 45 percent of children in foster care are African American.
- Over 25 percent of African American youth exposed to violence have proven to be at high risk for Post Traumatic Stress Disorder (PTSD).
- While studies show African Americans are just as much at risk for mental illness as their white counterparts, they receive substantially less treatment. An analysis of U.S. Census Bureau data shows that in 2005, African Americans were 7.3 times a likely to live in high poverty neighborhoods with limited to no access to mental health services.
- Nearly 25 percent of African Americans are uninsured and are also more likely to use emergency and/or primary care specialists who lack training in the diagnoses and treatment of mental and behavioral health problems. (Counselors and psychologists are better trained to identify mental illness and provide psychotherapy to treat disorders).
- African Americans are nearly twice as likely as non-Hispanic whites to be diagnosed with schizophrenia.
Leal does point out that the increased diagnosis of schizophrenia in African Americans and Blacks is questionable: “A counselor who is not culturally competent may see their mistrust in counseling as paranoia when it is actually a rational response to the experience of being Black in America,” she says. “‘Do you ever feel like you are being followed when you walk into a store?’ If you’re Black, this is likely a keen observation, not a paranoid delusion.”
A 2001 report by the Surgeon General, Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health points out the overwhelming need for culturally sensitive and competent psychological professionals to treat Blacks and African Americans. African Americans account for just 2 percent of all psychologists in America today. Increased funding for African American psychologists and other mental health providers can help increase the number of African Americans in treatment and lead to better and more effective outcomes.
The Hispanic and Latinx Community
Hispanics number more than 18 percent of the U.S. population according to Mental Health America, and 16 percent of this demographic have reported a mental illness in the last year. That is more than 10 million people which exceeds the population of New York City. The heightened focus on immigration and acculturation has been highlighted as contributing factors to these numbers.
Additionally, according to the National Alliance on Mental Illness, only 34 percent of Hispanic adults with mental illness receive treatment each year compared to the U.S. average of 45 percent. This is due to many unique barriers to care similar to other minority populations.
In the book Mental Health Care for New Hispanic Immigrants, the authors discuss multiple roadblocks to care. These include the lack of health benefits in the jobs and industries where immigrants are working, low wages coupled with the high cost of treatment, work pressures, and legal status. Family and religious shame may also play a part.
Mental Health America points out that churches and religious leaders can play a part in decreasing the stigma and referring those in need of help to professionals. Language obstacles are also a challenge that Latinx and Hispanic people face in finding proper treatment. The American Psychiatric Association points out these challenges:
- Hispanics are more likely to report poor communication with their health provider, once again highlighting the need for culturally sensitive and trained professionals.
- Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish and that Hispanics are more frequently undertreated.
- Approximately 10 percent of Hispanics with a mental disorder use mental health services from a general healthcare provider, while only one in 20 receive such services from a mental health specialist.
The Asian American Community
Data collected from a National Institutes of Health study found that Asian Americans have a 17.3 percent overall lifetime rate of any psychiatric disorders, yet Asian Americans are three times less likely to seek mental health services than whites. The American Psychiatric Association (APA) reports only 8.6 percent of Asian-Americans sought any type of mental health services or resources compared to nearly 18 percent of the general population nationwide.
The APA highlights several barriers for this population to seeking and getting help:
- Parental pressure to succeed in academics and professional life
- Discussing mental health concerns is considered taboo in many Asian cultures and as a result, Asian Americans may tend to dismiss, deny or neglect their symptoms
- Pressure to live up to the “model minority” stereotype (a view that inaccurately portrays Asian Americans as successfully integrating into mainstream culture and having overcome the challenges of racial bias)
- Family obligations based on strong traditional and cultural values
- Discrimination due to racial or cultural background
- Difficulty in balancing two different cultures and developing a bicultural sense of self
In the study Model Minority at Risk: Expressed Needs of Mental Health by Asian American Young Adults, the authors point out that young Asian Americans turn to close friends, partners, and their religious communities rather than seeking the help of professionals. Study participants indicated that Asian cultural norms do not prioritize mental health issues, and stigma is another limiting factor: “Our findings support a need for delivering culturally appropriate programs to raise awareness of mental health and cultural training for health providers to deliver culturally appropriate care,” wrote the authors.
The Indigenous American Community
Mental health within American Indian and Alaska Native communities is dire. The Indian Health Service points to pervasive issues within these populations:
- Alcohol and substance abuse (more likely to report than any other group)
- Suicide (1.6 times higher than all other US groups combined)
- Violence (women in this population report the highest rates of sexual assault and “intimate partner violence victimization”)
The Anxiety & Depression Association of America highlights the history of trauma experienced by Native and Indigenous communities as a leading factor in psychological issues within these populations. Reports show more this population has more than 2.5 times the experiences of major mental health distress. Poverty, alienation, isolation, acculturation, discrimination, a lack of care, and community violence are also contributing factors to high rates.
While Indigenous Americans have experienced a lack of quality healthcare throughout history, Covid-19 truly highlighted the disparities experienced. The Center for Disease Control and Prevention reports that this population has experienced a 3.5 times higher rate of Covid-19 diagnoses than non-Hispanic whites: “New Mexico is a stark example,” according to Medical News Today. “Here, Indigenous Americans make up only 8.8 percent of the population, but account for over 60 percent of deaths.”
The loss of life and community connections has been severe and has compelled tribal leaders to speak out. In a May 2020 news release, Navajo Nation Vice President Myron Lizer said “During this difficult time, we also ask our citizens to take care of their mental and physical health. Please stay connected with relatives and neighbors by phone or video chat and remind them that they have support. If you are feeling stress or anxious, take the time to take a deep breath, stretch, or pray. Exercise by working out or by doing household chores and avoid unhealthy foods and drinks. We must protect ourselves and others.”
Changes to Care: How To Increase Access to Mental Health Services
Leal points out that, “Racism, hate, and injustice are another pandemic.” It will most certainly take additional efforts toward culturally competent care, building a pipeline of trained counselors and other professionals, and also addressing the barriers to care in order to provide high-quality treatment for all people.
In closing, echoing the advise of Dr. Candice Hargons, Leal expressed the need for cultural humility: “We should teach counseling students to approach each client with humble curiosity, openness, and willingness to learn.”