History tells a bleak story of mental healthcare for Black Americans, dating back to the African diaspora. Much of the systemic racism that enslaved Black Americans faced can explain mental health disparities seen in this population today.

In honor of Black History Month and in support of this year's Black Resistance theme, we review the origins of mental healthcare for Black Americans, note changes over time, and suggest steps to continually resist systemic racism in mental healthcare, promoting positive Black mental health for current and future generations.

A brief history of mental healthcare for Black Americans

To understand what mental healthcare means for Black communities today, we must look back to how mental health treatment for Black Americans was approached as early as the 18th century. Early narratives about the nature of mental illness for Black Americans were circulated by slave owners and white supremacists with the goal of keeping Black Americans enslaved. As such, the most dominate ideas suggested that enslaved Black Americans were immune to mental illness due to their lack of freedom. Not unlike today, prevalent thinking likened mental illness with weakness and fragility. These characteristics were incompatible with the hard labor required of enslaved Black Americans.

A shift to over-pathologizing

Later, physicians began to dispute the claim that enslaved Black Americans could not experience mental illness. Instead, physicians began to create diagnoses to pathologize behavior that would be expected of enslaved people. Such "abnormal" behaviors included fleeing plantations and experiencing dull attitude (depression). Rather than providing mental health treatment in asylums, enslaved persons were housed in jails or outdoor quarters while still being forced to do labor. Thus, hospitals became another method to keep enslaved Black people institutionalized.

Harmful movements of the 20th century

Several more harmful ideas about Black mental illness were spread during the 20th century. Among the most damaging were the eugenics movement and the psychosurgical movement. Eugenicists largely promoted the idea of White supremacy by using sterilization to limit births of specific populations. Black people experiencing mental illness were one of many identities that medical professionals sought to eliminate. Black women were among the most affected by this practice.

Additionally, the psychosurgical movement encouraged the use of lobotomies: a cruel procedure that permanently altered their cognitive functioning. Lobotomies were meant to cure what was seen as "brain dysfunction," correlating with urban violence during the 1960s and 1970s. The wrongful link between civil unrest and mental illness led to the victimization of many Black Americans.

During this century, we also see abuse of Black Americans in research studies, such as the Tuskegee syphilis study and continued incarceration of Black Americans with mental illness. These historical events form the basis for much of the medical mistrust in the Black community today.

Modern-day challenges to Black mental health

While much progress has been made since the tragedies mentioned above, Black people continue to face unique threats to mental health and well-being. Research shows concerning trends related to mental illness prevalence and treatment utilization, contributing to Black mental health disparities:

• According to Mental Health America, in 2020, Black people with moderate to severe mental illness were more likely than any other racial group to list racism as a top 3 contributor to their symptoms.
• In 2020, suicide was the third-leading cause of death for Black Americans ages 10-24, equating to 979 deaths.
• While approximately 9.1 million Black adults experienced any mental illness in 2020, only about 900,000 adults received mental health services, according to the National Survey on Drug Use and Health.
• In 2017, Black people had the highest rate of non-methadone synthetic opioid-related deaths compared to other racial groups.
• Black Americans are often over-diagnosed with psychotic disorders and underdiagnosed with mood disorders, despite evidence of depressive symptoms.

Current events and racism-related stress

In recent years, one of the most pervasive factors contributing to poor mental health for Black Americans has been the mass sharing of police violence via social media.

According to Eichstaedt et al (2021), the 2020 murder of George Floyd, an unarmed Black man, resulted in significantly higher rates of sadness, anger, depression, and anxiety in Black Americans compared to White Americans. This statistic mirrors previous findings from Bor et al (2018) showing that Black adults who were exposed to 1 or more police killings were estimated to experience 0.14 more poor mental health days per exposure. This equates to 55 million more poor mental health days for Black Americans.

Some scholars have approached these findings as evidence for the link between racism, violence, and trauma. Theories suggest that police violence is a unique form of trauma that other Black people may be experiencing vicariously, thus leading to trauma-related symptoms. Relatedly, the idea of racial trauma, "mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes," is widely accepted in the field.

Reflection, resistance, and resilience in the Black community

While the current status of mental health and disparities in the Black community is heavy, there is tremendous opportunity for healthcare professionals and community members alike to come together and address these mental health inequities. Black Americans have resisted racial discrimination in mental healthcare for centuries, forging the way for a more equitable society. It is now the job of the US healthcare system to mend previous damage and ensure equitable access to high-quality, safe behavioral health services in the Black community. We review 3 major focus areas for decreasing racism in the mental health system:

1. Cultural mistrust and stigma
2. Diverse mental health providers
3. Access and payment

1. Creating a culture of trust

As noted previously, the Black community has a long history of medical mistreatment in America. As such, these instances of abuse have contributed to Black Americans' mistrust of healthcare professionals. A large body of research points to medical mistrust or cultural mistrust as a key reason that Black patients avoid initiating care. Stigma within the Black community is another barrier to mental health treatment. Ward et al. (2014) found that among a sample of African American men and women, many were not open to acknowledge psychological problems and feared stigma associated with mental illness.

Increasing mental health education in the Black community

Combating cultural mistrust and stigma requires work from clinicians to meet patients where they are and increase education about the nature of mental illness. An example of a non-profit doing this work is the Black Brain Campaign (BBC). Based in Pennsylvania, the BBC is dedicated to decreasing stigma around mental health treatment in the Black community. They accomplish this aim by hosting a wide variety of community educational events, offering free therapy, and providing training for Black clinicians who are seeking licensure.

Another strategy for building trust with Black patients could include incorporating alternative forms of coping into treatment, such as religious coping. Research shows that religion, specifically Christianity, can be helpful for reaching Black patients. Partnering with religious institutions and leaders to educate community members and connect them to mental health treatment could help mend issues of cultural mistrust and stigma around mental health issues.

2. Representation in providers

Another core barrier to culturally competent mental healthcare for Black Americans is the lack of Black mental health providers in the US. According to the American Psychological Association (APA), only 16% of the US psychology workforce are people of color and 4% of those providers are Black.

While all clinicians can and should pursue cultural competence, Black mental health providers may be more aware of the Black experience, reducing the need for the patient to educate the provider about racism and creating a quicker path to therapeutic alliance. Having more Black mental health providers may also help mend feelings of mistrust, due to the long history of overdiagnosis of Black patients.

Solving the problem of underrepresentation starts with education. The APA has created several programs, most notably the Minority Fellowship Program, to increase diversity in the field. The program provides monetary and training support to racial and ethnic minority students seeking graduate degrees in psychology or social work. The Association for Psychological Science also offers a number of fellowships aimed at providing support to diverse students pursuing minority mental health research or graduate school.

Burnout is at an all-time high

While increasing the number of Black mental health providers is imperative, we must also better support Black clinicians who are already doing this work and are themselves emotionally depleted. In a Forbes article titled "We Need To Talk About Black Therapist Burnout," Jessica Gold discussed the experiences of Black mental health providers who took on more patients during COVID-19 and the racial justice movements of 2020. Black therapists faced several barriers to well-being, such as continuous news about police brutality, exposure to COVID, and extra pressure to speak out about racial justice while feeling burnt out themselves.

Creating more supportive work environments will be essential to maintaining the Black mental health workforce. Increasing the volume of Black therapists could help reduce caseloads due to a wider pool of options for Black patients seeking Black therapists. Additionally, self-care and supportive communities are essential and could include forming support groups of Black mental health providers who can confide in one another through their unique challenges.

3. Mental healthcare access and payment

Health insurance coverage for Black Americans is another factor contributing to poor mental healthcare access. According to the 2021 National Health Information Survey, 33.1% of Black and Black/White biracial adults were uninsured, a higher proportion than any other racial group. Black and Black/White biracial adults also had the highest proportion of public health plan coverage (59.4%).

Helping Black Americans access low-cost health insurance is a priority of the Biden-Harris Administration. Through implementing the American Rescue Plan, opening a Special Enrollment Period, and extending Open Enrollment by 1 month, the administration helped millions of Americans sign up for low-cost plans, accounting for a 35% increase in enrollment of Black Americans.

On the commercial health side, health plans can more aggressively contract with Black behavioral health providers and vendors to help increase diversity and boost access to care. Collaborating with vendors like Health In Her Hue and Therapy for Black Girls could help expand access to culturally competent mental health services tailored to Black Americans. Additionally, requiring cultural competence training of all contracted providers and maintaining accurate behavioral health provider directories are other steps in the right direction.

Celebrating Black mental health

Just as Black Americans overcame the oppressive mental health systems of the 18th century, this community will continue to make strides toward equitable mental healthcare.

By deconstructing ideas about mental health stigma, expanding behavioral health access, and building diverse behavioral health provider networks, we will see healthier communities than ever before. The story of Black mental health is a story of Black resistance. As many Black Americans seek mental health services for the first time, we must ensure that the proper supports are in place to promote healing. Through open dialogue about racism in healthcare and its pervasive effects on the Black community, we can, and will, build a more equitable system.

If you would like to learn more about how you can promote behavioral health equity within your organization, consider partnering with RTI Health Advance for health equity consulting.