At the Crossroads of Racism and Serious Mental Illness: An Expert Roundtable

As a result of increasing awareness and outrage regarding systemic racism and police brutality in the United States, there has been growing recognition of the pervasive influence of racism across a range of settings, including the medical and scientific communities. Although Black clinicians and researchers have long voiced the need for increased attention toward the effects of racism on the mental health of Black Americans, experts of other races have recently begun to recognize and champion this goal as well.

Jasmine Mote, PhD, a postdoctoral research associate in the Approach Motivation & Participation (AMP) lab at Boston University, and Daniel Fulford, PhD, director of the AMP Lab and assistant professor in the departments of rehabilitation sciences, occupational therapy, and psychological and brain sciences at Boston University, are part of a multicultural research group that studies negative symptoms in serious mental illness (SMI). In a paper published online in JAMA Psychiatry in July 2020, they wrote that they had previously ignored the impact of racism on their research questions due to the assumption that they are not race researchers.¹

“We believe the differentiation between race vs nonrace researchers has held many in our field back from confronting the unique challenges of the Black SMI community,” they stated. Failing to do so implies that the construct of race does not warrant investigation and that the experiences of White participants represent a universal standard. “Our research inadvertently perpetuates the ongoing oppression of Black individuals in the US when we do not consider how one’s racialized experiences intersect with the experience of SMI.”

Dr Mote and Dr Fulford describe steps they are taking to begin remedying these gaps, including reading research on the impact of racism in SMI, as well as considering the role of racial trauma and discrimination in developing their research questions and testing hypotheses. They call on other researchers who study the experiences of individuals with SMI to similarly consider the impact of racism when developing their research questions.

To further explore this topic, we interviewed the authors along with the following experts: Angela Neal-Barnett, PhD, professor in the department of psychological sciences and director of the Program for Research on Anxiety Disorders among African Americans at Kent State University in Kent, Ohio, and author of Soothe Your Nerves: The Black Woman’s Guide to Understanding and Overcoming Anxiety, Panic, and Fear,² and Diane C. Gooding, PhD, researcher and professor in the department of psychology at the University of Wisconsin-Madison and vice president of NAMI Dane County in Madison.

The Mote and Fulford paper mentions that the recent and ongoing protests against police brutality and racism “have led many in the scientific community to acknowledge and scrutinize the effect that racism has in our fields.” What are some of the most notable of these issues in the field of psychiatry?

Dr Neal-Barnett: First, it is important to understand that Black psychiatrists and psychologists have acknowledged and scrutinized the effect that racism has in our field for over 70 years. Psychiatrists such as William Grier and Price Cobbs (Black Rage: Two Black Psychiatrists Tell It As It Is³), Frances Cress Welsing (The Isis Papers: The Keys to the Colors⁴), Alvin Poussaint, and Carl Bell, as well as psychologists such as Mamie and Kenneth Clark (Brown vs Board of Education) and Robert Guthrie (Even the Rat Was White: A Historical View of Psychology⁵) were early pioneers who researched and wrote eloquently about racism’s effects in the fields of psychiatry and psychology and mental health. Three generations of psychiatrists and psychologists have followed in their footsteps.

The dual pandemics of COVID-19 and racism as public health crises have led to an awakening among non-Black Americans as to how rampant racism is in the field of psychiatry and other mental health disciplines. A notable issue is the lack of Black mental health clinicians in the United States; <1% of psychiatrists are Black, and approximately 4% of psychologists are Black. In addition, disparities in diagnosis – Blacks are more likely to receive an SMI diagnosis than their White counterparts¹ – and access to care, as well as lack of access to culturally competent care, often result in SMI going untreated.

Dr Gooding: Black people, like all other people, deserve appropriate, culturally sensitive, and empirically based assessment, diagnosis, and treatment. Unfortunately, all too often the measures used have not been validated with diverse populations and different environmental contexts in mind. Therefore, a Black person may be perceived as paranoid when they are, in fact, appropriately aware of their surroundings and the work/living situation that they are in the midst of.

Dr Mote and Dr Fulford: Psychiatry and psychology are not immune to the larger systemic issues in treating Black, indigenous, and people of color (BIPOC) across health care in general in the United States; namely, inequities in access to care and biased treatment based on racist assumptions by providers. These issues are particularly pronounced in mental health as it is a sector of health care that is most often incredibly inaccessible and unaffordable for many, regardless of one’s identity. Additionally, we as a society still do not view mental health care as a necessity. There is stigma and shame for many people in seeking this care.

Thus, when people actually do seek mental health treatment, they are in an incredibly vulnerable position. Often it is a last resort to deal with a pressing problem. Imagine having to deal with a racist, sexist, or ableist comment from a provider who is there to help you in your lowest moment. It can be devastating and understandably represents a huge barrier for many people. If a person breaks an arm and goes to a physician who says something racist, they might still put up with it just so they can get their arm fixed.

Most people are not going to shame them that they’re “weak” because they need their arm fixed immediately or that they may just be “overreacting” to the broken arm. However, if they are suicidal and see a psychiatrist who says something racist, they may just decide to leave, never come back, and try to deal with it on their own because they were already reluctant and feeling ashamed about coming in the first place.

What are believed to be contributing factors to the high rates of SMI among Black individuals in the United States and their overrepresentation in the criminal justice system? In addition to possibly legitimately higher rates of SMI, are Black people more likely to be pathologized than Whites?

Dr Neal-Barrett: A disproportionate number of incarcerated Black Americans have been diagnosed with SMI or SMI and substance use disorder. Once again, we are looking at systemic racism. Several studies have shown that when a Black patient and a White patient exhibit the same symptoms, the Black patient is more often diagnosed with the SMI. This tendency to overdiagnose and misdiagnose SMI can lead to improper medication and treatment, resulting in behavior that is deemed criminal.

The criminalization and pathologizing of Black men and women starts early. Two articles that I recommend every mental health professional read are The Essence of Innocence by Goff and colleagues and Girlhood Interrupted by Epstein, Black, and González.^6,7 The authors address the young age at which Black boys and girls are perceived as less innocent, hostile, and suspicious and how this may fuel the school-to-prison pipeline.

Systemic racism also affects access to care. Often, agencies and hospitals that provide services for individuals with SMI are not in Black neighborhoods and not easily accessible by car or public transportation. Thus, help-seeking may be delayed, and the individual may deteriorate and engage in behavior in which the police are asked to intervene.

Stigma is another factor. Conversations about mental health within Black communities range from nonexistent to difficult. Psychiatrists and psychologists may have less-than-stellar reputations. This must and is beginning to change, but it is a slow process. Stigma creates a lack of information that in turn creates a lack of understanding about SMI.

Dr Mote and Dr Fulford: The question of high rates of SMI among Black individuals in the United States is complicated, and there are other experts who can better answer this question. To put it very simply, risk factors for developing SMI — such as early childhood trauma, poverty, and living in an urban environment — are often more prevalent in some Black communities.

However, there is also evidence suggesting that racial bias does play a role in the overdiagnosis of disorders like schizophrenia in Black people. Why? There are many answers to this question, but here is an example that may help to illustrate how bias can play a role in diagnosis. As we know, paranoia is a common symptom in psychotic disorders. Imagine that a patient discusses their belief that their neighbors are watching them all the time and talking about them behind their back. This patient also talks about how a neighbor called the police on them just because they were outside watering their lawn. This person believes that their neighbors are out to get them.

So, is this patient paranoid? Do you believe that a neighbor would call the police on someone just because they were watering their lawn? One clinician might believe that this sounds pretty unrealistic and might decide that yes, this patient is experiencing paranoia. What if the patient is Black and living in a predominantly white, conservative neighborhood? This context changes the diagnostic picture, as we know that Black Americans have had the police called on them for similar trivial matters. Thus, it is more difficult for a clinician to ascertain whether this patient is experiencing paranoia or describing something that is actually happening.

It seems that you are also asking a separate question, which pertains to the high rates of Black individuals with SMI in the criminal justice system. That is a larger, more complicated question, and again, we are not experts on this matter. Many people point to the deinstitutionalization movement in the 1960s and 1970s during which inpatient psychiatric institutions were shut down due to inhumane conditions found therein, with the hope that community-based mental health care centers would replace them. However, that never really materialized.

That context, combined with the perception that people with SMI are violent or unstable (which generally is false, as people with SMI are more likely to be victims than perpetrators of violence), in addition to the increased criminalization of substance use (which has its own racist history and from which many people with SMI also suffer), led to prisons becoming the place where people with SMI who had nowhere else to go ended up. For more detailed information regarding this, we recommend books like The Protest Psychosis: How Schizophrenia Became a Black Disease by Jonathan Metzl or Insane: America’s Criminal Treatment of Mental Illness by Alisa Roth.^8,9

What can psychiatrists and other mental health clinicians and researchers do to help turn the tide and advocate for this population and improve screening, treatment, and other forms of support?

Dr Neal-Barrett: The first step is to recognize there is a problem and that systemic racism is at its root. Second, when it comes to the mental health of Black Americans, we cannot do it alone. A community-based participatory research and intervention approach is needed. Partner with key stakeholders in the community and listen to them. Find ways to incorporate their thoughts, suggestions, and interpretations into interventions and screenings. It takes years, not months, to build the trust, culturally competent interventions, and tools needed to better understand SMI in Black populations and to ensure better diagnosis and treatment.

Dr Gooding: Early intervention is important for all youth and young adults so that SMI, if present, does not lead to some of the unfortunate secondary and tertiary effects such as homelessness and substance abuse. All too often, behavioral symptoms of mental illness among Black individuals in the United States end up being addressed by law enforcement, who are inadequately prepared to understand or handle these situations. Things can escalate and become misinterpreted, which can have unfortunate and sometimes deadly consequences.  

Dr Mote and Dr Fulford: Within our article we discuss the steps that our lab is trying to take to better understand the racialized experiences of people with SMI in even basic processes, like motivation. We have learned a lot about the intersection of racialized experiences and SMI, but there is a lot we don’t know, so even starting to ask more questions is a major step forward.

We also believe that it is critical to train and educate clinicians on what we do know regarding the impact of racism (as well as sexism, ableism, and homophobia) on the experience and expressions of mental health symptoms like psychosis. Also, if you want to help advocate for a specific population, get to know members of that population outside of your research participants or patients. Consider inviting an advocate with lived experience with SMI to give a talk at a psychiatry grand rounds or invite them to collaborate on your next research project.

Further, if you are in a position of power, use it to support your BIPOC students and colleagues. Invite them to coauthor papers and grants, participate as colloquium speakers or symposium members, and to take leadership roles. Hire more BIPOC faculty members. Mentor more students from different backgrounds. Psychiatry and psychology are overwhelmingly white fields but that is slowly changing. Do the work to continue to be an anti-racist clinician.

What are some of the most important remaining needs in this area? 

Dr Neal-Barrett: Remaining needs include recruitment of more Black psychiatrists and psychologists into the field and funding of Black scientists. The disparity in funding by the National Institutes of Health for Black researchers has doubled over the past 10 years. Not all Black SMI researchers study Black populations, but most do. Their voices are critical to our understanding of SMI and disseminating that knowledge into the community.

Additional needs are required courses on racism and mental health, as well as increased experience for interns, residents, and post-doctoral researchers in working with Black patients.

Systemic racism has been present in the field for a very long time. Substantive change will not happen overnight; however, if we continue to educate, listen, and advocate, then change will hopefully come in our lifetimes. 

Dr Gooding: Mental healthcare disparities, especially in terms of providing mental health services for poor, Black community members, have been well documented. It is imperative that we address this pandemic to help minimize the intergenerational effects of trauma that can result from untreated or undertreated SMI.

Dr Mote and Dr Fulford: As we mention in our article and in our responses, we fully believe that we as researchers have to more explicitly measure the impact of racism and racialized experiences on even our most basic and fundamental questions about psychosis and related symptoms. That, in combination with better training and education on what we do know, are integral steps toward advancing our field.

References

1. Mote J, Fulford D. Now is the time to support Black individuals in the US living with serious mental illness-a call to action. JAMA Psychiatry. Published online July 17, 2020. doi:10.1001/jamapsychiatry.2020.2656

2. Neal-Barnett A. Soothe Your Nerves: The Black Woman’s Guide to Understanding and Overcoming Anxiety, Panic, And Fear. Touchstone/Simon & Schuster; 2003.

3. Grier WH, Cobb PM. Black Rage: Two Black Psychiatrists Tell It As It Is. 4^th edition. Basic Books; 1968.

4. Welsing FC. The Isis Papers: The Keys To The Colors. 1^st edition. CW Publishing; 2004.

5.     Guthrie RV. Even the Rat Was White: A Historical View of Psychology. 2^nd edition. Pearson; 2003.  

6. Goff PA, Jackson MC, Di Leone BA, Culotta CM, DiTomasso NA. The essence of innocence: consequences of dehumanizing Black children. J Pers Soc Psychol. 2014;106(4):526-545. doi:10.1037/a0035663

7. Epstein R, Blake J, González T. Girlhood interrupted: the erasure of black girls’ childhood. Washington: Georgetown Law Center on Poverty and Inequality; 2017.

8.     Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon Press; 2011.

9. Roth A. Insane: America’s Criminal Treatment of Mental Illness. 1^st edition. Basic Books; 2018.