Improving Black Mental Health: A Collective Call to Action

The current syndemic of racism and the COVID-19 pandemic (1) underscores the long-standing need for culturally relevant, trustworthy, and effective mental health services for the Black community. Racism, stress, and trauma affect mental health at both the individual and community levels. We call on service providers, agency administrators, funders, and policy makers to mobilize as stakeholders to improve Black mental health outcomes.

BLACK MENTAL HEALTH: THE CURRENT CONTEXT

The COVID-19 pandemic

Black populations are experiencing disproportionate impacts of the COVID-19 pandemic. At one point, the likelihood for Black people of contracting the disease was three times higher than that of their White counterparts, with COVID-19–related death being twice as likely for Black persons (2). The increased likelihood of increased morbidity and mortality rates in Black communities is a reflection of the systems in the United States that have not been designed to support the health and well-being of non-White groups. As these disparate rates suggest, the pandemic also has negative impacts on Black mental health. In 2018, 3% of Black respondents to the National Health Interview Survey reported having serious mental health concerns. In April 2020, this rate among a representative sample obtained from the online survey platform Lucid increased dramatically to 28%. Both surveys used the Kessler‐6 Psychological Distress Scale (3).

The pandemic has had traumatic impacts on the physical, social, and economic well-being of Black communities. Black unemployment rose from a rate of 5.8% in February 2020 to 16.8% in May 2020, while White unemployment rose from 3.1% to 12.4% during the same period (4). The communities hit hardest by the pandemic’s direct impact are also experiencing the greatest losses in other areas of life. These outcomes were predictable and in alignment with the nature of a syndemic, defined as a “population-level clustering of social and health problems” (5), and such syndemics have happened before. Syndemics are most likely to manifest under adverse community experiences that cause health inequalities, such as poverty and structural violence (5).

Racial unrest

Data (6) indicate that rates of individuals showing signs of clinical depression and anxiety increased from 36% to 41% (an increase of more than 10%) among Black people after the murder of George Floyd in May 2020. In addition to the threats of the COVID-19 pandemic, Black neighborhoods continue to endure systemic racism in the policing industry. Recent events have increased awareness of overt bias, racism, and police brutality against Black people. This awareness has increased also among White people, reflected by polls indicating a shift toward increased recognition of the prevalence of racism and its impacts. For example, the Monmouth University Polling Institute (7) found that 67% (N=867) of respondents (63% of whom were White) considered racial discrimination in the United States a big problem in late June 2020, up from 51% of respondents with this opinion in 2015. Black people experience tension related to community-police relationships and ongoing public killings by police, while simultaneously navigating the White awakening to structural violence, racism, and oppression. These events take a toll on Black mental health.

Although the White awakening to the impacts of racism is overdue and necessary, in the first author’s lived and vicarious experiences as a Black woman, it can be saddening, painful, and frustrating to observe or participate in this awakening. Structural violence is persistent and continues in 2021. To observe the collective attention to racism ebb and flow in media headlines can be disturbing and demoralizing for those who experience racism, trauma, and retraumatization daily—those who have used, and will continue to use, their voices and bodies to call for Black liberation regardless of the headlines. We note that this White awakening further contributes to the exploitation of Black people. For example, in many workplaces, Black employees have been asked since spring 2020 to serve as experts and to provide antiracism education to colleagues—above and beyond the regular workload and often without compensation. This emotional labor adds substantial occupational stress. There is an emotional toll on Black people as increasing numbers of White people seek to process their shame, guilt, and complicity in systemic racism. It can be exhausting to serve as the educator, historian, and translator of collective Black trauma, while simultaneously experiencing structural violence. Other sources of information are available—such as websites, reading lists, tool kits, documentaries, and podcasts—that people can access to activate their own awakening without placing burdens on Black friends or colleagues.

HISTORICAL DISENFRANCHISEMENT BY THE MENTAL HEALTH SYSTEM

The current syndemic illuminates how existing structures have been designed to advantage some and disadvantage others, with racism as a driving factor. Racism influences and shapes the power structures that uphold White supremacy culture and perpetuate inequity. It contributes to the prevalence of mental health conditions in the Black community.

Racism created, and continues to create, distrust in U.S. mental health service systems (fostered, e.g., by the Tuskegee Syphilis Experiment, in which scientific research protocol and ethics around choice and the treatment of human subjects were ignored; the surreptitious harvesting and use of cells from a Black woman, Henrietta Lacks, in medical science; and present health inequities). Black people of all ages are less likely to seek help and, once in the mental health service system, tend to be less engaged in services. Black people face disparities related to screenings and prevention, accurate diagnostic procedures, and access to timely, high-quality treatment. These concerns are compounded by the disproportionately low numbers of mental health providers of color, limiting the availability of Black providers who could provide culturally relevant services. In short, “In our mental health system, people of color are overrepresented [as patients], misdiagnosed, and mistreated, and organized psychiatry has no plan to guide the correction of these well-studied and long-standing inequities” (8).

A CALL TO COLLECTIVE ACTION

White epistemology frameworks serve as the basis for the psychology and psychiatry disciplines, thereby excluding a comprehensive understanding of the impact of racism on mental health. These frameworks inform diagnoses of mental disorders and treatments, as well as the understanding of the nature of trauma and mental health. In other words, in Western medicine and psychiatry, White supremacy and racism have led to the exclusion of Black communities in the creation of shared knowledge and meaning, thus upholding racial inequality, rejecting Black experiences, and oppressing through the creation and implementation of racist, biased, and harmful psychiatric practices. Exclusion and oppression are not new issues, yet the alarm for urgent change is ringing loudly, because recent events have had detrimental impacts on Black mental health. To move toward addressing these issues, we suggest that stakeholders consider Black mental health through a Wellness First approach and a socioecological perspective.

WELLNESS FIRST

Wellness First (9) is an approach that leverages the human and social capital in communities in a way that is trauma informed and healing centered. Truthfully recognizing, acknowledging, and naming trauma experienced by Black people—including the historical and collective trauma fueling distrust of the medical system (10)—creates an opportunity for repair and restoration. The medical profession, including psychiatry, has reinforced systems of oppression and contributed to the mistreatment of Black people. Mental health service settings create traumatizing structures that uphold racism and prevent or pose barriers to supporting Black mental health. Reconciliation of this trauma requires being aware of the trauma and its impact. A trauma-informed lens creates the space for addressing trauma at all levels. An example can be found in the American Psychiatric Association’s January 2021 apology (11), which noted, “Since the APA’s inception, practitioners have at times subjected persons of African descent and Indigenous people who suffered from mental illness to abusive treatment, experimentation, victimization in the name of ‘scientific evidence,’ along with racialized theories that attempted to confirm their deficit status.” Naming trauma may help foster healing and wellness but must be done in an artful and skillful manner and through a strengths-based wellness lens. We have seen in our experiences that when done correctly, naming trauma can promote healing. Done incorrectly, naming trauma can be harmful, confirming the importance of Wellness First and centering community.

In Wellness First, well-being is at the center of action and organizing, with particular attention to community wellness. Poor mental health outcomes not only affect the individual experiencing them but also can affect relationships, families, and communities. The Wellness First approach is strengths based and posits that communities and neighborhoods ought to be validated and recognized as valuable wellsprings of healing resources. There is a need to create healing environments and practices at community levels, rather than to solely explore individual healing. For example, aligned with this approach and located in Albany, New York, Root3d is a wellness studio established in 2019 to offer a healing space that centers people of color and creates community around healing (12). The studio offers classes, such as “Healing in Masculinity,” “Divine Feminine Yoga,” “Black Health Matters,” and “Generative Journaling,” created with and for the community. The Wellness First approach involves improving well-being from inside the community, driven by local leadership. Within the context of structural competency, the Wellness First approach provides a lens for health professionals to identify the structures that influence well-being at the individual and population health levels. The approach also promotes the centering of wellness and ascertains the community strengths that can be applied to support addressing and healing from structural violence. Existing community-focused, strengths-based frameworks, such as Asset-Based Community Development (13), Adverse Community Experiences and Resilience (14), and Building Community Resilience (15), align with a Wellness First approach.

FOCUS ON INCLUSIVE POLICIES AND PRACTICES THAT PROMOTE WELLNESS AND HEALING

Engaging in truth-telling about the history of White supremacy in the mental health service system may facilitate trust and serve as a platform to shape future policies. Policies can be created to ensure equitable opportunities for aspiring Black psychiatrists and other mental health professionals in leadership and policy-making roles. Institutionally, entities can examine and revise existing policies and social norms to account for historical, collective, and individual traumas experienced by Black people. For example, policies pertaining to the use of physical restraints should be reviewed and amended to avoid retraumatization. Practices should be assessed to ensure they include Black cultural values. For example, a review of policies and practices that takes into account the harmful effects of White supremacy culture may lead to identification of specific values and norms, such as individualism, that are culturally exclusive (16). A disparity impact analysis of existing and proposed policies should be conducted to examine effects.

At the community level, dialogue is essential to confront racism. The harmful narratives related to Black people may be processed in community settings, and discussions should be held about the historical and contemporary racial contexts that influence mental health outcomes to shift community norms and values. For example, as an entry point to learn about the shifts necessary to ensure equity, restorative circles could be used in community settings to talk about racism and its impact, and community-based participatory research could be engaged to investigate wellness and healing within the community. There is a need for disparity impact analyses to identify particular impacts and needs in specific neighborhoods.

At the individual level, beliefs, attitudes, and behaviors may be explored. Implicit and unconscious biases could be uncovered, and individuals could make commitments and take actions to become antiracist. By utilizing available sources of information on racism and related topics, individuals can expand their awareness and knowledge to become activated in self-education around racism and its impact on Black mental health and well-being. Interpersonally, mental health providers may create opportunities for learning and sharing knowledge related to the history of psychiatry and to the unique experiences of Black people and Black neighborhoods that have impacts on mental health. In relation to one another and one’s social networks, intentional efforts could shift beliefs, attitudes, and behaviors through dialogue and learning. Holding one another accountable may help create safer, more equitable spaces for promoting Black mental health.

Organizationally, agencies should examine barriers to equitable, high-quality services. For example, a mental health organization’s behavioral health screening and assessment tools should be scrutinized to ensure that they are relevant, trauma informed, and appropriate for Black community members seeking services. Moreover, at the organizational level, cocreation of, or additional support allocated to, spaces that use the wellness strengths within Black communities could foster collective healing. Partnerships with Black-owned community organizations, social justice organizations, and other relevant partners may assist in deepening understanding of the issues and in determining actions to improve mental health outcomes.

CONCLUSIONS

We propose that all stakeholders, including individuals, health providers, organizations, funders, and policy makers, have a role in creating equitable and inclusive systems and processes so Black people can access timely, high-quality services that improve quality of life and increase life span. With no immediate action, the constellation of factors experienced by Black neighborhoods during the current syndemic will have far-reaching negative impacts. The brief recommendations given here are not exhaustive, and we urge everyone to consider their own role in adopting a Wellness First approach to dismantle the status quo, which continues to have detrimental effects on the health and well-being of Black communities.