Black American mental health clients have been found to underutilize mental health services and have significantly fewer treatment sessions than whites (Vernon & Roberts, 1982). What factors contribute to this situation? What are the cultural, social and economic considerations present in the psychotherapeutic process with blacks? This research will briefly touch on some of the issues involved in delivering psychotherapy to the black population.
Psychiatric diagnosis reflects social attitudes, and its source can be traced historically. The first recorded evidence of mental illness among blacks was noted during the period of slavery, when two psychiatric syndromes specifically related to blacks were advanced. In 1851, a treatise entitled “Diseases Peculiar to the Negro” was published by a Dr. Cartwright of New Orleans (Gallagher, 1987). One of the illnesses was called Dysaethesia aethiopica, a euphemism for rascality, which caused a slave to perform his duties in a careless, lackadaisical, irresponsible and headlong manner. The other disease, drapetomania, caused slaves to run away. According to Cartwright, the etiology of these diseases might be due to the Negro’s deficiencies of red blood in the lungs. During succeeding times the lower incidence of mental disorders among blacks was considered to be the result of the protected and secure lives blacks enjoyed as slaves. However, incidences of mental disorders were reported for blacks who were free.
In addition, abundant examples of the underdiagnosis, overdiagnosis or misdiagnosis of mental illness in blacks are found in the literature. Cannon and Lock (1977) discuss differential diagnostic patterns for blacks and assert that there is a hesitancy to diagnose blacks as affectively ill. This is overly compensated for by a strong tendency to diagnose blacks as schizophrenic more frequently than whites. While only limited national statistics concerning diagnoses of mental disorders for blacks are available, it is possible to draw some inferences about possible misdiagnosis from existing data on utilization of psychiatric facilities. For example, admissions to state mental hospitals in 1975 varied dramatically for the four race-sex groups, with alcohol disorders leading among white males at a rate of 79.5 per 100,000 population and schizophrenic disorders among black males at a rate of 97.1 per 100,000 (Gallagher, 1987).
Although these statistics are confounded by differential facility utilization patterns according to socioeconomic status, they nonetheless reflect biases in the assignment of diagnosis according to race. Black families and black children have similarly been the target of diagnostic labels, and it is highly probable, because of the kind of treatment that has been administered, that it is in this area that the greatest damage to blacks has been made.
For several decades, the black family has been viewed as matriarchal. Despite protests by a number of social and behavioral scientists, the belief in the malevolent influence of the black mother on her offspring, particularly the male, remains strong. Numerous studies have been reputed to find that males in these black-mother-headed-households produce children who are either overmasculine, criminal, or with diminished masculinity. However, the methodological procedures of these studies are greatly questioned. In any consideration of the causality of emotional illness in blacks, the effects of racism and poverty often become indistinguishable. This is not unusual given that the factors of oppressive racist practices prevail in all segments of American society, of which poverty is inevitably one of the results. Added to this is the almost daily barrage of insults based solely on race, which have a demoralizing impact on the black psyche. The resultant lowered conception of self-worth, lowered aspirations, and distortion of values in comparison with the views of the social majority not only affects personality development but also contributes to the maintenance of poverty. Thus, racism and poverty constitute a vicious self-perpetuating cycle, each reinforcing the other.
A broad range of psychopathological disorders noted in black children are often viewed as characteristically due to racial differences, but their striking prevalence in overcrowded ghetto neighborhoods makes it apparent that poverty is a major factor. Hyperkinesis, pica, learning problems, and unsocialized aggressive reactions of childhood are commonly seen. Poor prenatal care, marred parenting, and the atmosphere of poverty are noted in the history of these families. Similarly, differential diagnosis as a result of race have been noted. The infrequency of the diagnosis of autism leads to reports that this is a very rare disease among black children, but there is a strong probability that instead of being rare, it frequently may be diagnosed erroneously as mental retardation.
Problems Related to Treatment
Evidence has been provided by a number of investigations that differential diagnosis and treatment are associated with race. In psychiatric emergency rooms, the type of referral, as well as diagnosis, varies with the race of the patient. Accuracy in diagnosis appears to depend upon the distance of the sociocultural gap between patient and clinician. The greater the distance, the less accurate the diagnosis and the more nonspecific the disposition (Gross et al., 1969). It has been pointed out that blacks are seen more often than whites for diagnosis only. Further, whites are more often selected for insight-oriented therapy than blacks, and with greater frequency for long-term psychotherapy. Blacks are also more often seen by paraprofessionals than are whites.
In general, black patients receive second class therapy unless their presentation tends to approximate more closely the cultural position of the evaluator. Even when this is the case, some clinicians, because of their own stereotyping, believe that blacks cannot have a similar value system and will assign patients to a therapeutic regime that is inappropriate.
In black patients, particularly those entering public facilities, immediate threats of a crisis or near crisis are often the cause of their seeking therapy. After relief of these pressures there is frequently a reduction or dropping off of motivation to continue therapy.
In dealing with this pattern, Sager et al. (1972) formalized the interrupted or piecemeal approach for individual patients and families from ghetto settings. After successfully helping the patient and/or family deal with the presenting crisis in a limited number of sessions, the therapist then encouraged them to terminate. A number returned because of another crisis, often precipitated when new responsibilities were assumed. Generally, they worked toward achieving more changes that were not considered during the first group of sessions. The author states that if attempts are made to retain many of these patients in treatment, there is little or no drive toward doing further work since their own mission or purpose has been accomplished. What tends to occur is that subsequent scheduled visits, unless there is another crisis, are characterized by periods of tense silence, lateness in arrival for the appointed hour, absenteeism, or dropping out of therapy.
The type of therapeutic approach and its subsequent effectiveness are dependent upon the therapist’s assessment of the patient. An accurate evaluation of the psychological status of an individual can be made only in relationship to what is considered appropriate and effective functioning within that individual’s own specific cultural milieu (Acosta, Yamamoto, & Evans, 1982). If this is not kept in mind, the therapist runs the risk of using his own status as the norm and that of the patient as the deviation from the norm.
The majority of the literature deals almost exclusively with poor blacks. Little attention has been paid to the burgeoning black middle class with its own set of problems. Upwardly mobile blacks tend to take on the attitudes, aspirations and desires of the major pacesetters, the middle class whites. There are differences in values and lifestyles between middle class and lower class blacks just as there are differences between middle and lower class whites.
Over the past two decades a wide range of employment opportunities have been opened up to blacks, allowing those who avail themselves of them to achieve an economic and social status that was unavailable before. The attainment of these gains is accompanied, however, by an increase in responsibility, and many blacks, unprepared for this different kind of setting are unable to adapt quickly, and they respond with a variety of symptoms related to stress (Acosta, Yamamoto, & Evans, 1982). Despite an often good start, anxiety mounts when job related obligations intensify. This is particularly true when the black employee is from a background in which the major decisions in life were concerned with supporting immediate needs. A request for help is akin to an acceptance of ineptness and is perceived as a blow to the self concept. The anxiety may be defended against by increasing indifference, a display of incompetence and ineffectiveness not in keeping with actual ability, avoidance of responsibility, absenteeism and alcoholism. Racial situations may be magnified and used as the reason for job difficulties. If the patient is married, family problems may be noted that reflect both individual psychopathology and fallout symptoms from intrafamilial conflicts involving the spouse and also the children.
Evidence strongly indicates that social mobility is significantly related to emotional disorders and disturbances in interpersonal relations. Rates of illness are higher for both the upwardly mobile and the downwardly mobile than for the socially stable (Kliener & Dalgard, 1975). It has been found that as the distance moved increases, the rate of illness also increases. Social climbers particularly have been found to be more subject to chronic psychosomatic disorders.
Differential Therapeutic Processes
Therapy philosophically based in intrapsychic dynamics usually relates directly or indirectly to psychoanalytic concepts. Up to a decade ago it was believed that blacks were unsuited for, and could not profit from, psychoanalysis and psychoanalytic approaches. With modifications of classical techniques, particularly in this country, this belief has been for the most part abandoned, and there is little in psychoanalytic oriented therapy that is not applicable to blacks. In situations where basic life needs are foremost, however, the therapist may have to resort to pragmatic expediency before conducting what is regarded as traditional therapy. Nevertheless, the therapist’s knowledge of internal dynamics, if not too rigidly applied, will be useful in understanding his patients.
As with all patients, the most pressing concerns are those with which they must currently deal. For the poor black ghetto dwellers these more often pertain to the most concrete of things such as finding employment, surviving on a welfare budget, seeking housing outside a crime-ridden neighborhood, and/or obtaining clothing so that their children can attend school. Active assistance in attempting to lessen the patient’s overwhelming burdens should not be viewed as merely a prelude to, or a means of, getting into the real treatment. Rather, it should be seen as an integral part of the treatment itself (Sager et al., 1972). Only after dealing with these crisis-provoking situations can the patient and the therapist begin to contend with damaging underlying psychological factors.
There is some opinion that because of the commonality of race and experience, black therapists work better with black patients. However, a sufficient number of black therapists will probably never be trained which can deal with the growing number of black patients.
With the separation of the races and an environment that supports myths and stereotypes about anyone different, it can only be expected that the white therapist brings with him to the therapeutic situation varying degrees of misconceptions. This is why self-examination is of the utmost importance.
Black therapists are not necessarily immune to these same reactions. The effort necessary to become a professional places them in a middle class category. Coupled with the fact that most blacks receive their psychiatric training in white institutions, their own identification with whites and white middle class values can prompt a denial of identification with the race of their black patients.
It has been shown that blacks in need of psychological help will avoid mental health services because of a basic mistrust of white therapists. The implication here is that blacks would favor psychotherapy if more black therapists were available.
In a recent interview study with low income men and women who had prematurely terminated from therapy after two sessions, Acosta (1980) found an intriguing contrast in the responses of black patients. The primary reason given for their early self-termination was a negative attitude toward the therapist. The majority of the therapists were white and of middle class backgrounds. In spite of their negative attitude, however, black patients still reported a moderately positive attitude toward the potential usefulness of counseling and therapy for themselves and others in the future. The implication here was that while the black patients may have expressed negative feelings about their brief therapy experience, they were still willing to see therapy as a possible resource, if needed, in the future.
The findings of a study by Tien and Johnson (1987) raise issues concerning service provisions for minority clients. The number of subjects who preferred black therapists was not significantly larger than that of those who did not. Even if a black client preferred a black therapist, the major reasons rested on the therapist’s professional competence and positive attitudes, not just his or her cultural compatibility. For those subjects who preferred therapists from different ethnic backgrounds, although the results of statistical analysis did not show significance in their perceived importance of professional
competence, positive attitude and cultural sensitivity, the percentages were toward that direction.
Similarly, a study by Flaskerud (1986) examined the relationship between a cultural compatible approach to mental health service and utilization as measured by dropout and total number of outpatient visits. A cultural compatible approach was found to be effective in increasing utilization. Three culture compatibility components were the best predictors of dropout status: language match of therapists and clients, ethnic/racial match of therapists and clients, and agency location in the ethnic/racial community. Pharmacotherapy, education, previous treatment and a diagnosis of psychosis were significantly related to remaining in therapy.
Black patients also have their own stereotypes, and they do not leave them at home simply because they are seeking help. The white therapist is viewed as are all whites, as disinterested, dishonest, quick to show superiority and condescending. Black patients are therefore cautious. With better educated patients these may well be hidden. When the black patient encounters a black therapist who is part of an institutional setting, the therapist may be viewed as a part of the oppressive system and is related to with the same degree of suspicion as is the white therapist.
When working with someone of a different race, some therapists feel it is important that in the initial contact an inquiry be made into the patient’s feelings about the arrangements. It is felt that the boldness of such an approach challenges the patient to deal with his or her own prejudgments (Carter, 1979). This is held to be equally important if the therapist is black. Many black therapists refuse to acknowledge that the client is black in order to avoid the possible fear of weakening their own professional image and/or loss of control of the therapeutic contact.
The establishment of communicative exchange is an indispensable feature of psychotherapy. The black patient who utilizes principally street talk may present a perplexing dilemma to the therapist to whom this is not a part of his or her life experiences.