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Nation-wide, at 34,658,190, African Americans constitute 12.4% of the United States population (U.S. Census Bureau, 2000).
Demography & Immigration History
According to the 2005-2007 American Community Survey of the United States Census Bureau, the number of individuals in the United States identifying as black or African American alone is approximately 36,969,063. This magnitude, thanks to increased diversity in the late 20th century, represents more than a four-fold increase since the 1900s, when there were 8.8 million blacks or African Americans in the country (Hobbs & Stoops, 2002). Even with the growth of other minority groups in the U.S., the black population has remained larger than any other non-white population throughout the Northeast, Midwest, and South (Hobbs & Stoops, 2002).
Blacks and African Americans have also become more geographically dispersed throughout the Century. In the early 1900s, 90 percent of all blacks in the US lived in the Southern States. Since then, the population has migrated elsewhere. Nevertheless, blacks (along with Asians and Pacific Islanders) are one of the most regionally concentrated races, with slightly more than half (53 percent) of all blacks in the U.S. living in the South (Maloney, 2002; Hobbs & Stoops, 2002).
Of the 36.4 million blacks reported in 2000, 1.7 million of those claimed to be black in combination with one or more races; this suggests a sizeable interracial generation is resulting from the diversity boom (Hobbs & Stoops, 2002). The number of black/white married couples in the United States has increased from 51,000 in 1960 to 246,000 in 1992 (U.S. Census, 1998) and marriages between blacks and whites have increased by 400 percent from 1969 to 1999 (AACAP).
Similarly, the number of marriages between blacks and any other race (defined by the U.S. Census Bureau as “any race other than white or black, such as American Indian, Japanese, Chinese, etc.”) has increased. In 1980, there were 34,000 married black/other race couples, while in 2002, there were 57,000; this is approximately a 68% increase (U.S. Census, 2004). In 1990, 231,212 children or 6.3% of children with a black parent were of a different race than one or both of their parents (U.S. Census 1990); although the same data is not available for 2000, the general trends in interracial relationships and percent of interracial children suggest that this number has grown in the past twenty years (Lugaila & Overturf, 2004) or at least remained the same (U.S. Census, 2005-2007).
In terms of age composition, blacks are among several minorities classified as having “relatively younger” populations (Hobbs & Stoops, 2002). Despite this, demographers project that the number of African American elders will rise by 102 percent between 1990 and 2020. However, statistically, blacks and African Americans have a shorter life expectancy (73.2 years) compared to that of the general population (77.8 years) (National Center for Health Statistics, 2009). The reasons for this disparity are numerous, yet seem to be attributable to poverty and poor access to services like health care.
Historically, African Americans have been disadvantaged. Throughout the Transatlantic Slave Trade from 1450 to 1867, around half a million Africans were forced to migrate to the Southern United States, to work on plantations (Dodson, 2009). From 1760 to 1865 African American slaves were again forced to move, this time west, with the Westward Expansion (Dodson, 2009). After the Civil War, in an effort to move away from the Jim Crow South, large percentages of the population continued to move to Western states where they largely settled in all-black communities. During the “Great Migration” from 1916 and 1930, and again during the “Second Great Migration” from 1940 and 1970, over 5 million blacks moved north to urban cities.
Throughout the 20th Century, access to equitable services was limited. However, by the end of the century, conditions for blacks improved nationally. At this time, another migration occurred, when many blacks returned south. After the dismantling of Jim Crow laws and a string of Supreme Court decisions in the 1950s and 1960s, changes occurred in the South, despite initial resistance. Simultaneously, blacks began to have a voice in politics, with the number of black elected officials in the old Confederate states increasing from 72 in 1966 to 711 in 1971 (Dodson, 2009). The major reason for this growth was the passage of the Voting Rights Act. With its growing economy and better living conditions, the South became an accepting and desirable place for blacks to live. Since 1970, several million Afro-Caribbeans, sub-Saharan Africans and Haitians immigrated to the United States with the promise of a better life (Dodson, 2009).
Prevalence rates of mental illness
Mental illness prevalence rates for African Americans in community-based studies are generally reported to be similar to rates in the white population (Sue & Chu 2003; Kessler et al., 1996), and in fact one study reports that rates for major depression are lower than in the general population (Brown DR et al., 1995). Yet, African Americans are frequently found among the most vulnerable population sub-groups: comprising 40% of the homeless, 50% of prisoners, and 45% of children in the foster care system. They are also the most frequent victims of serious violent crime (Surgeon General's Report, 1999) and may have been excluded from counts of people with mental illness (Williams & Jackson, 2000).
In one study, 28.1% of African Americans had alcoholism, drug abuse, and mental health care problems (Wells K et al., 2001). Another study found African Americans more likely to suffer from phobias, somatic symptoms, and sleep paralysis than other populations (Cooper LA et al., 2003). African Americans also represent a large proportion of the military returning with diagnoses of Post-Traumatic Stress Disorder (Lim RF, 2006; U.S. Dept. of Veteran Affairs). Exposure to trauma leads to increased vulnerability to mental disorders (Kessler et al., 1994). Young adults between 20 – 29, and individuals in poor or fair health are especially at risk for depression (Brown DR et al., 1995).
A 1997 study indicates that African Americans are more likely to be hospitalized, rather than treated in outpatient settings. On the national level, 364 per 100,000 were admitted to state psychiatric hospitals, a figure significantly higher than for other ethnic groups or the white population (SAMHSA, WICHE, 2001). 56% of African Americans admitted to state hospitals receive a primary diagnosis of schizophrenia in contrast to 18% of all individuals admitted. However these figures require caution: research studies have demonstrated that frequent unnecessary hospitalizations are the result of misdiagnosis resulting from clinical failure to recognize cultural differences (WICHE).
Impact of cultural values on the use of mental health services
Many believe mental illness has spiritual or religious causes, this serving as a deterrent in seeking services (Alvidrez J, 1999; Paniagua, 1998). (See section on spirituality below). In a study of attitudes on suicide, African American college students were significantly less likely than European American college students to attribute suicide to interpersonal problems and significantly more likely to report that God is responsible for life (Walker, 2006).
The ancestors of most African Americans entered the United States under fearful and involuntary conditions. During the time of slavery, and in the periods afterward, their attempts to develop a social structure were undermined by racism and oppression. Disruptions in family life deprived many of the knowledge of their own history and rich African cultural heritage (Wilson, Stith 1998). This created a sense of powerlessness and disenfranchisement still experienced today (Black, 1966), that has an impact on mental health care-seeking patterns.
African American values can vary greatly. They may be based on cultural practices surviving from Africa, adaptations of American cultural norms, and personal experiences with the mainstream culture (Pinderhughes 1982, 1990). Those at poverty levels or lower economic status often differ in their views from middle- and upper-class African Americans (Wilson, Stith 1998). African Americans emphasize spirituality, and sharing. As a result many consult clergy for help with their problems rather than seeking psychiatric assistance. Lower income groups focus on present day concerns (Pinderhughes 1982, 1990). Therapists need to be aware of the desire to focus on day-to-day present issues in their treatment approach.
Racial pride, solidarity and support for the civil rights movements are an important part of the socialization experience. Only in recent times have African Americans begun to identify with their African roots. Families want their children to learn an African language, and a social consciousness for the people of Africa has developed (Billingsley A, 1992). While some react to their environment by reducing efforts to get ahead, for others the most appropriate response is to work collectively with other group members to make the system more open to opportunities for advancement (Neighbors HW et. al., 1996).
Modern-day challenges facing African Americans include dealing with racism and societal stereotypes, developing healthy means to handle the resultant feelings of anger and distress, and establishing a strong identity that gives life meaning and the ability to withstand stress (Wilson, Stith 1998). Too often racial and ethnic disparities in mental health are not readily understood and therefore too easily ignored by treatment agents. Therapists need to understand the impact of racism today as well as the legacy of the slavery experience (Hollar, 2001). Therapeutic bias is often based on unfounded assumptions, and community intolerance toward minority individuals with mental illness (Snowden L, 2003).
Adaptive behavior and the psychological well-being of African American men can be affected by prejudice and discrimination creating what has been called “an invisibility syndrome,” a psychological experience where the person feels his racial identity and self-abilities have been undermined by episodes of racism occurring in interpersonal circumstances. Therapists and counselors need to be aware of this dynamic and address racial identity issues in the counseling situation (Franklin AJ, 1999; and Franklin AJ & Boyd-Franklin N, 2000).
In 1985, 46% of African American families were married couples, the percentage being higher for those above the poverty level (Billingsley A, 1992). 54% live in single-parent households, 45% of these with female heads, and 9% with male heads (U.S. Census Bureau, 2004). Billingsley goes on to state, partners share egalitarian cooperative roles in household tasks, parenting and employment opportunities. Marriage, family life, education and home ownership are highly valued (1992). However as in general society, living together, separation, and divorce are increasingly normative behavior for African American families (Wilson, Stith 1998).
With wide variations in family structure, there is no typical model for an African American family (Pinderhughes, 1990). Family structure may be nuclear – related by marriage, blood ties, formal or informal adoptions, extended – multi-generational or with other relatives, augmented – nuclear with the addition of other members of the household who come together by feelings of affinity, blended – a nuclear family with children and step-children. Families will frequently take on the care of un-related children when necessary (Billingsley, 1992). Increasingly, elderly are becoming caregivers of their grandchildren. Family structure also varies by education level, socio-economic status, cultural identity, and personal experiences and reactions to racism (Jones, Gray 1983). Family therapy is an especially appropriate modality (Wilson, Stith, 1998). Since many African American families have extended family structures, the most important members of this far-reaching group need to be identified and made a part of the therapy process (Boyd-Franklin, 1990; Lindermuth, 1998). The Black family is also seen as vital to building the Black community (Johnson RC, 1981).
Role of women
Many women are faced with un- and under-employment, impoverished conditions and single family households. However, many are resilient in taking care of and providing for their children, often through extended families or informal community networks. Among intact families, roles are egalitarian (Billingsley A, 1992). Educated women have been advancing on career ladders at a faster pace than men but are still hindered by gender and racial “glass ceilings.” In one study, White women were much more likely to have made a mental health visit than African American or Latino women (Alvidrez J, 1999).
Data have shown many are moving up the social class ladder. One author found 5% of African Americans were in the upper class of the socio-economic ladder, 27% in the middle class, 42% in the working class, and 27% at the poverty level (Billingsley A, 1992). African American members of the lower socio-economic classes who receive Medicaid are more likely to receive mental health care than middle and upper-class individuals (Alegria M et al., 2002).
Failure to seek treatment may be based on stigma, as well as the lack of accessible resources and opportunities for treatment (Snowden L, 2001). Personal experiences of racism are a stress factor for African Americans (Combs DR et al., 2006) resulting in adverse immediate and cumulative effects on physical and mental well being (Jackson JS et al., 1996) and poorer mental health (Fischer AR et al., 1999). However, more recently, African Americans have shown positive attitudes towards seeking mental health services and are less likely to be embarrassed if friends know they sought treatment (Diala CC et al., 2001).
Work is valued as a path toward mobility, entering the mainstream of society, and fulfilling societal responsibilities. African Americans are under-represented in higher level occupations and over-represented in unskilled work (Billingsley A, 1992).
Spirituality is defined as the internalization of positive values, and is distinguished from, yet may be an outcome of religiosity (Mattis J, 2000). It encompasses quintessential, internal and external, consoling and transforming dimensions and is found globally and culturally prominent (Newlin K et al. 2002). Spirituality plays an important role for African American women. In a study of women in recovery from substance abuse, those who scored higher on a Spiritual Well-Being Scale had more positive self-concepts, an active coping style, healthier perceptions of family climate and parenting attitudes (Brome D et al., 2000). Another study of multi-generational families viewed health concerns from a spiritual rather than medical perspective affirming strong beliefs in divine healing, acceptance of health outcomes as an expression of God's sovereignty and transmitting these beliefs across generations (King S et al., 2005).
In recognition of African American beliefs that mental illness has spiritual causes, psychologists have developed African-centered models of therapy that emphasize spiritual development. In one model an African American Counseling Team was formed that integrated clinical assistance into the support system of the African American church, a community resource trusted, embraced, and used for a variety of personal, social, and spiritual needs. (Queener JE et al., 2001).
Mental health care seeking patterns
Sources and types of formal help
Over-representation of African Americans in high need populations implies a greater reliance on public hospitals, community health centers and local health departments for both physical and mental health care (Lewis, Altman 2000). African Americans are more likely to discuss mental health problems in general medical settings rather than in consultation with a mental health specialist. This provides a safety net for mental health for those who would otherwise not seek help (Cooper-Patrick L et al., 1999). Yet one study found physicians are less likely to detect mental illness in African Americans than in other ethnicities (Borowsky SJ et al., 2007). Many use emergency rooms for crises. Those who do seek treatment from outpatient providers in the specialty mental health sector are at risk of premature terminations and feelings of alienation (Snowden L, 2001).
Sources and types of informal help
A preferred coping strategy is not to shrink from problems, but to confront them directly (Broman, 1966). African Americans have a tradition of turning for aid to significant others in the community including family, friends, neighbors, voluntary associations and religious figures, this tradition having evolved from the historical experience of having to rely on each other for survival (Hatchett, Jackson 1993). Voluntary support groups, however, are used less often than by other cultural groups (Snowden L, 2001). As a result, mental health treatment may be delayed until problems have become especially intense and beyond the supports their environment can provide (SAMHSA, 1996). At times African Americans may consult a spirtualist, a voodoo priest or a minister (Paniagua, 1998). Women tend to seek help from their ministers, especially around problems related to death or bereavement problems. Regardless of the type or severity of the problem, those who contact clergy first are less likely to seek help from other professionals (Neighbors H, 2001).
Mental health service utilization problems
African Americans underutilize the mental health system, the percentage of African Americans receiving needed services only half that of the general population (Surgeon General's Report, 1999). Greater use is made of emergency rooms than outpatient care (Hu TW et al., 1991). Often, services are unavailable, not accessible, or not publicized (SAMHSA, 1996). Greater service access was found among those with self-reported substance abuse problems, those who have had friends or family who have used mental health services, and when mental illness was viewed as an externalized environmental problem rather than intrinsic to the individual (Alvidrez J, 1999).
African Americans are less likely than white persons to find antidepressant medication acceptable (Cooper LA et al., 2003). Often, they are prescribed anti-depressant medications at higher dosages than the white population due to perceived metabolic differences and often experience adverse side effects (Surgeon General’s Report, 1999). African Americans were less likely to be prescribed the newer atypical anti-psychotic medications (Daumit et al, 2003).
Standard English is the recognized norm for most African Americans. Some from the lower socio-economic classes find it hard to communicate thoughts and feelings using Standard English, and revert to dialects and a form of speech termed Black English (Wilson, Stith 1998) which may not be understood by non-African American counselors (Beaman, 1994). Tone, tempo and gesture (McCollum, 1997), and intensity and pitch of speech (Hines et al., 1996). affect the meaning of the spoken word. Of equal concern is the use of technical jargon by mental health counselors which is not readily understood by mental health consumers.
African Americans covered by Medicaid (21%) are more likely to receive outpatient mental health treatment than those with private insurance (50% of employed African Americans). When compared with privately insured persons eligible for care under either fee-for-service or managed care, the Black–White gap in outpatient service use was significantly smaller under Medicaid. There was no racial difference in outpatient treatment rates among the uninsured. Racial differences among those receiving outpatient mental health treatment is confined largely to the privately insured where Blacks have more limited access (Snowden L, et al., 2000). 25% have no insurance at all (U.S. Surgeon General Report, 1999).
Agencies may not locate services close to population centers of African Americans, and may offer restrictive hours of operation that do not accommodate working individuals or mothers with children.
African Americans most likely to use mental health services are those with substance abuse problems. Knowledge about other family members who have utilized mental health services successfully also promotes the seeking of mental health care (Alvidrez J, 1999).
Specific age/gender group problems
The first preference for parents of children with difficulties is to seek help from community sources and other family members. They are less likely than white families to seek psychiatric help initially (McMiller WP et al., 1996). The issue is crucial, for while suicide rates among young black men match those for young white men, they are higher for children between the ages of 10 to 14 (Cooper LA et al., 2003). A study of parents of children meeting criteria for Attention Deficit/ Hyperactivity Disorder found that African American parents were less likely than white parents to describe their child's difficulties using specific medical labels (Bussing et al., 1998). A study on children’s adjustment found African American children whose parents attended church weekly had fewer emotional or behavioral problems and provided greater resilience for children at risk despite growing up in poor families and problem communities. Children whose parents attributed negative life outcomes to racial attributions presented more frequent behavior problems (Christian MD, Barbarin OA, 2001).
W.E.B. DuBois, the noted Black scholar, placed importance on a liberal education, rather than mere vocational training. He emphasized teaching the values of moderation, avoidance of luxury, courtesy, a capacity to endure, a love for beauty, while recognizing education’s subversive functioning to maintain the social order under which they lived (re-published, 2001). A number of writers pose the theme that education is an imperative for African Americans to become self-determining, and education needs to become more Afrocentric if patterns of school failure are to be reversed (Shujaa M, 1994; & Irvine J, 1990). Traditional education emphasizes cultural assimilation of African Americans rather than affirming the African American cultural heritage, history and values (Lee C et al. 1995). Many believe the over-representation of African American children in special education programs is another indication of an educational system that does not have a cultural understanding of its students’ needs (Patton J, 1998).
Although many elderly remain active parts of extended families, 60% of older African Americans do not receive needed services (Surgeon General’s Report, 1999). A study of African American nursing home residents reveals that many need psychiatric care (Class et al., 1996).
Similar to the differences between white women and men, prevalence rates of depression, anxiety disorder and phobias were higher for African American women than men (Kessler et al., 1994).
Impact of acculturation on treatment
Acculturation of African Americans to mainstream life has received little study and many therapists fail to focus on acculturation issues, emphasize cultural deficits, and ignore family strengths (Landrine, Klonoff 1994). The assumption that African Americans have fully accepted the general population's value system has not been established in fact (Lindermuth 1998; Hines, Boyd-Franklin 1996), and many African Americans remain alienated from the society around them (Brunswick et al. 1991).
Treatment of African Americans needs to respect their history, understand their values, be aware of their support networks, and anticipate the role of racial differences between providers and consumers (Wilson, Stith 1998). Treatment needs to be directed towards enhancing existing strengths within the individual, family and community (Pinderhughes, 1982). Several writers caution against imposing mainstream concepts of healthy functioning and pathology without recognizing African American perspectives (Hays, 1996; Spaights 1990).
[Robert Schore, LCSW and James Railey, LMSW contributed to this report.]
© 2008, OMH
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