As the United States becomes more culturally, racially, and ethnically diverse, psychiatry will be faced with the need to treat more diverse populations. This article focuses on challenges and obstacles encountered when treating black patients with mental illness. The black population in the United States is not a monolithic, homogeneous community. The heterogeneity of the population as a function of the African diaspora is complex and deserving of an understanding that goes beyond the phenotypic identification and assignment of individuals to what we believe to be "black."1 Language; ethnic culture (eg, Caribbean vs Southern-born); religious practices; socioeconomic status; immigration or refugee status; and the historical participation, or lack thereof, in the unique American experience of race relations defines how persons experience being "black" and express mental illness.
The first skill necessary to appropriately treat patients from the black community is to avoid stereotyping members of this diverse group.2 Such stereotyping is at the root of behaviors that result in the expression of microinsults and microaggression toward members of the African diaspora.3-5 For example, psychiatric services staff need to learn not to automatically ask black patients for their "Medicaid cards," but should rather ask, "How does the patient intend to pay for services?"
Conversely, gratuitously attempting to overidentify with the black culture based on stereotypes is equally detrimental, (ie, a white therapist giving a black patient an unsolicited "soul" handshake at their first meeting). Alternatively, the supposition that leads a therapist to prematurely ask about substance abuse before eliciting relevant data to support this possibility may be offensive to a black patient. It is advisable to establish rapport and elicit data that more directly relate to the presenting problem before initiating this and other more sensitive types of inquiry.
Satcher's Culture, Race, and Ethnicity report6 is an excellent primer that combats stereotyping by emphasizing the importance of recognizing the diversity that exists within black communities. Consideration of the individual patient's social context is important for avoidance of stereotyping and for understanding the context in which the patient's mental illness occurs. Middle-class, working-class, and poor blacks have different patterns of family membership, employment and continuity of employment, number of children, family functions, interaction (egalitarian, patriarchal, matriarchal), income and spending, social and leisure activities, involvement in community affairs, education, attitudes toward work, success, self-reliance, and so on.7 Despite the myth that all black families are matriarchal, middle-class black families are often egalitarian, and those of Caribbean extraction may be very patriarchal; therefore, making assumptions about black family structure and function is a potential land mine. Factors that affect levels of cultural identity8,9 among persons of the African diaspora can be further understood by referring to the underused "Cultural Formulation" section of DSM-IV-TR.
Central to recognizing the diversity within the black community is the development of skills of "cultural sensitivity."6 It is important to recognize and understand that different cultural, racial, and ethnic groups may require different medication prescribing practices.10 For example, because blacks have higher blood levels of the medication, they may be more predisposed to tardive dyskinesia given the same dose of a neuroleptic agent than a white counterpart.11,12 Simultaneously, while cultural sensitivity is important in the treatment of blacks with mental illness, it is equally important to recognize that there are universal principles of treatment that should apply to all patients.13 Clinicians must become astute in their ability to draw from both culturally specific and universal principles in their work with black patients.
1. African Americans. Available at: http://encarta.msn.com/encyclopedia_761587467/African_
Americans.html. Accessed October 23, 2006.
2. Pinderhughes CA. Differential bonding: toward a psychophysiological theory of stereotyping. Am J Psychiatry. 1979;136:33-37.
3. Pierce CM, Earls FJ, Kleinman A. Race and culture in psychiatry. In: Nicholi AR, ed. The Harvard Guide to Psychiatry. Cambridge, Mass: Belknap Press of Harvard University Press; 1999:735-743.
4. Shahrokh NC, Hales RE, eds. Psychiatry Glossary. 8th ed. Washington, DC: American Psychiatric Press, Inc; 2003.
5. Bell CC. Treatment issues for African-American men. Psychiatric Ann. 1996;26:33-36.
6. US Public Health Service. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/cre. Accessed October 23, 2006.
7. Willie CV. Black Families. Bayside, NY: General Hall; 1981.
8. Carter RT. The Influence of Race and Racial Identity in Psychotherapy. New York: Wiley & Sons; 1995.
9. Spurlock J. Development of self-concept in Afro-American children. Hosp Community Psychiatry. 1986;37:
10. Herbeck DM, West JC, Ruditis I, et al. Variations in use of second-generation antipsychotic medication by race among adult psychiatric patient. Psychiatr Serv. 2004; 55:677-684.
11. Lawson WB. Clinical issues in the pharmacotherapy of African-Americans. Psychopharmacol Bull. 1996;32: 275-281.
12. Glazer WM, Morgenstern H, Doucette J. Race and
tardive dyskinesia among outpatients at a CMHC. Hosp Community Psychiatry. 1994;45:38-42.
13. Bell CC, Bhana A, McKay MM, Petersen I. A commentary on the triadic theory of influence as a guide for adapting HIV prevention programs for new contexts and populations: the CHAMP-South Africa story. Soc Work Mental Health. 2006;5:237-261.
14. Feagin J, Sikes MP. Living With Racism: The Black Middle Class Experience. Boston: Beacon Press; 1994.
15. Baker FM, Bell CC. Issues in the psychiatric treat-ment of African Americans. Psychiatric Serv. 1999;50:
16. American Psychiatric Association. Resolution Against Racism and Racial Discrimination and Their Adverse Impacts on Mental Health; Position Statement. 2006.
17. Benkert R, Peters RM, Clark R, Keves-Foster K. Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care. J Natl Med Assoc. 2006; 98:1532-1540.
18. Thomas A, Sillen S. Racism and Psychiatry. New York: Brunner/Mazel; 1972.
19. Dove HW, Anderson T, Bell CC. Mental health and its impact on the health in the US nonwhite population. In: Satcher D, Pamies RJ, eds. Multicultural Medicine and Health Disparities. New York: McGraw-Hill; 2005:295-303.
20. Bell CC, Flay B, Paikoff R. Strategies for health behavioral change. In: Chunn J, ed. The Health Behavioral Change Imperative: Theory, Education, and Practice in Diverse Populations. New York: Kluwer Academic/Plenum Publishers; 2002:17-40.
21. Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science. 1997;277:918-924.
22. Flay BR, Graumlich S, Segawa E, et al; Aban Aya Investigators. Effects of 2 prevention programs on high-risk behaviors among African American youth: a randomized trial. Arch Pediatr Adoles Med. 2004;158: 377-384.
23. Bell CC. Cultivating resiliency in youth. J Adolesc Health. 2001;29:375-381.
24. Williams K, Johnson V. Eliminating African American health disparity via history-based policy. Harvard Health Policy Review. 2002;3:1-4. Available at: http://www.hhpr.org/currentissue/fall2002/williams-
johnson.php. Accessed October 23, 2006.