Perceptions of racism
Another aspect of cultural sensitivity is recognizing that many blacks have been subjected to various degrees of racism14 and have varying levels of recognition of this reality. Misconceptions on the part of blacks may stem from a number of causes.5
There may be confusion on the part of blacks as to whether they are being tolerated or accepted by whites. Although some whites truly accept blacks, others may harbor negative stereotypes and only tolerate them. Rejecting the legitimate goodwill of whites is as big a mistake as trusting a white person who harbors racist attitudes. Many blacks have difficulty in recognizing who is who and consequently pay the price.
A second problem concerns the inability of blacks to distinguish between the supportive efforts of individual whites and the destructive actions of whites as a collective (eg, the long-standing and unaddressed health care disparities between blacks and whites). This confusion occurs when a black person is accepted by a white person and as a result, mistakenly believes that racism no longer exists.
Another problem is knowing when, where, and how to resist oppression (eg, microinsults or microaggression and overt discrimination) versus when, where, and how to accommodate it. There are occasions when racism should be fought bitterly but other times when the fight proves more detrimental than beneficial—for example, when a white psychiatrist stereotypes a black patient by diagnosing a psychotic spectrum disorder when an affective spectrum disorder is more suitable. Because of the power differential, the patient has a difficult choice to make regarding whether to challenge the treating psychiatrist's clinical acumen and authority.15
Finally, there may be confusion about whether the locus of control is internal or external. An internal locus of control implies that you attribute your successes to yourself and your failures to your lack of effort. An external locus of control implies that you attribute your failures or successes to something outside of your control. A major problem for blacks is determining when they are in control of their destiny and when there are external factors imposed by racism. If blacks assume an external locus of control (ie, "the man" controls everything blacks do), then blacks will lack motivation to help themselves, and they will lack feelings of self-efficacy. Conversely, if blacks do not recognize the toxic external constraints imposed on them, they could erroneously attribute their failure to their own perceived shortcomings.
The first 3 of these areas of confusion can seriously disrupt the establishment of rapport between the patient and the treatment provider. The American Psychiatric Association's position statement on racism emphasizes the importance of being mindful of the existence and impact of racism and racial discrimination in the lives of patients and their families, in clinical encounters, and in the development of mental health services.16 The confusion about locus of control has a tremendous impact on feelings of self-efficacy, making it critically important to discuss these issues with African American patients early in treatment.
Blacks may harbor fear, distrust, lack of confidence, and anxiety over the prospects of stigmatization—all born of a historical recognition of failures of the health care system to adequately address disparities and exploitation (eg, Tuskegee syphilis experiments).17,18 In addition, because exposure to trauma is another common issue for black patients, they should be asked about their experiences with racism and trauma.6,19
When treating black patients, it is critical to understand that risk factors are not necessarily predictive factors, since protective factors may intervene. Thus, psychiatrists must actively explore the protective factors surrounding blacks in risky contexts.20 In general, protective factors are the strength of social fabric surrounding the patient,21,22 the patient's access to state-of-the-art medical technology, the opportunities the patient has had for developing social skills (eg, the capacity for affect regulation), the patient's sense of self-efficacy and self-esteem,22 the protective shields in the patient's life (eg, family involvement, church), and the opportunity for the patient to develop a sense of self-efficacy by turning traumatic helplessness into learned helpfulness.23
It is imperative that objective, empiric, evidence-based research guides how best to adapt current practices to mental health issues relevant to the diverse black community. Humanistic interventions geared toward using existing community resources and strengths (including family support, ethnic and spiritual values, education, and belief systems born of tradition) and an understanding of the black experience can be used to construct culturally sensitive and effective mental health services and interventions.24
Dr Bell is president and CEO of the Community Mental Health Council and clinical professor in the department of psychiatry at the University of Illinois at Chicago. Dr Dove is interim head of psychiatry and associate professor of clinical psychiatry in the department of psychiatry at the University of Illinois in Chicago. Dr Williamson is a staff child psychiatrist at the Community Mental Health Council. They report that they have no conflicts of interest concerning the subject matter of this article.