Mental Health Care for Women of Color: Risk Factors, Barriers, and Clinical Recommendations

Women of color (WoC) are at an increased risk for experiencing mental health problems with long-lasting and detrimental effects. Gender, race, and culture-specific experiences and expectations may contribute to disparities in mental health. Despite their higher risk for mental health problems, WoC seek adequate mental health care less than half as often as white women (5% to 10% versus 21.5%). There are several potential reasons that may explain why WoC tend to underutilize mental health services, including lack of awareness, stigma, self and societal criticism, barriers to access, and lack of culturally sensitive care. To improve mental health care services for WoC, stigma around mental health in racialized communities should be challenged, and awareness and accessibility to appropriate services should be improved. To facilitate this, it is essential that clinicians take an active approach in creating a culturally safe space to provide mental health care to WoC.

Background

In the United States, 18% of adults live with at least one mental health disorder.¹ While the prevalence of mental health disorders often does not significantly differ across racial groups, the enduring nature and adverse consequences of these disorders disproportionately burden racial minorities, especially WoC.² Simultaneously, white women are almost twice as likely (21.5%) as Asian (5.3%), Black (10.3%), and Hispanic (9.2%) women to seek mental health care services.³ This stark disparity in utilization rates highlights that women from racial minority groups face significant barriers in accessing mental health care. This article examines the potential risk factors contributing to the burden of mental health problems faced by WoC, explores possible explanations for their underutilization of mental health services, and offers recommendations for clinicians to address the limitations within the mental health care system, with the goal of enhancing the provision of care for WoC.

Risk Factors and Stressors for Mental Health Challenges: Gender, Race and Culture-Specific Experiences

Typically, women experience increased rates of mental health problems compared to men regardless of their country of origin, ranging from depression to eating disorders.⁴ This may be explained by the greater rates of intimate partner violence and childhood sexual abuse as well as societal norms regarding gender roles.^4,5 Women are expected to be competitive and assertive, but also nurturing, vulnerable, and emotional, which may pose a unique stressor as they attempt to balance these conflicting gender roles.⁶

In comparison to white women, WoC may experience additional race and culture-related stressors that contribute to poorer mental health.⁷ WoC commonly report increased responsibilities related to family and childcare compared to white women.⁸ Moreover, professional WoC often face additional challenges, such as navigating financial and educational barriers while fulfilling family and community duties, which can lead to role strain.^9,10 Although securing employment may alleviate some of the financial and social struggles that women undergo, migrant WoC often encounter difficulties securing work in their respective fields, leading them to accept lower-skilled and lower-paying jobs, a phenomenon known as “de-skilling.”¹¹

Barriers to Mental Health Care

There are considerable barriers to mental health care in many ethnic communities. Main themes found to contribute to these barriers include: lack of awareness about mental illness; stigma and negative emotional responses towards self, family experiences; service barriers such as access and quality of care; and lack of culturally sensitive care.¹¹

Lack of Awareness

The lack of specific terms for mental health disorders in certain languages, such as Cambodian and Haitian, can contribute to a broader lack of awareness and discussion surrounding these issues within those communities.¹² When a language does not have specific words or phrases to describe mental health-related symptoms, it becomes challenging for individuals within those linguistic communities to articulate their experiences. Research has demonstrated that limited knowledge about mental health symptoms can also narrow awareness among immigrant women in Canada.¹³ Thus, WoC who lack awareness of mental health symptoms may not recognize that their experiences are potentially related to a mental health condition.

Stigma, Self-Criticism, & Family Experiences

Minority communities often view mental health problems as personal flaws, which can be understood by stigma and self-criticism. When individuals perceive mental health issues as character defects or moral failings, they engage in self-criticism, blaming, and may sweep such issues “under the rug.”¹⁴ A recent review identified that self- and public-stigma are greater in minority compared with white communities.¹⁵ Consequently, many WoC avoid seeking help for their mental health concerns out of concern for being viewed as nonresilient.¹⁶

Societal organization may also be relevant in consideration of the family structure and a woman’s role within it. While it is common for Westernized cultures to be more individualistic, non-Westernized cultures tend to be more collectivistic (ie, greater emphasis placed on group needs).¹⁷ Accordingly, a mental health problem may not only lead to feelings of shame in the affected individual, but also among family members.¹⁸ Hence, the stigma around mental health and towards individuals affected by mental illness may be a significant barrier for WoC to share their experiences with their family members and health care providers.

Service, Geographical, Institutional, & Financial Barriers

When WoC seek professional help, they face additional barriers that restrict access to mental health services. Such services are often located in white neighborhoods, and in migrant WoC populations there tends to be limited knowledge on how to access such supports.^13,14

Lack of education and outreach initiatives are additional barriers that prevent WoC from seeking help. Racialized neighborhoods are often unable to provide the education and support needed to detect mental health challenges or provide resources.¹⁹ Notably, it was found that non-white pregnant women, including African American, Hispanic, and non-Hispanic women, were significantly less likely to receive mental health or substance use treatment compared to white women, regardless of income and health insurance status.²⁰

Finally, financial barriers may prevent WoC from seeking help. WoC often do not have adequate insurance coverage, which makes it difficult to obtain the necessary evidence-based care that they need. Additionally, the need for childcare while attending therapy sessions can further contribute to this financial burden.¹³

Lack of Culturally Sensitive Care

Culturally sensitive care can be described as the ability of health care providers to effectively deliver care that respects and meets the social, cultural, and linguistic needs of patients.¹³ This may include the use and application of cultural knowledge, and understanding how culture interacts with mental health experiences. Unfortunately, there is a lack of culturally competent care for WoC.

The diversity amongst WoC warrants the need for linguistic compatibility and cultural sensitivity. Since English is not the first language of all WoC, it can be challenging to find appropriate services and to communicate with care providers, often leading to frustration and giving up on seeking care.¹³

Beyond language barriers, a culture-specific lens is also required by the care provider to fully understand the struggles faced by WoC. Certain aspects of patients’ cultural backgrounds, values, perspectives on health and disease, and preferences related to doctor-patient relationships can impact treatment efficacy.^21,22 Providers may be unable to detect and recognize symptoms or address the reasons behind them due to their own biases, ultimately leading to system mistrust.²³ Moreover, practitioners often lack diagnostic tools and guidelines that are sensitive to the experiences of non-Western populations.^24,25 Even after proper detection of pathology, existing evidence-based interventions are primarily based on Caucasian participants.¹⁶

Furthermore, it is important to address the existing mistrust for mental health care providers by minority communities.^8,26 WoC, notably Black women, are less likely to accept therapy or recommendations from their health care providers compared with white women. An interview with a Black mother stated, “I need someone who understands, who’s walked in my shoes, not just as a Black woman, a single Black woman with a child, but a woman who’s had a child by herself.”⁸ This need is difficult to meet given the lack of diversity among today’s landscape of health care providers (Figure).²⁷ Thus, barriers in the communication between the care providers and patients, coupled with the lack of diversity among care providers, may contribute to the difficulty in receiving proper diagnosis and treatment for WoC with mental illness.

Case Vignette

“Asha” migrated from Syria to the United States at age 10 with her family under refugee status. The transition required her to acclimatize to a novel culture, which involved learning a new language and unfamiliar societal norms.

When she first experienced academic challenges at age 16, Asha brushed it off as natural. In her family and her community, poor mental health was viewed as “shameful” and a “weakness.” Asha felt pressure from her family to succeed academically and to be “worthy” of the life that her parents struggled to create for her. The odd time that Asha brought up a mental health concern to her family, she was reminded to be grateful for living in the United States, where they were safe. Her parents taught her to never mention this to anyone outside of the family and to focus on her academics.

During freshman year, Asha found herself feeling very lonely and that her schoolwork was unbearable. Struggling with severe depression and anxiety, she attempted to find a mental health care provider. After months of waiting, she finally found a therapist. Unfortunately, soon after she began to share her concerns, she felt misunderstood by the therapist regarding her family and cultural experience, exacerbating her feelings of loneliness and isolation. Asha felt at a loss as even those designated to help her navigate her mental health challenges were unable to do so. Luckily, through the intervention of a school counselor with access to mental health resources, Asha connected to a clinic that provided care specialized in the experiences of refugee families. Here, she was able to safely communicate her experiences and receive the therapy that she needed.

Recommendations

1: Decrease of Stigma and Increased Awareness of Mental Health Resources

The initial step to improving mental health care services for WoC involves building strong partnerships between service providers and WoC to increase awareness of resources. Clinicians can take an active approach by educating their patients and respective communities on the symptoms of mental health conditions. This will improve self-recognition while simultaneously reducing the stigma of seeking treatment.

Mental health care providers need to emphasize the importance of holistic health and the importance of treating mental health challenges as seriously as their physical problems.¹⁶ Promoting therapy as a way to treat health issues may reduce the ambivalence associated with seeking treatment. This can include holding mental health awareness seminars in cultural centers, incorporating early intervention services to newly arrived migrants, and disseminating flyers and brochures in cultural community centers. Moreover, it is crucial for treatment providers to emphasize patient-clinician confidentiality given that fear of others discovering their treatment status is a significant barrier to treatment.¹⁶

Clinicians can also reduce the systemic barriers to awareness and access. Many WoC report that their lack of understanding of the health care system, including where and how to access mental health care is one of the biggest barriers to finding adequate postpartum depression treatment.¹³ Similarly, obtaining mental health care is a significant financial expense for most families. Although various financial options for mental health care as well as for childcare exist, many WoC are unaware of these opportunities. Hence, it is imperative that clinicians provide these resources to their communities. Collaborating with different local community centers from minority neighborhoods, using local multicultural media channels, and distributing information in the community, can collectively improve the outreach of these resources.¹³

Many immigrant WoC emphasize geographical barriers for accessing treatment.¹⁶ Providing virtual treatment options and creating clinic locations that are easily accessible by public transportation or embedded in immigrant neighborhoods can also significantly enhance treatment utilization.

2: Culturally Sensitive Care

Studies have consistently shown that a therapeutic alliance predicts successful treatment outcomes.²⁷ Cultivating a culturally sensitive space by increasing one’s knowledge of other cultural norms is of utmost importance to optimizing therapeutic alliances.

One approach to facilitate a trusting patient-practitioner relationship is to match individuals based on congruence in language and culture. Many women seeking mental health care prefer a culturally diverse care team to address their unique cultural experiences.¹³ For example, WoC receiving perinatal care report a preference for working with providers who are people of color due to cultural familiarity and comfort.²⁸ Therefore, inquiring about patient preferences regarding their health care providers (eg, language, culture) can significantly increase treatment retention. Supporting the next generation of women from minority groups to become mental health care practitioners can also facilitate representation in the system and increase trust in the health care system among minority populations.

While increasing the number of WoC providers may improve the outcomes of care, it does not address the quality of care from nonracialized providers. Thus, further education is necessary to promote culturally sensitive care. This should involve gaining an understanding of one’s personal biases and adopting compassionate approaches to cultural differences. Both WoC and white women seeking therapy have reported less shame and embarrassment when interacting with a culturally competent provider.²⁹ Numerous workshops are available, including guidelines from The Association for Multicultural Counseling and Development and The National Culturally and Linguistically Appropriate Services.

Finally, the development of culturally sensitive diagnostic tools can significantly improve outcomes in patients. This may involve adapting cognitive-behavioral therapy manuals to better suit diverse cultures.³⁰ Patients with African-Caribbean, Black-African/British, and South Asian Muslim backgrounds have benefited significantly from the culturally sensitive adaptations compared to patients that received standard Western treatment.³⁰ Consequently, it is crucial for clinicians to take an active approach in understanding their patients’ individual needs, and to develop methodologies that are culturally sensitive to enhance treatment outcomes.

Concluding Thoughts

WoC are at increased risk for developing long-lasting and detrimental mental health symptoms. Gender, race, and culture-specific experiences, as well as the barriers they encounter when accessing mental health care exacerbate the disparities in mental health problems. While heightened mental health stigma may limit their access to services, the lack of provision of culturally sensitive care may further decrease the efficacy of treatments. Therefore, to improve mental healthcare services for WoC, the stigma around mental health in various ethnic communities should be challenged while the awareness of services should be enhanced. It is essential for clinicians to take an active approach in creating a culturally safe space to provide the care that has been unavailable for WoC.

Ms Kant is a medical student at the University of Toronto. Ms Sorkou is a PhD student at the Institute of Medical Sciences at the University of Toronto. Ms De La Cruz is a master’s student at the Institute of Medical Sciences at the University of Toronto. Ms Katz is a PhD student in Clinical and Counseling Psychology at the University of Toronto. Dr Sharif-Razi is a clinical psychologist in private practice in Toronto, Canada. Dr George is Professor of Psychiatry in the Temerty Faculty of Medicine at the University of Toronto, and a Clinician-Scientist at CAMH. He is also an editorial board member at Psychiatric Times, and co-principal editor of Neuropsychopharmacology (NPP), the Official Journal of the American College of Neuropsychopharmacology.

References

1. Mental illness. National Institute of Mental Health. Updated March 2023. Accessed June 28, 2023. https://www.nimh.nih.gov/health/statistics/mental-illness

2. Budhwani H, Hearld KR, Chavez-Yenter D. Depression in racial and ethnic minorities: the impact of nativity and discrimination. J Racial Ethn Health Disparities. 2015;2(1):34-42.

3. Racial/ethnic differences in mental health service use among adults. Substance Abuse and Mental Health Services Administration. 2015. Accessed June 28, 2023. https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MHServicesUseAmongAdults.pdf

4. Seedat S, Scott KM, Angermeyer MC, et al. Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry. 2009;66(7):785-795.

5. Dela Cruz GA, Johnstone S, Singla DR, et al. A qualitative systematic review of experiences and barriers faced by migrant women with perinatal depression in Canada. Women. 2023;3(1):1-21.

6. Krestan JA, Bepko C. Codependency: the social reconstruction of female experience. Smith College Studies in Social Work. 1990;60(3):216-232.

7. Kim HG, Kuendig J, Prasad K, Sexter A. Exposure to racism and other adverse childhood experiences among perinatal women with moderate to severe mental illness. Community Ment Health J. 2020;56(5):867-874.

8. Copeland VC, Snyder K. Barriers to mental health treatment services for low-income African American women whose children receive behavioral health services: an ethnographic investigation. Soc Work Public Health. 2011;26(1):78-95.

9. Jardine SA, Dallalfar A. Sex and gender roles: examining gender dynamics in the context of African American Families. Journal of Pedagogy, Pluralism, and Practice. 2012;4(4):18.

10. Tang T, Tang C. Gender role internalization, multiple roles, and Chinese women's mental health. Psychol Women Q. 2001;25(3):181-196.

11. Morrow M, Smith JE, Lai Y, Jaswal S. Shifting landscapes: immigrant women and postpartum depression. Health Care Women Int. 2008;29(6):593-617.

12. Singh M. Why Cambodians never get 'depressed.' NPR. February 2, 2015. Accessed June 28, 2023. https://www.npr.org/sections/goatsandsoda/2015/02/02/382905977/why-cambodians-never-get-depressed

13. Ganann R, Sword W, Newbold KB, et al. Influences on mental health and health services accessibility in immigrant women with post-partum depression: an interpretive descriptive study. J Psychiatr Ment Health Nurs. 2020;27(1):87-96.

14. Hines-Martin V, Malone M, Kim S, Brown-Piper A. Barriers to mental health care access in an African American population. Issues Ment Health Nurs. 2003;24(3):237-256.

15. Misra S, Jackson VW, Chong J, et al. Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: implications for interventions. Am J Community Psychol. 2021;68(3-4):486-512.

16. Watson-Singleton NN, Black AR, Spivey BN. Recommendations for a culturally-responsive mindfulness-based intervention for African Americans. Complement Ther Clin Pract. 2019;34:132-138.

17. Hofstede G. Online readings in psychology and culture. Dimensionalizing Cultures: The Hofstede Model. 2011;2(1):3-26.

18. Duncan LE, Johnson D. Black undergraduate students attitude toward counseling and counselor preference. College Student Journal. 2007;41(3):696-720.

19. Zhang W, Chen Q, McCubbin H, et al. Predictors of mental and physical health: individual and neighborhood levels of education, social well-being, and ethnicity. Health Place. 2011;17(1):238-247.

20. Salameh TN, Hall LA, Crawford TN, et al. Racial/ethnic differences in mental health treatment among a national sample of pregnant women with mental health and/or substance use disorders in the United States. J Psychosom Res. 2019;121:74-80.

21. Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57 Suppl 1:108-145.

22. Lehti A, Hammarström A, Mattsson B. Recognition of depression in people of different cultures: a qualitative study. BMC Fam Pract. 2009;10(1):53.

23. Borowsky SJ, Rubenstein LV, Meredith LS, et al. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000;15(6):381-8.

24. Helman C. Culture, Health and Illness. CRC press; 2007.

25. Hegarty K, Gunn J, Blashki G, et al. How could depression guidelines be made more relevant and applicable to primary care? A quantitative and qualitative review of national guidelines. Br J Gen Pract. 2009;59(562):e149-156.

26. Barksdale CL, Molock SD. Perceived norms and mental health help seeking among African American college students. J Behav Health Serv Res. 2009;36(3):285-299.

27. Ardito RB, Rabellino D. Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Front Psychol. 2011;2:270.

28. Barnett KS, Banks AR, Morton T, et al. "I just want us to be heard": a qualitative study of perinatal experiences among women of color. Womens Health (Lond). 2022;18:17455057221123439.

29. Flynn PM, Betancourt H, Emerson ND, et al. Health professional cultural competence reduces the psychological and behavioral impact of negative healthcare encounters. Cultur Divers Ethnic Minor Psychol. 2020;26(3):271-279.

30. Rathod S, Kingdon D, Phiri P, Gobbi M. Developing culturally sensitive cognitive behaviour therapy for psychosis for ethnic minority patients by exploration and incorporation of service users' and health professionals' views and opinions. Behav Cogn Psychother. 2010;38(5):511-533.