A Look at the Biggest Barriers to Effective Mental Health Care for Women of Color

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What are the biggest barriers to effective mental health care for women of color?

In many minoritized cultures, stigma is a significant barrier for women of color (WOC) to receive effective mental health care. There are many minoritized cultures that do not believe that mental illness is real. In the United States, as each generation comes along, they tend to be more open to treatment themselves, but must still balance their realized need for help with the disapproval of their family and cultural circle.

In my years of practice, I have encountered individuals whose family members have suggested that they have too much going for them to be depressed, or that they have no right to be complaining about anxiety if they “aren’t even going to church.” Other times, individuals within a patient’s circle of influence have insisted that the patient throw away their medication because “all they need to fix them is God,” as if they cannot have both. In other minoritized cultures, there is the thought that an individual reporting mental illness is simply “not strong enough” or “not trying hard enough” to overcome their challenges or is even being “punished” for something they have previously done.¹

In 2020, the Asian Journal of Psychiatry published an article entitled “Silencing the self and women’s mental health problems.” The concept of “silencing the self” specifically speaks to the impact of social and cultural norms on women’s mental health issues such as eating disorders, depression, and premenstrual dysphoric disorder. Although previous exploration of this topic was focused on Western cultures, their review focuses on how it presents in Asian women.²

They propose that this angle is important to investigate because Asian culture emphasizes harmonious relationships, and suppression of anger is fostered more among Asians than their Caucasian counterparts. Among their findings are that normative gender roles and the sociocultural context significantly influence the mental health of women in that culture.²

Access to care and resources is also generally accepted as a barrier to receiving mental health care in underserved communities.³ However, systemic racism and the disparate treatment of minoritized people are major barriers to effective mental health care for WOC.

Once, early in the years of my training, there were 2 women in the same inpatient unit. Both women had psychosis with paranoia and hallucinations, and both were hostile toward the treatment team and staff. There was a significant difference, however, in how the inpatient nurses responded to each of these women as the team discussed their cases.

The woman who was white was characterized by the nursing staff as “sick” and “needing help.” The other woman, who was Black, was characterized by the male nurse as “a nasty woman”; he added that, “I can’t wait until she is off the unit,” and was not reprimanded for either of these statements. How many other historically excluded groups face this same discrimination both in treatment and while working with staff to treat others?

When I was an intern, during one lecture, an older white male attending said to our class, “If anyone ever tells you that they were arrested for smoking marijuana, they are lying! No one gets arrested for that.” This bold assertion was not only unfair, but factually incorrect. There are cases across all ethnicities of individuals being arrested for marijuana possession. More disturbingly, this attending should have been aware that the discriminatory practices of legal enforcement of marijuana use have been studied for many decades.

In 1977, the American Journal of Sociology published a study citing “persons under 25 have higher arrest probabilities than older persons,” and that “arrest probabilities are higher for Blacks than for non-Blacks.”⁴ A 1980 study on discriminatory practices in marijuana arrests interviewed more than 2000 males between the ages of 20 and 30 years and found⁵:

“Low arrest rates among heavy smokers indicates that smoking is hidden from official view; and high arrest rates among nonwhites who smoke infrequently indicates the influence of minority group identity. Findings show that the enforcement of the marijuana laws is neither consistent nor related to seriousness of the violation. Evidence is also provided that current enforcement practices are directed primarily at controlling groups seeking alternative lifestyles.”

In 2021, an article in the Journal of Policy Analysis and Management showed those same biases, and the Black-white racial disparity in the drug sales arrest rate persisted.⁶

Later, when I was in residency training, during one of the scheduled movie nights to view and discuss films that displayed mental illness, we watched the movie Infinitely Polar Bear.⁷ During the scene where one of the daughters, Amelia, questions if she is Black,⁸ my attending, an elderly white male, said, “Look at that—she said, ‘I don’t want to be Black.’ It’s like she’d rather have cancer—anything—than be Black.”

I reminded him that the girl was questioning if she were Black, not making a statement about not wanting to be Black. I even requested that he rewind the section, but he did not. I wanted to say, “So that’s what you imagine being Black is like? Comparable to cancer?”

The other attending—who was also a white male, but quite kind and perceptive—sat looking tense, a bit nervous, and watching my face. As the most senior Black person in the room as a second-year resident, and 1 of only 2 (the other being an intern), I decided this was not the hill I wanted to die on—not that day.

A scary reality about these encounters is they are but a snippet of many similar stories, not just in my own experience, but also in the experience of many of my colleagues of color. As dangerous as these internal biases are for the patients these individuals serve, these damaging prejudices are being passed on year after year to other trainees, many of whom will continue the cycle of misinformation.

Dr Charles Malveaux is a sports psychiatrist in Los Angeles, California, and CEO of WCM Sports Psych. She is an advocate and educator on the intersection of mental health, sports, and racial and social justice. Dr Charles Malveaux lends her expertise as a psychiatric consultant to multiple national sport-related agencies, professional sports teams, and organizations. She is also the Western Regional Trustee (region 4) on the Board of the Black Psychiatrists of America.

References

1. Emran A, Iqbal N, Dar IA. 'Silencing the self' and women's mental health problems: a narrative review. Asian J Psychiatr. 2020;53:102197.

2. Saloner B, Lê Cook B. Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff (Millwood). 2013;32(1):135-145.

3. Johnson WT, Petersen RE, Wells LE. Arrest probabilities for marijuana users as indicators of selective law enforcement. AJS. 1977;83(3):681-689.

4. Mosher JF. Discriminatory practices in marijuana arrests—results from a national survey of young men. Contemporary Drug Problems. 1980;9(1):85-105.

5. Cox RJA, Cunningham JP. Financing the war on drugs: the impact of law enforcement grants on racial disparities in drug arrests. J Policy Anal Manage. 2021;40(1):191-224.

6. McCann F. Infinitely Polar Bear: China Forbes on the movie of her family. Portland Monthly. October 28, 2016. Accessed May 21, 2023. https://www.pdxmonthly.com/arts-and-culture/2015/08/infinitely-polar-bear.

7. Forbes M. Infinitely polar bear. Script Slug. 2014. Accessed May 21, 2023. https://www.scriptslug.com/script/infinitely-polar-bear-2014.

8. Green TL, Hagiwara N. The problem with implicit bias training. Scientific American. August 28, 2020. Accessed May 20, 2023. https://www.scientificamerican.com/article/the-problem-with-implicit-bias-training/.