With rates of violence, suicide and depression rising fastest in communities of color, the need for clinicians who understand their clients’ needs is urgent
Hughes and Oyeniyi work with Youthcast Media Group, a nonprofit that trains high school students in journalism.
Dr. Itoro Ibia’s patient was set to be released from a hospital in Virginia last year when she told a nurse she felt like demonic spirits were hanging around. The woman was being treated for psychosis related to a bipolar manic episode; her confession led hospital staff to believe she was delusional, Ibia said.
“She was just being herself and expressing her religious view, but she was about to be detained longer in hospital for expressing those religious views,” said Ibia, a Virginia psychiatrist and fellow of the American Society of Clinical Psychopharmacologists. “The person at the hospital did not understand that. But I did.”
Dr. Racquel Reid had a similar experience as a psychiatric resident. While briefing an attending physician, another resident described a patient who was talking about how police were out to get him as delusional.
“That’s not psychosis,” said Reid, a Los Angeles-based psychiatrist and mental health activist who runs Radical Imagination Mental Health.
“He lives in Atlanta, in a neighborhood that was being gentrified. Of course he feels like the police are out to get him.” (Blacks in Atlanta are disproportionately vulnerable to police violence and are 15 times more likely than whites to be arrested for minor offenses.)
Those experiences have left Ibia and Reid, two Black female psychiatrists, acutely aware of the importance of culturally competent mental health services, which they’ve seen first-hand transform the quality of care received by Black patients.
Yet, in the current mental health care landscape, there aren’t enough Black providers, or providers with cultural understandings of historically marginalized communities, to go around.
Black psychiatrists make up only 2% of the profession, according to the American Psychiatric Association. That limited number has left many questioning the impact of that scarcity on Black patients, as have a spate of new statistics.
“She was being herself and expressing her religious view, but was about to be detained longer in hospital for expressing those religious views. The person at the hospital did not understand that. But I did.”
itorio Ibia, Virginia psychiatrist
Last year, the Centers for Disease Control published a study finding Black adults visited emergency rooms for mental health problems at rates nearly double the national average. Black boys are now twice as likely to die by suicide compared to their white peers. And recent studies have shown that racial violence, like the murder of George Floyd, has increased anxiety and depression in the Black community.
Last summer, the Biden administration announced plans to improve mental healthcare access by pushing insurance companies to expand in-network providers and reimburse mental health care like physical care. And in November, the administration announced grants to expand youth mental health access.
But Reid, Ibia and others in the field worry that entrenched barriers – racism, stigma and financial inequality – are still limiting the number of diverse psychiatrists and patients’ access to culturally competent care.
“The amount of Black patients that need to see me will never see me,” Reid said. “It creates a lot of barriers that I don’t think that the U.S. is as interested in reducing as it possibly could [be].”
Stigma, racism fuel reluctance to enter psychiatry
Ibia was practicing community medicine in Nigeria when she realized that some patients who didn’t get better had undiagnosed mental health conditions. It prompted her to go into psychiatry after moving to the U.S., and to speak up at her church about neurological and psychiatric issues.
“I noticed lots of people with mental health issues who did not see or did not get help because of stigma,” Ibia said. “Many people with a similar ethnic background as I do not believe that mental health conditions are medical. They think about mental health conditions as spiritual attacks.”
Stigma is a long-documented barrier to growing the ranks of Black psychiatrists and in treating Black patients. It’s part of a cycle that many describe as inhibiting change in mental health systems: Stigma and the effects of racism have left Black patients less likely to seek care or enter the field, and a field without adequate Black representation and cultural understanding has perpetuated stigma and racism.
Robert O. Motley, Jr., an assistant professor at the Boston College School of Social Work who studies the effects of racism, violence and trauma on young adults, believes much of the stigma around mental health care in the Black community is due to past racism, discrimination and unethical treatment in clinical settings.
“A lot of times in my focus groups talking with both Black men and Black women, there was an emphasis on being the strong Black man, or the super Black woman,” Motley said, making them less likely to seek mental health help or consider it as a career option.
Culturally competent care – the ability of providers to deliver services that meet the social, cultural and linguistic needs of patients – can help mitigate stigma, Motley said. Representation, “can enhance communication, understanding, and really a sense of validation.”
“It can also create a safe space, really, for patients to discuss their mental health concerns without fear of judgment or misunderstanding,” Motley said.
Research suggests a lack of representation and cultural understanding can lead to less effective care – Black patients are more likely to be misdiagnosed with schizophrenia, and less likely to be offered antidepressant drugs even when they have insurance, according to the American Psychiatric Association.
“I think there’s so much to say about how we’re taught psychiatry that takes away so much of the culture that makes people who they are, and then stigmatizes them for who they are, because you don’t understand them in the first place,” Reid said.
Another deterrent for would-be Black psychiatrists is lingering racism in medical institutions, Reid said, something she watched play out in medical school.
“I’ve definitely had colleagues who’ve had to switch residency because someone was discriminating,” Reid said.
Cost of education and treatment a barrier
It’s expensive to become a psychiatrist, and the cost of education can be even more of a barrier for Black students, who are more likely to come from lower-income families and have less accumulated wealth than their white counterparts.
“Many people are overwhelmed by the amount of money that they have to borrow. And there is no systemic support,” said Ibia, who also noted there’s little support for recruitment of “smart, Black young people to go into medicine.”
“We don’t have a pipeline as such,” she said.
In addition, psychiatry is ranked as one of the lowest paying medical specialties in the U.S., partly because insurance companies negotiate lower rates on average with psychiatrists than other medical fields for the same amount of work. That’s left many providers forgoing insurance reimbursements altogether, increasing the cost of seeing a therapist.
Ibia’s private practice is fee-for-service, though she does offer some pro bono work and sliding scale options based on what patients can pay.
Uncovered, out-of-network sessions can cost anywhere from $80-$200 per session, which many patients cannot afford, especially combined with other costs like time off work and the price of medication.
In addition, insurance does not always cover the full scope of the care needed by patients, setting limits on the number of sessions and types of authorized medication.
“I’m literally seeing people say, ‘Yeah, this person has been on this medication for 10 years, they’re doing great on it, but we refuse to pay for that.’ And then I see someone decompensate because they can’t pay for it anymore,” Reid said.
The Biden administration’s proposed updates to the Mental Health Parity and Addiction Equity Act would require insurance companies to review how they respond to doctor’s requests for mental health treatment compared to physical health, and audit how much they reimburse out-of-network providers. Insurers could see fines up to $100 per day per patient for not providing comparable mental health coverage.
“We’ve got to do something about this”
Keith Mascoll was still working through the effects of sexual abuse he experienced as a child when he turned to his wife, Roxann Mascoll, a psychotherapist at Harvard University Health Services, for help finding a therapist. They struggled for almost a year to find a Black male therapist familiar with Mascoll’s West Indian background.
“My wife is in the field and she couldn’t find anyone. And she was like, ‘This is crazy. Like, we got to do something about this,’” Mascoll said.
As an actor and producer, Mascoll turned to art to help address the problem. He and Roxann started The Trigger Project, a social program and awareness campaign aimed at breaking stigma for Black men who experience trauma and improving the clinical community’s ability to provide adequate care for them. Together, he and Roxann host a podcast and educate clinicians, in part through his one-man show “Triggered Life: A Requiem of Healing.”
It’s one of several creative solutions members of the Black mental health community have developed to help bridge the gap in care and providers.
While a doctoral student working at the Race and Opportunity Lab at Washington University in St. Louis, Motley was part of a project called Homegrown StL’s Healing Policy Initiative, focused on eliminating disparities in child mental health care using data and evidence-based training for social service providers.
“It wasn’t your typical, you know, healthcare professional,” he said. Rather, they were connected to the community, and worked as conduits to help get clinical services.
“So when you talk about on-the-ground, culturally relevant interventions, that’s transformative,” he said.
Ibia started a nonprofit in memory of her late husband, who was also a physician, to continue her work raising mental health awareness in ethnic minority and religious groups. As a recipient of a minority fellowship through the American Psychiatric Association, Ibia is also a proponent of increased investment to improve the Black medical student pipeline.
“Every time I see a young patient in my office, white or Black, I always say, ‘Listen… I’m trying to recruit you, we need more psychiatrists,’” she said.
“The more we talk about psychiatry, the more we highlight the usefulness and the need for more Black psychiatrists in the community, the more people will be interested.”
Hughes, a Syracuse University sophomore, is a contributor and former intern with Youthcast Media Group. Oyeniyi, a senior at Cristo Rey Philadelphia High School who is attending Harvard University in the fall, is a YMG contributor who was previously published in USA TODAY and Billy Penn.
