CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Exploring Why African-Americans May not be Utilizing Mental Health Services: Clinical Perspective
A graduate project submitted in partial fulfillment of the requirements
For the degree of Master of Social Work
By
Terrence Stewart
May 2018 The graduate project of Terrence Stewart is approved:
______Dr. Wendy Ashley Date
______Dr. Alex Acuna Date
______Dr. Judith A DeBonis, Chair Date
California State University, Northridge
ii Dedication
This paper it dedicated to J. Marks and other African Americans who are denied mental health treatment services due to the inability to access services and only seem to receive mental health services while being incarcerated.
iii
Table of Contents
Signature Page ii
Dedication iii
Abstract vi
Introduction 1
Literature Review 2
Method 8
Results 11
Discussion 18
Conclusion 23
References 24
Appendix A: Study Questions 27
iv
Abstract
Exploring Why African-Americans May not be Utilizing Mental Health Services: Clinical Perspective
By
Terrence Stewart
Master of Social Work
Purpose: The idea surrounding this research is to explore African American’s behavior towards mental health and how clinician’s behavior and practices may have an impact on
African American’s mental health treatment. In addition, the research explores mental health clinician’s engagement with African Americans and the level of care being provided. Clinicians who currently or previously worked with African Americans took a survey which consisted of questions relating to themes relating to relationship building, engagement, and cultural competencies. Previous research will explore African
Americans engagement when participating in mental health treatment. The study question was, are African Americans who are utilizing mental health services are being provided an adequate level of care from mental health clinicians? The objective of this exploratory study was to bring awareness and to this issue to reduce inadequate levels of care when working with African Americans that have mental health related issues.
vi Introduction
Mental health is part of our overall health and well-being. More often than not mental health is over looked as an actual health related issues. NAMI states, mental health is not solely based on emotions but are medical conditions that have an impact on how we live our lives and without proper treatment for mental health related issues conditions can worsen and make day-to-day life hard (NAMI 2017). African Americans are overrepresented in high-risk populations and are known to experience disadvantages in utilizing mental health services (Hackett 2014). According to Project LETS (Let’s
Erase the Stigma), African Americans do not seek mental health treatment due to the mistrust, inadequate treatment, and lack of cultural competency (African American
Communities Mental Health, 2017). Culture plays a significant role in a person’s beliefs and moral system. In an effort to better understand the barriers that prevent African
Americans from receiving adequate mental health services, this study used an anonymous online survey to gather clinical staff perspectives on the approaches clinicians use to engage, establish rapport and provide mental health services to African American clients on a multiple system level.
1 Literature review
Mental Health Impact on African American Communities
Mental health plays a vast role in the functioning in all communities. In comparison to the other communities, there are a great deal of African Americans who struggle with mental health related issues. The Health and Human Service Office of
Minority Health (OMH) estimates that African Americans are 20% more likely to experience serious mental health issues compared to the general population (Office of
Minority Health 2016). Furthermore, African Americans are 10% more likely to report having serious psychological distress that Non-Hispanic whites (Office of Minority
Health, 2016). According to NAMI, African Americans are more likely to be exposed to risk factors that contribute to their overall mental health (African American Mental
Health, 2017). NAMI expands on this by stating African Americans occasionally experience more serious forms of mental illness because their mental health needs are not met (African American Mental Health, 2017).
Stigma
Over one third of African Americans who have already received mental health treatment reports that having anxiety and/or depression would be considered crazy
(Alvidrez, 2008). Alvidrez implies that many African Americans do not utilize mental health services because they do not want to be stigmatized. Furthermore, Alvidrez’s
(2008) research displays that one of the main contributors towards African Americans not utilizing mental health services is stigma. Our culture has a major impact on our beliefs and perspectives. Culture also has an impact on how we view mental health and the culture we associate with influences what we think and what we do (Schatell, 2017).
2 William (2011) suggest, family does influence our cultural practices and cultural perspectives are often learned and practiced within the family. Furthermore, African
Americans may also be resistant to utilizing mental health treatment because they are afraid that it would give their family a bad representation as it relates to the family not being able to handle their issues internally (William, 2011). Most African Americans do not want to bring their family on the forefront of their mental illness. In a previous research study, African Americans who had received mental, and others who have not received services, stated that embarrassment and shame was a barrier to them receiving mental health services (Thompson, Bazile, & Akbar 2004).
Social Economical
In the United States, African Americans have the lowest household income compared to other cultural groups. According to the United States the real median income of nonHispanic White ($62,950), Black ($36,898), and Hispanic-origin ($45,148) households increased 4.4 percent, 4.1 percent, and 6.1 percent, respectively, between
2014 and 2015. Among the race groups, Asian households had the highest median income in 2015 ($77,166), though the 2014 to 2015 percentage change in their real median income was not statistically significant (Proctor, 2016).
In one qualitative study, an African American woman who lived in a rural area was limited to the mental health treatment facilities that only accepted Medicaid (Speed 2013 p. 73). In the county she lived in, there are not mental health providers that accepts
Medicaid, thus leaving her to have to travel outside of her county to receive services. In additional studies researchers have been able to display a correlation between African
Americans with a lower social economic status and the lack of access to adequate health
3 services (Kushel, Gupta, Gee, & Haas, 2006). In Kushel, Gupta, Gee, & Haas (2006) research, it was determined that African Americans with instability housing and food insecurity had a high rate of acute services and a lower use of health care services.
Cultural Competency
In a 2013 commentary review, a health professional stated that there was no curriculum taught on how to address issues or race, ethnicity, culture, or class even though they served a large number of African American clients (Drake, 2013). In a journal exploring clinician strategies, the author (Curtis-Boles) emphasizes the importance of cultural competency. Curtis-Boles (2017) states that cultural competency isn’t just a tactic that is best for the client, but it meets the ethical needs mandated by the
American Psychology Association (Curtis-Boles, 2017). In treatment, values systems behaviors, frame references, and symptoms may be viewed as deviant and dysfunctional when those symptoms could be a cultural idiosyncrasy (Atdijan & Vega, 2005). In a report by the United States Department of Human and Health Services, it stated that
African Americans may experience cultural-bond symptoms and higher stress levels due to the conditions in which African- Americans live in. Furthermore, these symptoms and stressors can differ from other ethnic groups (US Department of Human and Health
Services, 2001).
Misdiagnosis
In a study conducted in 2008 African American participants who needed to be treated for Post-Traumatic Stress Disorder (PTSD) were more than likely not to received
PTSD focus treatment. (Davis, Ressler, Schwartz, Stephens, & Bradley, 2008). The
4 study further discusses how PTSD in the African American community is undertreated due to the clinicians being poorly educated.
Snowden (2003), states that a clinician who’s makes unjustified decisions of a client based on biases of the client’s culture, race, or ethnicity may led the clinicians to make a poor clinical decision (Snowden, 2003). In another previous research studying racial bias and diagnosis it is stated that although clinicians are experts in their field using biomedical and behavioral evidence when creating a treatment options and conducting a diagnosis, it may be inevitable to dismiss race, gender, socioeconomic status, and other biases (Perry, Neltner, & Allen, 2013). This research further explores how the Diagnostic and Statistical Manuel of Mental Disorder (DSM) bias and Eurocentric view point may contribute to the misdiagnoses and over diagnoses of African Americans receiving mental health treatment.
Mistrust
In the United States, there has been a historical establishment of mistrust between
African Americans and health care systems. Medical experimentation on African
Americans during the time of slavery laid the foundation of mistrust towards health care providers (Washington, 2006). During the infamous U.S Public Health Service’s
Tuskegee Study of Untreated Syphilis in the Male Negro represents an egregious incident of in humane treatment that illustrates expectations that African Americans have towards health care providers (Brandon, 2005). Due to the historical mistrust of health institutions and the African American community, trust is a barrier to receiving adequate mental health treatment.
5 Dovan (2012) reported, according to Psychiatrist William Lawson, African
Americans will traditionally seek treatment from institutions they are familiar with and that they trust (Dovan, 2012). These institutions may include: primarily churches, barbershops, and hair salons. Being that mistrust is a barrier to proper mental health treatment for African Americans, then how can clinicians begin to develop trust with
African American clients? The National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care suggests that clinicians should provide effective, equitable, understandable, and respectful quality of care and services that are responsive to the diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs (National Standards for
Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care,
2017).
Summary
The literature review explores how cultural competencies can be essential to providing African Americans with adequate mental health treatment. African Americans are at a higher risk of being diagnosed with a serious mental illness. The research shows that this is due to African Americans not receiving adequate care. More often than not, if
African Americans can access proper mental health services they would be able to be proactive in their treatment instead of waiting until the illness proposes a high risk.
Having clinicians who are culturally competent may help African Americans clients feel more comfortable to participate in treatment. Due to the historical mistrust in health care providers in the African American community, the literature review suggests that the clinician must make a conscious effort to eliminate these cultural biases.
6 Furthermore, clinicians must challenge their own beliefs, biases, and prejudices as it may have an impact on the level of mental treatment that is provided.
Aims and objectives.
The purpose of this quantitative study is to explore clinician’s perspective on levels of mental health treatment for African American clients. The study findings will offer potential support and implications for clinical practice. The hope is that---first, the findings may be used as a tool to bring awareness to mental health clinicians on engagement issues when working with African American clients. Furthermore, this exploratory study will assist clinicians with the identification of possible skills that might help to provide African American clients with proper mental health treatment by mitigating cultural barriers. In addition, this research will explore the benefits to developing a holistic view of African American’s barriers towards treatment and how it can lead to having a positive outcome in retaining African Americans in mental health treatment.
7 Method
Participants
This was an exploratory quantitative study. The data was taken from 55 individuals who have worked with someone who identifies as an African American and who has/or currently receiving mental health treatment. A screening was conducted to ensure that the participants took the survey met the eligibility criteria. The criteria included that: participants must be over 18 years old, obtained a 2-year degree or higher, and have at least one year of experience working with African American in mental health treatment. All genders, cultural backgrounds, and ethnicities were welcome to participate.
Exclusion criteria included: participants are younger than 18 years old, individuals who have not received at minimum a 2-year degree and/or have at less than one year of experience working in mental health. Exclusion factors were not determined by gender, cultural background, and/or ethnicity.
This study utilized snowball sampling. A pool of agencies and individuals who work with African Americans in mental health treatment were considered as a primary source for collecting the data to voluntarily participate in the survey. Participates were encouraged to pass the survey to their colleagues and other people who may have met the criteria to participate. In addition, social media outlets such as Facebook and Instagram were utilized to recruit participants.
Measures
The reason for the research to be developed was to explore competent engagement as a factor towards African American’s level of care in mental health treatment. The further explore how social economical, mistrust, misdiagnoses and a lack
8 of cultural competency may have an impact on mental health treatment options for
African Americans. The survey consisted of 19 questions regarding the participants: gender, ethnicity, educational background, professional experience. Questions consisted of liker scales, multiple choice, and short answers pertaining to clinicians on their mental health treatment practices when working with African Americans.
Research Design
The overall design of the study was descriptive study using an online questionnaire distributed to participants to study the following. Exploring if African
Americans are being provided an adequate level of mental health treatment from mental health clinicians.
Procedure
Participates were given the survey electronically through email and social media outlets with the website link to conduct the survey. The content reads as follows: You are being asked to participate in a research study; Exploring African American’s Utilization of Mental Health Services: Clinical Perspective a study conducted by Terrence Stewart as part of the requirements for the MSW degree. This study will explore reason African
Americans may or may not be utilizing mental health services. You are being invited because you are over 18 years old, have a Bachelor’s degree or higher, and have at least one year of experience working with African American in mental health treatment. This study will take 5-10 minutes to complete. We do not expect any risks to you. Although, there will be no direct benefits for taking the survey, we hope that the knowledge we gain will help develop a better understanding of the impact cultural competency has in mental health treatment. Participation in this study is completely voluntary. You will not be
9 compensated for taking the survey. This study is anonymous (we will not ask your name) and all data will be reported aggregate (as a group, not individuals). You can choose not to take this survey, or not to answer any specific questions, without any negative consequence to you. Please past this survey on to other professionals who you know may be interested in participating in the survey.
10 Results
These results are to answer the study question of whether or not clinicians are providing an adequate level of mental health treatment to their African American clients.
The results are interpreted as a descriptive data sample using a total of 55 clinicians who met the criteria and completed the survey (n=55).
Table 1.
Gender
Gender Frequency Percentage
Male 9 16.4 Female 46 83.6 Total 55 100
83.6% (n=46) identified as female and 16.4% (n=9) identified as male.
Table 2.
What socioeconomic range would you say your African American clients fall under?
Social Economic Class Frequency Percentage
Lower 35 63.6 Middle 20 36.4 Total 55 100
63.6% (n=35) of clinicians reported that their African American clients are in the lower socioeconomic class and 36.4% of clinicians reported that their African American clients are in the middle social economic class.
11 Table 3.
Ethnicity
Ethnicity Frequency Percentage
White 10 18.2 Black or African American 29 52.7 Hispanic Latino/a 11 20.0 Asian 1 1.8 Other 1 1.8 Black or African American and Other 2 3.6 White and Hispanic Latino/a 1 1.8 Total 55 100
52% (n=29) of clinicians identified as African American/ Black, 20% (n=11)
Hispanic and/or Latin, and 18.2% (n=10) were White.
Table 4.
In your experience are African Americans initially resistant towards treatment?
Clinicians Frequency Percentage
Yes 39 70.9 No 16 29.1 Total 55 100
70.9% (n=39) of clinicians reported that their African American clients are initially resistant towards mental health treatment. 29.1% (n=16) of clinicians reported that their clients were receptive of mental health treatment.
12 Table 5.
Do you take time in your assessment and/or treatment process for an African American client to share their beliefs, values, and/or cultural characteristics?
Clinicians Frequency Percentage
Yes 49 89.1 No 6 10.9 Total 55 100
89.1% (n=49) of clinicians stated that they take time to assess for cultural beliefs when working with African American clients. 10.9%(n=6) of clinicians stated that they sometimes take time to assess for cultural beliefs when working with African American clients.
13 Table 6.
What reason(s) your African American clients attend treatment? (Check all that apply)
Clinicians Frequency Percentage
Mandate or court ordered to attend 12 21.8 Seeking to participate in therapy/ counseling 12 21.8 Seeking psychotropic medication 2 3.6 Seeking participation in therapy/ counseling, 5 9.1 seeking psychotropic medication, and mandated or court ordered to attend Seeking psychotropic medication and 2 3.6 mandated or court ordered to attend Seeking participation in therapy/ counseling 16 29.1 and mandated or court ordered to attend Seeking participation in therapy/ counseling, 1 1.8 other, and mandated or court ordered to attend Seeking participation in therapy/ counseling, 1 1.8 and seeking psychotropic medication Seeking psychotropic medication, and other 1 1.8 Other 2 3.6 -99.00 1 1.8 Total 55 100
29.1% (n=16) of clinicians reported that their African Americans clients have been mandated or court ordered to attend treatment and seek to participate in treatment.
21.8% (n=12) of clinicians reported that their African Americans clients have been mandated or court ordered to attend treatment. 21.8% (n=12) of clinicians reported that their African Americans clients seek to participate in therapy/ counseling.
14 Table 7.
Do you feel that African American clients trust you as a clinician?
Clinicians Frequency Percentage
Definitely Yes 24 43.6 Probably Yes 26 47.3 Might or Might Not 4 7.3 Definitely Not 1 1.8 Total 55 100
43.6 % (n=24) of clinicians reported that they “definitely yes” feel that their clients trust them as a clinician. 47.3% (n=26) of clinicians reported that they “probably yes” feel that their clients trust them as a clinician.
Table 8.
From a scale of 1-10 (1 being extremely uncomfortable and 10 being extremely comfortable) how comfortable are you with providing mental health treatment for African Americans?
Clinicians Frequency Percentage
2 1 1.8 3 1 1.8 5 1 1.8 6 2 3.6 7 4 7.3 8 5 9.1 9 8 14.5 10 33 60 Total 1 100
60% (n=33) scored themselves a 10, 14.5% (n=8) scored themselves an 9, and
9.1% (n=5) scored themselves an 8.
15 Table 9.
Have you received professional training on cultural competency relating to African
Americans?
Clinicians Frequency Percentage
Yes 40 72.7 No 15 27.3 Total 55 100
72.7% (n=40) of clinicians reported that they have received professional training on cultural competency relating to African Americans. 27.3% (n=15) of clinicians reported not having received professional training on cultural competency relating to
African Americans.
Table 10.
After building a relationship with an African American client, have you ever felt that the client had been misdiagnosed?
Clinicians Frequency Percentage
Yes 35 63.6 Maybe 11 20.0 No 9 16.4 Total 55 100
63.6% (n=35) of clinicians reported that after building a relationship with their
African American clients, they felt that their clients were misdiagnosed. While 20%
(n=11) reported that maybe they were misdiagnosed and 16.4% (n=9) reported they were properly diagnosed.
16 When clinicians where asked to describe what they do to establish trust with
African American clients many clinicians responded by saying they build rapport with the client. Another common theme was that clinicians do the same thing they do with their other clients of different ethnicities. The third common theme was to allow the client to share their story and be vulnerable and clinicians would share their story.
17 Discussion
There is still a great deal of work that still needs to be done for African Americans receiving mental health treatment. African Americans are at a disadvantage when receiving mental health treatment because they are provided an inadequate level of care, thus potentially contributing to them not appropriately utilizing mental health services.
Contributing factors such as socioeconomic barriers, misdiagnoses, and mistrust fuel the argument on whether or not African Americans are receiving an adequate level of mental health treatment.
This research tested the question of whether or not African American clients are initially resistant towards treatment. In previous research conducted by Schatell (2017), culture plays a role in what we think and what we do (Schatell, 2017). Thompson,
Bazile, & Akbar (2004), brings into perspective how an individual’s shame and embarrassment toward the family play a role. In the responses of the participants, it shows that the majority of African Americans clients are initially resistant towards mental health treatment.
In this study, the reasons and type of mental health treatment African Americans clients were receiving may have an impact on the population being resistant. Almost one- third of clinicians reported that their clients were not attending treatment willingly. This means that their clients were forced to attend treatment by institutions such as the criminal justice system (i.e. probation and/or parole). It may be implied that these clients may have been resistant because they were attending unwillingly, which can play a role in the level of participation in current and future treatment.
18 Many African Americans may not be utilizing mental services because there is a lack of access to mental health treatments. The research reports that 63.6% of Africans
Americans fall under the lower socioeconomic status. Kushel, Gupta, Gee, & Haas,
(2006) reports its stated that there is a correlation between lower class status and access to adequate level of treatment (Kushel, Gupta, Gee, & Haas, 2006). This may be an additional barrier for treatment for African Americans that are unable afford adequate care.
In this study, a high volume of clinicians reported taking time to asses for cultural beliefs. In many assessments of African American client, culture can be over looked as not being important in the treatment process. Cultural is often looked as a personal belief system that should only stay within the culture. In addition, it brings the idea of everyone being treated the same with the same equal care. Providing the same type of care to everyone does not serve well for the clients, practically African American clients.
Cultural competency for African Americans validates, acknowledges, and provides a more adequate horizon to their bio-psycho-social-spiritual needs in treatment. Clinicians should be aware that providing inadequate mental health services for African Americans may be considered maltreatment.
Many mental health treatment practices have been deprived by a Eurocentric perspective. As Perry, Neltner, and Allen’s (2013) research stated, many clinicians may use tools to diagnose an African American client and still misdiagnose them based on their own biases of African American culture (Perry, Neltner, & Allen, 2013). Almost
90% (89.1%) of participants in this study stated that they do take time asses for cultural beliefs. By making the treatment client centered, it may mitigate biases and prejudices
19 that a clinician may propose. The traditional treatment practices may not always be the most effective with African American clients. Being that cultural stigmas play a predominate in African American participating and continuing mental health treatment, clinicians must be aware and attempt to break these barriers to ensure that African
Americans feel more comfortable in participating in mental health treatment. By utilizing cultural competencies in practices, it may position a clinician to make a better assessment for their African American clients.
An additional risk are individuals who struggle with mental health related issues and do not received the proper treatment to help manage their symptoms. Particular in the
African American community, individuals are at greater risk of having mental health issues due to the increase of risk factors. These risk factors include poverty, lack of education, and a rise to acceptability to trauma. The majority of clinicians felt that their clients trusted them as a clinician, felt comfortable providing mental health treatment to
African Americans, and claimed to have received professional cultural competency training. It is important for clinicians to be aware of these conditions of their African
American clients and the treatment being provided as it relates to their overall utilization of mental health treatment services. This data was contrary to previous research that focused on the client’s outcome and prospective. These results gave a high percentage of ideal clinicians that the previous research would suggest should be providing mental health services to African American clients. Ideally, from this prospective it appears that
African American are receiving an adequate level of mental health treatment. On the other hand, over 60% reported after building a relationship with their African American client they felt that their client was misdiagnosed. Treating a client for something they do
20 not need to be treat for and/or not the primary issue is providing an inadequate level of care. In the mental health field, many symptoms can seem invisible and/or over looked.
For African Americans, misdiagnosis is an additional barrier that may limit their level of treatment.
Limitations
As this research unveils a clinical perspective by surveying solely clinicians, there are limitations to the research as it relates to answering the study question on whether or not African Americans are receiving an adequate level of mental health treatment. In the survey, there are 3 errors that may have impacted the results of the study. The first error is not allowing to cross reference the question regarding reasons why African Americans are seeking services. There may have been a higher percentage of African Americans receiving mandate mental health treatment services if the question was limited to having the clinicians select one option for the majority of their African American clients. The second limitation relates to clinicians self-assessing themselves without providing any additional support to correlate how they are practicing. For examples, it may be unlikely that a clinician will say that they are either not comfortable working with African
Americans, not culturally competent, and their African American clients do not trust them as they would want to feel that they are doing a good job as a clinician. These statements should have been followed up with questions regarding their responses such as
“What makes you culturally competent in your practice?” and compare their answers to a cultural competent guideline. The third limitation is completing more comparative data with other ethnicities. This would give more specific correlations to the level of treatment being provided to African Americans compared to other ethnicities.
21 Directions for future study
Being that there are not many researches that provide a clinician perspective on mental health treatment for African Americans, this would be a decent research to build with consideration of its limitations. This survey was conducted using an anonymous survey with clinicians. It would be suggested that the next study be a qualitative study which will include some more thorough qualifications for participating in the survey (i.e. a higher level of education, Masters minimum). If future studies prefer to use a qualitative data, it is recommended to diversify participants and use a larger sample size.
22 Conclusion
In summary, this study was designed to explore if African American’s are receiving mental health services from a clinical perspective. The research showed that
African American client are still receiving an inadequate level of care based on being misdiagnosed. The research may help with clinical practices for African Americans to help provide adequate levels of treatment. This research contributes to the overall picture on building a bridge between the African American community and mental health. By developing additional research and creating dialogue around this subject, we can begin to mitigate the inadequate level of care for African Americans. It is imperative that everyone has access to an adequate level of care, but African Americans are more vulnerable to not receiving an adequate level of treatment due to their social and economic conditions. Clinicians must continue to utilize and develop their cultural competent skills when working with African American clients.
23 References
African American Communities Mental Health. (n.d.). Retrieved December 19, 2017, from http://www.letserasethestigma.com/african-american-mental-health/
African American Mental Health. (n.d.). Retrieved December 21, 2017, from https://www.nami.org/Find-Support/Diverse-Communities/African-Americans
Alvidrez, J., Snowden, L. R., and Kaiser, D. M. (2008). The Experience of Stigma among Black Mental Health Consumers. Journal of Health Care for the Poor and Underserved, 19,874-893.
Atdjian, S., & Vega, W. A. (2005, December). Disparities in mental health treatment in U.S. racial and ethnic minority groups: Implications for psychiatrists. Retrieved January 9, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/16339626
Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc. 2005 Jul;97(7):951–956.
Curtis-Bole, H. (2017, October 01). Clinical Strategies for Working with Clients of African Descent. Retrieved February 3, 2018, from https://www.questia.com/library/journal/1P4-2011562647/clinical-strategies-for- working-with-clients-of-african
Davis, R. G., Ressler, K. J., Schwartz, A. C., Stephens, K. J., & Bradley, R. G. (2008). Treatment barriers for low-income, urban African Americans with undiagnosed Posttraumatic stress disorder. Journal of Traumatic Stress,21(2), 218-222. doi:10.1002/jts.20313
Donvan , J. (2012, August 20). Behind Mental Health Stigmas In Black Communities. RetrievedDecember 18, 2017, from https://www.npr.org/2012/08/20/159376802/behind-mental- health- stigmas-in-black-communities
Drake, R. E. (2013, April 02). A Mental Health Clinician's View of Cultural Competence Training. Retrieved March 2, 2018, from https://link.springer.com/article/10.1007/s11013-013-9318-y
Hackett, Jamie Rose, “Mental Health in the African American Community and the Impact of Historical Trauma: Systematic Barriers.” 2014. School of Social Work St. Catherine University and the University of St. Thomas. Retrieve November 10, 2017
24 Kushel, M. B., Gupta, R., Gee, L., & Haas, J. S. (2006). Housing instability and food insecurity as barriers to health care among low-income Americans. Journal of General Internal Medicine, 21, 71–77.
Perry, B. L., Neltner, M., & Allen, T. (2013). A Paradox of Bias: Racial Differences in Forensic Psychiatric Diagnosis and Determinations of Criminal Responsibility. Race and Social Problems,5(4), 239-249. doi:10.1007/s12552- 013-9100-3
Proctor, B. D. (2016, September 13). Income and Poverty in the United States: 2015. Retrieved March 30, 2018, from https://www.census.gov/library/publications/2016/demo/p60-256.html
NAMI. (2017). Retrieved November 17, 2017, from https://www.nami.org/Find- Support/Diverse-Communities/African-Americans
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. (2017). Retrieved December 18, 2017, from https://www.thinkculturalhealth.hhs.gov/pdfs/enhancednationalclasstandards.pdf
Office of Minority Health. (2016). Retrieved December 19, 2017, from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24
Schatell, E. (2017, July 10). Challenging Multicultural Disparities In Mental Health. Retrieved November 10, 2017, from https://www.nami.org/Blogs/NAMI- Blog/July- 2017/Challenging-Multicultural-Disparities-in-Mental-He
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Speed, Carmelia L. (2013) EXPLORING THE LIVED EXPERIENCES OF RURAL AFRICAN AMERICANS ACCESSING MENTAL HEALTH SERVICES.Capella University p73
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U.S. Department of Health and Human Services. Mental health: culture, race, and ethnicity; a supplement to mental health. Rockville, MD: U.S. Department of Health and Human Services, 2001
Washington HA. Medical apartheid: the dark history of the medical experimentation on black Americans from colonial times to the present. New York, NY: Random House Digital, Inc.; 2006
25
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26 Appendix A
Study Survey Questions 1. Did you graduate from college and/or university? 2. Gender 3. Ethnicity 4. How old are you? 5. How many years have you worked with African Americans with a mental health related issues? 6. What reason(s) your African American clients attend treatment? (Check all that apply) 7. In your experience are African Americans initially resistant towards treatment? 8. Do you feel that African American clients trust you as a clinician? 9. Please describe what do you do to establish trust with African American clients? 10. What socioeconomic range would you say your African American clients fall under? 11. How much do your African American clients pay for their services? (Check all that apply) 12. From a scale of 1-10 (1 being extremely uncomfortable and 10 being extremely comfortable) how comfortable are you with providing mental health treatment for African Americans? 13. Do you take time in your assessment and/or treatment process for an African American client to share their beliefs, values, and/or cultural characteristics? 14. Do you feel an African American's cultural background influences their progress in treatment? 15. Have you received professional training on cultural competency relating to African Americans? 16. After building a relationship with an African American client, have you ever felt that the client had been misdiagnosed? 17. Are you available on platforms for African Americans to access you for services? (Ex. Psychology Today, Social Media, Websites) 18. According to NAMI (National Alliance on Mental Illness) culture—a person’s beliefs, norms, values and language—plays a key role in every aspect of our lives, including our mental health. Cultural competence is a doctor’s ability to recognize and understand the role culture (yours and the doctor's) plays in treatment and to adapt to this reality to meet your needs. Unfortunately, research has shown lack of cultural competence in mental health care. This results in misdiagnosis and inadequate treatment. African Americans and other multicultural communities tend to receive poorer quality of care (NAMI). From your experience, how true is this? 19. Are there any additional comments you would like to make relating to your responses towards any of the questions?
27