I recently completed an interview with BIG THINK — Mental Health Channel on mental health issues in the Black community. BIG THINK does incredible life enhancing work, via a media platform, on various health, political and social topics.  I will keep you posted on when it airs.

Here’s the transcript of the interview:

BIG THINK: Please tell us about yourself and the focus of your work.

Dr. Michael Lindsey: I am an Associate Professor at the Silver School of Social Work, New York University. I am also an affiliated faculty member at the Center for School Mental Health, University of Maryland, Baltimore.

I am a child and adolescent mental health services researcher. My research investigates the factors that prohibit mental health service use for youth and their families. We know from large-scale epidemiological investigations that only about a 3^rd of the youth who need mental health treatment actually receive the necessary services to address their needs. The problems of access to and use of care can be particularly problematic for youth of color. And, so, my work is especially attuned to the factors that influence mental health treatment among African American youth with serious mental health needs. To be even more concrete, my program of investigations has focused on the development and test of a targeted intervention to combat the perceptual and actual barriers to treatment for African American youth. What we know is that when this population does not receive the requisite mental health services to address their needs, the outcomes for them are most severe – particularly those who live in urban, high-stressed environments. We’re talking about increased engagement in suicidal behaviors, poor school performance, substance abuse, early sexual experimentation, to name a few of the many deleterious consequences associated with untreated mental illness for this population.

In the last few years my work, in conjunction with my colleague, Dr. Laura Mufson (Columbia University), has focused on the delivery of stigma reduction and depression treatment in urban school settings, again, specifically targeting African American youth with serious symptoms of depression. Our work in this regard focuses on the amelioration of depression as it relates to improving poor school performance among youth. In addition, we are addressing the matter of how to bring evidence-based practices into the “real-world” context of schools and urban communities so that those in need might benefit from the best of what we know works regarding depression treatment.

BIG THINK: How does mental health needs in the black community compare to society at large?

Dr. Michael Lindsey: Most large-scale epidemiological studies will indicate that the prevalence rates for mental disorders are higher for Whites than African Americans (Williams et al., 2007; Lincoln et al., 2010). While this is true, the bigger concern regards the chronicity and burden of mental health problems, e.g., depression, which tend to be more problematic for African Americans. There is also the fact that many African Americans, relative to their White counterparts, do not receive treatment for mental health problems. This consistently continues to be true across all disorders. African Americans simply do not get the appropriate level of mental health treatment to meet their emotional, psychological needs.

Lack of treatment for depression, in particular, accounts for the rising rates of suicide among African Americans.

BIG THINK: What forces impact mental health in the black community? Historical and present-day.

Dr. Michael Lindsey:

Historical

From a historical perspective, you cannot consider the matter of mental health without discussing the issue of slavery and its vestiges. African Americans have been traumatized from this experience and the enduring forces of racism and discrimination continue to take its toll on the emotional, psychological wellbeing of African Americans today. The scars of trauma are fairly evident for African Americans, which creates a lack of trust in institutions or entities that ostensibly adhere to the wellbeing of all mankind, yet continue to treat Blacks in dehumanized ways (e.g., the state of the police force and African American males in the U.S.). The distrust is far-reaching, leading African Americans to socialize their children against “taking their problems outside the home.” “Outsiders” are not to be trusted, and there is the perception that no one can handle your cares better than your family. African Americans have historically been treated unfairly by “the system,” and thus families and others among their social networks promote the perception, even if unintentional, that the system cannot be trusted.

Present-day

I would say lack of trust of mental health providers. And, the perception that services will be irrelevant to one’s presenting concerns. Concerns about what others may say regarding one’s mental health treatment. Or, concerns about how going to services would make one look and providers lack of understanding and cultural attunement to the African American experience.

 BIG THINK: How would you characterize the way mental health is dealt with in the black community, both on an individual level and at large?

Dr. Michael Lindsey:

At an individual level

Many individuals suffer in silence. They are afraid to acknowledge a mental health struggle for fear of being ostracized due to family or community members’ stigmas regarding mental illness. And, it is not just the shunning. Mental illness in our society is accorded personal failure—one’s inability to weather a storm in their life. I think when you add the complexity of race, for African Americans, there is a double-edged sword, so to speak: At one end, there are the attempts to overcome and live with a mental illness. At the other end, there is the matter of living in a world that is hostile toward and micro aggresses against African Americans. At the individual level, that is a pretty intense struggle for African Americans who suffer with mental illness.

At large

Again, as a society, we shun those who suffer from mental illness. We see it as a personal defect. In the African American community, it is no different. The world (and its stressors) is already a struggle unto itself, and to have a mental illness is yet another thorn in the side, so to speak. I remember hearing as a kid, in my community, about people “going down south” for a while. I used to wonder what that meant. As I grew older, I came to understand that people were sent down south when they were struggling with some emotional or psychological problem. Drugs may have been involved, you know, as a coping mechanism. Generally, the African American community at large has been afraid to talk about mental illness. It is a taboo subject. In the church, from a historical perspective, mental illness has been associated with demonic possession. The African American community has been conditioned to believe that if you just pray about it, Jesus will take your burdens away. Meanwhile, professional care is never sought, which then leads to coping or self-medicating through alcohol or drugs.

BIG THINK: What are some of the obstacles that African Americans face in receiving treatment? Culturally and socioeconomically.

Dr. Michael Lindsey:

Culturally, I’d say this notion that going to therapy is something that Whites or individuals who have money do. As mentioned, there’s also the belief that you can pray your burdens away. Let Jesus fix it. We have to put these perspectives on how best to deal with mental illness in context, though. These are not erroneous or far-fetched perspectives. They are very proximal to the daily struggles accorded to what it means to be African American in the U.S. Therapy is not seen as a option, historically, because how many people in our network do we know who are therapists? Are there clinics or private practices in majority African American communities? Even if there were clinics, who would frequent them for fear of being stigmatized? These are very real concerns.

Socioeconomically, you know, is an interesting one. Sure, mental health treatment is seen as expensive, and perhaps not affordable. To some extent, creating better financial access to care increases the likelihood that services will be used. Some studies of the federal Medicaid/Medicare programs suggest that having health insurance increases access to care. Extant research, however, tells us that access alone will not totally eliminate the disproportionate amount of individuals who will not receive mental health treatment. Perceptual barriers (e.g., the perceived relevance of services, stigma associated with having a mental illness or seeking treatment) still factor hugely in the receipt of care for African Americans.

BIG THINK: Can you speak to some of the socioeconomic factors that limit access to mental health care for many African Americans?

Dr. Michael Lindsey: Again, we are talking about lack of insurance coverage, perceptions that services will not be affordable, and the number of providers who have a sliding fee scale, all work to limit access to mental health care for African Americans.

BIG THINK: Does the church, and a reliance on faith, factor into the mental health care trajectory of many?

Dr. Michael Lindsey: Absolutely, it does. Many are consoled to pray about the problem. Or, pastors or lay ministers offer counseling, but they are not always equipped to do so. Some do not have the requisite specialized training.

I believe that faith and spirituality are quite important, but I also believe that mental health treatment for those with mental health needs should be a combination of professional care and being part of a supportive community that will lift your spirits and encourage you to keep focused on the healing process. And, to attend your appointments.

BIG THINK: How can the church help the black community in its understanding of and response to mental health?

Dr. Michael Lindsey:

How can it do a better job of this in the future?

• Pastors are key.
  • In their sermons and messages to congregants, I think they need to emphasize that it is okay to seek professional help for mental health needs. It would be incredible if pastors were knowledgeable about the signs and symptoms of mental illness, and even highlight examples from the scriptures. Several biblical figures struggled with depression, anxiety, for example. In other words, pastors can go a long way in humanizing the experience of mental illness.
  • In the same vein, I think pastors are key to organizing programs to assist those with mental health needs. Since many folks in the church will take their cares/concerns to the church, pastors can be a bridge to connecting those in need to treatment. Imagine the church as a triage unit, whereby they would do an initial assessment of needs, but then refer those in need to treatment.
• At a minimum, churches should have a list of providers on hand – a list of providers from therapists to psychiatrists.
• Churches should also do mental health promotion programs, but the kind that screen and get folks connected to care, e.g., education programs that train on the signs and symptoms of disorders, or that promote mental and psychological wellness.
• No one should attempt to deliver mental health treatment without the proper training. Nor, should people fashion themselves as “counselors” without the proper training and credentialing. This happens a lot in churches, and it can be dangerous.

BIG THINK: Can you speak to how African American men in particular deal with depression? Often feel that experiencing depression or seeking help makes them “less of a man?”

Dr. Michael Lindsey: Certainly, and this is a huge problem with respect to help-seeking and service use for depression. We have all kinds of ill-conceived notions of what it means to be a man. We socialize boys differently than girls. We tell them it is not “man-ly” to cry, or even to express emotions. “Man-up.” “Fight it off.” “Be tough.” These are all familiar edicts expressed to boys versus girls. Notions of masculinity have much to do with how men with depression conceptualize their problems and whether they will actually admit to being depressed, and actually seek treatment because “real men” tough it out.

This is so off base and out of touch with the healing process for a condition like depression.

Normally, asking for help, seeking guidance, and even acknowledging vulnerabilities related to depression is a sign of strength. But, for African American men, these postulates are antithetical to the experience of masculinity, i.e., what it means to be a man. In many of the contexts and spaces African American men are operating in, whether in corporate America or in the “hood,” one cannot afford to be weak. For, to be weak or even express weakness in some form, may make one more vulnerable or susceptible to ridicule or harsh treatment. Many African American men will NEVER admit to being depressed.

We see these same notions of masculinity impact other health behaviors, e.g., going to a medical doctor for a physical health issue. You would be hard pressed to get many men, and certainly Black men, to go in for an annual physical.

If you want to improve access and connections to mental health and health care among African American men, you definitely have to combat the perceptions of masculinity and what it means to be man.

BIG THINK: Can you speak to the need for culturally competent mental health care providers, and culturally appropriate treatment strategies?

Dr. Michael Lindsey: Culturally competent care is so critical to everything. If patients perceive that the provider is inauthentic or the nature of the services do not speak to their unique circumstances, you have lost before you have even started. Services have to be experienced as meaningful, and meaning is derived from going through a process that speaks to the challenges going on in one’s life. For example, you do not go to the supermarket to get a haircut. One is most likely to go to the place that meets their needs.

I endorse something that I’ve framed as “authentic engagement,” and I believe providers must exemplify this. What do I mean? Cultural competency, for example, is not just about having knowledge of someone’s unique history insofar as ethnicity. You cannot read it all in a book and then purport to be competent. It is as much about knowing the culture of your patient’s community. What are the current and historical trends in their neighborhood? Having an earnest interest in this information builds ones authenticity as a provider. One may say our patients are not there to “teach us” or we are not there to learn from them. No, but what are you doing outside of the treatment context to better understand your patients’ lives?

Treatment strategies should be adherent to the norms and expectations that patients bring. How might one apply an intervention strategy to Black adolescent boys versus White adolescent girls? There you have an ethnicity by gender interaction, but the point is that your treatment is not so much a cookie cutter approach.

Some might argue that interventionists need to stick close to the intervention model as intended, and I agree. I simply mean that at least some thought should be given to the unique vantage point from which our patients present. Boys might respond differently than girls. Blacks differently than Whites. I would argue there’s a need for more clinical flexibility. One should be beholden to the model, but be quick on their feet as well, and perhaps bring that nuance presentation into the model of care.

BIG THINK: Recent studies suggest that African Americans may metabolize psychotropic medication more slowly than whites, yet often receive higher dosages. As a result, many experience more severe side effects and are less likely to stick with a course of treatment. Can you speak to this and whether there is any work being done to make sure that treatment can be more effective for this group?

Dr. Michael Lindsey: I believe these studies to be mixed. Some have found that Blacks metabolize psychotropic medication slowly than Whites, and some have found that there may be heterogeneity within Blacks. So, we want to be careful about these assertions. We need more data to confirm. What we do know is the following:

• Blacks tend to be receive antipsychotic medication at higher rates (Arnold et al., 2004).
• They receive higher doses (Arnold et al., 2004).
• They tend to receive older drugs (Arnold et al., 2004; Puyat et al., 2013).
• And, they tend to be less likely to receive antidepressant medication, which is consistent with their lower rates of overall treatment for depression relative to Whites (NHANES Survey, 2005-2010).

BIG THINK: What could be done to help reduce stigma, increase access to care, and improve treatment in the black community?

Dr. Michael Lindsey:

Campaign efforts. There needs to be more stigma reduction campaigns. We need more popular people, be they athletes, entertainers, politicians, or even ministers to acknowledge their struggles with mental illness and how they sought help for their struggles. Such messages of struggle and triumph with respect to mental illness would be so incredibly powerful.

• Raise the level of surveillance. Mental illness occurs in a context, and those close to the individual struggling with a mental illness are critically important. Thus, we need to raise the level of surveillance, universally, regarding the signs and symptoms of a mental illness. If you see something, say something is a popular refrain regarding terrorism. Well, it strikes me that mental illness, if gone untreated, can result in catastrophic outcomes, and so we need to have our antenna up regarding greater awareness and recognition of one’s cry for help, and the signs/symptoms of mental illness. We know works, and what are effective forms of care. For example, in the care of those with psychosis, we know that families play a critical role in the receipt of care. We have to raise the level of awareness in critical ways. Thus, families, teachers and professors, friends, co-workers, ministers play a pivotal role helping one get connected to care.

• Market testimonials. It would be wonderful if we have concerted marketing efforts to advise of the warning signs, or as mentioned earlier, provide testimonials of struggle and triumph. We love the story of the underdog, and how one overcame personal struggles to achieve success. I so wish we could frame mental illness in the same way.

• Be real with yourself. We all struggle with emotional or psychological turmoil from time to time. Let’s stop pretending, living behind a veil, and be forthright about these struggles. If you cannot talk about something, it is out of control.

BIG THINK: What would you say to an individual experiencing symptoms of depression or another disorder who is afraid to seek help due to this stigma?

Dr. Michael Lindsey: We know that untreated depression is associated with a host of negative outcomes. In the long run, it will do irreparable damage. Getting help is a sign of strength, not personal weakness.

I would identify with that person what things get in the way of treatment. Fears, insecurities, what is it? I would also ask that person to identify the things that would help him or her get to treatment, e.g., a supportive family, an earnest interest in wanting to change. I would then sort through with that person how we can use those facilitators to overcome the barriers to care. I would emphasize that treatment works, and provide examples of it working. I would not leave it to chance. I would also support that person getting treatment, and follow-up to make sure that person has actually received treatment.

BIG THINK: What do you see for mental health in the black community in 10 years? 50 years? What are you most hopeful about in this area?

Dr. Michael Lindsey:

In 10 years, in 50 years:

This is a great question. Honestly, I see greater awareness and recognition of mental illness. This is unfortunate, but there will likely be high profile suicides and other calamitous events that will increase greater awareness of the fact that untreated mental illness can be extremely problematic. Professional help is a sure best way to address mental illness given that we know effective treatments.

I see the language of mental illness, its signs and symptoms, becoming a part of the typical nomenclature of families, schools, and churches. Of course, I see care as being delivered in non-conventional ways, e.g., through computers, or interactively via multi-media or even gaming platforms.

Most hopeful

The historical barriers and prohibitions no longer having an impact on treatment access because people will see that mental illness is normalized and accepted in our society. I am hopeful that people, in general – not just Blacks, will go to get annual check-ups for their mental wellbeing just like they do for their physical wellbeing.

I am also hopeful that federal, state and local policies will continue to create opportunities for innovative programs to be developed, but most importantly that greater access to care is created.

References

1. Arnold, L. M., Strakowski, S. M., Schwiers, M. L., Amicone, J., Fleck, D. E., Corey, K. B., & Farrow, J. E. (2004). Sex, ethnicity, and antipsychotic medication use in patients with psychosis. Schizophrenia research, 66(2), 169-175.

2. CDC/NCHS, National Health and Nutrition Examination Survey, 2005–2010. http://www.cdc.gov/nchs/data/databriefs/db135.htm

3. Lincoln, K. D., Taylor, R. J., Watkins, D. C., & Chatters, L. M. (2011). Correlates of psychological distress and major depressive disorder among African American men. Research on Social Work Practice, 21(3), 278-288.

4. Puyat, J. H., Daw, J. R., Cunningham, C. M., Law, M. R., Wong, S. T., Greyson, D. L., & Morgan, S. G. (2013). Racial and ethnic disparities in the use of antipsychotic medication: a systematic review and meta-analysis. Social psychiatry and psychiatric epidemiology, 48(12), 1861-1872.

5. Williams, D. R., Gonzalez, H. M., Neighbors, H., Nesse, R., Abelson, J. M., Sweetman, J., & Jackson, J. S. (2007). Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Archives of General Psychiatry, 64(3), 305-315.