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Social Work in Mental Health
ISSN: 1533-2985 (Print) 1533-2993 (Online) Journal homepage: http://www.tandfonline.com/loi/wsmh20
Perception of Mental Health Services among BlackAmericans
Gina B. Gaston PhD, LCSW, Tara R. Earl MSW, PhD, Aslihan Nisanci MSW, MA& Blake Glomb BA
To cite this article: Gina B. Gaston PhD, LCSW, Tara R. Earl MSW, PhD, Aslihan Nisanci MSW, MA& Blake Glomb BA (2016): Perception of Mental Health Services among Black Americans, SocialWork in Mental Health, DOI: 10.1080/15332985.2015.1137257
To link to this article: http://dx.doi.org/10.1080/15332985.2015.1137257
Accepted author version posted online: 01Feb 2016.
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Perception of Mental Health Services among Black
Americans
Corresponding Author:
Gina B. Gaston, PhD, LCSW
Assistant Professor
University of Illinois at Chicago
Jane Addams College of Social Work
1040 West Harrison, (M/C 309)
Chicago, Illinois 60607
Tara R. Earl, MSW, PhD
ICF International, Public Health and Survey Research, 3 Corporate Boulevard Northeast #370,
Atlanta, United States
Aslihan Nisanci, MSW, MA
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PhD Student
University of Illinois at Chicago
Jane Addams College of Social Work
1040 West Harrison, (M/C 309)
Chicago, Illinois 60607
Blake Glomb, BA
MSW Student
University of Illinois at Chicago
Jane Addams College of Social Work
1040 West Harrison, (M/C 309)
Chicago, Illinois 60607
Abstract
As the Black Americans’ population becomes more diverse, it is important to extrapolate
differences amongst individuals who have historically been grouped as Black or African
American in the literature. This review systematically explores differences in the perceptions of
mental health services among Black Americans of African American, African, and Caribbean
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Black descent. Thirty studies were included in the analysis. The paucity of literature limited the
author’s ability to identify themes substantial themes for Africans and Caribbean Blacks, stigma,
discrimination, and racism mired the perceptions of mental health services for African
Americans. The findings underscored the need for more research to be able to adequately
identify and better understand important and nuanced differences in perceptions of mental health
within the Black American population. Implications for how to better serve Black Americans
through social work practice, intervention and prevention are discussed.
Keywords: African Americans, Africans, Caribbean Blacks, perceptions, mental health services,
stigma, discrimination, racism, Black Americans, Social work
INTRODUCTION
As the American population becomes more diverse, acknowledging important cultural
differences and perceptions of care amongst subgroups of people of African descent becomes
paramount (Lincoln, Chatters, Taylor, & Jackson, 2007; U.S. Census, 2011). Identifying as
“Black” in the United States can include a heritage of Caribbean or West Indian, African, or
another non-American descent. For the purposes of this paper, we focus on African Americans,
Africans and Caribbean Blacks. Collectively, Black Americans alone—not including Blacks of
multiple races—encompass about 13.2% of the U.S. population (U.S. Census 2014). Albeit not
easy to discern, within the Black American population, approximately 1.6 million (4%) identify
as being African (e.g. Ghanaian or Kenyan) and 1.7 million (4.4%) report as being of Caribbean
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Black decent (e.g., Haitian or Jamaican) (American Community Survey; Logan & Deane, 2003;
Migration Policy Institute, 2012).
While significant differences between African Americans and Caribbean Blacks on measures of
physical health have been widely reported (Singh & Siahpush, 2002; Read, Emerson, Taylor,
2005; Read, & Emerson, 2005), considerably less is known about variations in mental health,
despite a small, yet growing, body of evidence (Earl & Williams, 2008; Jackson et al., 2007). In
order to ensure equitable access to adequate care for Black Americans, it is important to
understand the complex role culture and diversity play within race. These factors impact how
symptoms of mental illness are expressed, understood and ultimately diagnosed (Earl, Fortuna,
Gao, Williams, Neighbors, Takeuchi, & Alegría, 2014). Understanding the impact of a person’s
cultural background on their perceptions about mental health treatment is especially important
given that, for some, seeking mental health care may not be something with which they are
familiar (World Health Organization, 2011); Migration Policy Institute, 2012; Miranda et al.,
2005). For example, as a result of the earthquake that crippled Haiti in 2010, the dearth of mental
health services and infrastructure within the country was brought to national attention and in
Africa less than 1% of the total healthcare budget is allocated to mental health (Bird et al., 2010).
Social workers comprise nearly half of the behavioral health care workforce therefore it is
essential for them to be trained in specialized skills to provide evidence-based behavioral health
services (Rosen, 2003; Walrath et al., 2006) that facilitate mental health care among this diverse
population. While there are common experiences across the Black American community, there is
also a great deal of heterogeneity that requires social workers and other mental health service
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providers to understand and be able to provide high quality care that is appropriately tailored to
the unique needs of their patients (Rosen, 2003).
SYSTEMTIC LITERATURE REVIEW APPROACH
In an effort to help the field better understand and disentangle important differences in
perceptions of mental health care within the Black American population We systematically
reviewed the literature using Medline, PsychInfo, Academic Search Complete, PubMed, Ebsco,
and Social Work Abstracts. Our search was guided by a combination of key words that focused
on mental health care, patient perceptions of mental health care and ethnic variations of Black
Americans. We specifically sought to include peer-reviewed articles because these are more
widely reviewed to inform clinical practice and service delivery. We included a broad range of
articles that were published between 2002 and 2014 and emphasized care and perceptions of
American and/or foreign-born Blacks who resided in the states. Examples of key words included,
mental health, perceptions of care and/or treatment, mental health, mental health communication,
patient and provider communication, culture competence, trauma, clinical encounter, and
communication styles. In order to discuss literature that represented the diversity within the
Black American population, we looked for articles that used the terms like, African American,
Black, African, Haitian, Jamaican, Dominican, Trinidad and Tobago, Afro Caribbean, Caribbean
Black, immigrant, and refugee.
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ANALYSIS STRATEGY
We used a three-step process to identify the studies that met our inclusion criteria. The
first step involved examining all studies that were (1) published in peer-reviewed journals, (2)
that were specifically focused on mental health, (3) recruited African Americans, Africans,
and/or Caribbean Black participants, and (4) included African and Caribbean Blacks (foreign- or
U.S.–born) who lived in the United States at the time of the study. Any differences between
foreign-born and U.S.–born Africans and Caribbean Blacks will be identified. Studies were
excluded from the review if results were not reported separately by race and nationality of the
participants. A total of 560 studies were reviewed. See Table 1 for the total number of studies
reviewed by population. Upon further examination, a total of 278 out of 560, met possible
inclusion in the study.
We were interested exclusively in studies that met at least one of two search criteria. Studies
must have examined: (1) the perceptions of mental health services among specific African and
Caribbean Black groups, and/or (2) the perceptions of mental health services among African
Americans. The review was expanded to include peer-reviewed studies published from January
2002 and December 2014.
The second step involved reviewing and employing thematic analysis of the 278 studies. Two
members of the team conducted independent reviews of the literature using the specified key
words as a guided framework. Matrixes were constructed and used by the researchers in order to
allow for study comparison and identification of emergent themes. The matrixes included the
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author(s), date of publication, methodology used, study participants inclusive of racial/ethnic
groups and nationality, location of the study to ensure individuals living in the U.S. were the
subject of the study, results, and study recommendations. The team members met weekly to
review and discuss their independent findings until they reached consensus.
Matrixes were then compiled and categorized according to African American, Caribbean Black,
and African participants. In the end, we found 30 studies that met the inclusion criteria. Twenty-
three of the studies examined African Americans’ perceptions of mental health care. See Table 2
for studies examining African Americans’ perceptions of mental health services. Two studies
examined perceptions of mental health services among Caribbean Blacks. Two studies examined
perceptions of mental health services among Africans living in the United States. Three studies
included mixed populations. See Table 3 for Caribbean Black, African, and mixed population
perceptions. The final step involved using the matrixes to identify emergent themes. Two raters
(the principal author and the PhD student) were used to identify themes. Raters independently
reviewed each study, wrote notes regarding possible themes, and met twice weekly until there
was agreement about emergent themes. The total review process took approximately 6 months to
complete.
EMERGENT THEMES
Two primary themes emerged that seemed to best describe the perceptions of mental health care
within the literature. The themes were: (1) perceptions that influenced service use and (2)
perceptions related to barriers to mental health help-seeking. Subthemes for African American
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participants are also displayed in Table 2. Subthemes and themes could not be identified for
African and Caribbean Blacks due to the paucity of studies found.
RESULTS
Overall, as shown in Tables 2 and 3, of the 30 studies reviewed, 23 focused on African
Americans, 2 focused Africans, 2 focused on Caribbean Blacks, and 3 included a combination of
Black Americans. There were a number of studies that met the inclusion criteria, informed
perceptions about mental health service use, discussed “African Americans” or “Blacks”, but did
not identify or discuss ethnicity or country of origin. Therefore, we present the findings in an
order that aligns with the number of available articles that were reviewed for each of the three
subgroups of Black Americans.
Perceptions of African American
Service Use and Access. African Americans’ negative perception of mental health and the
mental health system was identified as a barrier to service use. Their experiences of societal
discrimination may lead to skepticism and distrust of the mental health system (Copeland &
Snyder, 2010; Earl, Alegría, Mendieta, & Linhart, 2011). We identified three reasons for varying
service use among African Americans. A client’s trust in their provider was one important
reason; a service provider’s competence was a second theme found in the review and a client
feeling that they were respected by their provider were all common themes in service use among
African Americans.
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The importance of trust and comfort with the provider were common reasons across various
studies (Earl et al., 2011; Leis, Mendelson, Perry, & Tandon, 2011; Lindsey & Marcell, 2012;
Thompson, Dancy, Wiley, Perry, & Najdowski, 2011; Ward, 2005). African Americans
identified several dimensions of trust including the need for providers to be nonthreatening and
reassuring. It was important that providers be emotionally and personally accessible. Having
similar spiritual beliefs would also help the client trust their provider. Participants also preferred
their provider to have professional credibility, which was defined as having expertise, fame, and
being the same race (Mishra, Lucksted, Gioia, Barnet, & Baquet, 2009).
Ward (2005) found that clients were constantly evaluating the practitioner’s effectiveness on the
basis of years of education, training, and experience working with African Americans.
Confidentiality-related concerns negatively influenced client-provider relationships (Leis et al.,
2011; Lindsey & Marcell, 2012; Thompson et al., 2011). Findings indicate that clients were
concerned that the information they disclosed in therapy could be used against them in the court,
especially when treatment was court-mandated (Ward, 2005).
The desire to be respected and understood by the provider was a common theme across studies
(Copeland & Snyder, 2010; Earl et al., 2011; Leis et al., 2011; Mulvaney-Day, Earl, Diaz-
Linhart, & Alegria, 2011). For example, African American women were concerned that
clinicians would not understand the unique societal challenges they encountered (Copeland &
Snyder, 2010). In their analysis of African American, Latino and White patients’ preferences for
relational styles in encounters with mental health providers, Mulvaney-Day et al. (2011) found
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that African American clients specifically emphasized the provider’s listening skills. They
wanted to be understood and were appreciated as experts of their lived experiences.
Barriers to Mental Health Help-Seeking. After further examination, four subthemes were
identified as barriers to mental health help seeking: stigma; structural barriers such as poverty,
racism, discrimination; reliance on other coping mechanisms; and fear (Brown et al., 2010;
Barksdale & Molock, 2009; Conner et al., 2010a; Copeland & Snyder, 2011; Lindsey & Marcell,
2012; Leis et al, 2011; Mishra, Lucksted, Gioia, Barnet, & Baquet, 2009; Neighbors et al., 2009;
Richman, Kohn-Wood, & Williams, 2007; Thompson et al., 2011; Ward, Clark, & Heidrich,
2009; Ward & Heidrich, 2009).
Among structural barriers, African American women identified poverty, lack of health insurance,
unemployment, housing issues, and low education as barriers to mental health service use (Ward
et al., 2009). Copeland and Snyder (2010) found that low-income women were not seeking
mental health treatment largely because of economic stressors and stress from conflicting roles in
their lives. Richman et al. (2007) explored the impact of race, discrimination, and racial identity
on mental health service use among African Americans. They found that past discrimination and
identity were more important than education and income in explaining disparities in mental
health service use.
The perception of racism and stigma were also identified as major barriers to seeking mental
health information and services (Conner et al., 2010b; Mishra et al., 2009). Brown et al. (2010)
found that African Americans reported more negative attitudes toward mental health treatment
than Whites. Both African Americans and Whites internalized stigma, which led to negative
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attitudes about mental health. One study found that among African American women,
internalized stigma and not the perception of mental illness by their community was a major
factor influencing help-seeking (Ward & Heidrich, 2009). On the other hand, among young
African American males, negative community beliefs about mental health care were barriers to
seeking treatment (Lindsey & Marcell, 2012). Among African Americans in their late
adolescence, family norms toward mental health treatment were the strongest predictor of help-
seeking intentions (Barksdale & Molock, 2009).
Cultural perceptions that African Americans are “strong” and do need mental health treatment
was another barrier. Lindsey and Marcell (2012) found that young adult African American males
were engaging coping activities in isolation or were engaging in negative coping mechanisms
such as drug use instead of seeking mental health treatment. Ward et al. (2009) found that
African American women were not seeking help because of their belief that Black women “had
to be strong,” or because they believed that they could handle it on their own. Women were
relying on their informal support groups, religious coping, reading, normalizing mental health
problems, and/or denying mental health issues altogether. An analysis of the National Survey of
American Life (NSAL) documented that African American older adults underutilized mental
health services but may be due to a variety of reasons (Neighbors et al., 2009). For example,
cultural perceptions that African Americans are “strong” and do need mental health treatment
was a barrier. Additional contributors were the belief that depression was normal and that
seeking treatment was a sign of weakness (Conner et al., 2010).
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Fear also appeared to hinder access to mental health services for African Americans (Copeland
& Snyder, 2011; Leis et al, 2011; Lindsey & Marcell, 2012; Thompson et al., 2011). The fear of
breached confidentiality emerged as a barrier to treatment-seeking for young adult males in a
study by Lindsey and Marcell (2012). Women may also have unique fears, such as the fear of
losing their children should they seek treatment (Copeland & Snyder, 2011). Another concern
noted across studies was the negative attitude toward psychotropic drugs (Leis et al., 2011);
including fear of overmedication (Copeland & Snyder, 2011) or of side effects (Thompson et al.,
2011).
Perceptions of Caribbean Blacks
Examining a sample of 150 Haitian immigrants living in the United States, Schwartz, Bernal,
Smith, and Nicolas (2012) found that Haitians were more likely to seek help from family rather
than mental health professionals. Jackson et al. (2007) found that Spanish-speaking Haitians
were more likely to report satisfaction with mental health than respondents from the English-
speaking Caribbean.
Perceptions of Africans
Piwowarczyk et al. (2014) examined both concepts of mental illness in addition to attitudes and
beliefs about treatment and potential barriers to seeking mental health treatment among a sample
(n= 296) of Congolese and Somali men and women in the U.S. They found that mental health
concerns were often first dealt within the family. Commonly, faith based coping methods were
used to address mental health issues. Also, the role of formalized mental health was not well
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understood, intact, participants were hesitant to seek services due to issues such as stigma.
Through a phenomenological study by Ezeobel, Malecha, Landrum & Symes, (2010), which
examined perceptions of depression among 19 Nigerian women living in the U.S., stigma was
associated with seeking mental health services. They avoided such stigma by relying more on
religious coping mechanisms. Seeking mental health services was stigmatizing when specifically
being diagnosed with depression. Many participants reported being isolated from family after
being diagnosed with depression due to stigma. DeJesus and Earl (2014) explored the
perceptions of the quality of mental health care among Brazilians and Cape Verdeans. Cape
Verdean is located off the coast of Africa. Focus groups of 24 Brazilians and 24 Cape Verdeans
who received outpatient mental health treatment in the U.S. found that aspects of mental health
care were linked to psychosocial and environmental factors.
DISCUSSION
Given the potential depth and breadth of the ways in which culture can mediate the expression of
what might be considered psychotic-like experiences, the accuracy of diagnosis and efficacy of
treatment for psychotic disorders depends on the recognition of potential racial, ethnic and
cultural variations and influences on symptom presentation. Not attending to socio-cultural
influences, limits diagnostic accuracy and the quality of psychiatric care for those who are most
in need. The systematic review suggests that social workers must be aware of the myriad of
perceptions associated with barriers to mental health care among African Americans, Africans,
and Caribbean Blacks. For African Americans, perceptions about mental health services
appeared to be associated with two major themes—mental health help-seeking and service use.
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Barriers to service use and help-seeking for African Americans were associated with perceived
discrimination and racism in care, distrust, and practitioner factors such as the perception of
practitioner expertise and the perceived quality of their listening skills. The review also revealed
additional perceptions that specifically affected help-seeking among African American women
such as their own stress and the belief that seeking treatment was a reflection of personal
weakness. Limitations to this study include the lack of research exploring the perceptions of
mental health services among Africans and Caribbean Blacks is the significant gap in literature.
The limited amount of studies, which focused on specific groups of Africans and Caribbean
Blacks living in the U.S. coming from different cultural backgrounds are not available and
therefore a limitation to this study. The few studies found that explored the topic of mental health
services perceptions among Africans and Caribbean Blacks revealed some similarities among
African Americans, but also highlight cultural differences that require additional attention. It is
important for additional research to also extrapolate perceptions of mental health among Africans
from various countries
Implications for Social Work Practice, Intervention and Prevention
Diversity, Culture and Practice
Discrimination and racism increase African Americans’ and Caribbean Blacks’ risk for mental
health problems (Clark, Salas-Wright, Vaughn, & Whitfield, 2014) and adversely affect their
access to mental health care (Conner et al., 2010; Mishra et al., 2009; Richman et al., 2007). The
perception of discrimination and racism in mental health services for African Americans
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appeared to be a significant barrier to care. While the relationship between discrimination and
racism was less clear among Africans and Caribbean Blacks, social workers and other mental
health professionals should be cognizant of the experiential and historical differences that may
influence these perceptions.
Research suggests that the perception of discrimination and racism by African Americans stems
from a history of racism and discriminatory health and medical research practices inclusive of
medical experimentation in slavery, involuntary family planning sterilization, and the Tuskegee
Syphilis Study, which revealed unethical medical practices conducted by the United States
Public Health Service (Boulware et al., 2003; Washington, 2006). It is this legacy of
maltreatment that may influence perceptions of distrust, racism, and discrimination about mental
health by some African Americans. African Americans integrate experiences from previous
social or clinical interactions to appraise current clinical encounters (Earl et al., 2011) and
transfer experiences of perceived discrimination and racism to future relationships with
providers.
The relationship between perceived discrimination and satisfaction with mental health is less
clear for Caribbean Blacks. Jackson et al. (2007) found that Spanish-speaking Caribbean Blacks
and Haitian respondents are more satisfied with mental health and medical services than are
respondents from predominantly English-speaking parts of the Caribbean. In a seminal study
conducted by Eaton and Garrison (1992) it found that Haitians reported more discrimination and
less satisfaction with mental health and with life in the U.S. than Cuban refugees. The study
examined differences in psychopathology and use of the mental health system among 952 Cuban
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and Haitian refugees living in Florida. Additional research is needed to explore the possible
impact of discrimination and racisim on mental health services use among Caribbean Blacks and
Africans living in the U.S.
The review revealed one study conducted by Jackson et al. (2007), which found both African
Americans and Caribbean Blacks utilized formal mental health infrequently, but U.S.–born
individuals were more likely to receive care than first-generation immigrants. There is also a
need to explore the phenomenon of “the immigrant paradox” for Caribbean immigrants.
According to the immigrant paradox, the longer the immigrants stay in the U.S., the more mental
health problems they have (Suarez-Orozco, Todorova, & Qin, 2006). The relationship between
the generation status of immigrants on their perceptions and use of mental health status should be
further investigated. Miranda, Siddique, Belin, and Kohn-Wood (2005) found that Black women
born outside the United States (in Africa or the Caribbean) were less likely to screen positive for
depression. However, the longer they lived in the United States, the more likely they were to
screen positive for depression. Social workers should be aware of the impact of immigration on
the mental health risk of Caribbean Blacks. Additionally, more needs to be known about the
impact of immigration on mental risk and access among Africans living in the U.S. as well.
Social workers must pay attention to structural racism, its implications, and underlying
ideologies that foster discrimination against individuals (Viruell-Fuentes, Miranda, &
Abdulrahim, 2012). Social workers are mental health providers and can act as conduits and
facilitators of communication between patients and providers (Gaston, Gutierrez, & Nisanci,
2014). They should actively engage in dialogue with their clients and health care professionals in
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their practice settings about the everyday realities of African, African American, and Caribbean
Black clients that include experiences of racial discrimination and oppression.
The most salient cultural barrier found was stigma attached to mental health problems and
treatment among African Americans, Africans, and Caribbean Blacks. Research suggests that
stigma related to accessing and engaging in mental health treatment often discourages patients
from pursuing care (Hine, Howell, & Yonkers, 2008; Corrigan, 2004). Stigma is a well-
documented barrier for African Americans’ access to mental health care (Brown et al., 2010;
Conner et al., 2010b; Mishra et al., 2009). The pressure to be “strong” may be one factor that
perpetuates mental health stigma among African American women. For example, Ward et al.
(2009) found that the normalization of challenging life conditions and community pressure to be
a “strong Black person” decrease African Americans’ awareness of their need for treatment.
Social workers can challenge such issues related to stigma by educating clients and the
community about mental health (Kohli, 2012; Mishra et al., 2008). Secondly, attempting to
integrate family and other sources of support will aid in the treatment process (Schwartz, Bernal,
Smith, Nicholas, 2014). Educating clients and their support system can also serve to address
potential barriers to treatment (Kohli, 2012). Finally, social workers can also work individually
with clients to deconstruct narratives and reduce self-blame about mental health issues related to
maneuvering significant structural barriers such as poverty, lack of community resources,
unemployment/underemployment, and discrimination (Corrigan, 2004; Kohli, 2012; Misra,
2008; Mulvaney-Day, 2011).”
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It would also be important for scholars to explore whether a similar phenomenon exists among
Caribbean Blacks. To date, there is a paucity of research on Caribbean Blacks’ perceptions of
mental health and U.S.–based mental health services, even though they are the largest Black
immigrant population. We found no information on mental health perceptions among individuals
from Jamaica, the Dominican Republic, Trinidad and Tobago, and only two studies on those
from Haiti. Although it is unclear if this preference is related to stigma, one study on Haitians
residing in the United States shows that they prefer to seek assistance from family versus mental
health professionals, (Schwartz et al., 2012). Nadeem, Lange, Edge, Fongwa, Belin, & Miranda
(2007) found that, among a sample of 15,383 immigrant and U.S.–born Black and Latina
women, African and Caribbean immigrants were more likely to worry about stigma related to
mental health care. This raises concerns of stigma being an issue for Caribbean Blacks.
Some international studies also support this idea and associate stigma with reduced mental health
access among Caribbean’s. Youssef, Bachew, Bodie, Leach, Morris, and Sherma (2012) studied
knowledge and attitudes about mental illness among a sample of 673 individuals from university
campuses in Jamaica, Barbados, and Trinidad and Tobago and found that stigma is associated
with being diagnosed with schizophrenia and substance abuse. These findings suggest that
educational campaigns may be needed to reduce stigma and discrimination for individuals with
certain mental health issues. Similarly, Arthur, Hickling, Hickling-Robertson, Haynes-Robinson,
Abel, and Whitney (2010) in a study of 126 socioeconomically diverse individuals from
Kingston, Jamaica, found that barriers to mental health include perceptions of stigma, negative
associations of mental illness with “madness,” and avoidance. More research needs to explore if
stigma affects mental health use among Caribbean Blacks living in the U.S.
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The literature revealed only two studies on African immigrant perceptions of mental health in the
United States. While themes could not be generated, stigma appeared to influence perceptions of
mental health services (Ezeobele, 2010; Piwowarczyk et al., 2014). Similarly, in an international
study conducted in South Africa, Egbe et al (2014) found among a sample of 77 South African
mental health services users that stigma was perpetuated by family members, friends, employers,
community leaders and health providers. The authors suggested that mental health services
aimed at treating this population should integrate the patient’s support system and teach the
patient how to deal with internalized stigma. It is important for additional research to extrapolate
perceptions of mental health among Africans from various countries. The African continent is
rich in diversity; researchers and social workers need to continue to explore the specific needs of
African immigrants from specific countries.
Conclusion
It is important for social workers to help create an environment where mental health perception
barriers can be addressed by engaging in culturally specific practice. Multilayered and complex
factors appear to affect African Americans,’ Africans, and Caribbean Blacks’ access to and use
of mental health services. Diversity within the Black population calls for additional research that
explores perception barriers about mental health among African Americans, Africans, and
Caribbean Blacks. The increasing recognition of culture as an important factor in public health
and communication has the potential to contribute to the development of new and more effective
strategies to help eliminate health (Kreuter & McClure, 2004) and behavioral health disparities.
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Of concern was the limited number of studies that focused on specific groups of Africans and
Caribbean Blacks living in the U.S. Social workers need to be aware that African and Caribbean
clients might be coming from different cultural backgrounds and may be facing challenges that
stem from immigrant status and history. Behavioral health specialists should be clinically
trained, bi-lingual, and culturally competent social workers or psychologists (Manoleas, 2008).
In the end, the paucity of research that extrapolates intra-group diversity among Black
Americans in the U.S. underscores the need for a deeper understanding of this complex interplay
of attitudes, barriers, and other forces influencing perceptions of mental health services and
subsequent access to care.
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Table 1—Total of Number of Studies Reviewed,
Population
Total Number
of Studies
Reviewed
Studies Meeting
Search Criteria
Total included in the
Review
African Americans 345 197 23
Caribbean Blacks 121 42 2
Africans 38 7 2
Mixed Population 56 32 3
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2002-2014
Study Research
Focus
Research
Design
Sample
Size
Population Key Findings Subthemes
Alvidrez
et. al.
2010
Examine
whether
stigma and
other
concerns
about
entering
treatment
had an
impact on
engagement
and service
use across 3
months.
Quantitative
42
African
Americans
African
American men
and those with
more education
perceived more
stigma in
mental health
care. However,
perceived
stigma was not
related to
treatment
engagement.
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Barksdale
and
Examine
whether
Cross-
sectional
219 African
Americans
Individually,
peer and family
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Molock,
2009
perceived
negative
peer and
family
norms
about help
seeking
influence
help-
seeking
intentions.
internet
survey
norms were
related to help-
seeking
intentions.
Individuals
with higher
negative family
norms had
lower help-
seeking
intention scores
(strongest
predictor).
Family
influence is a
unique
predictor for
African
Americans.
Brown et. Examine
level of
Telephone 449 African
American
The
internalization
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al. 2010 depressive
symptoms,
stigma and
treatment
related
attitudes
and
behaviors.
survey
and
White.
of stigma is key
in the
development of
negative
attitudes
toward mental
health
treatment
among African
Americans.
Conner
et. al.
2010
Explore
attitudes
and beliefs
about
depression
and mental
health
treatment.
Qualitative
42 Older
adult
African
Americans
Barriers to
treatment were
perceptions of
depression
(“this is
normal”, not
recognizing
symptoms), the
African
American
experience
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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(racism,
discrimination),
treatment
weakness and
last resort, and
negative
beliefs.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research
Focus
Research
Design
Sample
Size
Population Key Findings Subthemes
Conner
et al.,
2010
Examine
older adult
African
Americans
with
depression
perceptions
of barriers to
seeking
mental
health
treatment.
Qualitative 37 African
American
older
adults
Participants
reported fear of
stigma, mistrust
of mental health
treatment, lack
of access, sense
of being too old
to seek
treatment, and
the lack of
recognition of
mental health
symptoms due
to persistent
stress in the
community were
barriers to
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Subthemes
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mental health
treatment
seeking.
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Copeland
and
Snyder
2011
Explore
barriers to
mental
health care
among
women that
sought care
for their
children, but
not
themselves.
Qualitative 64 African
American
women
Barriers to
seeking mental
health treatment
was the fear of
losing their
children,
economic
stressors, and
beliefs that
providers were
not trustful and
would
overmedicate
them.
Earl et.
al. 2011
Explore the
initial
interpersonal
Qualitative 25 African
American
patients
Patients have
previous within
and outside
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interactions
between
African
American
patients and
their non-
African
American
mental
health
providers.
and their
non-
African
American
providers
treatment
experiences
(discrimination,
mistrust, and
stereotyping)
that can lead to
healthy cultural
paranoia
(caution and
skepticism).
Facilitators of
good
interactions
were discussed.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research
Focus
Research
Design
Sample
Size
Population Key Findings Subthemes
Hines-
Martin et.
al. 2003
Examine
the barriers
to mental
health care
service use
among
low-
income
African
Americans.
Qualitative 24 African
Americans
Individual
barriers were
fear, denial,
economic, and
values.
Environmental
barriers were
family issues,
community,
and resources.
Institutional
barriers were
time,
limitations,
gatekeepers
and rules.
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Subthemes
Discrimination
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Leis et. al.
2011
Explore
perceptions
of mental
health
services
and its
effect on
service use
among
clients
from a
home
visiting
program.
Qualitative 64 African
Americans
Overall,
perceptions of
mental health
services were
negative.
Negative
perceptions
included
beliefs that
providers gave
medications
without
listening,
concerns about
confidentiality,
suspicion
about
psychotherapy
and
psychotropic
drugs.
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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Leis, J. A.,
Mendelson,
T., Perry,
D. F., and
Tandon, D.
T., 2011
Explore
perceptions
of mental
health
services as
a barriers
to use
among
perinatal
African
American
women.
Qualitative 38
clients
26
staff
African
American
women
Perceptions of
mental health
were negative
with many
participants
believing that
stigma, lack of
confidentiality,
psychotropic
medication,
and
questionable
effectiveness
of
psychotherapy
was significant
barriers to
mental health
treatment
seeking.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research
Focus
Research
Design
Sample
Size
Population Key
Findings
Subthemes
Lindsey
and
Marcell,
2012
Explore
African
American
males’
perceptions
of help-
seeking for
mental
health.
Qualitative 27 Young
adult
African
American
men
Barriers to
mental
health
seeking were
engaging in
coping
activities in
isolation, at
the social
level (drug
use), and
negative
community
beliefs about
mental
health.
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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Mishra et.
al. 2009
Better
understand
mental and
illness
information
and service
delivery
preferences.
Qualitative 42 African
Americans
Providers
should be
non-
threatening,
credible,
accessible,
and
incorporate
spirituality in
treatment.
Stigma and
perceptions
of racism as
barriers to
seeking
treatment.
Mulvaney-
Day et. al.
2011
Examine
preferences
for
relational
Qualitative 51 African
American,
Latino,
and White.
No primary
differences
in major
preferences
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styles in
encounters
with mental
health
providers
among a
diverse
sample.
among
ethnic
groups.
However,
African
American
patients
believed it
was
important to
be
understood
and
respected as
experts.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health,
2003-2013
Study Research
Focus
Research
Design
Sample
Size
Populatio
n
Key Finding Subthemes
Murry,
Heflinger
, Suiter,
and
Brody,
2011
Examine
perception
s about
mental
health and
help-
seeking
among
rural
families of
adolescent
s with
mental
illness
Mixed
method
163
(survey)
21
(qualitativ
e
interviews
)
African
American
mothers
Preferences
for social
support were
family,
religious
institutions,
and school.
Stigma and
cultural
mistrust were
barriers to
help seeking.
Discriminatio
n
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Subthemes Neighbor Examine Quantitativ 55 Older Mental health
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s et. al.
2009
mental
health
services
utilization.
e African
American
s
services were
underutilized.
Those who
were 65 and
older were
less likely to
receive
mental health
or general
medical
treatment
compared to
those under
the age of 65.
Participants
with a high
school
education or
higher were
more likely to
use mental
health
Discriminatio
n
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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services.
Newhill
and
Harris,
2007
Explore
how
African
American
consumers
of mental
health
perceive
and
experience
disparities
in
accessing
and
utilizing
mental
health
services.
Qualitative 35 African
American
men and
women
Participants
reported that
the fear of
stigma was a
barrier to help
seeking.
Suggestions
to ameliorate
this issue
would be for
practitioners
to outreach
and engage
pastors and
their
congregations
. Another
barrier was
the shortage
of African
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American
psychiatrists
and therapist.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research Focus Research
Design
Sampl
e Size
Populatio
n
Key Findings Subthemes
Richman
et. al.
2007
Examine the
role of race,
discrimination
and racial
identity in
explaining
mental health
service
utilization.
Quantitativ
e
955
African
American
and
White
adults.
Past
discrimination
and identity
variables are
more
important than
structural
variables such
as education or
income in
explaining
mental health
utilization.
Discriminatio
n
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Subthemes Sanders-
Thompso
n, Bazile,
Examine
beliefs
regarding
Qualitative 201 African
American
men and
Participants
associated the
term
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and
Akbar,
2004
psychotherapist
s,
psychotherapy,
and barriers to
seeking mental
health
treatment.
women psychotherapy
with stigma.
Psychologists
were perceived
to be White
male elitists
who were
unsympathetic,
uncaring, and
unavailable.
They preferred
the term
counseling.
Barriers to
treatment were
stigma,
financial costs,
and the lack of
recognition of
mental health
issues.
Discriminatio
n
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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Thompso
n et. al.
2011
Explore
participants’
past experience
and satisfaction
with mental
health services.
Qualitative
40
African
American
s mothers
and their
youths.
About half of
the mothers
dissatisfied
with services.
Group and
family therapy
was positively
regarded.
Dissatisfaction
centered on
medication
concerns, lack
of
professionalis
m,
confidentiality,
and poor
quality
treatment.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research
Focus
Research
Design
Sample
Size
Population Key Findings Subthemes
Thurston
and
Phares,
2010
Examine
the
influence of
parents’
gender,
race, and
mental
health on
perceived
barriers and
attitudes
about
treatment.
Quantitative
194
African
American
and White
parents.
White parents
were not
significantly
different in
child-related
attitudes.
White parents
did perceive
fewer barriers
to treatment
utilization for
themselves and
their children
than did
African
American
Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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parents. Discrimination
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
Ward
2005
Examine
African
American
client’s
subjective
experiences
in
counseling.
Qualitative
13 African
Americans
Participants
engaged in
continuous
assessment of
client-therapist
match
(salience of
Black identity,
confidentiality,
and similarity
in ideology
and
perspectives
about
parenting),
safety, and
previous
experience
working with
African
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Americans.
Ward
and
Heidrich
2009
Examine
beliefs
about
mental
illness,
coping
behaviors,
and
treatment
seeking.
Exploratory,
cross-
sectional
survey.
185 African
American
women
83% reported
feeling
comfortable
talking to a
mental health
professional.
60% would not
be
embarrassed if
friends knew
they were
seeking mental
health
treatment.
However,
stigma was
significantly
related to
treatment
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seeking.
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Table 2—Summary of Studies that Explore African American Perceptions of Mental Health, 2003-2013
Study Research
Focus
Research
Design
Sampl
e Size
Population Key Findings Subthemes
Ward et.
al. 2009
Examine
beliefs about
mental
illness,
coping
behaviors,
barriers to
treatment
seeking.
Qualitative 15 African
American
women
Individual
level barriers
were more
prevalent than
systemic
barriers.
Treatment-
seeking
barriers
included poor
access to care
(agency and
socioeconomic
issues),
stigma, and
lack of
awareness of
Discriminatio
n
Stigma
Peer/Family
Support
Mistrust
Racism
Economic
stress
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mental illness.
Ward,
Wiltshire
, Detry,
and
Brown,
2013
Examine
African
Americans’
beliefs about
mental
illness, help
seeking, and
coping
mechanisms
.
Quantitativ
e
272 African
American
men and
women
Participants
were not very
open to
acknowledgin
g
psychological
problems due
to stigma
concerns.
Participants
were
somewhat
open to
seeking help,
but preferred
religious based
coping
mechanisms.
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Williams
et al.,
2007
Examine the
prevalence
of
psychiatric
disorders
among
Black
Caribbean
immigrants
and African
Americans.
Quantitativ
e
6082 African
Americans
,
Caribbean
Black, and
non-
Hispanic
Whites.
Compared to
African
American
men,
Caribbean
Black men had
higher risk for
psychiatric
disorders.
Haitian and
Spanish men
had lower
odds for mood
disorders than
men from
English-
speaking
Caribbean.
Third
generation
Caribbean
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Blacks had
elevated rates
of psychiatric
disorders than
first and
second
generation.
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Table 3— African and Caribbean Black Perceptions of Mental Health Services in the United States, 2002-2014
Study Research
Focus
Research
Design
Sample
Size
Population Key Findings
Jackson et al.,
2007
Examine the
use and
correlates of
formal
psychiatric
services
between U.S
born and
immigrant
Caribbean
Blacks.
Quantitative 3570 Spanish-
speaking
Caribbean’s,
Haitians, and
English-
speaking
Caribbean’s.
Haitian
respondents were
more likely to
report satisfaction
for specialty
mental health and
African
Americans.
Caribbean Blacks
from English-
speaking
countries were
less likely than
those from
Spanish-speaking
Caribbean and
Haiti as less
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helpful.
Schwartz,
Bernal, Smith,
and Nicolas,
2012
Examines
help-seeking
patterns of
behavior
among
Haitian
immigrants
living in the
U.S.
Quantitative
150
Haitian
immigrants
living in the
U.S.
Participants were
least likely to go
to professionals
for mental health
services.
Participants relied
upon family or
relatives
regardless of the
problem.
Piwowarczky
et al., 2014
Examined
both concepts
of mental
illness in
addition to
attitude and
beliefs about
treatment and
barriers to
Mixed
methods
344 Congolese
and Somali
immigrants
Mental health
concerns were
often dealt with in
the family. Faith
based coping was
used to address
mental health
concerns.
Formalized
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seeking
treatment
among
Congolese
and Somali
men and
women living
in the U.S.
mental health
services in the
U.S. were not
well understood
by the sample.
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Table 3— African and Caribbean Black Perceptions of Mental Health Services in the United States, 2002-2014
Study Research Focus Research Design Sample
Size
Population Key Findings
Ezeobele
2010
Examined
perceptions of
depression
among Nigerian
immigrant
women living in
the U.S.
Phenomenological
study
19 Nigerian
immigrant
women
Stigma was a
major barrier to
seeking mental
health services.
Participants
reported being
isolated from
family after
being
diagnosed with
depression.
Religious
coping was
used more than
formalized
mental health
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services.
DeJesus
and Earl
2014
The aim of this
study was to
identify
indicators of
quality of mental
health care that
matter most to
two
underrepresented
immigrant
patient groups:
Brazilians and
Cape Verdeans.
Qualitative; focus
groups
24
Brazilians
and 24
Cape
Verdeans
Brazilians
and Cape
Verdeans
The
effectiveness of
mental health
care treatment
was related to
two categories
inclusive of the
therapeutic
relationship
and treatment
outcomes.
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