Walker, who is Black, sees two barriers to access for African Americans: getting in the door, and sticking with treatment long enough to get well. The former is often influenced by a combination of socio-economic factors—we know poverty and isolation discriminate along stark racial lines—and the assumption you don’t need or deserve help.
The tendency of Black Americans and other minorities to quit care is complex but it’s attributable in part to a sense of un-belonging, Walker says. And it’s on the clinician to address it. “There’s this idea that, ‘Oh, no one’s even presenting themselves for care.’ And I think, no, the burden is on the therapist that when someone does show up, you make an extra effort to keep that person in care. Even if you’re uncomfortable.”
Gursharan Virdee, who is a Toronto-based psychologist and researcher, tells me she sees it in the patients she works with—young South Asian Canadian women who come to her multilingual practice after seeking mental health help from more mainstream providers and not feeling seen.
“I’ve worked with a young woman who wears hijab, was never asked by her therapist about her religion and so on, and the not asking actually led this young woman to disengage because she didn’t feel empowered to share or kind of talk from that position,” she says to me by phone.6 Another young woman felt her former therapist didn’t get her family dynamic, where she was undervalued relative to the men in her family and how that factored into pathological feelings of worthlessness. “There’s a lack of awareness of the role of culture in one’s experience and how that might shape a person’s mental health.”
Napoleon Harrington, a Michigan-based counsellor who focuses much of his work and advocacy on communities of colour, sees three factors preventing Black Americans from accessing mental health care when they need it. One is a cultural mythology of strength. “We’ve been identified as a strong people, and when strength is mischaracterized it gets identified as not needing support or not needing help or not being willing to depend on resources that may in one regard oppress you and maybe in another way render you weak. So I think because strength has been mischaracterized in our culture it gives the impression that we can’t find those resources.”7
The second is religion—a powerful protective factor when it comes to thinking of killing yourself, but also a potential deterrent from seeking secular care. “Reliance on God is extremely heavy, and reliance on God to cure you, to deliver you, to heal you and all of those conversations that come from each of those convictions…[means] I don’t have faith if I get help.”
The third: Would you trust your thoughts and feelings to a doctor, a counsellor, embedded within a system with a long history of treating you and people who look like you like lesser persons? “Black folks and brown folks have a challenge with a system that has not always been in their best interest…it makes us very, very mistrusting of anybody who works within that system.” And if people of colour are more likely to be incarcerated and more likely to have their kids taken from them by child welfare agencies, maybe you’re less likely to confide in a clinician with the power to set either of those things in motion.
Of those three factors, Harrington is best positioned to tackle the first—to convince people of colour, especially in the Black community, that mental health is something that should be on their mind, that mental health care is something they may need and that there’s no shame in seeking it. He tries to meet people where they’re at; use straightforward “stigma-free” language; use slang and Ebonics if it seems helpful.
I ask him, a Black counsellor, if he has advice for a white clinician working with people of colour. What should they take into account, without projecting?
“The intolerant history of America and its behaviour toward Black and brown people has created a layer of anxiety, trauma, depression, you name it…a layer that’s palpable enough for anyone who’s brown in America to feel it….So I think the major difference is, every time you’re working with someone of a Black or brown context, [remember that] that layer somehow is always present even if they’re wildly successful, they have enough money or what have you, they will always meet something or someone that reminds them that race is still present.”
JASMIN
No one thought to ask Jasmin what was going on in her mind when she tried to annihilate herself. When she swallowed a pack of high-strength allergy medication and wound up delirious and hospitalized. Not when her mom came to the emergency department to meet her and the panicked friends who’d rushed her there. Not when she drank, at nurses’ urging, an activated charcoal smoothie to keep toxins from sinking into her system. Not when she was discharged back out into the world.
“Why didn’t anyone think to say, ‘Are you depressed? What’s going on?’ I just knew I wanted to die.”8
Eighteen years old, getting over a bad breakup, preparing to move out of her mom’s place and go to college, Jasmin felt her life become inexplicably unbearable. “I just felt like the walls were closing in on me.”
That time—the first time—the decision to swallow the entire off-brand allergy prescription she’d just filled was entirely impulsive. “I wasn’t really thinking straight….After I did it, I was like, ‘Why did I do that?’ I didn’t understand.”
In the hospital, with her worried mom and friends, Jasmin felt more embarrassed than anything. They asked, “‘Why would you do something like that? Why would you want to take your own life?’ I told them there was a lot going on.”
She was mad at herself. She felt stupid. Overemotional, overreacting. “After a while I just let it go.”
And that was that. Jasmin moved from Kentucky to Louisiana, living with her dad in New Orleans while she went to college.
But it didn’t go well and she didn’t know why. She couldn’t concentrate, kept having to retake classes. Kept messing up orders at the pizza place where she worked. She blamed her skittering brain on distractedness. Admonished herself to do better.
But the walls kept closing in. The second time, at age twenty, Jasmin meant it. “The second time I was like, ‘Okay, I know for sure I don’t want to be here anymore.’”
She swallowed a bottle of Tylenol. Her dad, home from work early, found her and took her to hospital. This time it took a tube snaking down her throat to exhume the poison. Thirty minutes watching gunk slurp through the clear plastic tube clawing against her esophagus.
“That was a really horrible day….I was mad that it didn’t work.”
This time, she was sent to a psychiatric facility. “It was a really nice place, but of course I didn’t want to be there. I didn’t want anybody to be all up in my business.” And it freaked her out to be in close quarters for the first time with people with severe mental illness, behaving erratically. She wasn’t one of them, she told herself. She wasn’t nuts. “It was scary. I saw things I’d never seen before….At the time I was like, ‘Why do you have me in here with people like this?’ I was angry. I wanted to leave….My family came and saw me a few times. I felt so embarrassed: here she is, in a psychiatric hospital.”
She refused to talk to the psychiatrist at first, furious at her captivity. Changed tack the second day “because I was determined to get out of there and I knew if I didn’t talk to anybody, I couldn’t.”
He diagnosed her with depression. The diagnosis was not comforting.
“It actually felt worse. I just thought that people who had mental illness were crazy. That’s what you saw on TV,” she said. “I’m like, ‘Well, I’m not crazy, so why are they telling me I’m depressed?’”
For six months Jasmin got what vanishingly few depressed people get: evidence-based treatment. Antidepressants and psychotherapy based on science. Unfortunately, six months is a nanosecond when it comes to chronic mood disorders. The meds dampened her depression but didn’t alleviate it. When the side effects—irritability and insomnia were the worst—threatened to eclipse the symptoms the drugs tried to treat, she went off them entirely. “You get really frustrated after a while
.” Her psychiatric visits lasted a few months more. “He was a good doctor, but I still wasn’t really comfortable talking about my feelings or emotions.” In a lot of ways, Jasmin knows, she was still in denial. Refused to consider herself crazy. Didn’t tell anyone for fear they’d respond the same way she had when confronted with her fellow psych patients.
Community support systems can be a powerful protective factor for anyone dealing with mental illness, but she discovered that deep-seated communal misconceptions about sicknesses of the brain can make them worse.
“I think that one of the reasons I was so in denial for so long and I thought people with mental illness were crazy was because in the Black community, they make you think you’re just supposed to pray away a mental illness. It’s like, ‘Oh, you’re depressed? Well you’re not praying enough. You need to get closer to God.’ I think that’s the worst thing to tell somebody: How do you know someone with a mental illness hasn’t already been praying? How do you know they’re not close to God? Telling somebody something like that, it makes them feel worse.”
Jasmin’s still trying to figure out what it is that makes her community’s exhortations to stick-to-itiveness backfire when it comes to psychological resilience, why it remains so tough to reconcile the capacity to survive waves of collective and personal trauma with the reality that overwhelming psychic pain comes in different, uncontrollable forms.
“I think it goes back generations. A lot of Black people feel like we got through slavery, we got through all this, we’re supposed to be strong all the time. But don’t you think they were depressed back then? Just because you got through something doesn’t mean you don’t still have emotions.”
Even Jasmin’s dad, who never judged, who wanted to help, who wanted to convince his daughter her life was worth living, made things tougher sometimes. “There were times when he was like, ‘You need to be stronger than this.’ He never told me to snap out of it, but he’s like, ‘You have a lot going for yourself.’ That’s not a really good thing to tell someone who has a mental illness. But he didn’t understand that at the time.”
Then there was the worst year. Jasmin was out of school, out of treatment and shortly out of a job. That last, especially, was a body blow. “I’d never been fired from a job in my life. The walls were closing in on me again. This was years of everything finally building up.” She overdosed on every drug she could lay her hands on. Prescription and off the pharmacy shelf and everything at the back of the medicine cabinet. Benadryl, Tylenol, high-strength nasal decongestant, “four different prescription medications all at once.”
The nurses saved her life and Jasmin was miserable about it. “I was like, ‘I took all of this medication and I’m still alive?’ I felt like a failure. ‘I fail at life and I fail at trying to kill myself. This is just ridiculous.’”
Jasmin spent almost a week in intensive care before being transferred to a different psychiatric inpatient facility, this one a couple of hours out of town.
When she assured them she had a psychiatrist already (the guy she’d stopped seeing a while back), they discharged her relatively quickly. Her twenty-sixth birthday was the following week.
It was not a great birthday. By that point she really, really, really needed to get better. She could not countenance another trip to the ICU, another psychiatric sojourn, that claustrophobic sense of failure.
Then she found psychic respite in the unlikeliest confidante: a friend of her dad’s with no formal training but who listened in a way no one else did. “I finally found someone I can talk to and feel good afterward….It’s hard to find someone who’ll actually listen to you.” And she started doing research. It was revelatory.
“I thought I was alone the whole time. I never knew that many people, millions of people, suffer from it every day….It’s like a silent illness no one wants to talk about.”
She worked up the courage to tell people. Friends and family at first. Then everyone who would listen. She made a video of her experience, posted it on YouTube.
“I was really afraid to make that video. I made it one time and I deleted it and then I made it again. It took a couple of weeks to actually post it.” Was taken aback at the positive response. “‘You look fine on the outside but on the inside you’re not okay.’ That’s the kind of response.”
So she kept talking. Wrote a book. Participated in a documentary that screened at the Tribeca Film Festival.
It’s a redemptive story even if she knows it isn’t over. Remission isn’t the same as cure. Recovery doesn’t preclude relapse. But “I’m not ashamed of it anymore….I wanted other people to realize they’re not crazy, either.”
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IF RACE CAN be a barrier, so can culture. Reluctance to seek treatment for a progressively debilitating chronic illness—because you don’t think you need it or deserve it or the shame associated with seeking a cure seems worse than anything illness can throw at you—means that by the time you get necessary care, the disorder’s already had a chance to rip your guts out.
Maria Chiu, staff scientist with the not-for-profit Institute for Clinical Evaluative Sciences (ICES) in Toronto, has seen that reticence play out along ethnic and cultural lines: South Asian Canadian and Chinese Canadian patients admitted to a psychiatric emergency department in a Toronto hospital were in much more acute condition when they arrived compared with others in the psych ER with them. Chiu’s research revealed that Chinese patients were more likely to be admitted against their will, were more likely to be acting aggressively and were more likely to have more than three symptoms of a serious illness. South Asian patients were also more likely to be showing signs of a severe mental illness compared with the general population.9 This held true across the board. “We controlled for everything—age, sex, income, education, immigration status, marital status, urban or rural residents,” she says. “As well as the diagnosis, which is really important. I can’t think of anything else we could have adjusted for, because we took into account a lot.”10
Culture can mediate both what a person considers a mental illness and how comfortable they feel getting help for it. Fear of what seeking medical help for your mind says about you, fear of what your family or friends or community will think of you, shame at having this problem keep you from seeking help even if you’re pretty sure something is not right. There may be more reluctance to share these shameful conditions with outsiders.
“You don’t want to bring shame to the family either. And if people feel like, ‘Oh, that’s the family of the person who’s mentally ill—avoid them at all costs,’” Chiu says. “Then it’s also hard to find a job, it’s hard to find a husband or a wife in certain cultures.”
Or people view this as something to be dealt with discreetly at home, in private. “Mental hospitals in general have a bad rap. You think, ‘I don’t want to be a psych patient: people will think I’m crazy.’” So they try to manage on their own until they can’t, and they end up in hospital whether they want to be there or not. Even in families or communities that have been in Canada for generations, Chiu says, there remains an ethos that “we have to work really hard for what we have, we should not show weakness—these are things that you’re taught very young, especially if you’re an ethnic minority. And so having mental illness is seen as a weakness.”
A lack of language facility or knowledge of the health system can act as systemic barriers to accessing care too. That’s something you’d expect to see with relatively recent immigrants, but the study’s findings held true whether someone was a recent immigrant, had arrived in the country more than a decade earlier, or had been born and lived their entire lives there. “It’s the ethnicity or the culture that seems to be more important than the immigration status….You may not be as willing to share your story or your struggle because you may not think your provider can relate,” Chiu says.
We know that catching mental illness early can prevent it from getting worse, can make it less likely
to recur. The immediate and long-term harms of not addressing serious health problems early are obvious. So is the irony: by delaying care because the idea of a mental illness is too freaky to contemplate, people deteriorate and end up receiving that care in the freakiest manner possible. It affects the health care system, because hospitalization is the most costly and intensive treatment option out there.
And the response to Chiu’s research paper, once it was published, is enough to indicate she’s onto something. “People shared stories,” she tells me, “saying, ‘I’ve been through something similar; it was hard to talk to my family.’ It’s been really, really eye-opening, and really gratifying that it reached a wide audience.”
Her follow-up study had more encouraging findings: even though they show up in hospital in worse mental shape, Chinese and South Asian Canadians got better once they connected with care. Chinese patients were more likely to see psychiatrists; South Asian patients were more likely to seek mental health care from general practitioners; both were less likely to die or wind up back in hospital in the year following their hospitalization.11
Sometimes the way you’ve grown up, the community you’re in, can preclude even conceptualizing a mood disorder. Clinical depression “simply did not exist within the realm of my possibilities; or, for that matter, within the realm of possibilities for any of the black women in my world,” Meri Nana-Ama Danquah writes in her book Willow Weep for Me: A Black Woman’s Journey through Depression. Danquah, born in Ghana and raised in the US, is a writer, editor and public speaker. “The one myth that I have had to endure my entire life is that of my supposed birthright to strength. Black women are supposed to be strong—caretakers, nurturers, healers of other people—any of the twelve dozen variations of Mammy. Emotional hardship is supposed to be built into the structure of our lives. It went along with the territory….When a black woman suffers from a mental disorder, the overwhelming opinion is that she is weak. And weakness in black women is intolerable. I’ve frequently been told things like: ‘Girl, you’ve been hanging out with too many white folk’; ‘What do you have to be depressed about? If our people could make it through slavery, we can make it through anything’; ‘Take your troubles to Jesus, not no damn psychiatrist.’”
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