Structural Racism as a Determinant of Black Mental Health: Looking Back to Move Forward

Since the founding of colonial America, scientific racism has been used to justify the enslavement of Black people under false claims of mental inferiority and innate physical abilities that made them uniquely suited to bondage. In the mid-1800s, Dr. Samuel Cartwright, a prominent pro-slavery physician, published scientific literature asserting that enslaved individuals attempting to flee captivity (a diagnosis called “Drapetomania”) or who were insubordinate to their oppressors were suffering from mental illnesses that could only be “treated” with further subjugation (Cartwright, 1851; Krieger, 2011; Bassett & Graves, 2018). Flawed statistics demonstrating so-called higher insanity rates among Black individuals in free states versus slave states were used justify the continuation of slavery in the South and served as a common argument that was backed with “data” against abolition (Krieger, 2011). Scientific racism persisted well into the 20^th century, perpetuating ideas of Black “inferiority” to justify continued dehumanization in the medical system and medical experimentation in Black communities (Washington, 2006; Bailey et al., 2021).

Leading up to the Civil Rights Movement, schizophrenia was increasingly reframed as a disease that mostly afflicted middle class white women to an aggressive disorder that primarily manifested in Black men (Metzl, 2010; Metzl & Roberts, 2014). Subsequently, Black men were viewed and treated as innately aggressive, prone to violence, and mentally ill – creating the grounds for institutionalization and intervention by medical institutions to treat, cure, or otherwise contain these individuals. Black Civil Rights activists were labeled as delusional, psychotic, and schizophrenic—symptoms and conditions that were seemingly triggered by their participation in the social and political movements at the time (Bromberg & Simon, 1968). This reframing of schizophrenia and the portrayal of Black men as mentally unwell created another pathway by which the medical system could exert social control over Black bodies who were seen as a threat to the existing white dominant order. This false narrative of Black men as inherently aggressive or criminal likewise provided justification for increased police presence and accompanying police violence to maintain “social order” in Black communities. A similar vilification of Black women occurred where, in the late 1980s, hospitals and law enforcement officials, urged on by the “crack epidemic” and the War on Drugs, began drug testing, arresting, and incarcerating pregnant women, most of whom were Black (Metzl & Roberts, 2014). Instead of receiving much needed treatment for their substance use, these women were vilified and criminalized – a practice that was a result of problematic racial stereotypes and federal policy that unequally criminalized substance use taking place in Black communities compared to white communities (Metzl & Roberts, 2014).

The continued criminalization of Black men and women experiencing mental health issues has created a perpetual cycle wherein these individuals are perceived as inherently aggressive or threatening and are responded to with violence. In just the past few years, the use of police as first responders to mental health crises led to the needless deaths of Black Americans such as Marcus-David Peters, Natasha McKenna, Daniel Prude, and perhaps unnamed others (Boyd et al., 2016; Jordan et al., 2021). A study by Thomas, Jewell, and Allen (2018) indicates that police are more likely to fatally kill unarmed, older Black, mentally ill men compared to their white counterparts. Black individuals in need of mental health treatment may be racially profiled, experience police violence, be taken into police custody, and experience subsequent incarceration. Incarceration itself is associated with several poor health outcomes, infectious disease risk, psychological distress, and further victimization for experiencing mental health symptoms instead of receiving treatment (e.g., solitary confinement) (Nowotny & Kuptsevych‐Timmer, 2018). Those with mental health conditions are overrepresented in the incarcerated population. One study from Los Angeles county indicated that 40% of Black inmates were receiving mental health services although only representing 30% of the incarcerated population (Appel, 2020). Police violence and mass incarceration have a negative impact on the mental health of entire communities. Bor, Venkataramani, Williams, and Tsai (2018) provide evidence that the occurrence of police killings damages the mental health of Black individuals, even if they are not directly related or involved with these incidents. The use of police as first responders to mental health crises is one mechanism that continues to traumatize whole communities and maintain the disproportionate incarceration of Black individuals.

The funneling of Black individuals with mental illness into the prison pipeline is also a consequence of the many failures of the U.S. healthcare system to provide access to adequate and appropriate mental health treatment. Lack of guaranteed access to health insurance in the U.S. can make it difficult for these individuals to enter the health care system in the first place. Once in the healthcare setting, provider bias and unconscious internalization of harmful stereotypes may mean that Black individuals in need of treatment are not asked about their symptoms, do not receive treatment, and if they do receive treatment – it is divorced from their social and environmental contexts. Today, doctors are still more likely to overdiagnosis Black men with schizophrenia, prescribe higher dosages of antipsychotic medication, and describe these patients as hostile or violent (Metzl, 2010; Metzl & Roberts, 2014). Black patients are far more likely to be diagnosed with schizophrenia and less likely to be diagnosed with mood disorders, despite exhibiting the same symptoms as white patients (Gara et al., 2012; Schwartz & Blankenship, 2014). Doctors are also less likely to prescribe medication or offer treatment to Black patients (McGuire & Miranda, 2008).

Current mental health supports are likely not meeting the needs of Black individuals with mental health conditions. In addition to provider bias, lack of culturally-appropriate care and the absence of a systematic trauma-informed approach that acknowledges the unique stressors and generational trauma experienced in Black communities remain substantial barriers to treatment (Novacek et al., 2020). In 2015, data from the American Community Survey indicated that only 4% of psychologists were Black compared to the 86% who identified as white (Lin et al., 2018), and in 2017, only 2% of the members of the American Psychological Association identified as Black (American Psychological Association, 2017). These systemic issues in the health care setting are compounded by generational distrust of the medical system due to historical exploitation and experimentation in Black communities (Washington, 2006).

Underscoring the issues posed by scientific racism, mass incarceration, and healthcare fragmentation are the settings in which these systemic barriers play out. Racial residential segregation and racial redlining are mechanisms that have concentrated poverty in communities of color for generations and many urban communities continue to be racially segregated today (Osypuk & Acevedo-Garcia, 2010; Rothstein, 2017). Racial residential segregation led to the deliberate disinvestment of resources from neighborhoods where Black people were forced to reside (Fullilove, 2001). Segregation systematically structures racialized access to education, employment, safe living conditions, food, tobacco, alcohol, and medical care – all of which are important determinants of mental health (Williams & Collins, 2001; Fullilove, 2001; Maguire et al., 2016;). Redlining is independently associated with higher preterm birth, lower life expectancy and greater prevalence of chronic diseases (McClure et al., 2019; Krieger et al., 2020; Nardone et al., 2020). The stressful conditions created by segregation such as poverty, violence, and crime can all work together to create mental harm among the residents who reside in these segregated neighborhoods (Fowler et al., 2009). Furthermore, crime and violence in these communities is often used to justify and maintain a high police presence and perpetuates the practice of police as first responders to mental health crises. Descriptions of Black, segregated communities as “inherently more violent or criminal” typically fail to mention the historical policies that created these conditions such as the 1970s “War on Drugs” and various criminal justice reforms in the 1980s and 1990s that triggered mass incarceration, disproportionately criminalized the actions of Black people, widely expanded police funding and presence, and facilitated the ease by formerly incarcerated individuals could and would be reincarcerated (Moore & Elkavich, 2008; Schoenfeld, 2012). Indefinite police presence also serves as a way to maintain the racial boundaries of communities created by segregation.

On the interpersonal level, stigma – in the form of negative attitudes to those with mental health conditions – may prevent individuals from seeking treatment. If mental illness is framed as a personal failing, people may feel shame, fear about opening up with others in their support network, and fear provider bias (Brown et al., 2010). There is evidence to suggest that stigma may be a more important barrier in seeking mental health treatment among Black individuals compared to other racial or ethnic groups and that mental health stigma may be stronger in Black communities. A qualitative study by Campbell and Mowbray (2016) found that Black American participants perceived that those with depression are seen as “crazy” or “weak” and thus either hid their symptoms or did not seek treatment at all to avoid being seen or treated differently. Among some participants, depression was racialized and gendered as being something that primarily affected white women and not something prevalent in their community (Campbell & Mowbray, 2016). While the stigma of mental illness serves as a deterrent for seeking treatment for anyone, this effect may be especially pronounced in Black communities.

Importantly, we must consider the occurrence of everyday discrimination that may wear and tear on a Black individual’s mental health. Both interpersonal discrimination and wider systemic inequities lead to poorer mental health outcomes among Black and African-American individuals in the U.S. (Williams, 2018; Williams, Lawrence, Davis, & Vu, 2019). There are several mechanisms by which discrimination can induce stressful conditions that uniquely impact people of color and harm mental health. Experiences of interpersonal discrimination can prompt feelings of “self-defilement” wherein discriminated individuals feel misunderstood, disrespected, over-scrutinized and feel distressed over the contradictory nature of these experiences to larger U.S. societal messages and expectations of equality and fairness for all (Fleming et al., 2012; Williams, 2018). Past experiences with interpersonal discrimination as well as the perceived threat of discrimination can trigger a state of “heightened vigilance,” by which people of color navigate through life in a constant state of psychological arousal in order to better anticipate and protect themselves from potential threats of discrimination from people and environments (Himmelstein et al., 2015; Williams, 2018). Exposure to persistent negative stereotypes in the media and microaggressions in interpersonal encounters (broadly, cultural racism) can cause acute feelings of distress, and the accumulation of these experiences over time can impact mental health and wellbeing (Nadal et al., 2014; Williams, 2018). Repeated experiences of interpersonal discrimination may also contribute to feelings of internalized racism or internalized stigma. Internalized racism is characterized by acceptance of one’s marginalized status in society, negative feelings toward same race and other nonwhite racial groups, endorsement of white superiority, acceptance of negative stereotypes, and feelings of low self-esteem and worthlessness (Kwate & Meyer 2011; Williams, 2018). Studies measuring internalized racism have found associations between higher feelings of internalized racism and lower levels of self-esteem, greater levels of depressive symptoms and more psychological distress (Brown et al., 2002; Hughes et al. 2015; Mouzon & McLean, 2017; Williams, 2018).