Mental-health care needs a culture check
More than 30 years ago, I published a paper that examined violent incidents involving African-American and white patients in an inpatient psychiatric facility. To the surprise of nearly everyone at the time, the study found AfricanAmericans patients were less violent than whites. The study has been replicated multiple times, and the explanation was that African-American patients were more closely supervised, more likely to be put into restraints and given heavier doses of medication. In fact, the staff perceived the African-American patients as being more violent even though the evidence was to the contrary.
As a result, the staff was more aggressive in responding to any behavioral problems. At the time, I did not see the findings having broad implications. Now, decades later I am finding that I underestimated the importance and generalizability of the findings.
African-Americans and particularly African-American men continue to be perceived as being violent when they are not. This phenomenon is not simply a belief system but also appears to be an overriding perceptual reality that directs the behavior of caretakers and law enforcement officers.
A parallel narrative is that a person who is severely mentally ill is often perceived as being dangerous and violent. Violent acts and murders with no obvious motive are often blamed on someone having a mental disorder. This perception is held despite evidence showing that people who are mentally ill are not more violent than the general population when substance abuse is controlled or treatment is provided.
So the real problem happens when these two thoughts are combined — the combination of minority status and mental illness apparently is especially violent.
There have been more newsworthy events of violence against African Americans by police or violence toward police. Often the explanation is of the police or community being threatened by a violent mentally unstable African American. The response has often been lethal force.
Most recently, a Miami police officer shot an African-American caretaker of an autistic man playing in the street with his toy truck. The officer stated at the time that he did not know why he shot and that he was aiming at the autistic man. A common theme in these episodes is that disturbed individuals were dealt with by lethal force, and that they were African-American and mentally disturbed.
These events must be taken into the context of recurrent findings that African Americans get the least optimistic diagnoses when mentally ill, are more likely to be incarcerated, and if hospitalized to be treated involuntarily are sometimes given excessive doses of medication.
African-Americans are at risk in multiple ways. First, treatment is often unavailable. When an intervention is available, treatment appears to be a last resort. Punitive force seems to be the intervention of choice. The lack of treatment resources for mental health and substance abuse treatment increases the risk of violence. Underlying much of these behaviors are beliefs about African Americans and the mentally ill that shape perceptions that end up victimizing the individual.
Moving forward, medical students, first responders, law enforcement officers and those who teach these professions should receive cultural competence training on a regular basis. They should have dialogues with minority communities on a more regular basis and receive more in-depth mental health first-aid training. First responders and law enforcement officers should also have regular attitudinal evaluations and ongoing assessments for job stress. In all cases, recognition and awards should be given for positive encounters.
There clearly has been an unwillingness to discuss racial issues because some feel that such talk is divisive. Yet such a dialogue is necessary to gain an appreciation of how negative racial attitudes can impact not only beliefs but perceptions. Such dialogues are a first step, but more is needed. Active programs must be implemented to reduce stigma, improve mental health literacy and most important, to improve access to care.