Rep. Jesse Jackson Jr.'s recent diagnosis of bipolar disorder has focused attention on the shame that sometimes accompanies mental health diagnoses in the African-American community. Psychiatrist William Lawson joins NPR's John Donvan to discuss why such a stigma exists.
Copyright NPR. View this article on npr.org.
JOHN DONVAN, HOST:
This is TALK OF THE NATION. I'm John Donvan in Washington. Neal Conan is away. Time was a politician admitting to needing treatment for mental illness was taking a very big chance. Time was, how about time still is? We've just had the case of congressman Jesse Jackson Jr., the Mayo Clinic now confirming that he has been there being treated for a form of bipolar disorder.
But that was only after Jackson, who had disappeared from public view, kept quiet about the reason for two months. We don't know why he chose silence for so long, though we do all understand the need for privacy. But at least Jackson, who is of course African-American, is now getting help.
Put aside the fact that he's a politician. It turns out that black men in general do not get treatment for mental illness at the same rate as other sufferers, though their rates of mental illness are just as high. What is in play there? Whose attitudes count in that equation, the patients' or the system's - or possibly both?
If you have lived any part of this experience, yourself or a loved one or a mental health care provider, give us a call. We want to hear the story. Our number is 800-989-8255. Our email address is email@example.com. And you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
Later on in the program, the unique relationship between walking and fitness. But first, black men, mental health and stigma. And I want to welcome to the program Dr. William Lawson. He is a professor and chairman of psychiatry at Howard University College of Medicine. He has done a lot of work on mood disorders among African-Americans and joins us now in Studio 3A. Welcome, Dr. Lawson, to TALK OF THE NATION.
WILLIAM LAWSON: Thank you.
DONVAN: So what are some of the factors that lead African-American men to be less likely to be getting treatment? Is it that they're less likely to seek it, or is it less available to them?
LAWSON: Unfortunately, it's all of the above. Dr. Satcher in his surgeon general's report noted that there was less accessibility of mental health services for people of color for a variety of reasons. Part of it is that many of the systems simply aren't located proximity to where people of color are. Part of it is that many professionals simply don't know how to diagnose properly African-Americans.
Many African-Americans have a lot of negative feelings about, or not even aware of mental health services. They may not be aware of the symptoms of many mental disorders, or they may believe that to be mentally ill is a sign of weakness or a sign of a character fault.
DONVAN: So there's both practicality, and there's a whole issue of stigma. There's a psychology to the psychiatry.
LAWSON: Exactly, exactly.
DONVAN: To put it that way. I've read in some places that actually the black church plays a role in African-Americans being - not going into the mainstream route to treatment?
LAWSON: I'd put it another way, that African-Americans tend to like to seek treatment or help from those institutions that they're familiar with and trust. Unfortunately, in the past, the church, while it has been very helpful in terms of general medical conditions and putting on health fairs and other support organizations, many times some of the members simply aren't aware that mental disorders of some types are in fact medical problems and need the kind of support and help that can come.
Not to say that spirituality isn't a help. It is a great help. It's not to say that you cannot get support from the church itself, but to say that it's entirely a spiritual weakness, or it's entirely a problem that has to do with your relationship with God is - misses the point. It can be treated just like diabetes, hypertension or anything else in terms of the role of spirituality and support in addressing these issues.
DONVAN: Is there a way to put - to quantify the difference between the amount of treatment that black men are getting and everybody else?
LAWSON: Yes, about - it's about half as likely, right, that they'll not get the appropriate services. We actually did a survey and found that half of the time, the disorder is underdiagnosed or misdiagnosed, and of those people who are underdiagnosed and misdiagnosed, only about half of them are adequately treated.
And of those that get treatment, and of those people who get treatment, only half of them are adequately treated. So the actual numbers that are appropriately and adequately treated are maybe much smaller, maybe as small as an eighth.
DONVAN: We're asking our listeners also to join into this conversation. If you have - if you're a black man who has experienced or is now dealing with mental illness or have a loved one who is or who have worked professionally with the black men in treating his mental illness, give us a call. We want to get your insights on what this disparity is about. Our number is 800-989-8255. And we're talking to Dr. William Lawson, who is a professor and chairman of psychiatry at Howard University.
And Dr. Lawson, you went through a lot of reasons that this disparity exists, and I want to go back and look at some of them in more detail. And the one that really interests me - because it's somewhat timeless and I thought universal - is the issue of stigma. You said that black men will feel that if they, I guess, admit to having a mental illness that it makes them less of a man.
But that's - isn't that everybody? I mean, isn't that one of the great challenges facing the mental health field as a whole, that people are embarrassed and feel weak and ashamed in acknowledging that they might have a mental illness? Is it different in the black community, or is there more of a stigma, or is there a piece of this that the rest of us don't get? Or is it the same thing that everybody else feels?
LAWSON: Yes. The stigma problem comes from two directions. One is comes from the profession, the field in of itself. When I was in medical school, I was told that black people didn't get depressed.
DONVAN: No, wait, seriously?
LAWSON: Seriously. I was told - one of my faculty members, he said, you know, you guys are lucky. You guys don't have to worry about getting these depressed feelings. And I'm told that bipolar disorder was rare to unknown in the African-American community, and I have several colleagues who have gotten accolades for discovering bipolar disorder in the African-American community.
And then the other direction is that African-American men have a lot of pressures to not only to be successful, to be competent, but to reacting as a larger society that says that African-American men are less confident, less able to do things and have - and are mentally weak.
In the field, we were originally told that African-Americans didn't have the mental apparatus to become depressed or other kinds of...
DONVAN: Wait, seriously, what era are we talking about? Because it sounds like you're talking about 1920.
LAWSON: No, we're talking about - this was actually published in papers in 1970s, 1980s, and the issue is still arising, and occasionally you see in the 1990s and even in the 21st century.
DONVAN: I want to bring in John Head. John Head is a journalist and author of a book called "Standing in the Shadows: Understanding and Overcoming Depression in Black Men." And he joins us from studios at UNCU in Durham, North Carolina. John Head, welcome to TALK OF THE NATION.
JOHN HEAD: Thank you for having me.
DONVAN: So you are very open in your book about the fact that you have dealt with depression for a long time, that it's been a long struggle for you. And we were just on the topic of stigma, and I want to know, you know, you're a guy who wrote a book about it, which sounds as though you've put this stigma aside. Well, have you put the stigma aside?
HEAD: Well, I'm not sure that anyone could put the stigma aside, and, you know, I have to agree with Dr. Lawson on this point. And one of the things people ask me is, you know, how's it different, experiencing depression as a black man. And when I get that question, I borrow a line from the movie "Casablanca" and say it's like depression in any other man, only more so.
And that's because there are factors that do play into aggravating, I think, depression for black men, and stigma is one of those things. It's one of the key things, I think, that we have to deal with. And there is a heightened stigma regarding depression and mental illness in African-American communities, as there is in most minority communities.
So this is an issue that we still don't - I think there are improvements; still a major issue.
DONVAN: I mean, I want to push back a little bit on the notion that the stigma is different in the black community just so that I can understand it. But I'm thinking back to 1972, when the vice presidential candidate on the Democratic ticket acknowledged that he had electric shock treatments for depression, and they pushed him out. They made him step down.
And, you know, he was from a long-established American, you know, Pilgrim-type of family, and they pushed him out. Now OK, it was almost 40 years ago. But how is the basic fact of shame and embarrassment that I think we're talking about, how is it different for black men than for a white guy like that?
HEAD: Well, I think there a number of factors, including, again, within the community. There was a survey done for Mental Health America in I think 1997, looking at attitudes toward mental illness and mental health. And one of the findings was that there was a heightened sense in the African-American community that depression was a weakness or a character flaw, compared to the general population.
And again, I think there are improvements, but that still persists. So there is a different attitude, and I think part of it is, you know, internally, there's this idea that we really can't show weakness, that we've had enough things against us that we really can't have this weakness called depression or mental illness.
DONVAN: So I want to let our listeners know that we want them to join this conversation, and we're going to take a break shortly, but when we come back, if you are experiencing this yourself, or if you have a loved one who has, or if you've worked with somebody in the field, our number is 800-989-8255.
And John, I just want to get a sense, when you finally decided to seek professional help, was that a difficult decision?
HEAD: It was a very difficult decision, and there were people around me who were trying to help me, family members, and the more they tried to help me, the more I pushed back, in fact, the more I felt I was not worthy of their help. So it was a very difficult decision.
But the decision, once it was made, basically saved my life. I have no doubt about that.
DONVAN: And what's your counsel for other guys in your situation?
HEAD: I would say get help. Accept the help that's offered and get the help you need. The help you're offered is only the beginning. Once you do that, you begin to see the help you need, and that may be professional help. You know, (unintelligible), I think that's a place where some people are finding help these days.
It's not as much as there should be, but I would say find someone you trust and begin to talk about what you're going through. That's really a major step forward.
DONVAN: All right, we are talking about black men, mental health and stigma, and if you have lived any part of this experience, give us a call. Our number is 800-989-8255. We're going to get to those calls in a moment; we have quite a few lined up. I'm John Donvan. This is TALK OF THE NATION from NPR News.
(SOUNDBITE OF MUSIC)
DONVAN: This is TALK OF THE NATION. We are talking about black men, mental health and stigma, and we have asked those of you who have thoughts on this, for having lived these challenges, to give us a call, and we have a lot of you lined up at this point. So I'd like to go first to James in Dayton, Ohio. Hi, James, you're on TALK OF THE NATION.
JAMES: Good afternoon.
DONVAN: Good afternoon.
JAMES: I was calling because I wanted to present that I am a practicing mental health professional, working both in clinical neuropsychology and clinical psychology. And I just wanted to point out to your listeners that the field of psychology and psychiatry has had sometimes a very negative role in the diagnosis of African-Americans and in the general sort of - a general sort of racist orientation towards African-Americans and their problems.
And this is not limited to psychiatry. I mean, it's other fields, it's certainly medicine, as well, but...
DONVAN: Could you give an example of the kind of thing you mean?
JAMES: I'm sorry? I was just going to refer people to a publication, a book called "Even the Rat Was White" that deals with the history of psychology and the role of African-Americans in this country.
DONVAN: Well thanks, James, for your call, and I want to bring this to Dr. Lawson because we were talking a minute ago during the break that I had read that a disproportionate number of black American men who exhibit - who are diagnosed with schizophrenia are actually misdiagnosed with schizophrenia, and the schizophrenia involves delusion, a loss of touch with reality.
It could be seeing things that aren't there or hearing things that aren't there, in addition to social breakdown, withdrawal, and it comes and goes. And you were telling me, Dr. Lawson, that this particular diagnosis is stuck a lot on black men incorrectly. Why?
LAWSON: For a lot of reasons. I have to agree with the previous caller, and that is a lot of historical reasons; the idea that you first - the idea that the person doesn't have the mental apparatus for feeling sad or depressed. When you see them, you then assume that the only diagnosis they can have could be schizophrenia, that they just can't become depressed.
The other part of it has to do with how people present, the lack of cultural awareness. Even though we speak the same language, I mean, you know, we live in the same culture, the experience of black men oftentimes is quite different. So when black men experience what we call not just racism but micro-insults, and they present it to other people, they are looked at as discounted, as some sort of perhaps delusional belief.
And then there's this phenomenon that we note that many folks are reticent to talk about their inner feelings, especially with someone of a different ethnicity. And that is sometimes misinterpreted as being paranoid, suspicious or somehow severely mentally ill.
DONVAN: And let me ask John Head that question. When you - picking up from what Dr. Lawson was saying about who it is you're actually going to sit down with face to face and talk about your problems with, as an African-American, John Head, was there something you were looking for in particular in a mental health professional?
HEAD: Well, I mean, I was looking for someone who would listen to me, first of all. And, you know, I think sharing some cultural touchstones is helpful. It's not the only thing. I'm not saying that a white therapist can't listen to a black patient. But there are touchstones and places where you both have been.
And just to give a quick example, if a black man were to tell his therapist, for example, that every time he's stopped by a police officer, he gets very anxious and nervous and thinks something bad is going to happen. Well, someone may say well, that's paranoid. But no, that's basically cultural experience, that possibility there.
So there is an emphasis now on what they call cultural competence and trying to get therapists to be aware of the different role that culture can play in treatment. I think this is a very important thing.
DONVAN: Can that be learned? I mean, isn't that a lifetime of experience?
HEAD: Well, it's - that's a part of it. I think Dr. Lawson probably could talk better about that than I can. But I think that's part of it. But it can be learned, just as empathy can be learned, I think. But I think Dr. Lawson probably would be the better person to ask about that.
DONVAN: All right, well, I want to get back to Dr. Lawson on that but get to another caller first, and James, thanks very much for your call. And let's go to Steven(ph) in Cincinnati. Steven, hi, you're on TALK OF THE NATION. Steven, hi.
DONVAN: Hi, you're on the air.
STEVEN: OK, my name is Steven, and I'm from Cincinnati, and I have had mental health issues for as long as I can remember. And I had the great fortune of going to an Ivy League school and attempted to address my issues. And when I met with the psychiatrist, his only response to me was that my only problem was that I wanted to be white.
And needless to say, I never saw him again because I knew I had more extenuating problems than that.
DONVAN: Did you continue looking to a mental health professional after that? Did you find somebody better?
STEVEN: No, I basically backed away and just allowed whatever was happening to happen for the next 40 years, and then I started into therapy, and I'm starting to get better.
DONVAN: All right, Steven, thanks for your call. I want to let Dr. Lawson respond to a part of what you were talking about there. And Dr. Lawson, I know you weren't there at that particular session, but I find it hard to believe that a health care professional would be as insensitive as the one that Steven just described.
And John Head and I were just talking about can - you know, I think we're saying can a white guy learn what he needs to know. And he said that's a question to put to you. Is it trainable, the ability to cross the cultural divide that may exist, enough so that in Steven's case you wouldn't say something like that to a patient?
LAWSON: Absolutely, and you find that the excellent therapist, irrespective of ethnicity, will do a good job. It's not just cultural awareness, although cultural awareness is extremely important, but also cultural sensitivity and also a willingness to recognize that one's own culture should not necessarily define the rest of the world.
And we found that just working with individuals for a very short period of time, people who are well-trained, that they can quickly reorient themselves in terms of the experience of how they see the world. I often use the example of the U.S. military when it first integrated its forces. We found that individuals who had deep-seeded beliefs changed quickly when they began to work with people of different ethnicities.
So it can be done, it can be changed, we just have to make sure that our system reinforces the idea that cultural sensitivity and cultural awareness is an important part of the treatment process.
DONVAN: So you're not sounding enthusiastic about the notion of African-American patients only go to see African-American doctors, and Caucasian patients only go to see Caucasian doctors. You don't like that idea.
LAWSON: It's impossible.
DONVAN: There aren't enough?
LAWSON: There just is - no, we look at the disparities in terms of the problems of underdiagnosed or misdiagnosed, but when we look at the number of providers who are African-American, the numbers are really, really small compared to the need, as well as to the number of other providers of different ethnicities.
DONVAN: I have read that 2 percent of psychiatrists in America are African-American.
LAWSON: Yes, it's between 1 and 2 percent now, and psychologists, we almost got up to 2 to 3 percent, social workers is less than 4 percent. And unfortunately, these numbers have not changed very much over the last decade, and in some cases, the disparities again began to increase again.
DONVAN: Let's bring in James from Dayton. Hi, James, you're on TALK OF THE NATION.
JAMES: Yeah, I would agree with Dr. Lawson. I mean, one of the problems is that when you train, you're not training with very many mentors who have had experience...
DONVAN: Are you - just to back up, are you a professional in the field yourself?
JAMES: I'm a neuropsychologist, a clinical psychologist, and I trained as a school psychologist.
DONVAN: OK, I didn't mean to interrupt you, I just wanted - you sounded like you were talking from experience. So keep going.
JAMES: Yeah, I'm speaking from experience. I mean, just in training, I mean, the things I'm hearing Dr. Lawson experienced is some of the things you hear that's being taught just come from a lack of experience with, quote-unquote, "normal, regular people."
I mean, your colleagues are for the most part 90 percent white. And if you train at many major institutions, including Howard, many of your patients are going to be white. And so, if you're not training under someone who's seen black patients and experienced culture and psychopathology in that context, you're going to have problems diagnosing.
And, you know, it is - I mean, it's just, you know, people are looking to solve your problems and to be a professional, but they just have no experience. And some of the things that you say are attributed to paranoia or other psychopathology when in fact that's just a part of your experience. I mean, that's, you know, just the way it is. And I would agree with him also that you can't match patients and professionals on race. Certainly, in my experience, most of the people who I have treated are probably 90 percent to 10 percent racial in favor of majority culture, or white folks. I mean, it's not - it's just not the group of people in professions that are helpful. I mean, in neuropsychology, it's even worse than the clinical psychology (unintelligible).
DONVAN: All right, James. Thanks very much for sharing that point with us. And I want to bring in...
DONVAN: ...CR. You are in Charlotte, North Carolina. Hi, CR. You're on TALK OF THE NATION.
CR: Yes. I want to bring to the attention of the people that I'm a Vietnam veteran. And when I came back, I was spit on, called a baby killer. And then the way people was treating me after coming back from fighting for my country, you know, along with the fact that being black, you know, the racism and all, it kind of put me in a cultural shock and in a bad state that calls me to be withdrawn. And I refused to get help because I didn't want to be labeled, because once you're labeled, all of these negative names and treatment, you know, people looking at you crazy, saying you're shell-shocked, you know, you - don't mess with him or don't talk to him or he's this and he's that, you know.
DONVAN: Didn't the Veterans Administration offer you, you know, the opportunity for private treatment that nobody would know about?
CR: Well, we say yes, but how do you go to a VA hospital and someone don't see you and then, in the street, you know, say, hey, I saw you at the VA hospital? Are you this or you're that, you know? I've experienced that with other veterans.
DONVAN: Dr. Lawson?
LAWSON: Yeah. Unfortunately, your experience is very similar to other veterans. Before I came to Howard, I worked in the VA system as chief of service and worked with an organization. The Congressional Black Caucus was very, very concerned about, again, the problem of under-diagnosis and misdiagnosis and making sure that people get competent, caring services. We just don't see our veterans getting the access to services, especially our black veterans, that they should. And as a result, folks end up homeless, drug problems and other problems that they shouldn't really have to experience with the technology that we have to provide adequate treatment today.
DONVAN: CR, did you get a diagnosis, ultimately, and how long did it take?
CR: Well, for a long time, I kept it to myself and just did not want to - deal with it. And then it got so bad that my wife and my friends kept telling me, you know, what is wrong? What is wrong? What is wrong? You need to get some help and all. But I couldn't really talk to them about it. And what I found is that, you know, most of the people in the black community just - they just wasn't educated or aware or just didn't have - didn't know how to give you the support that you needed. And you can't talk with them openly about it without being, you know, criticized, you know, saying all, he's just crazy.
DONVAN: CR, thanks very much for sharing that with us. We really do appreciate it.
CR: And now, what - I want to add that once I went to the VA and I was diagnosed, it was several doctors that I stopped going to treatment from because they were not able to relate to my problem.
DONVAN: Uh-huh. That's what Dr. Lawson's been talking about.
DONVAN: CR, thanks very much for making the call. We appreciate it. You're listening to TALK OF THE NATION from NPR News.
John Head, I want to - you know, CR was talking about not wanting people to know. I'm assuming, once you sought treatment for your depression, that your friends and loved ones knew what you were doing. What kind of reaction did you get from that?
HEAD: Well, you know, first of all, I was very worried about this being revealed to co-workers and friends and family members. And, of course, the people who are close to me, once they found out, they were very supportive and just, you know, asked me why I didn't come to them sooner, why I didn't let them know what was going on.
There were, you know, a few instances of people at work trying to make a joke of it. And I, you know, I, you know, put that up to them being uncomfortable with the subject and not being able to talk about it, you know, regularly. I mean, if I had told them that I had had a heart problem, they wouldn't joke about a heart problem. But when they found out that I was having, you know, a mental health problem, they made a joke of it.
But overall, I got a lot of support, a lot of people who were glad that I had finally done something. I mean, they knew that there was something wrong, but they didn't know what. And then when they found out, they were just very supportive and made it, you know, easier for me to continue to get help when I got that positive reinforcement from people who said, yes. You're doing what needs to be done, and we support you in doing it.
DONVAN: Dr. William Lawson, I've read something that suggests that studies have actually show that black men have a certain kind of resilience when it comes to mental health issues, that there's also a countervailing toughness that develops in them. Are you familiar with that? Is there anything to that?
LAWSON: Yeah. I wouldn't - yeah. I think the term is resilience, not necessarily toughness. But also, it's being able to appreciate - get in touch with one's own sensitivity that many African-American men have that other groups don't have and - or happen(ph) to both, and that I think is very important in terms of having a positive outcome. You know, these study show that we - if folks get the appropriate treatment, they can have good outcomes.
We have - we also tend to be supportive of each other once you get past the point that a mental disorder is some sort of person not going to go crazy and kill you, we have a much support from our families of being able to provide support for those who have a mental disorder and who are also much more understanding - we mentioned the church. When the church can play a role, it can play a very, very positive role that we've seen, that those people who are more spiritually inclined often have better outcomes.
DONVAN: So there's all kinds of ways to heal?
DONVAN: All right. I want to thank Dr. William Lawson. He's a professor and chairman of the Department of Psychiatry at Howard University College of Medicine. And he has conducted research on mood disorders among African-Americans, and joined us here in studio 3A. Dr. Lawson, thanks very much for your time.
LAWSON: Thank you.
DONVAN: And John Head is a journalist and author of "Standing in the Shadows: Understanding and Overcoming Depression in Black Men," and joined us from WNCU in Durham, North Carolina. John Head, thanks very much for joining us.
HEAD: Thank you for having me.
DONVAN: And coming up, the health benefits of walking. If it's your chosen form of exercise, why does it work for you? Let us know. Our number is 800-989-8255. Or drop an email: firstname.lastname@example.org. I'm John Donvan. It's TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.