Psychosocial, socio-cultural, and environmental influences on mental health help-seeking among African-American men

Abstract

The social determinants unique to African-American men’s health contribute to limited access and utilization of health and mental health care services and can have a deleterious effect on their overall health and well-being. There is a need to examine the complex issues concerning African-American men’s help-seeking behaviors relative to mental health concerns. Current research estimates that African-American men are approximately 30% more likely to report having a mental illness compared to non-Hispanic Whites and are less likely to receive proper diagnosis and treatment. There is an extensive body of research that supports the view that women are more likely to seek help for psychological problems than African-American men. This review explores the psychosocial, environmental and socio-cultural factors that influence mental health help-seeking behavior among African-American men and explains the urgency to engage various stakeholders to pursue effective behavioral strategies. Research literature concerning the relationships between social determinants of health and their mental health help-seeking behaviors is reviewed and discussed in this paper. The article illustrates the need for mental health providers and researchers to establish feasible, culturally competent prevention and intervention strategies to increase help seeking behavior among African-American men, thereby contributing to the reduction of mental health disparities.

Introduction

African-American men may be among the most underserved populations with respect to mental and behavioral health services [1]. There is a dearth of research about help-seeking behaviors among African-American men with co-occurring mental and substance abuse disorders, which often require a complex, multi-faceted approach to care [2]. Furthermore, African-Americans dually diagnosed with mental illness and substance use disorders constitute only one segment of the population with mental illness in the African-American community; yet, it remains a significant and problematic issue [3]. Some common mental disorders associated with chronic drug abuse include schizophrenia, bipolar disorder, manic depression, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder, panic disorder, and antisocial personality disorder. Some of these disorders carry with them an increased risk of drug use, abuse, and dependency [4]. The evidence is clear; the psychosocial and socio-cultural factors that influence the help-seeking behaviors of African-American men have strong implications for behavioral health outcomes and deserve closer analysis due to the intervention implications for clinicians, policymakers and researchers targeting this group as well as men from other racial minority groups.

According to the United States (U.S) Department of Health and Human Services, Office of Minority Health [5], African-Americans, when compared to non-Hispanic Whites, are approximately 30% more likely to report having some type of mental illness. African-Americans are less likely to receive proper diagnosis and treatment for mental illnesses and are more likely to experience poorer functioning and greater disability from untreated mental illnesses [6]. For example, African-Americans suffer from depression for longer periods of time than do their White counterparts [7, 8]. African-Americans are also more likely to receive mental care from primary care physicians than a certified mental health professional. There is some evidence that treatment setting factors may negatively impact service utilization in primary care settings [8].

Young African-American men face several challenges that can negatively influence their psychological development and well-being. Among them are social and environmental determinants such as education, minority status, family, and urban demographics [9]. Although the suicide rate for adolescent African-American males’ aged 15–19 years decreased from 9.5 per 100,000 of the population in 2000 to 6.7 per 100,000 of the population in 2007, suicide attempts in 2007 were still 1.6 times higher among Black male adolescents than among their White counterparts. Furthermore, suicide is still ranked as the third leading cause of death among this demographic [10, 11].

Failure to address the improvement of mental health help-seeking behavior among African-American men, as a strategy to strengthen their mental health treatment and outcomes, may have a detrimental effect on the livelihood of not just the men but their families, their children, and the communities in which they live. If nothing is done now to reverse these habits that continuously impact men’s overall health, the results will lead to a further widening of the already prominent health and behavioral health disparities that exist among racial groups today. The U.S. prison population is on a downward trend for many states, according to the latest report by the Bureau of Justice Statistics [12], indicating that the number of African-American men released from prison, who are at increased risk for mental illness, is increasing. Thus, the potentially positive impact of stronger help-seeking behaviors among African-American men, and men from other ethnic groups with similar experiences, on the social and economic burden of society’s institutions is well worth the increased attention from clinicians, policy makers and researchers.

Men and help-seeking

The help-seeking literature suggests three conditions that are fundamental for seeking support: (1) endorsement of masculine norms, (2) self-stigma, and (3) attitudes toward seeking help [13]. Research has indicated that there can be real or perceived barriers to help-seeking. Some of the issues may relate to cultural attitudes, previous unsatisfactory contacts with professional caregivers, lack of trust in mental health professionals, issues of confidentiality, gender role socialization, a belief that nothing can help change the situation of distress, fears of negative repercussions such as being institutionalized, a lack of knowledge of helping resources, and resources that are inaccessible or too costly [13, 14]. While these barriers are significant, there are multiple points of clinical intervention where cognitive and behavioral strategies may be aimed to minimize or completely remove these real or perceived barriers to help-seeking.

There is an extensive body of research that supports the view that women are more likely than men to seek help for physical and psychological problems across all racial groups within the United States [15, 16]. Many theories have been presented to explain this discrepancy, most of which attribute males’ embarrassment and relative lack of help-seeking to conflicts resulting from gender-role socialization [17–20]. Researchers have also examined issues that serve to discourage help-seeking among men in an attempt to determine which aspects of these barriers may make help-seeking least desirable [21]. Most research concerning help-seeking among men tends to focus on perceived negative attitudes toward, and detrimental consequences of, help-seeking [18–22]; yet, there is low ethnic variability within these studies’ samples.

Psychosocial issues impacting help-seeking for African-American men

African-Americans share a strong history of self-reliance and resiliency that may correlate with denial of mental health problems [23]. Shame and denial of mental health issues have also been identified as barriers to African-Americans’ care-seeking behaviors [24, 25]. Research evidence indicates that when African-American men perceive discrimination and racism, it leads to increased stress, limited help-seeking behaviors and lower psychological well-being [26–28]. Franklin [28] suggests that the psychological experience of invisibility leads to impaired personal identity and ability undermined by racism in a myriad of interpersonal circumstances. He further explains that African-Americans may feel a sense of “psychological invisibility” when dealing with prejudice, discrimination and racism which in turn hinders their ability to develop certain adaptive behaviors to cope with simultaneous personal, familial, community, and societal level stressors [28]. It is possible that many African-American men feel the burdens of invisibility. These burdens further augment mental and emotional anguish that, in turn, exacerbate stressors and adversely affect physical and psychological well-being. Subsequently, these men may seek non-traditional forms of help for dealing with mental and behavioral health problems such as relying on community members, religious institutions, and lay professionals. It is also noted that when African-Americans engage in formal mental health care, such as psychotherapy, they have lower adherence and retention to treatment plans when compared to Whites [29,30]. These outcomes are especially troubling to clinicians, many of whom are aware of the larger psychosocial and cultural influences on their patients’ behaviors but often feel unempowered to implement the changes needed to improve mental health outcomes in clinical settings. Further, similar dynamics likely apply to men from other disenfranchised groups including Latin and Native Americans, thus findings about mental health help-seeking among African-American men may be extrapolated to these men. However, increased research among these other groups should also be a priority among clinicians and researchers.

Among ethnic minorities, some of the formidable barriers to seeking treatment include stigma surrounding mental illnesses, misperceptions of mental disorders as a sign of weakness or mental instability, and the limited health insurance coverage for mental health care [31, 32]. Stigma is composed of unconstructive attitudes, beliefs, views, and behaviors that affect the person or society, causing fear, rejection, avoidance, prejudice, and discrimination. Stigma is evident in language, interpersonal relationships, and private and social behaviors [33]. Stigma is a process that involves negative beliefs (frequently based on erroneous or incomplete knowledge), and underlies prejudice expressed as negative attitudes [34, 35]. The negative attitudes ultimately manifest as discrimination, poor behavioral outcomes, and diminished human capital [34, 35].

The U.S. Surgeon General’s report on mental illness emphasized stigma as a chief obstacle to consuming and receiving satisfactory mental health services, particularly among racial and ethnic minority populations [32]. Racial minority populations, who already face prejudice and discrimination due to their group membership, experience double stigma when confronted with the effects and impact of mental illness [33]. The notion of double stigma is conjectured to be an added burden that face ethnic minority populations in the U.S., but may impact disparate cultural groups in particular ways [33]. Double stigma among African-Americans engenders maltreatment, misdiagnosis, distrust of healthcare and mental health care systems and providers brought on by inadequate cultural competence, communication failures, conscious and unconscious stereotyping, and limited access [33]. There is little empirical evidence to suggest potential interventions to reduce this stigma; however, some evidence suggests a focus on educating, contacting, and protesting within the community, especially through churches and community-based organizations that may serve as advocates for addressing mental and behavioral health issues [34]. These strategies to stimulate discussion about removing stigma, particularly among behavioral health care and consumer advocates may lead to funding opportunities for rigorous investigation of correlates of poor mental health among African-American men, including help-seeking behaviors.

Socio-cultural and environmental issues impacting help-seeking for African-American men

Few empirical research studies exist about the specific societal level factors that may impact mental health help-seeking behaviors for African-American men. Issues such as financial strain and unemployment among men may lead to reduced self-esteem, loss of autonomy and identify, and lowered self-confidence signaling coping difficulties. Generally, men in the workforce enjoy better physical and mental health than those who are unemployed [37]. This disparity may be related to the association between unemployment, physical illness and premature death [37]. While health promotion is of importance to African-American men, with the backdrop of a depressed housing market and unemployment rates double that of their Caucasian counterparts, 15.2 versus 7.5 respectively [38], health promoting behaviors may not be prioritized ahead of other more immediate concerns.

It may be that the concepts of race, ethnicity, and culture may sometimes be used as proxies for social and environmental influences on health-promoting behaviors for African-American men [39]. Wallace & Constantine [40] conducted a study that investigated the relationships among Afri-centric cultural values (i.e., the extent to which an individual adheres to a worldview emphasizing communalism, unity, harmony, spirituality, and authenticity), favorable psychological help-seeking attitudes, perceived counseling stigma, and self-concealment (i.e., the tendency to withhold personal, sensitive information that is perceived as negative or upsetting). The researchers found that for both African-American women and men, higher degrees of Afri-centric cultural values were associated with greater perceived stigma about counseling and greater self-concealment. In addition, findings indicated that neither favorable psychological help-seeking attitudes nor perceived counseling stigma significantly mediated the relationship between Afri-centric cultural values and self-concealment behavior [40]. In a 2005 study on the factors influencing help-seeking behaviors among African-American university students, Miller (unpublished results) indicated that African-American men ranked embarrassment, lack of trust in service providers, denial, fear of how they might be perceived, and fear of breach of confidentiality among the most inhibiting factors to help-seeking for mental and behavioral health problems.

As discussed earlier, key factors that can influence African-American men’s mental health help-seeking behaviors may include poor access to culturally responsive mental health providers and care services, lack of awareness and acceptance of mental and behavioral health concerns, internalization of emotions and difficulty disclosing personal stressors and problems, and lack of supportive social networks. Notably, mistrust of the health and mental health care system is a well-researched explanation that relates to limited help-seeking among African-American men that can benefit from treatment [41, 42]. It has been contended that the negative effects of African-Americans’ cultural mistrust of other races during interpersonal interactions is not only unique to counseling and psychotherapy, but represents a broader perspective of discontent within U.S. healthcare systems [41, 42]. From another perspective, Leary [43]suggested the idea that Black men in the U.S. have endured “Post Traumatic Slave Syndrome” which has negatively impacted their levels of trust and interest in accessing current health and mental health care systems, because of an intense fear of negative outcomes related to their treatment. Williams et al. [44] suggested that discrimination is associated with multiple indicators of poorer physical and mental health status for African-Americans. Thus, many health and mental health issues go untreated among African-American men, contributing to increased morbidity when compared to other racial/ethnic and gender groups.

According to findings from focus group discussions conducted with African-American men by H. Treadwell & K.B.H in Washington, DC in 2007, their unwillingness to prioritize their mental healthcare may overlap with similar barriers and reservations that they have adopted regarding poor attention to their physical health (Table 1). Copeland [45] suggests that African-American men are interested in seeking help from mental health providers who are sensitive to the cultural issues that are important contributors to their lives. However, the lack of cultural competence in the delivery of mental health services can lead to misdiagnosis, a general alienation of African-Americans from the mental health system, and subsequently a poor use of mental health services [45]. These shortcomings of mental health services are exacerbated by the lack of African-American mental health service providers. In fact, African-Americans account for only 3.9 % of all of the psychologists in the U.S. [46]. There are sections of the Affordable Care Act related to developing and improving the health care workforce and shortage in key areas [46].

Table 1.

Overview of barriers to mental health care for African American men

Intrapersonal factors	Socio-cultural factors	Systemic factors
Lack of trust of health and mental health care systems	Negative judgments shared by family and friends	Limited understanding of how to navigate through complex mental health care systems
Fears relating to stigma, personal shame about their problems	Lack of appropriate vocabulary to discuss sensitive health issues	Lack of culturally-centered and gender-specific clinical environments, prevention programs, and treatment approaches
The inability to “handle it” on their own
Lack of appropriate vocabulary to discuss sensitive health issues

Conclusion

African-American men are limited in their access and utilization of comprehensive mental health care. There are several broad strategies that may address this concern for African-Americans in general and African-American men in particular, supported by the research literature. Stakeholders must take the lead in establishing culturally competent prevention and intervention strategies that attract African-American men to mental health care systems, and which establish benchmarks that provide the framework for policy initiatives important to sustaining a commitment to improved care. Some of the recommended strategies include reducing stigma, eliminating financial barriers, integrating primary care and behavioral health services, supporting comprehensive and culturally responsive prevention efforts, targeting the mental health needs of vulnerable populations (i.e., homeless and formerly incarcerated men) and increasing funding for clinical and translational mental health research. Most, if not all, of these strategies are supported by initiatives in the Affordable Care Act which understands that improvement in the health care outcomes of underrepresented and underserved communities is inextricably tied to the overall effectiveness and efficiency of our evolving health care system. If there is not an energetic and urgent collective response to the clarion call sounded by the sobering physical health and behavioral health statistics of African-American men, we will continue to witness the progressive decline of their mental health outcomes, which, in turn, contributes to the fragmentation of African-American families and the siphoning of social and economic resources away from their communities. Men with mental illness often have poor physical health which significantly impairs their ability to provide the economic, social and emotional supports their families’ need. Thus, improving their health means improving the health of families, communities, states and the nation. Stakeholders from the clinical, research and policy advocacy communities must collaborate to frame the discussion, create national attention and leverage the necessary resources to investigate African-American men’s mental health help-seeking behaviors.