Whaley AL.
Racism in the provision of mental health services: a socio-cognitive analysis.
Am J Orthopsychiatry 1998;68(1):47-57.

This review article summarizes the evidence for racial bias and stereotyping in mental health services. The author proposes a social-cognitive model to explain these processes, delineates the implications of racism or racial bias among mental health professionals for research and clinical practice, and recommends training procedures that can alleviate the effects of racism on the provision of services to black clients.

Overall, the evidence indicates that white Americans possess beliefs about racial stereotypes that influence their attitudes and behavior toward black Americans. The author proposes that whites stereotype regardless of their political orientation (liberal versus conservative), which he uses as a proxy for their level of racial sensitivity. He further explains that liberals and conservative generally deal with (racial stereotypes) differently, but "in situations where race is not a salient variable, liberal whites are as likely as conservative whites to act on these negative stereotypes and discriminate against blacks (aversive racism)."

The author provides an application of his aversive racism theory to the mental health services. He suggests that the stereotype of blacks as aggressive and violent might come into play in the psychiatric diagnostic process and describes how aversive racism influences this process. Liberal clinicians faced with black clients they perceive as aggressive or violent may feel uncomfortable with these perceptions. In response, they may assign more severe diagnoses or recommend more restrictive interventions to such patients, indicating that they perceive these black patients as aggressive or violent due to their severe mental illnesses rather than the clinician's own racial stereotypes. Several other examples are given.

Suggestions for alleviating this problem include altering the power imbalance between white clinicians and black clients by establishing client feedback as a part of clinical performance evaluations. He also summarizes Garb's work (Garb HN. The representativeness and past-behavior heuristics in clinical judgment. Professional Psychology: Research and Practice 1996; 27:181-194.), which suggests that clinicians may be able to alter their approach toward making diagnoses in order to alleviate racial bias in diagnosis. Typically, clinicians assign diagnoses based on a comparison of the patient with prototypes for each diagnostic group. Racial stereotypes that fit in with specific diagnoses (e.g. violence as a stereotype of blacks and schizophrenics) may lead to racial bias in the diagnostic process. If clinicians instead compared patient’s behavior with past behavior, racial stereotypes might have a less negative influence on the diagnostic process.

The author also suggests that cultural sensitivity training might alter the influence of racism in mental health services. "While the elimination of societal racism is the ultimate solution to improving the decision-making of white clinicians with respect to the mental health needs of black patients, the next best solution is for the effect of racism on both providers and recipients of service to become a part of the core curriculum of clinical training."

Whaley AL.
Racism in the provision of mental health services: a socio-cognitive analysis.
Am J Orthopsychiatry 1998;68(1):47-57.

A SECOND ANNOTATION - QUOTATIONS

“Black patients who encounter a white mental health professional are less likely to be viewed as individuals when it is their first contact, the clinician has a large caseload, or they behave in a manner that fits the clinician’s stereotypic profile of blacks. Because professionals need to make assessments, they generally seek information rather than provide it; this involves interpreting the behavior of the patient, whereas their own behavior is relatively unconstrained or unjudged because of their position of authority (references).”

“Interpretations by white mental health professionals of hostile intent or aggressiveness on the part of black clients are especially likely to produce the uncomfortable feelings of aversive racism. This, in turn, may lead clinicians to assign more severe diagnoses or recommend more restrictive interventions.”

“A recent study by Segal et al. (1996) found that clinicians prescribe more antipsychotic medications and devote less time to the evaluation of African-American patients, compared with Caucasian patients, during emergency psychiatric services. Black psychiatric patients with case information identical to that if white patients are often given a more severe diagnosis, because they are stereotyped as being more dangerous (Loring and Powell, 1988). These racial disparities in diagnostic and dispositional decisions have severe outcomes.…Black psychiatric patients are much more likely than white patients to receive a diagnosis of schizophrenia (references)….
….Both Lawson et al. and Strakowski et al. found that black patients are more likely to be referred for inpatient than outpatient treatment. Consequently, as indicated in a review by Lindsey and Paul (1989), black patients are overrepresented among involuntary hospitalizations in public mental institutions. Black patients’ stays in these public institutions tend to be shorted than those of whites, but they are more likely to be readmitted and less likely to be referred to community-based programs (Wade, 1993). This “revolving door” phenomenon reflects inadequate and discriminatory treatment with regard to the public mental health care of black people…
…Flaskerud and Hu (1992), reported that black psychiatric patients had fewer sessions with their primary therapist and received more treatment with medication than did their white counterparts. In his classic study of community mental health services, Sue (1977) found that being black was associated with similar inadequacies in service delivery independent of diagnosis.
…Thus, the stereotype of violence is the common denominator in perceptions of black individuals and the diagnosis of schizophrenic disorders….”

“…Jenkins-Hall and Sacco (1991), who found that white therapists evaluated a videotape of a black depressed client more negatively than they did that of a white depressed client expressing identical symptoms, explained their results in terms of the concept of aversive racism. Geller (1988), in a vignette study in which race and IQ level of a prospective client were manipulated, found that a highly intelligent black patient (IQ=120) was considered by a group of white psychiatrists to be less psychologically equipped for verbal therapy than a less intelligent white patient (IQ=85). In this same study, in which homicidal tendencies were part of the profile of both black and white patients, medication was more likely to be recommended for the black patient, leading to the conclusion that stereotypic thinking influenced the treatment decision.
…European-American psychologists, compared with African-American psychologists, rated the African-American client as less physically attractive and less likely to benefit from therapy, indicated less positive feelings and lower levels of comfort in working with the client. And gave the client more severe diagnostic ratings—findings that are consistent with the notion of aversive racism.”

“De Hoyos and De Hoyos (1965) found that white clinicians recorded significantly fewer symptoms from intake interviews with blacks diagnosed with schizophrenia than for whites with the same diagnosis. A more recent study (Segal et al., 1996) indicated that clinicians devoted significantly less time than required in their emergency psychiatric evaluation of black patients.”