Special Report: The Mental Health Impact of Racism on Black Communities—Acknowledging Patients’ Lived Experience

In 2021, racism was declared a public health issue by the Centers for Disease Control and Prevention. Every day there are numerous violent tragedies across the United States, and many of them involve racism. On May 24, Secretary Alejandro N. Mayorkas of the Department of Homeland Security issued a new National Terrorism Advisory System Bulletin pertaining to the heightened threat environment across the United States (see box).

It is particularly dangerous at this time to be a Black person in America, and we must recognize that this takes a significant toll on mental health. The month of July—Bebe Moore Campbell National Minority Mental Health Awareness Month, along with this country’s annual celebration of freedom and liberty—is an opportune time to contemplate the fact that not all people in this country are living with and experiencing fully American ideals of democracy.

Conditions Affecting Life in Black Communities

COVID-19 devastated the United States, killing over one million people, including disproportionate numbers of older adults and Black and Latinx people. This resulted in significant losses of parents and caregivers of children and youth, with more than 65% of those losses affecting children of color. In many ways, losses from COVID-19 parallel those resulting from HIV/AIDS, which remain disproportionately high among people of color. Many Black children were orphaned by HIV/AIDS and went into foster care but ultimately were not adopted. The combination of these impacts adds to the trauma experienced by this population.

Grief and loss, social isolation, and loneliness combined with economic insecurity have compounded the negative mental health impacts of the pandemic on people of color. Furthermore, the pandemic curtailed cultural and religious rituals such as weddings, funerals, and church gatherings, which usually offer opportunities for fellowship in Black communities. This was a paradoxical set of circumstances in which the risk of contagion and increased morbidity and mortality prohibited the physical support and contact with others that people need during times of crisis.

Many people lost their jobs during the pandemic, and essential workers such as those in health care, public safety, food retail and supply, and public transportation had to continue working despite their risk of exposure to COVID-19. Black and other people of color were overrepresented among essential workers and did not have the opportunity to work from home. Furthermore, Black people’s shorter longevity has been such that many do not have the chance to collect Social Security after contributing to it during their work life.

The murders of unarmed Black people such as George Floyd and Breonna Taylor at the hands of law enforcement exacerbated trauma to people in an already stressful environment. A succession of episodes of mass violence against Black communities and other racial, religious, and LGBTQ+ communities in schools, supermarkets, and other public settings further compounded the trauma and added to the weight of collective loss, grief, and horror associated with the pandemic.

Black and other people of color continue to face barriers to treatment for opioid use disorder and overdose. Now that Narcan has been made available over the counter, it appears that people of limited economic means, a disproportionate number of whom are people of color, may not be able to afford it. Black people are dying disproportionately from overdoses. Only since overdose deaths began to affect suburban and rural populations—populations that are predominantly White—has the opioid crisis gained traction in the mainstream media. This point is underscored in the 2023 book, by psychiatrist Helena Hansen, M.D., M.P.H., and colleagues, Whiteout: How Racial Capitalism Changed the Color of Opioids in America. There is a need for greater public and private access to appropriate inpatient and outpatient services, including treatment with buprenorphine, in Black communities.

Natural disasters are another source of disproportionate impact on Black communities, particularly in the South, a region rendered more vulnerable to climate-related disasters because of its geography. The South has the greatest concentration of Black people in the United States, and many Black communities there are economically distressed, which makes it difficult for people to prepare, evacuate, and recover from disasters and increases the likelihood of death, destruction of housing, and other losses that compound the negative mental health impact of natural disasters. In the South, these disasters included Hurricane Ida, Hurricane Ian, and a succession of tornadoes in early 2023 in Alabama, Georgia, Mississippi, Missouri, Tennessee, and Texas, all of which have underscored the pattern of significant suffering in Black and economically challenged communities.

Lived Realities of Racism

Being a Black person in this society is dangerous: There is no guarantee of safety when going about one’s life doing mundane things like grocery shopping, attending church, studying at a university, or sleeping in one’s own bed. It is impossible to be emotionally prepared to respond in real time to the racist actions of people who see Black skin as a threat to their physical safety. Living in such a charged environment can cause hypervigilance, anxiety, and psychological distress.

Experiencing racial microaggressions in day-to-day life can be humiliating, accumulating over time and assaulting one’s sense of dignity. One must determine one’s threshold for responding to microaggressions and decide whether to address them immediately or ignore them. Under these circumstances, it is possible to become overwhelmed by the frequency of microaggressions, which can have a deleterious psychological impact.

Studies have shown that structural racism and the accumulation of trauma serve as critical drivers of the transmission of depression across generations. Being a victim of microaggressions and hate crimes and experiencing adverse childhood events such as a parent’s incarceration and difficulty in finding employment, which has further downstream consequences, are sources of cumulative trauma in Black communities. Exposure to these traumatic events can increase the risk of clinically significant symptoms; substance use disorders; school refusal, trouble in school, and dropout; disordered sleep; depression; anxiety; and suicidal ideation.

Black people are less likely than their White counterparts to receive mental health care because of barriers such as stigma; lack of insurance; limited access to mental health services; and lack of local mental health professionals, thus necessitating inconvenient and costly travel. Although many patients seek or request clinicians with similar cultural experiences, there are insufficient numbers of Black clinicians to service Black communities. Thus, it is imperative that mental health professionals of all backgrounds demonstrate cultural humility and responsiveness to patients’ needs to ensure quality care.

When victimization of Black people is publicized in the mass media, collective trauma affects members of Black communities, even among those who are physically distant from the event. Black people recognize that these are not just random events but are possible in their own lives and the lives of their families and friends. This experience of vicarious trauma can trigger a sense of helplessness and hopelessness, but it can also motivate people to engage in activism, protest against injustice, and move toward empowerment.

The racist attack of mass violence that targeted a Black community in Buffalo, N.Y., at the Tops Supermarket in May 2022 resulted in the deaths of 10 Black people. This tragedy underscored the reality of racially motivated domestic terrorism and traumatized not only a Black community in Buffalo, but other Black communities throughout the country. People in Buffalo’s East Side, a predominantly Black neighborhood, felt so unsafe that many were afraid to engage in any activities outside of their homes. Tops had been the only grocery store to serve the area before the incident, and its temporary closure in the wake of the shooting left this residential area food insecure, which brought additional suffering to the people who live there.

Black-led mental health and human service organizations such as the All Healers Mental Health Alliance, Black Family Summit, Black Psychiatrists of America, Community Healing Network, National Association of Black Social Workers, National Medical Association, and the Association of Black Psychologists connected with lay, political, and religious leaders in Buffalo to offer support and consultation regarding the traumatic impact on survivors and caregivers.

One of the initiatives developed in response to this crisis included healing circles to give people an opportunity to manage their grief and recognize that they were not alone. The New York State Office of Mental Health, under the leadership of Commissioner Ann Marie T. Sullivan, M.D., a psychiatrist and leader in APA, authorized grant funding for Black-led healing circles and training to build capacity for this culturally affirming approach to support the mental health of Black residents of New York State. This is a groundbreaking development in support of culturally aligned crisis response.

Several states have proposed executive orders and/or legislative actions that restrict diversity, equity, and inclusion initiatives; the teaching of Black history; and voting rights. In order for our country not to repeat the mistakes of the past, it is crucial to have an accurate historical record as a foundation to plan for a better future.

Racism and Leadership

Recently, young Black leaders Justin Jones and Justin Pearson were expelled from the Tennessee legislature after refusing to be silenced. They took a moral and ethical stance regarding gun violence in the aftermath of a school shooting that killed six people and challenged the majority of the legislative body. Many saw their expulsion as being motivated by race given that a White colleague who joined them in protest, Gloria Johnson, retained her seat. Former Attorney General Eric Holder, who is among six attorneys representing Jones and Pearson, threatened legal action against the Tennessee legislature unless they were reinstated. Both legislators were quickly reelected by their home districts and returned to their respective legislative seats.

Leaders like these must speak up and speak out on social issues as they pertain to the mental health and well-being of all communities—this should not be seen as a radical stance but a humanistic stance. It is critical that psychiatrists recognize the totality of humanity, the challenges that people face in the current environment, and the impact of the social determinants of mental health.

Psychiatrists are trained to be “blank slates” in the clinical setting and not to interject their personal opinions about social issues, including current events, into their discussions with patients. However, when patients voice concerns about racism, psychiatrists should be prepared to listen and allow patients to explore how these realities affect their mental health and daily life. Regarding the matter of violence, as psychiatrists we must protect ourselves from harm as well as support public health and safety.

Additionally, other societal controversies may present in clinical settings posing a conflict with the psychiatrist's own personal values. Psychiatrists can manage these therapeutic dilemmas by seeking out resources such as courses in anti-racism; scholarly papers and books on the subject; consultation with appropriate colleagues; and discussions on diversity, equity, and inclusion in the APA district branches and other psychiatric organizations.

Looking to the Future

In spite of the myriad challenges to health, safety, and well-being that Black people face today, there is still an indomitable spirit within Black communities to remain hopeful and carry on toward the achievement of equity, opportunity, and improved quality of life. Enlightened and principled leadership in psychiatry is required to bring these goals to fruition. Psychiatrists can find their own way of contributing to community preparedness and becoming anti-racist to address the social determinants of mental health at the local level.

There are encouraging signs within APA and other mental health professional organizations, including the establishment of various committees and workgroups focused on topics such as social determinants of mental health; diversity, equity, inclusion, and belonging; systemic injustice; structural inequities; and anti-racism. A promising new group formed by early career psychiatrists is the National Anti-Racism in Medicine Curriculum Coalition, which is sponsored by the American Board of Psychiatry and Neurology. Initiatives like these will inspire young psychiatrists and trainees to join such efforts to promote diverse and socially conscious leadership.

In these turbulent times of continued racial conflict, it is imperative that psychiatrists are involved in developing innovative solutions that address the mental health needs of people of all racial backgrounds.

Mental Health, Racism, and Contemporary Challenges of Being Black in America provides perspectives on the multiplicity of factors that impinge on the lives of Black people today. Through the words of leaders in Black communities, most of whom were APA Solomon Carter Fuller Award lecturers or their proteges, this book paints a picture of the complexities of lived experience among Black people in the United States and their impact on mental health and well-being. ■

Donna M. Norris, M.D., is an assistant professor of psychiatry at Beth Israel Deaconess Medical Center, Harvard Medical School, and a member of the Editorial Board of APA Publishing. She was the first woman and first African American speaker of the APA Assembly; she is also a former APA secretary-treasurer and secretary of the APA Foundation.

Annelle B. Primm, M.D., M.P.H., is senior medical director for The Steve Fund and an associate professor of psychiatry, part-time, volunteer at The Johns Hopkins School of Medicine. She is a former APA deputy medical director and former director of APA’s Division of Diversity and Health Equity.

Norris and Primm are the co-editors of Mental Health, Racism, and Contemporary Challenges of Being Black in America. APA members may purchase the book at a discount.