Modern beliefs and symbolism in our community has created significant difficulties.  The “strong black women” and the “angry black women” stereotypes depict images of proud women who don’t take no for an answer.  Black girls are often taught to “keep your head up” to get through anything.  While it can be seen as a great life lesson, it may also allow black women to use this same coping strategy through adulthood which may foster an environment in which they have to manage everything.  Regardless of what is happening in your life, black women are literally bred to be strong ‘all the time’.  While this can be seen as positive in some aspects, the image has been carved in order to not allow ourselves our humanity. If you are suffering from depression or anxiety, black women often don’t acknowledge it because they believe that they can’t. The stereotypical image of the strong black woman can also be seen as a barrier to access to mental health treatment.  Issues may not be seen as mental health related due to societal mental health stigma.  Prior to discussing the concept of the “strong black woman and its impact on the mental health and well being of women of African descent, in particular women of African Caribbean heritage, a brief history of the development of mental health services in the Caribbean will be addressed in order to understand the historical context of mental health prior to addressing the potential gaps in psychotherapeutic care and how these gaps can be addressed.

Mental Health and the Caribbean

Public perception of mental health care remains almost entirely derived from the pattern of mental health service development that focuses on a major mental health hospital (small psychiatry units in general hospitals) and satellite clinics geographically dispersed throughout each island.  Since these clinics are conducted in the primary care health facilities, they reinforce the medical model as the basis for treating mental health problems from a purely biological, medication based perspective.  What is lacking is a more whole person approach and interventions that focus more specifically on psychological and social issues rather than medical and psychiatric ones.  This has led to the maintenance of the pervasive belief system that mental health problems only require significant intervention when the afflicted are demonstrably a risk to themselves or others as evidenced by aggressive or violent behaviour or consistently inappropriate socially disruptive behavior.  The use of substances (licit and illicit) remains the most frequently utilized response by people experiencing stress in the population particularly those in rural areas who are not well served by the community health system (Valtonen, Sogren, & Cameron-Padmore, 2006).  This leads to a treatment gap which is partially addressed by services being provided by churches and other religious organizations, non-governmental organizations providing services to families and victims of various kinds of trauma, and the healers of the religio-magic variety.  As these services become more accessible, there has been a growing demand for counseling type services not just from mental health practitioners but also from churches and other community groups (Sutherland, Moodley, & Chevannes 2013).  The inability to further the community mental health agenda has been partly due to lack of resources, and to the stigma and perception that those deemed to be mad are permanently afflicted and likely to be eventually violent.  The development of mental health services in the English speaking Caribbean has occurred in parallel with the training of mental health professionals in the region.

Mental Health and Stigma

One out of five Canadians (20%) will experience mental illness in their lifetime (Mental Health Commission of Canada, 2013). Research reveals that newcomers to Canada arriving since the 1990’s are facing greater socio-economic hurdles than previous groups of migrants in spite of higher education and skill levels (Omidvar & Richmond 2003).  Seeking and securing services and support remains a challenge and barriers such as limited access, stigma, language and unemployment continue to plague ethnic communities.  Ethnoracial and cultural groups face additional challenges including racism and culturally-rooted stigma. For African, Caribbean and Black Canadians, the struggle for mental health is often a silent one. With misunderstandings within the community around what mental illness means, and barriers that prevent individuals from accessing help or safe spaces, dealing with anxiety, depression and other mental illnesses becomes challenging and complicated.  Mental health resources that have specifically been designed to meet these populations’ needs also remain scarce.  Many individuals who could benefit from care that is culturally adapted and appropriate to serve their specific needs never receive these services.  Difficulties finding a therapist of colour or an organization that specifically caters to our community remain scarce and play into the larger barriers for finding types of therapies and/or medications that will fit an individuals’ needs

Perception of Mental Health in the Caribbean Community

There are several popular beliefs of the causes of mental illness that the African Canadian community continue to embody that impact and entrench the culturally rooted stigma:  

• It is brought on by a spell or spirits
• It is a punishment for wrongful deeds
• Person is crazy, dangerous, weak in character
• It is hereditary
• The person affected are pretending to have mental health problems

Furthermore, there continues to be a pervasive perception that mental health problems are caused by supernatural or spiritual factors rather than by changes in brain or central nervous system functioning.  As much as 30% of medical students in Trinidad, for example, believe that mental health problems are caused by supernatural practices or influences (Hutchinson, Neehall, Simeon & Littlewood, (1999).  This has led to a conflict between traditional religio-magic thinking and the more recently embraced Western empirical tradition from which the training of the mental health professionals have been drawn.  These issues have implications for the expectations that are placed on mental health service delivery and the ways in which services have developed to meet these expectations.

While there are common beliefs regarding the cause of mental illness in the African Caribbean community, there are also common beliefs regarding mental illness treatment

• Treatment will not cure or help control one’s problems
• If you admit to having mental health problems and seek treatment you will be institutionalized and drugged for the rest of your life
• Going to church and repenting will cure your problems
• Home herbal remedies and spiritual healers will resolve your problems
• High stigma concerning mental illness in the community means that emotional problems or seeking help for emotional problems is not usually disclosed to friends or family
• Withdrawal, anger, irritation, and complaints about nerves, nervous problems, feeling bad, feeling pressured, feeling low-spirited and feeling vexed are common indicators of emotional distress

The Architype of the Strong Black Woman

Modern beliefs and symbolism in our community has created some significant issues.  The “strong black women” and the “angry black women” stereotypes depict images of proud women who don’t take no for an answer.  Black girls are often taught to “keep your head up” to get through anything.  While it can be seen as a great life lesson, it may also allow black women to use this same coping strategy through adulthood which may foster an environment in which they have to manage everything.  Regardless of what is happening in your life, black women are literally bred to be strong ‘all the time’.  While this can be seen as positive in some aspects, the image has been carved in order to not allow ourselves our humanity.  If you are suffering from depression or anxiety, women often don’t acknowledge it because they believe that they cant.  Women of African decent continue to find themselves behind Caucasian and other women in health and mental health indices. For example, United States based data indicates that the depression rate among African American women is estimated to be almost 50% higher than that of Caucasian women.  African American people account for approximately 25% of the mental health needs in the United States though they only make up 11- 12% of the national population (blackwomenshealth.com) 

Psychological Implications

The stereotypical image of the strong black woman can be seen as a barrier to access to mental health treatment.  It would be viewed as “treason” to admit that black women cannot cope.  Issues that many black women face may not be seen as mental health related due to societal mental health stigma.  There are few black women that will seek mental health treatment and if they do seek treatment, many times it is for somatic concerns with their primary physician.  It has historically been difficult to treat mental health problems in African Canadian women. There exists a stigma placed on mental health problems within the African Canadian culture that mental illness is a sign of personal weakness, not a sickness.  Many times African Canadian women tend to rely on supports other than mental health services which can include the local community , the support of family, and the religious community during periods of emotional distress.  African Canadian women seek mental health care services at reduced rates in comparison to Caucasian women; and, when they do seek it, they do so later in life and at later stages of their illness. Part of the explanation for this is the poor service that African Canadian women receive from mental health professionals who, historically, have consistently under-diagnosed disorders like depression and over-diagnosed disorders like schizophrenia in the African Canadian community.  In addition, because of socioeconomic factors African Canadian women have limited access to health care compared to Caucasian women. 

How do we address the gaps?

In Canada, research has begun regarding culturally adapting Westernized evidenced based practice  models to address the specific needs of women of African decent.  However, some clinicians may question the applicability of adapting westernized modalities for ethnic communities and clinicians may turn to indiginous practices to effectively treat ethnocultural communities.  Organizations such as the Association of Black Psychologists uphold their mission which is, “the liberation of the African Mind, empowerment of the African Character, and enlivenment and illumination of the African Spirit”. 

The organization embodies the principles of Black/African centered psychology which is defined as:

“a dynamic manifestation of unifying African principles, values and traditions. It is the self conscious “centering” of psychological analyses and applications in African realities, cultures, and epistemologies. Black/African centered psychology, as a system of thought and action, examines the processes that allow for the illumination and liberation of the Spirit. Relying on the principles of harmony within the universe as a natural order of existence, Black/African centered psychology recognizes: the Spirit that permeates everything that is; the notion that everything in the universe is interconnected; the value that the collective is the most salient element of existence; and the idea that communal self knowledge is the key to mental health. Black/African Centered psychology is ultimately concerned with understanding the systems of meaning of human beingness, the features of human functioning, and the restoration of normal/natural order to human development. As such, it is used to resolve personal and social problems and to promote optimal functioning.”

Some of the exciting and important research Black psychologists are doing today includes studying the importance of racial identity as a protective factor against depression and stress, studying the detrimental effects of racism and evaluating the effects of the media on the Black psyche. 

To improve ones mental health, Black psychologists and other mental health professionals agree that spirituality is a necessary concept in healing. Emphasizing spirituality creates attitudes that embrace hope and positivity. In addition to the emphasis of spirituality in the approach to mental health treatment there are other ideals that psychologists and other mental health practitioners should focus on when they are engaged in a psychotherapeutic relationship with women of African decent

Know Thyself. A healthy identity is critical for overall good mental health. For women of African decent, this means seeing themselves as the recipients of generations of collective wisdom and experience from African and African diasporic culture. 

Use Social Supports. Using social networks found in the family, neighborhood, church, mosque, temple and community is how women of African decent seek healing through others with similar experiences. 

Build Self-Confidence. This comes from action. Those who put forth effort to achieve their positive ambitions must overcome fear and work hard. Regardless of how successful we are in the end, it is our determination and sense of control that gives us confidence in self. 

Recognize Symptoms. No two people experience mental disorders in the same manner. Symptoms will vary in severity and duration among different people. For example, while feelings of worthlessness is a common symptom of depression in Caucasian women, changes in appetite is cited as a common sign of depression for women of African decent (Blackwomenshealth.com).

In conclusion, it is important to understand the historical context of mental health and mental illness in the African Canadian Caribbean community.  African Canadian women are faced with several barriers and obstacles which may impact their ability and willingness to seek and secure mental health treatment. Practitioners must aim to appreciate this historical context in order to inform their approaches to treatment and to enhance the psychotherapeutic alliance.  This understanding will inform the mental health practitioner in regards to the presentation of the symptomatology and inform treatment approaches and protocols.

References

Hutchinson. G, Neehall. J. E, Simeon. D. T & Littlewood. R. (1999). Perceptions about Mental Illness among Pre-Clinical Medical Students in Trinidad and Tobago. The West Indian Medical Journal. 48(2). 84-1. 

Mental Health Commission of Canada (2013). Making the Case for Investing in Mental Health in Canada.

Sutherland. P, Moodley. R, Chevannes. B. (2013). Caribbean Healing Traditions: Implications for Health & Mental Health. New York. Routledge 

Omidvar. R & Richmond. T. (2003). Immigrant Settlement and Social Inclusion in Canada. Toronto. The Laidlaw Foundation

Valtonen. K, Sogren. M, & Cameron-Padmore. J. (2006). Coping Styles in Persons Recovering from Substance Abuse. British Journal of Social Work. 36(1). 57-73White. E. (1994). The Black Women’s Health Book: Speaking for Ourselves. Washington. Publishers Group West