The historical roots of racial disparities in the mental health system - Counseling Today (2023)

Racial disparities, or unfair differences, within the system of mental health are well documented. Research indicates that compared with people who are white, black, indigenous and people of color (BIPOC) are:

  • Less likely to have access to mental health services
  • Less likely to seek out services
  • Less likely to receive needed care
  • More likely to receive poor quality of care
  • More likely to end services prematurely

Regarding racial disparities in misdiagnosis, black men, for example, are overdiagnosed with schizophrenia (four times more likely than white men to be diagnosed), while underdiagnosed with posttraumatic stress disorder and mood disorders. Additionally, concerns are compounded by the fact that for BIPOC, mental health care is often provided in prisons, which infers a multitude of issues.

BIPOC are overrepresented in the criminal justice system, as the system overlays race with criminality. Statistics show that over 50% of those incarcerated have mental health concerns. This suggests that rather than receiving treatment for mental illness, BIPOC end up incarcerated because of their symptoms. In jails and prisons, the standard of care for mental health treatment is generally low, and prison practices themselves are often traumatic.

The vast majority of mental health treatment providers in the United States are white. For example, approximately 86% of psychologists are white, and less than 2% of American Psychological Association members are African American. Some research has demonstrated that provider bias and stereotyping are relevant factors in health disparities. For nearly four decades, the mental health field has been called to focus on increasing cultural competency training, which has focused on the examination of provider attitudes/beliefs and increasing cultural awareness, knowledge and skills.

Despite such efforts, racial disparities still exist even after controlling for factors such as income, insurance status, age, and symptom presentation.Established barriers for BIPOC are the following:

  • Different cultural perceptions about mental illness, help-seeking behaviors and well-being
  • Racism and discrimination
  • Greater vulnerability to being uninsured, access barriers, and communication barriers
  • Fear and mistrust of treatment

In addition to emphasizing culturally competent services, other recommendations to bridging the gaps and addressing barriers have largely focused on diversifying workforces and reducing stigma of mental illness in communities of color.

(Video) The Historical Roots of Racial Disparities in the Mental Health System

One area not often noted is the historical (and traumatic) context of systemic racism within the institution of mental health, although it is well known that race and insanity share a long and troubled past. This focus may begin to account for how racial differences shape treatment encounters, or a lack thereof, even when barriers are controlled for and the explicit races of the provider and client are not at issue.

Historical context

In the United States, scientific racism was used to justify slavery to appease the moral opposition to the Atlantic slave trade. Black men were described as having “primitive psychological organization,” making them “uniquely fitted for bondage.”

Benjamin Rush, often referred to as the “father of American psychiatry” and a signer of the Declaration of Independence, described “Negroes as suffering from an affliction called Negritude.” This “disorder” was thought to be a mild form of leprosy in which the only cure was to become white. Ironically Rush was a leading mental health reformer and co-founder of the first anti-slavery society in America. Rush did observe, however, that “the Africans become insane, we are told, in some instances, soon after they enter upon the toils of perpetual slavery in the West Indies.”

In 1851, prominent American physician Samuel Cartwright defined “drapetomania” as a treatable mental illness that caused black slaves to flee captivity. He stated that the disorder was a consequence of slave masters who “made themselves too familiar with the slaves, treating them as equals.” Cartwright used the Bible as support for his position, stating that slaves needed to be kept in a submissive state and treated like children to both prevent and cure them from running away. Treatment included “whipping the devil out of them” as a preventative measure if the warning sign of “sulky and dissatisfied without cause” was present. Remedy included the removal of big toes to make running a physical impossibility.

Cartwright also described “dysaethesia aethiopica,” an alleged mental illness that was the proposed cause of laziness, “rascality” and “disrespect for the master’s property” among slaves. Cartwright claimed that the disorder was characterized by symptoms of lesions or insensitivity of the skin and “so great a hebetude [mental dullness or lethargy] of the intellectual faculties, as to be like a person half asleep.” Undoubtedly, whipping was prescribed as treatment. Furthermore, according to Cartwright dysaethesia aethiopica was more prevalent among “free negroes.”

(Video) Racial Disparities in Mental Health Care

The claim that those who were free suffered mental illness at higher rates than those who were enslaved was not unique to Cartwright. The U.S. census made the same claim, and this was used as a political weapon against abolitionists, although the claim was found to be based on flawed statistics.

Even at the turn of the 20th century, leading academic psychiatrists claimed that “negroes” were “psychologically unfit” for freedom. And as late as 1914, drapetomania was listed in the Practical Medical Dictionary.

Furthermore, after slavery was abolished, Southern states embraced the criminal justice system as a means of racial control. “Black codes” led to the imprisonment of unprecedented numbers of black men, women and children, who were returned to slavery-like conditions through forced labor and convict leasing that lasted well into the 20th century.

Scientific racism early on indicates motives of control and containment for profitability. Leading health professionals propagated the idea that blacks were “less than” to justify exploitation and experimentation. The mislabeling of behavior, such as escaping slavery, as a byproduct of mental illness did not stop there. Significant transformations in defining mental illness also occurred in the civil rights era, suggesting that institutional racism becomes more powerful in the context of moments of heightened racial tensions in the collective social consciousness.

Prior to the civil rights movement, schizophrenia was described as a largely white, docile and generally harmless condition. Mainstream magazines from the 1920s to the 1950s connected schizophrenia to neurosis and, as a result, attached the term to middle-class housewives.

Assumptions about the race, gender and temperament of schizophrenia changed beginning in the 1960s. The American public and the scientific community began to increasingly describe schizophrenia as a violent social disease, even as psychiatry took its first steps toward defining The historical roots of racial disparities in the mental health system - Counseling Today (1)schizophrenia as a disorder of biological brain function. Growing numbers of research articles asserted that the disorder manifested by rage, volatility and aggression, and was a condition that afflicted “Negro men.” The cause of urban violence was now due to “brain dysfunction,” and the use of psychosurgery to prevent outbreaks of violence was recommended by leading neuroscientists.

(Video) Understanding the Roots of Racism: Mental Health

Researchers further conflated the symptoms of black individuals with perceived schizophrenia of civil rights protests. In a 1968 article in the esteemed Archives of General Psychiatry, schizophrenia was described as a “protest psychosis” in which black men developed “hostile and aggressive feelings” and “delusional anti-whiteness” after listening to or aligning with activist groups such as Black Power, the Black Panthers or the Nation of Islam. The authors wrote that psychiatric treatment was required because symptoms threatened black men’s own sanity as well as the social order of white America.

Advertisements for new pharmacological treatments for schizophrenia in the 1960s and 1970s reflected similar themes. An ad for the antipsychotic Haldol depicted angry black men with clenched fists in urban scenes with the headline: “Assaultive and belligerent?” At the same time, mainstream white media was describing schizophrenia as a condition of angry black masculinity or warning of crazed black schizophrenic killers on the loose. A category of paranoid schizophrenia for black males was created, while casting women, neurotics and other nonthreatening individuals into other expanded categories of mood disorders.

The black psyche was increasingly portrayed as unwell, immoral and inherently criminal. This helped justify the need for police brutality in the civil rights movement, Jim Crow laws, and mass incarceration in prisons and psychiatric hospitals, which at times was an exceedingly thin line. In general, attempts to rehabilitate took a back seat to structural attempts to control. Some state hospitals, presided over by white male superintendents, employed unlicensed doctors to administer massive amounts of electroshock and chemical “therapies,” and put patients to work in the fields. Deplorable conditions went unchallenged as late as 1969 in some states.

Deinstitutionalization, a government policy of closing state psychiatric hospitals and instead funding community mental health centers, began in 1955. Over the next four decades, most state hospitals were closed, discharging those with mental illness and permanently reducing the availability of long-term inpatient care facilities. Currently, there are more than three times as many people with serious mental illnesses in jails and prisons than in hospitals. The shifts in defining what constitutes mental health reflects the reality that the definition is shaped by social, political and, ultimately, institutional factors in addition to chemical or biological ones.


Looking at the historical and systemic context of the mental health system may provide insight into why racial disparities continue to exist and why these disparities have been resistant to interventions such as cultural competency training and standardized diagnostic tools. Focusing primarily on the race of the provider and the client, while valid, is an approach that does not consider the system itself, the functions of the diagnosis, and its structurally developed links to protest, resistance, racism and other associations that work against the therapeutic connection.

(Video) Overcoming Racial Disparities in Health and Mental Health

Racial concerns, including overt racism at times, were written into the mental health system in ways that are invisible to us now. Understanding the past enables new ways of addressing current implications and identified barriers, including how schizophrenia became a “black disease,” why prisons emerged where hospitals once stood, and how racial disparities continue to exist in the mental health system today.


Additional resources


Tahmi Perzichilli is a licensed professional clinical counselor and licensed alcohol and drug counselor working as a psychotherapist in private practice in Minneapolis. Contact her at


(Video) Pandemic Shines Light on Racial Disparities in Mental Health Care

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.


What causes mental health disparities? ›

Racial/ethnic, gender, and sexual minorities often suffer from poor mental health outcomes due to multiple factors including inaccessibility of high quality mental health care services, cultural stigma surrounding mental health care, discrimination, and overall lack of awareness about mental health.

What demographic has the most mental health issues? ›

Just over a quarter of Black (28%) and Hispanic (27%) nonelderly adults reported having a mental illness or substance use disorder in 2020, compared to 36% of White nonelderly adults (Figure 4).

What are racial disparities health? ›

The term "health disparities" is often defined as "a difference in which disadvantaged social groups such as the poor, racial/ethnic minorities, women and other groups who have persistently experienced social disadvantage or discrimination systematically experience worse health or greater health risks than more ...

How does Mexico deal with mental health? ›

The Mexican government does little to prioritize mental health for its own people, let alone people from other countries. Mexico trails its peers in both mental health spending and number of mental health professionals, making services hard to access all around.

What does disparities in mental health mean? ›

Behavioral health disparities refer to differences in outcomes and access to services related to mental health and substance misuse which are experienced by groups based on their social, ethnic, and economic status.

What are the 5 key areas of disparities in health care? ›

Disparities occur across many dimensions, including race/ethnicity, socioeconomic status, age, location, gender, disability status, and sexual orientation. 2.

Which racial group is most likely to receive mental health services? ›

People of color are less likely to access treatment for their mental illnesses than white people. On average, 43% of all adults with a mental illness receive mental healthcare. White people with a mental illness are the most likely group to get care, with nearly half receiving the care that they need.

What demographic goes to therapy the most? ›

Furthermore, mental health treatment in general is far more common among white adults in the U.S. than among other races or ethnicities. In 2020, around 24.4 percent of white adults received some form of mental health treatment in the past year compared to 15.3 percent of black adults and 12.6 percent of Hispanics.

What demographic has the least access to mental health care? ›

Among adults reporting moderate to severe symptoms of anxiety and/or depression, receipt of mental health treatment was lowest among several demographic groups – including young adults, Black adults, men, and uninsured people.

What are three root causes of racial and ethnic health disparities? ›

The sources of racial and ethnic health care disparities include differences in geography, lack of access to adequate health coverage, communication diffi- culties between patient and provider, cultural barriers, provider stereotyping, and lack of access to providers.

What are three major areas of health disparities today? ›

Of the 30 million uninsured Americans, about half are people of color, according to Brookings.
Examples of Health Disparities
  • Mortality.
  • Life expectancy.
  • Burden of disease.
  • Mental health.
  • Uninsured/underinsured.
  • Lack of access to care.

Which country treats mental illness the best? ›

Sweden tops our positive mental health index, and with good reason. The Nordic nation ranked high for the percentage of green space, as it plays host to lush coniferous forests that take up the majority of its land providing the perfect environment for relaxation and mental wellbeing.

Which country has the best mental healthcare? ›

The best countries for mental wellbeing
  • Sweden. While Sweden might not have the warmest climate with an average temperature of 2.1°C, there are several reasons why this Nordic nation ranks first in the world for mental wellbeing. ...
  • Germany. ...
  • Finland. ...
  • France. ...
  • The Netherlands. ...
  • Italy. ...
  • Canada. ...
  • Norway.
28 Jun 2022

How is mental health viewed in Hispanic culture? ›

Hispanic cultures fear being labeled “loco” if they express mental anxiety or concerns, and do not want be viewed as weak or mentally unfit. It is more acceptable to have a neurological or physical condition so many describe their mental health symptoms in physical terms rather than emotional.

What are the five sources of disparities? ›

Amartya Sen traced five sources of disparity between real incomes and actual advantages:
  • Personal heterogeneities.
  • Environmental diversities.
  • Social climate variations.
  • Differences in relational perspectives.
  • Distribution within family.

How can we reduce disparities in mental health care? ›

Promoting connectedness among members of a community, building alliances with local communities, and improving culturally appropriate access to care can help reduce some factors that contribute to disparity.

What are examples of disparities? ›

For example, disparities occur across socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Research also suggests that disparities occur across the life course, from birth, through mid-life, and among older adults.

What are 10 factors that can contribute to health care disparities? ›

Causes of Health Disparities
  • Poverty. Poverty is a factor that contributes to health disparities tremendously. ...
  • Environmental Threats. Environmental threats on health disparities can range in many ways. ...
  • Inadequate or Unequal Access To Health Care. ...
  • Individual and Behavioral Factors.

What are the 4 social determinants of health care disparities? ›

Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities. The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people's lives by reducing health inequities.

How can racial disparities be reduced in healthcare? ›

Improving Neighborhood and Housing Conditions. Given that virtually every health-enhancing resource is linked to where one lives in the U.S., a key to improving health and reducing disparities is to improve the quality of neighborhood and housing environments in the United States.

Do racial and ethnic disparities in mental health treatment vary with underlying mental health? ›

We find that in contrast to physical health treatment, Black–White and Hispanic–White disparities in any mental health treatment use widen with higher levels of psychological distress.

What social groups are most at risk of developing mental health problems? ›

Mental health inequalities
  • poverty.
  • poor housing.
  • family conflict.
  • unemployment.
  • childhood adversity.
  • chronic health problems.
24 Dec 2021

What percentage of mental health counselors are black? ›

The most common ethnicity among mental health counselors is White, which makes up 71.2% of all mental health counselors. Comparatively, there are 11.2% of the Black or African American ethnicity and 10.3% of the Hispanic or Latino ethnicity.

What race are most therapists? ›

The most common ethnicity among therapists is White, which makes up 76.4% of all therapists.

Does race matter when choosing a therapist? ›

Maramba and Hall (2002) conducted a meta-analysis of seven studies and found that clients matched with therapists of the same ethnicity were less likely to drop out of therapy and more likely to attend more sessions; however, the effect was small, indicating that ethnic match alone was a weak predictor.

Who needs Counselling the most? ›

Many people who seek counseling have anxiety disorders, which cause excessive fear and worry. People with mood disorders, including depression and bipolar disorder, can also benefit from counseling. There are numerous other mental illnesses that counseling can be a helpful treatment option for.

What are three common barriers to mental health care? ›

(1) Common barriers to mental health care access include limited availability and affordability of mental health care services, insufficient mental health care policies, lack of education about mental illness, and stigma.

What are the barriers to accessing support for mental health? ›

Barriers to accessing mental health support include difficulties in identifying and communicating distress, stigmatising beliefs, shame, a preference for self-reliance, and anticipation that help will be difficult to access.

What percentage of mental health counselors are white? ›

Mental Health Therapist Statistics By Race

The most common ethnicity among mental health therapists is White, which makes up 80.9% of all mental health therapists. Comparatively, there are 9.1% of the Hispanic or Latino ethnicity and 6.7% of the Black or African American ethnicity.

What are reasons for the persistence of racial disparity in healthcare? ›

This is a result of many factors, including the higher rates of uninsured and the limited availability of primary care physicians in some communities of color. Even when health care resources are geographically accessible, language and cultural barriers are sometimes a problem.

What is racial disparity in simple terms? ›

Racial disparity refers to the imbalances and incongruities between the treatment of racial groups, including economic status, income, housing options, societal treatment, safety, and myriad other aspects of life and society.

What are some of the contributing factors to the health disparities among ethnic minorities? ›

These disparities may stem from many factors, including accessibility of health care, increased risk of disease from occupational exposure, and increased risk of disease from underlying genetic, ethnic, or familial factors.

How does race and ethnicity affect health care? ›

The data show that racial and ethnic minority groups, throughout the United States, experience higher rates of illness and death across a wide range of health conditions, including diabetes, hypertension, obesity, asthma, and heart disease, when compared to their White counterparts.

What are disparities of health and why are they important to address? ›

Health disparities and health inequities are differences between the health outcomes of Whites and people of color in terms of length of life, quality of life, and social well-being. In the United States, life expectancy is 79 years, and any death occurring before that age is premature.

What factor is often considered the most fundamental cause of health disparities? ›

We tend to study health inequalities as differentials in disease and death that exist within a population. But the most important cause of health inequality is social stratification, and social stratification only varies between populations.

What are the roots of health disparities? ›

The report describes nine determinants of health that are drivers of health inequities: income and wealth, housing, health systems and services, employment, education, transportation, social environment, public safety, and physical environment.

What are the root causes of health disparities? ›

Many factors contribute to health disparities, including genetics, access to care, poor quality of care, community features (e.g., inadequate access to healthy foods, poverty, limited personal support systems and violence), environmental conditions (e.g., poor air quality), language barriers and health behaviors.

What are disparities in mental health? ›

Behavioral health disparities refer to differences in outcomes and access to services related to mental health and substance misuse which are experienced by groups based on their social, ethnic, and economic status.

What city has the most mental health issues? ›

American Cities With the Highest Rates of Depression
RankMetropolitan AreaPercentage
1Billings, MT31.00
2Kingsport-Bristol-Bristol, TN-VA30.60
3Knoxville, TN30.20
4Charleston, WV29.00
47 more rows
8 Feb 2022

How does Japan view mental health? ›

In Japan, the loss of 'mental self-control' or mental health conditions such as depression and anxiety were seen as something over which a person is unable to exercise will power. Ingrained in Japanese culture, those who are unable to practice will power are taught to feel a sense of shame as a result.

Where is world's best mental hospital? ›

  • McLean Hospital. Belmont, MA 02478-1064. ...
  • Johns Hopkins Hospital. Baltimore, MD 21287-2182. ...
  • Massachusetts General Hospital. Boston, MA 02114-2696. ...
  • New York-Presbyterian Hospital-Columbia and Cornell. 1-848-276-6630. ...
  • UCSF Health-UCSF Medical Center. ...
  • Resnick Neuropsychiatric Hospital at UCLA. ...
  • Mayo Clinic. ...
  • Yale New Haven Hospital.

What is the best state to live in for mental health? ›

The best access to mental healthcare occurs in Vermont, Massachusetts, Maine, Wisconsin, and Minnesota. Texas, Alabama, Florida, Georgia, and Mississippi rank the lowest. Affordability still remains the primary barrier facing patients who are seeking mental healthcare.

What countries have the lowest rates of mental illness? ›

The most depressed country is Afghanistan, where more than one in five people suffer from the disorder. The least depressed is Japan, with a diagnosed rate of less than 2.5 percent.

Why did mental institutions go away? ›

In 1965, the creation of Medicaid accelerated the shift from inpatient to outpatient care: One key part of the Medicaid legislation stipulated that the federal government would not pay for inpatient care in psychiatric hospitals. This further pushed states to move patients out of costly state facilities.

How is mental health influenced by culture? ›

Culture significantly impacts various aspects of mental health including the perception of health and illness, treatment-seeking behaviour and coping styles. As such, simplified mainstreaming of mental health approaches may not cater to the needs of a culturally diverse population from different communities.

How does cultural identity affect mental health? ›

Your cultural identity can influence your sense of belonging and fitting in. It can influence what you eat, who you spend time with and what you do for fun. It also shapes your values and your views on health and wellbeing. This isn't always defined by the country that you're born in.

Why are cultural factors important in mental health? ›

But a society's culture also impacts a person's beliefs, norms and values. It impacts how you view certain ideas or behaviors. And in the case of mental health, it can impact whether or not you seek help, what type of help you seek and what support you have around you.

What are the major reasons for such disparities? ›

some of the main reasons of such disparities are :
  • on the basis of geography there are differences in regions.
  • In developmental terms some regions are more user friendly.
  • There is differences of importance in some cities and regions by government policies.
12 Feb 2020

What are the factors of disparity? ›

For example, disparities occur across socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Research also suggests that disparities occur across the life course, from birth, through mid-life, and among older adults.

What are 4 environmental factors that can contribute to mental illness? ›

Substance abuse. Pollution. Exposure to toxins during childhood. Extreme weather conditions (such as excessive rain or snow)

What are some ways that we can address root causes of health disparities? ›

To address health inequities, communities must remove obstacles to good health such as poverty, discrimination, and their consequences, including: powerlessness and lack of access to well-paying jobs, quality education and housing, safe environments, and health care (Braveman et al., 2017).

What are the main determinants in health disparities? ›

Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities. The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people's lives by reducing health inequities.

What are some ways to reduce racial disparities? ›

Build Back Better Reduces Racial Disparities
  • Cut poverty — especially among children — and narrow long-standing racial disparities in child poverty. ...
  • Reduce homelessness and housing instability. ...
  • Expand health coverage and access to care. ...
  • Improve access to preschool and child care.
4 Nov 2021

What are 3 health disparities? ›

Examples of Health Disparities
  • Mortality.
  • Life expectancy.
  • Burden of disease.
  • Mental health.
  • Uninsured/underinsured.
  • Lack of access to care.

What is an example of a disparity? ›

Disparity Sentence Examples

Their life seems an immense disparity between effort and opportunity. The disparity of force was not so great as to make resistance altogether hopeless. In some other respects also a certain disparity is apparent between a minister and his elders. The disparity disturbed him.

How do you explain disparity? ›

Disparity is the condition of being unequal, and a disparity is a noticeable difference. Disparity usually refers to a difference that is unfair: economic disparities exist among ethnic groups, there is a disparity between what men and women earn in the same job.

What are the three 3 main contributors and causes of mental illness? ›

For example, the following factors could potentially result in a period of poor mental health: childhood abuse, trauma, or neglect. social isolation or loneliness. experiencing discrimination and stigma, including racism.

What are two major factors that influence mental health? ›

There are so many factors that have an impact on our mental health, including genetics, family history, childhood experiences — and even big societal issues like violence, discrimination or poverty.

What social factors affect mental health? ›

Social factors that can influence mental health include race, class, gender, religion, family and peer networks. Our age and stage, and the social roles we have at any time in our life all contribute to this.


1. Historical Frameworks: How the History of Racism Has Impacted Black Mental Health and Healthcare
(Virginia DBHDS)
2. Racial, Ethnic, Cultural and National Disparities in Psychological Treatment Outcomes are Inevitable
(Dr. Bedi's Research, Teaching, and Service Lab)
3. Why Race Matters: Black Mental Health
(PBS Wisconsin)
4. Racism as a Mental Health Challenge: An Antiracist Counseling Perspective
(TCSPP Counselor Ed. Department)
5. Historical Trauma and Mental Health
(Eckerd College)
6. A Troubling Prognosis: Race Disparities and Health Outcomes
(The Aspen Institute)
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