Part One: The Past
Must our mental health community, both locally, nationally, and internationally, surrender to the many mistakes that occurred in the past regarding the care and treatment of African Americans? Or is it possible that we can critically examine the historical antecedents, thinking processes, including the many patterns of ethnocentrism that impacted the understanding, perception, and conflicting identity of African Americans and need for caring and therapeutic mental health treatment. Are there concepts and ideas from the past that can provide critical assistance in understanding the present state of African American mental health and at the same time utilizing that essential information to initiate critical and substantive steps toward change.
The association and power of the word “Sankofa” which is part of the language spoken by the Akan people in Ghana and is part of the Twi language may provide assistance as we review the past care of African Americans by the mental health community (berea.edu/cgwc/the-power-of-Sankofa). Ironically, this group was an integral part of those who traversed the horrific “last mile,” and boarded ships experiencing the terrors of the “middle passages.” The Akan ethnic group is part of the larger group in West African, the Ashanti, known for their tremendous cultural, socio political and economic systems. In addition, like many West African ethnic and cultural groups there are a knowledgeable and educated group of people. The translation of Sankofa is “it is not taboo to fetch what is at risk of being left behind” (Ibid). The actual symbol seen in weaved patterns, sculptures, photos, and paintings depicts a mythical bird whose feet are securely planted on the ground (Ibid). Interestingly, while its feet are securely planted on the ground its head is turned backwards. The beautiful and graphic image is meant to remind us that we must examine the past as we design, research, and implement the future. Further, we must utilize the past as a guide, providing us wisdom, learning and insight in planning the future. The Akans, a learned and intelligent people, fostered a belief that learning is key to pursuing improvement and excellence, utilizing the lessons from the past, not allowing ourselves to be deeply enmeshed in continued ignorance fueled by prejudice, bias, and hate.
Since the forced capture and enslavement of Black Americans and landing in Virginia circa 1619, their identity and humanity was thwarted with conflictual consciousness; being seen as potential money makers given their highly trained skills in the agricultural domain while at the same time relegated to being less than human based on a need for greed coupled with hate, ambivalence, and other conflictual sensations based on “differentness.”
Early in the colonies here in the United States it was hypothesized that there was a relationship between ownership of property, wealth, and responsibilities focused on wealth management were at risk of mental illness. It was thought there was a connection between the experience of increased stress and the symptoms of mental illness among white men (Journey of Blacks in Higher Education, 2014). However, the reasoning and hypothesis was quite different for the enslaved African Americans. Some of the earliest “mental health” care and/or treatment of African Americans began with the 1840 census with damaging, incorrect and unethical utilization of research, so-called researchers noted increased rates of insanity among freed Blacks in the north. This fallacious data also indicated that, as Black people migrated north, rates of insanity increased (this so-called research was utilized to substantiate the need for African Americans to be continually enslaved to avoid insanity) (Jackson, V. 2002). This fallacy colored the thinking and reinforced in the minds of slave owners that indeed the continual enslavement of Black Americans was indeed a good thing. Further on, in 1851, Louisiana physician Dr. Samuel Cartwright identified a mental disorder among enslaved Black Americans he called “Drapetomania,” a disease causing Negroes to run away from their slave owners.” Further, he felt the “treatment” intervention for slaves evidencing this so-called mental disorder was whipping (Ibid). Cartwright’s article, “Report on the diseases and Physical Peculiarities of the Negro Race,” indicated that African Americans, based on lung size and other factors, are “made to do labor and exercise” (Washington Post, 2021). So here again we note the proliferation of expert opinion of suitability of Black Americans for enslavement.
As one can imagine, there were indeed enslaved people who were mentally ill. However, their treatment consisted of being “punished, abandoned, sold, jailed or killed” (Davis, King, 2021). An enslaved person’s worth was dependent upon their ability to work, garnering profit for their enslavers no matter of illness, disability, etc. (Ibid). This thinking and reasoning exerted a pervasive and essential impact on the mental health needs of African Americans going forward in history. Essentially, prior to Emancipation especially in the South, there was no need for mental health care for Black Americans, and that in fact “race and skin color offered immunity from mental illness” (Davis, K., 2020, YouTube). Yet in Virginia prior to the Civil War, there existed a “series of public policies to allow discretionary admission of enslaved African Americans as long as their admission did not interfere with whites” (Ibid).
Did this lunacy, misinformation and horrific treatment of African Americans continue post Emancipation? Dr. King Davis, Research Professor, School of Information, The University of Texas at Austin, and Mike Hogg Professor Emeritus, Institute for Urban Policy Research, College of Liberal Arts, African and African Diaspora Studies, The University of Austin, together with a team for the past fifteen years unearthed and analyzed 36,000 photos, 5 to 7 million pages of materials, including admissions information, 800,000 records of the Central State Lunatic Asylum for the Colored Insane, the first segregated psychiatric hospital, opening its’ doors in 1868 in Virginia (Ibid). Dr. King was asked by the administration of Central State in 2007 to provide assistance in managing the numerous documents regarding the patients and history of Central State. He immediately responded as he was previously a mental health commissioner for Virginia. Dr. Davis responded to the call obtaining assistance from the National Association of State Mental Health Program Directors and began the monumental task of digitizing the huge amount of hospital and patient records (Washington Post 2021).
What prompted the governmental leadership in Virginia to plan and implement a segregated psychiatric facility for African Americans post-Civil War? Again, examining the thought processes and perceptions, it was felt among the leadership of the Freedman Bureau, which was the department within the Federal Government whose mission, values, and responsibilities were to manage the needs of African Americans who were newly emancipated. The Freedmen’s Bureau urged the governmental leadership in Virginia to create and implement health care (including mental health care) for newly-freed African Americans. In addition, two Virginia psychiatrists who were in charge of the existing psychiatric hospitals in Virginia felt that segregated facilities were needed for the newly emancipated Black Americans. Their fallacious and inaccurate perception was based upon their assessment that Black and white patients could not be treated at the same facility (Davis, King 2021).
The first location of the Central State Lunatic Asylum for the Colored Insane was housed in a former hospital for the confederacy outside of Richmond, Virginia, at the Howard Grove Hospital (American Slavery, 2015). The asylum opened in an “annex of the Howard Grove Hospital which had served as the smallpox hospital for Richmond’s Black population” (Davis, King 2020). Their doors opened as the first segregated facility in the United States in 1868 and they continued to be opened until 1968 (Ibid). However, in 1968 the segregation within the facility was struck down by the Federal Government (Ibid). Once the facility’s management was turned over to the state of Virginia, the census steadily increased from 373 patients in 1885 reaching a startling 5,000 patients in 1950 (Washington Post 3/29/2021).
In the initial decades of the opening of this segregated psychiatric facility for Black Americans, approximately 1870-1970, thousands of Black families faced involuntary commitment of their loved ones. As illiteracy remained high as a result of the former enslaved individuals being denied the opportunity and resources to read and write, as well as the power dynamic that existed between Blacks and whites, there was little chance that a commitment order could be fought. As this was the only facility for psychiatrically ill African Americans, many families lack resources to visit and intervene on behalf of their loved ones. Both loved ones, patients, and Sheriff’s officers were required to travel many hundreds of miles to Central Sate (Davis, 2021). Reportedly, conditions were described as highly unsanitary and unsuitable for one to live, possibly get well and return to one’s family (Washington Post, 3/29/2021). In addition, both forced sterilizations and experimental surgeries without informed consent and adequate medical facilities (Ibid). At the forefront in perception and belief among hospital leadership was the understanding that mental health among Black citizens was dependent on hard labor, surely a false belief emanating from the enslavement of Black Americans. Inpatients were required to engage in heavy farm work, various domestic chores, laundry, cleaning and so forth, basically performing all the physical labor in the hospital (Ibid).
The reasons for hospitalization were confusing and based upon circumstances that had little to do with psychopathology. According to research conducted by the Washington Post, “women could be admitted because they were upset about their husband’s desertion or because they had intense menstrual pain” (Washington Post, 3/29/2021). The commitment system was such a sham that admission could be based on the testimony of a white employer or hearsay. People were admitted for “talking back to a white person or refusing to step aside when a white person was walking (Jackson, 2020). In many cases, the reasons for admission to the hospital had much to do with social, economic, and political circumstances such as a need for medical care, economic and dire financial circumstances, housing needs, old agedness, unemployment, poverty, fear, and continuous trauma (Davis, 2021). Some patients may have suffered from some form of psychoses, alcoholism, and mania, however the diagnostic criteria were unclear. In some of the clinical records that were reviewed, patients were hospitalized based on “mania” due to “religious excitement or being free” (Davis, 2021). However, the diagnosis of mania was disproportionately applied to Blacks versus white (Ibid). It was also noted that perceptions of Black men as being angry and potentially violent were also utilized to initiate commitment (Davis, 2021). While some of the patients attempted to escape from these horrific conditions, many died due to illness contracted at Central State, such as one patient “Benjamin S., 35 years old, unmarried, a laborer, with a diagnosis of epilepsy. He never obtained discharge from Central State and after a two-year stay died of tuberculosis (Washington Post, 3/29/2021). Sadly, many African Americans who died in this facility were placed in unmarked graves without their families and loved ones given the opportunity for a funeral and of course closure (Ibid). Additionally, some of the bodies of former patients were “stolen by grave robbers seeking cadavers to be used at the local medical college” (Ibid).
There were additional psychiatric facilities in the southern part of the United States during this time period such as “The Alabama Insane Hospital.” However, it was a separate facility on the grounds of the whites only facility (Jackson, 2020). Similar to the so-called treatment approach at Central State, hospitalized in-patients were required to engaged in ongoing and relentless physical labor. Again, similar psychiatric care was also provided at the South Carolina State Hospital where again Black in-patients, both male and female, were required to engage in hard labor. In March of 1875, financial allocations were appropriated to erect a “colored insane asylum” (Ibid). There were several name changes such as The Eastern Asylum for the Colored Insane, opening in 1880 and later Goldsboro. Like many unfortunate yet horrific experiences at this facility, a patient named Junius who was admitted at 17 years old was deaf and unable to speak. He was accused of rape, was castrated, and remained at the hospital (Ibid). While the rape charges were dropped, this gentleman remained at the facility, eventually dying in March, 2001. In 1919, The Rusk State Penitentiary in Texas was redesigned and named a facility for the “Negro insane.” Last, Maryland initiated and implemented a hospital for the “colored insane” in 1911. The patients were required to live in tents and worked on building a facility.
The extensive detailed, painstaking research at Central State has not been undertaken by the above captioned facilities. What they have in common besides admitting individuals who did not participate in the main require psychiatric treatment and in all circumstances were required to engage in heavy and onerous physical labor. The stories and experiences of the African American in-patients need to be discerned and shared.
Part Two: The Present and Recommendations to Promote Mental Health Care for African Americans
Much of the foregoing discussion pointed to the fact that mental health care for African Americans post-Emancipation was focused on containment, disempowerment, and a return to enslavement. The political landscape at that time post-enslavement was confused, chaotic, and without an ethical, moral, and strategic plan to provide assistance to the newly emancipated. The perception of the larger society and those in charge with design and funding, managing, and providing mental health care was colored with a continual and unrelenting perception of African Americans as less than human and potentially dangerous. In addition, commitment to these facilities was chaotic, unlegislated, and based upon an unfair and horrific system. Seemingly, the main focus of the larger society at that time as well as the mental health community was reenactment of enslavement albeit with another name.
Let us examine the legacy in our current mental health systems of care and ways in which knowledge of the past can help improve, enhance, and promote a more effective and humane mental health system.
- For example, we continue to note continual misdiagnosis and overdiagnosis of psychoses in the black community which indeed was identified during (Davis, 2020) the post-Emancipation period to present. There continues a tendency to over-pathologize the mental health presentation of Black Americans (Bell CC et al., 2015).
- Involuntary admission both then and now continue to plague our systems of care (Davis, 2020).
- Previously, homelessness, poverty, and unemployment were often the criteria for admission post-Emancipation and remain a key issue among the people we wish to serve (Davis, 2020).
- Unlike the historical period we have reviewed, deinstitutionalization currently remains at the forefront. However, much needed services such as housing remains one of the key elements in measuring success outcomes for those leaving in-patient facilities – both for African Americans and other people of color. Some of the existing facilities for consumers lack the basic environmental standards akin to the legacy of the past (Davis, 2020). We continue to lack much needed community mental health facilities which are also key to successful discharge. Recent data indicated “only one in three adult African Americans with mental health illness receive treatment (nami.org). We have learned presently that consumers must exert and develop alternative treatment options that they believe will ultimately help. These options include creative pursuits, yoga, educational options, acupuncture, massage, and lots more. However, access is not forthcoming due to access (i.e. insurance) and availability.
- Many of the people admitted to Central State evidenced a number of medical challenges. Additionally, if they were not already ill upon admission, they developed medical diseases during their stay. Early on at Central State, they were adjacent to a hospital for Black Americans who had smallpox (Davis, 2021). Presently, we understand the critical importance of medical care for African Americans who are endangered by the many social determinants of health including intersectionality. Therefore, it is critical that as we design mental health systems of care and that we integrate medical care. While presently we have recognized this need, the much-needed substantive changes need to be implemented.
- The role of churches, pastors, and community supports remain constant both in post-Emancipation and present. Churches remain a resource not fully utilized in the care of mentally challenged Black Americans. Churches can be utilized to increase mental health literacy and to challenge perceptions of stigma (McRae, 1998, Davis, 2020).
- While racism, oppression, and a variety of “Isms” (i.e. ableism, homophobia) were rampant during the post-Emancipation and onwards period, we continue to see evidence that these views still present themselves among present day clinicians.
- While there was no sense that post-Emancipation mental health clinicians had no understanding of the pressing need for culturally competent, and responsive care, on the present scene we are making a number of inroads but have not fully implemented this in the care of African Americans. This continues to be a pressing issue especially in the treatment of Black men. On the whole, past perceptions remain the same in that Black men are often seen as potentially violent, aggressive, and angry and require containment. Thus, the reasons for high rates of seclusion and restraint, although this is slowly changing.
- Hard physical labor for African Americans appeared as a basic mindset among those who were at the forefront of mental health care post-Emancipation. On the current scene, many consumers seek meaningful and important paths in the world of work. However, these continue to be a profound lack.
- While there were few if any clinicians of color post-Emancipation, there still exists a profound need to increase these numbers of individuals.
- Research and analysis post-Emancipation regarding African Americans was spurious, incorrect, unethical, and was based on racist dogma. While research has improved, we are not at the point where research on the needs, expression of symptoms, relationship building, help-seeking behavior, and so much more is lacking (org). There is particular concern regarding research samples that include African Americans in evidenced-based practices.
- While there was little or no understanding of the relationship between beliefs about race and mental illness and the initiation of public policy post-Emancipation, this is an arena that still requires focus and enhanced implementation.
- The concept of stigma was present post Emancipation and certainly we must infer that the majority of African Americans avoided hospitalization and that when a family member was involuntarily admitted, the remaining family members experienced stigma. On the present scene, stigma remains an ever-present issue for African Americans and must be addressed at multiple levels including Federal, state, and locally as well as by mental health groups and stakeholders.
Bell CC, Jackson WM, Bell BH. Misdiagnosis of African Americans with Psychiatric Issues-Part ii. National Medical Association. 2015 Mar;107 (3):35-41. Doi:10.1016/S0027-9684 (15)30049-3Epub 2015 Dec 2. PMID 27282721.
Bailey ZD, Krieger N, Agenor M, Graves J. Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 Apr 8;389(10077):1453-1463. doi:10.1016/S01406736(17)30569-X. PMID:28402827.
Centers for Disease Control (2019) Summary Health Statistics: National Health Interview Survey:2017. Table A-7 Retrieved from https://www.cdc.gov/nchs/nhis/shs/tables.htm
Davis, King (June 17,2021). The Central State Hospital Archives: Creating, preserving, interpreting, and comparing findings from 1840. National Association of State Mental Health Program Directors (Zoom Presentation). Austin Texas
Davis, King (May 21, 2019). The Benjamin Rush Lecture: The Central Lunatic Asylum for Colored Insane Archives: Access, Privacy and Utility of Historical Records in the Digital Age. The American Psychiatric Association Annual Conference. San Francisco
Jackson, Vanessa (2002), In Our Own Voices: African American Stories of Oppression: Survival and Recovery in the Mental Health System”, pp 1-36, p 4-8 Retrieved from: http://academic.Udayton.edu/health/01status/mental01.htm
www.nami.org Black/African American