Mental health stigma among people of color: An examination of the impact of racial discrimination

Abstract

Objective:

The primary goal of this study was to examine the relations between racial discrimination experiences and different dimensions of mental health stigma among a diverse sample of people of color.

Method:

Participants were recruited through blast emails at a large public university and completed an online survey (N = 205). Four linear regressions were completed predicting from recent racial discrimination experiences to (1) negative beliefs about mental health problems, (2) treatments, (3) treatment seeking and (4) anticipated stigma.

Results:

Results indicated that recent racial discrimination experiences contributed unique variance in anticipated stigma from loved ones, as well as negative beliefs about mental health problems.

Conclusion and Implications for Practice:

Racial discrimination contributes to increased anticipated stigma and negative beliefs about mental health problems. Addressing the impact of racial discrimination as it influences these dimensions of mental health stigma is important to promote recovery among people of color.

Keywords

Racial discrimination mental health stigma people of color

Impact and Implications Statement: Anti-stigma interventions should address the impact of racial discrimination on individuals’ concerns about anticipated stigma, as well as how racial discrimination may influence internalized negative beliefs about experiencing mental health problems. Further qualitative and quantitative research should examine the unique and overlapping coping strategies to resist oppression from both mental health stigma and racial discrimination to enhance recovery and resilience.

There are significant inequalities in the utilization and quality of mental health care provided to people of color (Atdjian & Vega, 2005; Smedley, Stith, & Nelson, 2003; Smith & Trimble, 2016; Williams, Neighbors, & Jackson, 2003). Nationally representative research comparing mental health care utilization among White, Black and Latinx¹ individuals indicates that Black and Latinx individuals are not at higher risk of developing mental health problems, but suffer significantly longer from mood and anxiety disorders when compared with White individuals (Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005). Furthermore, research indicates that Black individuals are less likely to receive mental health care services, even when controlling for other demographic and income variables, and psychiatric diagnosis and comorbidities, when compared with White and non-White Latinx individuals (Alegría et al., 2002). Furthermore, Latinx individuals are about half as likely to seek mental health care compared with White individuals (Guzman, Woods-Giscombe, & Beeber, 2015; U.S. Department of Health and Human Services, 2001). In addition, Asian American individuals with a lifetime prevalence of substance-use, mood or anxiety disorders were least likely to receive mental health care services in outpatient, inpatient or emergency settings, when compared with White, Black and Latinx individuals (Lee, Martin, Keyes, & Lee, 2011).

Given the under-utilization of mental health care resources among people of color of diverse racial identities, it is important to identify mutable individual-level and contextual targets to reduce barriers to mental health care initiation and retention. However, health care behavior is multifaceted and is likely influenced by a complex array of interacting personal (e.g. mental health literacy, health-related beliefs, educational status, symptom severity) and contextual variables (e.g. social class, environmental context). One important contextual barrier influencing health care behavior may be racial discrimination.

Racial discrimination is defined as the attitudes and beliefs of individual or group inferiority based on phenotypic characteristics (i.e. race; Jones, 1997). Racism also encompasses a broad range of complex and nuanced behavioral experiences of discrimination, including interpersonal racism (e.g. racial slurs), institutional/systemic racism (e.g. educational inequality), cultural racism (e.g. valuing Western European philosophies) and sociopolitical policies and other collective experiences that disproportionately impact an entire racial group (Harrell, 2000; Jones, 1997). Experiences of discrimination can be overt (macroaggressions) or subtle denigrating slights that suggest inferiority (microaggressions; Sue et al., 2007). Race-related discrimination is a recurrent and chronic stressor (Bryant-Davis & Ocampo, 2005; Ford, 2008; Lowe, Okubo, & Reilly, 2012) experienced at least once annually by about 98% of individuals who identify as people of color (Alvarez, Juang, & Liang, 2006; Klonoff & Landrine, 1999). It is associated with detrimental mental health consequences, including general distress, anxiety and depression (Klonoff, Landrine, & Ullman, 1999; Paradies, 2006; Pieterse, Todd, Neville, & Carter, 2012), and lower self-esteem (Alvarez & Helms, 2001; Liang & Fassinger, 2008).

There is some evidence that racial discrimination also impacts utilization of mental health services. For example, in a sample of Chinese Americans, Spencer and Chen (2004) found that participants who experienced racial discrimination resulting from speaking a language other than English or speaking English with an accent were more likely to seek help for mental health problems from informal sources (e.g. religious or spiritual leader, herbalist) and family and friends, as compared with participants who did not report experiencing this type of discrimination. Also, results from a national study of Asian Americans from diverse ethnic backgrounds indicated that perceived racial/ethnic discrimination was associated with greater likelihood of seeking help for emotions, nerves or use of alcohol or drugs from informal sources (Spencer, Chen, Gee, Fabian, & Takeuchi, 2010). No relation was found between discrimination and utilization of formal mental health services in Spencer and Chen’s sample. However, results from another study conducted with a sample of American Indian, Latinx, US-born Black, African-born Black, Southeast Asian and White participants indicated that experiencing racial discrimination was associated with higher odds of delaying or not getting mental health care they thought they needed (i.e. underutilizing mental health services; Burgess, Ding, Hargreaves, van Ryn, & Phelan, 2008). Specifically, participants who endorsed experiencing ‘major’ discrimination (in housing, employment, social service, policing or loans/mortgage) were more than twice as likely to underutilize mental health services compared with participants who did not endorse experiencing those forms of discrimination. Similarly, compared with those who infrequently or never experienced racial or ethnic discrimination, participants who indicated that they were ‘in situations that [made them] feel unaccepted because of [their] culture’ every week or more were 2.41 times more likely to underutilize mental health services, and those who were discriminated against in this way one to two times a month or a few times a year were 1.75 times more likely to underutilize mental health services.

The literature has suggested multiple reasons for discrimination’s impact on mental health service utilization. Previous experiences of racial or ethnic discrimination may reinforce mistrust of individuals in positions of power, such as health care providers, and systems, such as health care institutions and negative expectations about services (Whaley, 2001). It is important to note that this cultural mistrust can be adaptive and protective, and emerges from a history of mistreatment, including horrific and inhumane medical experimentation (Bates & Harris, 2004; Brandon, Isaac, & LaVeist, 2005). Furthermore, the field of psychology, mental health providers and mental health care institutions also have a history of racial bias and perpetuating racism and discrimination (see Guthrie, 1976, for a review). These experiences laid the foundation for understanding medical and mental health care providers as neglectful and/or abusive, and untrustworthy. Mistrust of health care providers has been identified in many qualitative studies as a perceived barrier to health care among diverse people of color seeking services (Cuevas, O’Brien, & Saha, 2016; Rastogi, Massey-Hastings, & Wieling, 2012; Watson, 2014).

Racial discrimination’s impact on mental health service utilization could also be a result of attempts to distance oneself from ‘double stigma’, the stigma associated with being a person of color and the added stigma of seeking services for mental health problems (Gary, 2005). People experiencing oppression due to their race and other identities (e.g. gender, religion, sexual orientation) may work to protect themselves from experiencing the oppression associated with mental illness (Weisser, Morrow, & Jamer, 2011). Gary (2005) posits that the double stigma that people of color with mental health problems experience contributes to avoidance of the mental health care system, which in turn leads to a delay in seeking mental health services. Thus, racial discrimination experienced by people of color may influence the development of internalized negative mental health beliefs, and become a barrier to seeking mental health care. However, little research has examined these relations empirically.

Given the documented impact of racial discrimination on mental health, and the evidence of under-utilization of mental health care services among people of color, it is important to clarify the impact of racial discrimination experiences on other factors that influence health care behavior, such as attitudes and beliefs about mental health problems and treatments, in a multidimensional framework, to expand the way individual-level barriers to care are conceptualized, measured and intervened upon. This could inform anti-stigma and mental health literacy initiatives to reduce individual-level barriers to care among people of color and inform efforts to train health care providers in anti-racist clinical practices that do not intentionally or unintentionally perpetuate racism or discrimination in the process of assessment or intervention with clients who identify as people of color. Therefore, the purpose of this study is to preliminarily examine the relations between racial discrimination experiences and mental health stigma, measured multidimensionally (including negative beliefs about mental health problems, treatments, treatment seeking and anticipated stigma from loved ones; Vogt et al., 2014), in a diverse sample of people of color.

Hypotheses

We hypothesized that when accounting for demographic covariates and psychological distress, variables known to relate to negative mental health-related beliefs (Vogt et al., 2014), recent racial discrimination experiences would be associated with unique variance in mental health-related beliefs, such that people experiencing higher recent racial discrimination experiences would report higher negative beliefs about mental health problems, treatments, treatment seeking and anticipated stigma.

We chose to examine this research question in a diverse group of people of color rather than examine racial groups in separate analyses because this is a cross-sectional preliminary investigation to broadly explore the impact of racial discrimination on mental health-related beliefs as an early contribution to the literature. Although there is vast variability in the specific types of racial discrimination people of color experience based on how they are racially coded, previous research has suggested similar impacts of discrimination experiences on utilization of mental health care across people of color (e.g. Burgess et al., 2008). Furthermore, the experience of discrimination is consistent across groups in that it is rooted in systematic injustice based on race and implies inferiority, and it is therefore helpful to evaluate the impact of a common experience among people of color (Harrell, 2000). In addition, we did not have measurements of culturally specific variables that may inform mental health-related beliefs across racial and ethnic groups, which would be essential in interpreting racial group comparison data. Therefore, we chose to focus our analyses on the impact of the common experience of racial discrimination among people of color.

Method

Participants

Participants were 205 adults who self-identified as people of color and were enrolled as students at a large, public New England university. Participants were excluded from this study if they racially identified as White only. Participants who identified as biracial or multiracial, and who endorsed identifying as a person of color on a dichotomous question, were included in the study. The majority of the sample racially self-identified as Asian American (n = 85). The next most frequent racial identity was Black (n = 44), followed by Latinx non-White (n = 33), and Latinx White (n = 26). In addition, 17 individuals identified as multiracial, and 12 individuals indicated ‘other’ for their racial identity and wrote in responses including Arab/Middle Eastern, White and Asian, Black, and Indian. Detailed information about participants’ ethnic and racial identity is presented in Table 1. Please note, participants were encouraged to endorse as many racial and ethnic categories that represents their identity, therefore percentages are not included in Table 1 for those characteristics.

Table 1.

Demographic characteristics.

Characteristic	n (%)
Self-identified race^a
Asian	85
Latinx non-White	33
Latinx White	26
Black	44
Pacific Islander	1
Multiracial	17
Other^b	12
Self-identified ethnicity
Latinx/Latinx American^c	28
African/African Immigrant	11
African American	10
Asian/Asian American^d	17
Middle Eastern/Middle Eastern American^e	7
Indigenous	1
Afro-Caribbean	31
Missing	17
Birth country
United States/territory	101 (49.3)
Outside of the United States	101 (49.3)
Missing	3 (1.4)
Sexual orientation
Bisexual	16 (7.8)
Gay/lesbian	6 (2.9)
Other^f	12 (5.8)
Heterosexual	170 (83.3)
Missing	1 (0.5)
Gender identity
Female	146 (71.2)
Male	58 (28.2)
Transgender	0 (0.0)
Missing	1 (0.5)
Current annual household income
US$0–US$25,000	90 (44.2)
US$25,000–US$50,000	57 (28.0)
US$50,000–US$100,000	41 (20.1)
>US$100,000	12 (5.9)
Missing	1 (0.5)
Age M (SD)	22.3 (5.1)

Self-identified race and ethnicity are presented as frequencies, and therefore sums do not equal total sample sizes, and percentages are not calculated.

Twelve participants selected ‘other’ for their racial identity, and those that wrote in their self-identified race identified as Ethiopian (1), Arabic/Middle Eastern (4), White and Asian (1), Black, White, Indian (1), Native American (1), Taiwanese (1), West Indian and Asian (1), Asian and Hispanic (1), Middle Eastern and South Asian (1), Cape Verdean (2), Indian (1), Greek and Indian (1), Indian and Jamaican (1).

Collapsing responses categorized as Caribbean Latinx/Caribbean Latinx American (8), South-American (14), Mexican/Mexican American (4), Central American (12).

Collapsing responses categorized as Asian/Asian American (13), East-Asian/East-Asian American (21), South-East Asian/South-East Asian American (20), South-Asian/South Asian American (4).

Collapsing responses categorized as Middle Eastern/Middle Eastern American (6), Central Asian (1).

Participants who selected ‘other’ wrote in their self-identified sexual orientation as pansexual (2), asexual (1), questioning (9).

In terms of self-reported psychological distress, on average, participants reported symptoms consistent with mild depression (DASS-Depression M = 13.4, SD = 11.35), moderate anxiety (DASS-Anxiety M = 12.97, SD = 9.27), and moderate stress (DASS-Stress M = 15.79, SD = 9.93). Further demographic data are presented in Table 1.

Measures

Demographics

We used an adapted version of the UMass Boston Comprehensive Demographics Questionnaire (Suyemoto et al., 2016) to assess participants’ age, sex, gender identity, race, ethnicity, income as well as marital status. We used this information to describe the sample, and we entered gender and education as covariates in our analyses.

Mental health-related beliefs

The Endorsed and Anticipated Stigma Inventory (EASI; Vogt et al., 2014) is a multidimensional measure of mental health–related beliefs. It consists of five distinct eight-item scales that assess the degree to which individuals endorse negative beliefs about mental health problems (EASI-1, for example, ‘people with mental health problems can’t be counted on’), beliefs about mental health treatment (EASI-2, for example, ‘mental health treatment just makes things worse’), beliefs about treatment seeking (EASI-3, for example, ‘if I had a mental health problem I would prefer to deal with it on my own rather than seek treatment’), beliefs about the extent of anticipated stigma from loved ones (EASI-4, for example, ‘if I had a mental health problem and friends and family knew they would think less of me’) as well as beliefs about the extent of anticipated stigma from colleagues in the workplace (EASI-5). Items are rated on a 1 (strongly disagree) to 5 (strongly agree) Likert-type scale, with higher scores indicating higher negative beliefs about mental health and higher concerns about anticipated stigma. The EASI has demonstrated structural, convergent and discriminant validity, as well as good reliability (Vogt et al., 2014). The first four scales were used separately as outcome measurements of multidimensional aspects of mental health beliefs. The workplace specific scale (EASI-5) was not included in this study due to the college campus context of our sample. The EASI scales demonstrated adequate reliability in the current sample (EASI-1 α = .88, EASI-2 α = .89, EASI-3 α = .87, EASI-4 α = .93).

Discrimination experiences

The Generalized Ethnic Discrimination Scale (GEDS; Landrine, Klonoff, Corral, Fernandez, & Roesch, 2006) is a modified scale of the Schedule of Racist Events (SRE; Klonoff & Landrine, 1999). The GEDS is distinguished from the SRE because stems of the items are changed from ‘because you are Black’ to ‘because of your race/ethnic group’. For the purposes of this study, we modified the wording from asking about discrimination based on ‘race/ethnic group’ to ‘race’ to focus on race-based discrimination. The GEDS is an 18-item self-report measure designed to assess the frequency of perceived racial discrimination in the past week, past year, and over a lifetime. This measure also asked participants to rate how much endorsed racial discrimination was evaluated as stressful, although this subscale was not included in our analyses. Examples of items include, ‘How many times have you been treated unfairly by people in service jobs (by store clerks, waiters, bartenders, bank-tellers and others) because of your race?’ ‘How many times have you been accused or suspected of doing something wrong (such as stealing, cheating, not doing your share of the work, or breaking the law) because of your race?’ and ‘How many times have you been made fun of, picked on, shoved, hit, or threatened with harm because of your race?’ For this study, the GEDS-Recent (past week) scale was used, and participants were asked to answer each question on a 1 (never) to 6 (almost all the time) Likert-type scale. Higher scores indicate higher frequency and perceived stressfulness of racial discrimination experiences. The GEDS-Recent has demonstrated high internal reliability (α = .94), and among different racial groups (α = .91–.92 for Whites; .93–.95 for African Americans; .91–.94 for Asian Americans; .93–.94 for Latinos; Landrine et al., 2006). In this study, the GEDS demonstrated high internal consistency (α = .96). The GEDS-Recent sum score was used as a predictor of mental health–related beliefs.

Psychological distress

The Depression, Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) is a 21-item self-report measure of anxiety and depression symptoms. The DASS-21 has three factors: depression, anxiety and stress. Items are rated on a 0 (not at all) to 3 (most of the time) Likert-type scale. The DASS-21 has been shown to have adequate construct validity, internal consistency, temporal stability and strong reliabilities within community and clinical samples. Because this is a non-clinical sample, a total score including each scale was used as a predictor of mental health-related beliefs, as it captures the most generalized type of psychological stress (e.g. ‘I found it difficult to relax’, ‘I was intolerant of anything that kept me from getting on with what I was doing’). The DASS demonstrated adequate reliability in the current sample (α = .86). Higher scores indicate higher distress.

Procedure

This study was approved by the authors’ university Institutional Review Board. Online survey methodology, using Psychdata to collect and download survey data, was used. Participants were recruited through university-wide student email announcements. The email announcement included an electronic link to the survey, which began with an informed consent form, and participants were informed they could withdraw participation at any time. Participants had to be 18 years of age to participate. A sub-sample of participants (n = 205) who self-identified as a person of color on a categorical single-item question included on the demographics measure were included in the current analyses. Once data collection was complete, data were downloaded and analyzed using SPSS v.24 statistical software (IBM Corp. Released, 2016).

Results

Prior to hypothesis testing, all data were screened for violations of normality, including kurtosis and skewness. Results indicated that the recent scale of the General Ethnic Discrimination (GEDS-Recent) was significantly positively skewed and kurtotic and was therefore logarithmically transformed. All analyses were conducted on both transformed and non-transformed data. Given that no significant differences emerged in transformed and untransformed findings, results are reported on untransformed data. Table 2 displays means and standard deviations of study variables. Table 3 shows correlations for all (untransformed) study variables.

Table 2.

Means and standard deviations of study variables.

Variable	M (SD)
EASI-1	18.7 (6.3)
EASI-2	19.3 (5.9)
EASI-3	20.5 (6.6)
EASI-4	19.9 (7.5)
GEDS-Recent	26.5 (10.3)
DASS-Stress	15.8 (9.9)
DASS-Anxiety	12.9 (9.3)
DASS-Depression	13.4 (11.4)

EASI: Endorsed and Anticipated Stigma Inventory; GEDS: Generalized Ethnic Discrimination Scale; DASS: Depression, Anxiety and Stress Scale.

EASI-1: negative beliefs about mental health problems, total EASI-1 scores ranged from 8 to 40. EASI-2: negative beliefs about mental health treatments, total EASI-2 scores ranged from 8 to 37. EASI-3: negative beliefs about treatment seeking, total scores ranged from 8 to 39. EASI-4: concerns about anticipated stigma, total scores ranged from 8 to 39. GEDS: General Ethnic Discrimination Scale–Recent, scores ranged from 5 to 82. DASS-Stress total scores ranged from 0 to 42; DASS-Anxiety total scores ranged from 0 to 42; DASS-Depression Sores ranged from 0 to 42.

Table 3.

Correlation matrix of study variables.

Study variables
	1	2	3	4	5	6
1. EASI-1	1
2. EASI-2	.62**	1
3. EASI-3	.51**	.57**	1
4. EASI-4	.50**	.53**	.59**	1
5. Discrimination	.18**	.19**	.14**	.35**	1
6. Distress	.17*	.26**	.37**	.34**	.27**	1

EASI: Endorsed and Anticipated Stigma Inventory; DASS: Depression, Anxiety and Stress Scale.

EASI-1: negative beliefs about mental health problems; EASI-2: negative beliefs about treatments; EASI-3: negative beliefs about treatment seeking; EASI-4: concerns about anticipated stigma; Discrimination: General Ethnic Discrimination–Recent Score; Distress: sum score of DASS.

Using Pearson correlations and t tests, relations were explored between demographic (gender, age, education, income), predictor (psychological distress, discrimination) and outcome variables (mental health-related beliefs). Gender was associated with increased negative beliefs about mental health problems and treatments, such that men reported higher negative beliefs about mental health problems (EASI-1: M_men = 20.9 (6.8), M_women = 17.8 (5.8), t(201) = 3.72, p = .001) and treatments (EASI-2: M_men = 20.7 (6.2), M_women = 18.7 (5.8), t(201) = 2.20, p = .03) than women. Higher educational attainment and age were associated with less negative beliefs about treatment seeking (r = –.15). These covariates were entered in the first step of linear regressions that included the stigma scales they were associated with. Finally, no demographic or distress variables were associated with concerns about anticipated stigma from friends and family members (EASI-4), and therefore none were entered into the regression.

Regression results predicting negative beliefs about mental health problems (EASI-1) indicated that recent discrimination experiences contributed unique variance (β = .14, p = .05) at a trend level when accounting for gender and distress. Overall, this model accounted for 7% of the variance in beliefs about mental health problems ( $R_{adj}^{2}$ = .07, F(3, 201) = 6.10, p = .001). These results are presented in Table 4. Results from the regression model predicting negative beliefs about mental health treatments (EASI-2) indicated that only distress accounted for unique variance (β = .22, p < .01), and racial discrimination experiences were non-significant. The overall model accounted for 8% of the variance in beliefs about treatments ( $R_{adj}^{2}$ = .08, F(3, 202) = 7.12, p < .001). These results are presented in Table 5. In the regression predicting negative beliefs about treatment seeking (EASI-3), only distress (β = .33, p < .001) predicted unique variance in negative beliefs about treatment seeking, and age, educational attainment and recent racial discrimination experiences did not predict unique variance in the final model. This model accounted for 15% of the variance in negative beliefs about treatment seeking ( $R_{adj}^{2}$ = .15, F(3, 202) = 9.89, p < .001). These results are presented in Table 6. Finally, recent racial discrimination experiences (β = .28, p < .001) and distress (β = .29, p < .001) predicted unique variance in anticipated stigma (EASI-4). No covariates were included in this model. This model accounted for 21% of the variance in beliefs about anticipated stigma from friends and family members ( $R_{adj}^{2}$ = .21, F(2, 203) = 26.07, p < .001). These results are presented in Table 7.

Table 4.

Regression predicting negative beliefs about mental health problems.

Step		β	SE	β
1	Gender	−3.09	.93	−.23***
2	Gender	−2.92	.93	−.21***
2	Distress	0.03	.04	0.13
3	Gender	−2.72	.94	−.20**
	Distress	.02	.04	.09
	Discrimination	.08	.04	.14*

SE: standard error.

p = .05; **p < .05; ***p < .01.

Table 5.

Regression predicting negative beliefs about treatments.

Step		β	SE	β
1	Gender	−3.09	.94	−.15**
2	Gender	−2.92	.94	−.13**
2	Distress	.03	.02	.25***
3	Gender	−1.5	.87	−.12**
	Distress	.05	.04	0.22***
	Discrimination	.06	.04	0.11

SE: standard error.

p < .05; ***p < .01.

Table 6.

Regression predicting negative beliefs about treatment seeking.

Step		β	SE	β
1	Age	−.23	.09	−.18***
2	Age	−.20	.11	−.12**
2	Education	−.13	.37	−.06
3	Age	−.15	.09	−.12
	Education	−.20	.35	.09
	Distress	.08	.04	.35***
4	Age	−.17	.09	−.13
	Education	−.20	.35	−.09
	Distress	.08	.04	.33***
	Discrimination	.05	.04	.08

SE: standard error.

p < .05; ***p < .01.

Table 7.

Regression predicting anticipated stigma from friends and family.

Step		β	SE	β
1	Distress	.10	.05	.36***
2	Distress	.08	.05	.29***
2	Discrimination	.21	.04	.28***

SE: standard error.

***

p < .01.

Discussion

This study examined the cross-sectional relations between recent racial discrimination experiences and mental health stigma, while controlling for relevant demographic characteristics (i.e. sex, age, educational status) and psychological distress, in a sample of racially and ethnically diverse students who identified as people of color. This is the first study, to our knowledge, to examine the impact of racial discrimination experiences on diverse dimensions of stigma in a sample of people of color. Consistent with our hypotheses, results indicated that recent discrimination experiences predicted unique variance in beliefs about mental health problems, such that individuals experiencing more discrimination reported higher negative beliefs about mental health problems, over and above the impact of psychological distress and demographic covariates. In addition, results indicated that recent discrimination experiences predicted unique variance in concerns about anticipated stigma, such that individuals experiencing more recent discrimination reported higher concerns about anticipated stigma from family or friends for having a mental health problem. However, recent discrimination experiences were not predictive of unique variance in beliefs about mental health treatments or treatment seeking, contrary to our hypotheses.

These results highlight that another deleterious outcome of experiences of racial discrimination may be increasing negative beliefs about mental health problems and concerns about anticipated stigma among people of color already experiencing racial discrimination. This exemplifies the complex interactions between the enabling and impeding contextual factors and barriers (i.e. discrimination) and individual-level, predisposing factors and barriers (i.e. beliefs about mental health problems and anticipated stigma) that can impact mental health care utilization according to various theories of health care utilization, including Andersen’s (1995) and Ajzen’s (1991) models of health care utilization. The results of this study suggest that discrimination experiences themselves may exacerbate some individual-level barriers to mental health care and may influence individuals’ likelihood of seeking mental health care, or recommending mental health care to a peer in distress. Future research is needed to longitudinally examine the relations between racial discrimination, these individual-level variables and mental health care utilization within a clinical sample.

One potential interpretation of these relations is that experiencing a mental health problem, or holding a mental health diagnosis, may be viewed as an additional stigmatized identity, on top of an already stigmatized racial identity for people of color. People of color who are experiencing race-related stress may be especially reluctant to disclose mental health problems to family or friends for fear of adding another layer of stigmatization to their experience, or fear of being discriminated against within a peer group or community in which a sense of safety, belonging, and understanding is experienced. In this way, mental health problems may be viewed as particularly risky and/or negative to personally identify with, or disclose to others.

In addition, many individuals with marginalized identities have developed empowerment-based schemas for coping that emphasize resilience and strength in the face of discrimination. For example, the archetype of the ‘Strong Black Woman’ is based on historical images of matriarchal strength and resilience through slavery (Mullings, 2005) and is characterized by having emotionless strength and self-sacrifice (Lafontant, 2007). In light of this archetype, culturally congruent methods of coping with racism involve community leadership, care-giving and religious practices (Abrams, Maxwell, Pope, & Belgrave, 2014). An individual who is experiencing increased discrimination may therefore feel compelled to display emotionless strength, whereas disclosing mental health difficulties would be culturally incongruent or taboo.

The null results in regressions predicting negative beliefs about treatments and treatment seeking may be due to type 2 error. This study, unfortunately, did not include measurements of cultural mistrust of health care providers, or culturally specific beliefs about different types of mental health problems, interventions or providers. Given the literature on the highly variable beliefs about etiology, labeling and pathways to wellness related to mental health problems across cultures, these null results may be due to the racial and ethnic heterogeneity in the sample, and the lack of culturally specific measures. These null results may also be due to unmeasured moderating variables as well, such as mental health literacy or social support, which have been constructs shown to impact beliefs about treatments and treatment seeking in other samples (Johnson & Coles, 2013; Jorm, 2012; Stecker, Shiner, Watts, Jones, & Conner, 2013; Vogel, Wade, Wester, Larson, & Hackler, 2007).

Furthermore, this sample was diverse in terms of mental health symptoms, and these associations may be different among clinical samples. Future research should examine these relations more in depth, potentially with qualitative and experimental methodologies, and consider culturally specific variables, and other demographic variables, such as national origin. Finally, important to note, these models accounted for between 8% and 21% of the variance in mental health beliefs subscales, suggesting that while discrimination impacts mental health-related beliefs, many other variables also account for significant variance.

Limitations

It is important to note that this study is a cross-sectional analysis, and therefore causal relations between mental health-related beliefs, discrimination experiences and psychological distress cannot be established. In addition, this is a non-representative, college student sample and therefore relations may be different in other samples. Our study examined psychological distress related to depression, stress and anxiety, but did not examine distress related to other mental health problems such as schizophrenia or bi-polar disorder. It is possible that relations between racial and ethnic discrimination, and mental health stigma among individual’s experiencing disorders perceived as more severe, such as psychosis or bi-polar disorder, may be different. This would be an important topic for further study. Furthermore, this study examined a diverse sample of people of color, in terms of racial and ethnic identity, national origin, mental health symptoms, immigration status, social class, gender identity and sexual orientation. This heterogeneity increases the risk of type 2 error. In addition, we chose to collapse diverse racial and ethnic groups for this preliminary analysis, to provide initial evidence that discrimination does impact specific dimensions of mental health stigma. However, one major limitation of this approach is that we cannot examine variation and nuances within different racial and ethnic groups in these relations. This is a critical topic for further study. Furthermore, we did not measure experiences of discrimination related to other marginalized statuses (e.g. sexual orientation, religion, ability) to determine if there is a unique impact of racial and ethnic discrimination on mental health beliefs, or if these relations persist across discrimination experiences more generally. Finally, we did not include measures of ethnic and cultural values that may influence mental health-related beliefs or buffer the harmful impact of discrimination. These are important variables for further studies, and may potentially moderate the relations between discrimination experiences and mental health beliefs.

Clinical implications

The results of this study suggest that efforts to reduce negative beliefs about mental health problems and anticipated stigma may be improved by explicitly addressing the impact of racial discrimination on these beliefs, and that anti-stigma interventions that do not consider the impact of the contextual stressor of discrimination among people of color may be less effective. In addition, clinicians need to ensure that they are sensitive to the likelihood that mental health difficulties may lead to heightened feelings of marginalization or isolation among individuals who are already marginalized as people of color in society. Interventions that utilize a range of therapeutic techniques or approaches may help individuals reduce the internalization and harm from both anticipated mental health stigma as well as racial and ethnic discrimination, as well as enhance recovery and resilience. For example, working with an individual to identify their personally meaningful values and clarify specific valued-actions that one can take in the face of dual stigmatization may help empower an individual to lead the life they would like to have in the face of challenging contextual barriers and oppression (e.g. racism, mental health stigma). There is emerging clinical evidence that values-clarification can be beneficial in the face of racism (West, Graham, & Roemer, 2013), though this has not been examined among individuals experiencing mental health problems or severe mental illness and is an important question for future study. In addition, building positive social relationships with individuals who share similar marginalized experiences and identities may also promote resilience, and positive mental health in the face of dual stigmatization (Kondrat, Sullivan, Wilkins, Barrett, & Beerbower, 2018).

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

ORCID iD

Sarah Krill Williston

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