Obstructed Use: Reconceptualizing the Mental Health (Help-Seeking) Experiences of Black Americans

Abstract

The present body of scholarship suggests that Black Americans seek mental health services at much lower rates than their White American counterparts. The explanations for these decreased levels of mental health help-seeking typically distinguish “barriers” such as stigmatization, lack of culturally relevant treatment models, and negative attitudes toward mental health services. The final results of these analyses are not invalid; however, this researcher contends that they are arguably incomplete. Black Americans must navigate countless obstacles rooted in systematic oppression, institutional inequalities, and structural disparities when seeking help for mental health concerns. This article reviews a set of key terms to offer a historically based and culturally candid perspective on those mental health service seeking experiences for underresourced Black Americans living in environmentally toxic urban spaces. The four theoretical concepts of historical trauma, environmental toxicity, culturally bound economic insecurity, and cultural mistrust both individually and interactively are used to present a more realistic topography of the mental health (help-seeking) experiences for underresourced Black Americans. These ideas are collectively positioned as the theoretical construct of obstructed use.

Keywords

mental health help-seeking behavior mental health disparities obstructed use

The narrative that interweaves both historical and contemporary experiences of Black Americans in need of mental health services is intricate and can benefit from an inclusion of additional concepts that represent a more complete story. Several examinations report that Black Americans seek mental health help at much lower rates than White Americans (Barksdale, Azur, & Leaf, 2010; Garland et al., 2005; Holden & Xanthos, 2009; Kataoka, Zhang, & Wells, 2002; Stagman & Cooper, 2010). The bevy of literature within this area typically identifies “barriers” such as stigmatization, fear, negative attitudes, and the absence of culturally sensitive treatments as explanations for low rates of seeking mental health services by Black Americans (Copeland, 2006; Holden & Xanthos, 2009; Jang, Yoon, Chiriboga, Molinari, & Powers, 2015; V. L. S. Thompson, Bazile, & Akbar, 2004). The previous analyses and examinations are not invalid; yet they are arguably incomplete. Despite the sizeable volume of scholarship about mental health service use for Black American adults (Barksdale & Molock, 2009; Snowden, 2001; R. Thompson, Dancy, Wiley, Perry, & Najdowski, 2011) and children (Alegria et al., 2002; Barksdale et al., 2010; Copeland, 2006) the trends still remain insufficiently comprehended (R. Thompson et al., 2013).

The pathways by which Black Americans enter or participate in mental health services may be determined less by clinical and administrative decision making but more based on social structures and community traditions (Snowden, 2001). The negotiation between those cultural experiences (e.g., historical trauma and cultural mistrust) and social components (e.g., environmental toxicity) gives rise to obstructed mental health (help-seeking) experiences for underresourced Black Americans residing in environmentally toxic neighborhoods. Black Americans must navigate a maze of obstacles that are built of systematic oppression, institutional inequalities, and structural disparities when seeking mental health services. This article presents a set of key concepts to offer a more historically anchored and culturally candid description of the mental health (help-seeking) experiences for Black Americans. A discussion of the four theoretical concepts: historical trauma, environmental toxicity, culturally bound economic insecurity, and cultural mistrust, individually and interactively, are intended to provide a more realistic topography of this route encountered by Black Americans when they seek mental health services. These concepts are collectively positioned as the theoretical construct of obstructed use.

Mental Health Service Need and Utilization by Black Americans

Research investigations concerning the use of mental health services among different ethnic/racial populations reveal a significant underutilization specifically among Black Americans (Anglin, Alberti, Link, & Phelan, 2008; Bailey, Blackmon, & Stevens, 2009; Garland et al., 2005; Nickerson, Elms, & Terrell, 1994; Whaley, 2001). R. Thompson et al. (2013) mention that Black Americans tend to have higher rates of underuse when compared to other groups. The National Comorbidity Survey and the Epidemiology Catchment Areas Survey both reported that Black Americans receive mental health services at a frequency that is one half of their White American counterparts (Barksdale & Molock, 2009; Swartz et al., 1998). Results from the National Survey on American Life indicate that only 32% of Black Americans are shown to use professional mental health services, whereby the youngest and oldest participants were least likely to obtain help (Neighbors et al., 2007). However, research suggests that Black Americans, regardless of gender and age, use mental health services at much lower rates than do other ethnic groups (R. Thompson et al., 2013).

Studies consistently report that one in five children under the age of 18 suffers from a diagnosable mental health condition (Children’s Defense Fund, 2010; Stagman & Cooper, 2010). This trend in use difference is significant among high-risk youth and their parents, even considering the countless integral determinants for mental health service seeking (Garland et al., 2005). Mental health service underutilization and unmet mental health needs is quite prevalent among racial/ethnic minorities, particularly for Black American children and youth (Barksdale et al., 2010; Garland et al., 2005).

Thurston and Phares (2008) found that Black American mothers and fathers compared to White American parents believe that more obstacles exist to mental health (help-seeking) for themselves and for their children. These obstacles in conjunction with an untreated mental illness can create learning disruptions, interfere with interacting and socializing with peers, or diminish levels of school engagement for many children (Children’s Defense Fund, 2010). Pescosolido et al. (2008) mentioned that the rates of unsatisfied mental health needs for Black American children has not improved in 25+ years. The mental health disorder that receives no or improper attention increases the frequency of school drop-out, juvenile imprisonments, disruption of family, substance abuse, and joblessness (Satcher, 2004).

Black American adults, children, and youth are often receive initial mental health assessment or care in a setting where these are not the primary services delivered (e.g., prisons or emergency rooms). Many Black American individuals are given their first treatment for a persistent mental health condition through social services or during their time served in correctional departments as opposed to private mental health providers (Cauce et al., 2002; Lowe, 2006). Our jails and prisons in this nation have emerged as the largest institutions that house mentally ill persons (Dumont, Brockmann, Dickman, Alexander, & Rich, 2012). The high percentage of Black Americans in prison and juvenile justice systems alone exemplifies the likelihood that a large percentage of this population will be exposed to mental health care in less than positive circumstances. Furthermore, Black American children and youth troubled by social and emotional disorders are more likely to enter mental health care through law enforcement or an involuntary commitment (Cauce et al., 2002). An overwhelming proportion of the children and youth, approximately 70%, who are involved with the juvenile justice system have a diagnosable mental health condition (Stagman & Cooper, 2010). A compulsory introduction to mental health care is devastatingly prominent within underresourced and low-income neighborhoods (Chow, Jaffee, & Snowden, 2003). The possibility that any mental health treatment received will be involuntary is increased while living under impoverished conditions. The stringent tactics that comes with being introduced to mental health care through an authoritarian or punitive based institution can be a less than ideal strategy toward helping those Black American adults, children, or youth who may have a mental health disorder. The latter represents one reason why those decreased utilization rates of formal mental health care for Black Americans should be of major concern for mental health practitioners, policymakers, researchers, and scholars (Neighbors et al., 2007). Given the previously reported reduced use rates among Black Americans, it is imperative to form a more thorough comprehension of those actual deterrents to their mental health treatment seeking (Shim, Compton, Rust, Druss, & Kaslow, 2009).

Obstructed Use: Reconceptualizing the Route to Mental Health Care

Several pervasive social, environmental, economic hindrances disrupt the daily lives of many Black Americans. Barriers is a term that is often used by researchers to classify both personal and structural reasons for the reluctance among several racial/ethnic minorities in this nation to seeking mental health services or completing actual treatment (Holden & Xanthos, 2009; Jang et al., 2015; V. L. S. Thompson et al., 2004). Personal attributions such as cultural differences, stigma, or self-reliance (Copeland, 2006; Thurston & Phares, 2008), and structural characteristics such as transportation, location, or provider traits (Owens et al., 2002; Townes, Chavez-Korell, & Cunningham, 2009) lack critical analyses through a historical lens that includes trauma or environmental conditions.

Obstructed use contends that “barriers” identified in the literature have historical origins with contemporary manifestations that prohibit or disrupt access to competent care, thus reaching well beyond cultural differences or an inability to afford necessitated treatment. This term is rooted in those historical mental health (help-seeking) experiences for Black Americans. The manifestation of each obstruction is determined by numerous micro- and macro-oriented forces. This construct has been conceptualized to serve as a culturally enriched and accurate description of the mental health (help-seeking) experiences for underresourced Black Americans living in environmentally toxic neighborhoods. Obstructed use consists of four primary theoretical components: (1) historical trauma, (2) environmental toxicity, (3) culturally bound economic insecurity, and (4) cultural mistrust. These essential conceptual elements will be detailed individually, but they are undoubtedly interrelating terms.

Black American Historical and Cultural Trauma

Historical trauma provides initial support in describing the construct of obstructed use. Historical trauma is defined as the collective psychological and emotional injuries which happen throughout a life span and across generations caused by traumatic events that have been directed at one cultural group (Mohatt, Thompson, Thai, & Tebes, 2014; Sotero, 2006). Williams, Neighbors, and Jackson (2003) describe historical trauma as a large-scale, systems-related macro-stressor that negatively influences both the physical and mental health of an affected racial group. Moreover, historical trauma consists of the following elements:

A trauma or wounding that is shared by a group of people, opposed to being individually experienced and spans multiple generations, such that contemporary members of the affected group may encounter trauma-related symptoms without having been present for the past traumatizing event(s) (Mohatt et al., 2014, p. 128)

Those historically traumatic events for Black Americans involves the racial, cultural, psychological, and intergenerational bruising that stems from a forced enslavement of their ancestors, burgeoning through Jim Crow segregation, and sustained by institutionalized or systemic racism (e.g., residential segregation and gentrification). Historical trauma has produced a succession of noxious consequences for Black Americans such as (1) diminished community solidarity due to prolonged oppression, (2) impeded and compromised psychological development or mental health well-being, (3) sustained skepticism toward formal mental health service sectors, and (4) marginalized comprehensions of complex traumas (Bullard, 2005; Eyerman, 2004; Phelps, Taylor, & Gerard, 2001; Randall, 1995; Suite, La Bril, Primm, & Harrison-Ross, 2007; Washington, 2006).

The historical trauma endured by Black Americans is intensely injurious both externally and internally across all generations. The first 20 Africans were brought to Jamestown Virginia by a Dutch ship and sold as involuntary laborers to British colonies in the year of 1619 (Horton & Horton, 2005). This event marks the beginning of institutionalized servitude, thus setting forth a methodical and deliberate attempt at eroding Black American communities. This original historical trauma surfacing from slavery and its horrific aftermath (e.g., widespread institutionalized racism) was deepened further in the 1800s when Black Americans were used as test subjects for countless documented unethical and harmful scientific examinations (Randall, 1995; Suite et al., 2007; Washington, 2006). This malicious practice continued well into the 1900s, as evidenced by the below asinine assertion made by Thomas Murrell (a public health service physician) in 1940:

the future of the Negro lies more in the research laboratory [rather] than in schools . . . when diseased, he should be registered and forced to take treatment before he offers his diseased mind and body on the altar of academic and professional education. (Washington, 2006, p. 10)

The examples of egregious examinations are numerous and varied.

Dr. Walter F. Jones used several slaves to test a remedy for typhoid pneumonia that entailed pouring five gallons of boiling water on their spines (Reverby, 2001). The widely known Tuskegee Syphilis debacle occurred from 1932 to 1972. Furthermore, a few doctors injected approximately 22 chronically ill Black American patients with live cancer cells in 1963 (Corbie-Smith & Jacob Arriola, 2012). Public assistance workers duped Black American welfare recipients during the 1970s and 1980s into having their teenage daughters’ sterilized (Randall, 1995; Suite et al., 2007). Still, Washington (2006) reports that between 1992 and 1997 researchers administered the harmful drug fenfluramine to Black American and Black Latino children with the intent on exploring links between violence and genetics. Fenfluramine, or half of the notoriously cardio toxic Fen-Phen, was later associated with heart valve damage in adults (Washington, 2006).

While at a Tulane Medical School, Harry Bailey, MD, ranted, “[It was] cheaper to use Ni***rs [rather] than cats because they were everywhere and cheap experimental animals” (Washington, 2006, p. 10). Although this may seem to be a dated statement, the convergence of racism and medical practice in the United States has a powerful history, with many of these events occurring quite recently. The litany of negative occurrences has produced a distinct distrust among many Black Americans toward health care professionals, especially mental health care providers.

Historical trauma incites internal hindrances for Black American children and their families residing in environmentally toxic urban neighborhoods such as self-doubt, self-depreciation, and pessimistic expectations or dispositions about seeking formal mental health care. The concept typifies reflective and reciprocal bewilderment, fosters a foundation of self-loathing, depicts a profound pain, and produces a supported isolation.

Collective Cultural Traumatic Memory

Arguably, the legacies of historical trauma continue and present themselves across all generations of Black Americans. The egregious events of institutional slavery, segregation, and systemic racism have been firmly embedded in the collective memories and everyday lives of Black Americans. Historical trauma is an umbrella term that includes cultural trauma and is remembered through the shared collective memory of a particular cultural group. Cultural trauma is an emblematic event that affects a specific set of people across time (Alexander, 2004; Eyerman, Alexander, & Bresse, 2013). The collective cultural memory represents a pool whereby these individuals acknowledge, translate, and address a persistent trauma. Collective cultural memory is a series of culturally based recollections that are shaped and shared among a certain population. According to Assman (2008), cultural memory is “exteriorized, objectified, and stored away in symbolic forms that, unlike the sounds of words or the sight of gestures, are stable and situation-transcendent” (pp. 110-111). The cultural memory can be described as a socially transmittable neurobiological synapse.

Cultural trauma is created by an unprecedented amount of incidents faced by a certain cultural group. This concept is centered on the exposure to several of traumatic events or one encounter by an individual or collective. This experience can be indirect, which is often the case when stories are passed across generations by family members, or shared through media sources. For example, events that are associated with the cultural trauma are often mediated through newspapers, radio, or television, and more recently multiple forms of digital media (Ostertag & Ortiz, 2013). The use of erroneously hyperbolic characterizations from these sources may inadvertently compound both cultural and psychological trauma. A level of temporal distance emerges between an incident and its direct recipient cultural group when traumatic instances are depicted in these sources for extended periods to younger generations. Therefore, some Black Americans may not be fully aware of the role cultural trauma plays in their current lives or its overall scope (Eyerman, 2004).

The notion of collective memory continues to be examined by researchers and better understood as a useful concept (Hirst & Manier, 2008). Scholars agree that collective memory includes the disclosing of relevant cultural information within a group surrounding past events and co-constructing meaning for these moments. Many memories from slavery and segregation are included in the past, present, and future collective knowledge bases for Black Americans. Eyerman (2004) notes that collective memory illustrates what has happened to this cultural group and is the source of justification for current conditions and projections of future experiences.

Intergenerational Trauma Transmission

The intergenerational transmission of trauma or traumatic stress is becoming better understood as a multidimensional process. The transmitting of traumatic strain from one generation to another can occur biologically (Shonkoff, 2012) or through a tradition of storytelling aimed at imparting lessons (Denham, 2008). Essentially, Black Americans from older generations communicate their experiences of physical, mental, and emotional violence to their children in the form of personal narratives. The intimate encounters with “ . . . traumas during the formative years (late adolescence and early adulthood) tend to have a disproportionate effect on any given generational unit” (Neal, 1998, p. 204). The institution of slavery and its subsequent negative outcomes has interestingly instigated a sense of solidarity or unifying force for Black Americans (Eyerman, 2004). In essence, these experiences constitute elements of a collective Black American consciousness and shape their responses to the health and mental health care system though all of them may not be able to provide details about horrendous historical experimentations or abuse (Randall, 1995). The memories of the historical mistreatment of Black Americans beginning with institutionalized slavery, its aftermath, including systematic racism are used as teaching tools and passed on through racial socialization.

A Racially Socialized Traumatic Memory

Racial socialization is described as an adapted protective mechanism designed to promote racial pride, enhance self-esteem, and prepare young Black Americans for the inevitable prejudice, discrimination, and racism that they will encounter as adults (Caughy, O’Campo, Nettles, & Lohrfink, 2006; Stevenson, 1994). Racial socialization is a complex concept that has been explored in-depth through various research examinations (Dotterer, McHale, & Crouter, 2009; Harris-Britt, Valrie, Kurtz-Costes, & Rowley, 2007; Neblett, Rivas-Drake, & Umaña-Taylor, 2012; Neblett, Smalls, Ford, Nguyen, & Sellers, 2009). Racial socialization is a tool by which parents or guardians communicate overt or indirect information (both verbal and nonverbal) about the significance of race and being included in a racial group that is intended to assist their children and youth with adapting to racism, discrimination, and other prejudicial behavior (Neblett et al., 2012). Specifically, these adults transmit messages to younger generations of children that are aimed at fostering strong cultural values, attitudes, behaviors, and perspectives about the meaning of race, racial identity, intergroup and intragroup relations, or racial categorization (Caughy et al., 2006). Coard and Sellers (2005) mentioned that Black American parents use racial socialization to establish psychological well-being and physical health among all their children. Black American parents use racial socialization to provide their kids with the tools to recognize, thrive, cope with collective memories of historical trauma, institutional racism, and its extensive by-products.

Historical trauma has been proposed as the initiating theoretical component of obstructed use. The concept includes those events that were/are intentionally geared toward debilitating Black American livelihoods. Historical trauma obstructs the use of mental health services through its continued effects and persistent activation of fear that arises from ongoing acts of institutional racism endured by Black Americans. The fear associated with a potential retraumatization and new trauma experiences deter the use of formal mental health care by this group.

Environmental Toxicity

The second theoretical component of obstructed use is environmental toxicity. Environmental toxicity includes the unnatural physical and unseen hazards that continue to plague urban underresourced neighborhoods (Bullard, 2005; Liu & Lewis, 2014). The concept refers to those intangible and tangible physical (chemical) pollutants and contaminants that engulf many urban areas. Environmental toxicity consists of all the water, land, and air pollution caused by our daily activities of living (Liu & Lewis, 2014). There is a bevy of dangerous (toxic) elements that are visibly pronounced within urban places. Specifically, Greenberg and Schneider (1996) identify four general types of harmful and individually perilous elements that are present in underresourced urban communities while constituting key contributors to environmental toxicity: First, massive technology sites (i.e., factories, landfills, and airports); second, local activity spaces (i.e., liquor stores, fast-food places, and gasoline stations); third, blight (i.e., abandoned houses, litter, broken sidewalks); and last, crime and other behavioral issues such as violence, rude neighbors, and feral animals. Basically, environmental toxicity is defined by these categorical distinctions and their components. Undeniably, environmental toxicity exists in the urban communities that are occupied by Black Americans. This presence of both visible and invisible toxins in an urban environment further compounds the existing historical collective memory of cultural trauma. Essentially, the physical appearance and general condition of countless Black American urban neighborhoods reflect these torrid recollections. In essence, the noted areas are concrete reminders, tangible remnants, and legacies of historical trauma (Barbarin, 2015; Wandersman & Nation, 1998).

Many urban places were once home to vast industrial centers that used most of the surrounding waterways as their personal sewers, thus releasing an immeasurable amount of toxins (e.g., polychlorinated biphenyls, dioxins, arsenic and gasoline) that continue to pollute them long after the industry has left these areas. Cooke (2016) reports that 80,000 chemicals, including petrochemicals are currently used by industries in the United States. Children are especially vulnerable to environmental hazards and pollutants, for instance lead (Liu & Lewis, 2014). Air pollution alone is a significant concern, contributing to 70,000 deaths each year, nearly double the amount of people killed in traffic accidents (Bullard, 2005). The contamination emitted from vehicles gives rise to significant rates of illnesses and hospitalization (Bullard, 2008; Gee & Payne-Sturges, 2012). According to the Environmental Protection Agency gasoline is one of the most toxic and dangerous substances that we regularly encounter because one gallon of gasoline can pollute 750,000 gallons of water (Cooke, 2016).

The presence of everyday trash is equally hazardous. The deluge of beer bottles, soda cans, fast food wrappers, and discarded tobacco products, etc. that sheaths an environmentally toxic urban area is both representative of its blight in addition to those various mental health and health issues its residents experience. According to Bullard (2008), race dictates how the government responds to environmental toxicity, whereby Black American neighborhoods encounter less rapid, if any response, to public health threats, factory accidents, or weather-related disasters. Hurricane Katrina is a primary example as areas of New Orleans remain devastated from this horrific natural catastrophe (Bullard, 2008; Ostertag & Ortiz, 2013).

Previous studies have noted that environmentally toxic neighborhoods and communities are associated with more social problems (Hayward, 2012; Li, Nussbaum, & Richards, 2007). An environment that is saturated with substandard housing, depleted or limited resources, or troubling rates of crime, creates a physically and emotionally stressful life for underresourced Black American families residing in such neighborhoods (Black & Krishnakumar, 1998; Holden & Xanthos, 2009) and pose threats to the well-being of their developing children.

Accumulated Toxic Strain

The environmentally toxic setting can also be considered mentally paralyzing and psychologically traumatizing. A compounded toxic strain surfaces due to this physical and mental scarring created by the environmentally toxic urban neighborhood. Williams Shanks and Robinson (2013) describe stress as any observed undesirable situation that disturbs a child, parent, or household ranging from a task for homework to the loss of a relative. Furthermore, this term denotes an individually based condition of the mind and an element of expression that reflects not only major life events but also those realities and pressures of daily life that amplify psychological functioning or well-being.

Toxic stress is viewed as the most dangerous form of psychological tension which results from an uncomfortably persistent and sustained triggering of the stress response system of a human body, particularly when support and protection are absent, or such empathetic relationships are overwhelmed by this type of poisonous pressure (Franke, 2014; Shonkoff et al., 2012). Environmentally toxic urban neighborhoods, inclusive of poverty, potentiate the vulnerability to toxic stress by its residents. Prior scholarship suggests that toxic stress is associated with negative physical and mental health outcomes for children and adults (McLoyd, 1990; Williams Shanks & Robinson, 2013). For example, children who live in low-income households are at an increased risk for mental health problems (Stagman & Cooper, 2010). According to Atkins et al. (2006), the majority of impoverished children in this nation reside in underresourced urban places. The latter existence ultimately disrupts academic achievement, and increases the likelihood of depression and behavioral issues among this population. This researcher calls for a closer examination of the presence and frequency of toxic stress that is experienced while residing in environmentally toxic neighborhoods.

Environmental toxicity is presented as the second component of obstructed use. The environmentally toxic urban neighborhood presents various insurmountable challenges for its residents. The quality of life within these contaminated environments creates mental health issues for developing children, while deepening the wounds of historical trauma of its elders. Environmentally toxic neighborhoods fail to supply sufficient resources that promote the development of a healthy physical and mental health well-being, for instance transportation, child care, proximal service availability, or hours of accessibility.

Culturally Bound Economic Insecurity

Economic security can be immensely detrimental for the livelihood of an individual or community, because the outcomes of economic distress are endlessly disruptive (Williams Shanks & Robinson, 2013). Economic insecurity can be described as the general anxiety, stress, and strife that develops from an inability to afford adequate food and housing nor pay bills. Economic insecurity includes the risk of unforeseen financial loss suffered by employees and their households, abrupt unemployment, undesirable jobs, and economic strain (Catalano, 1991; Western, Bloome, Sosnaud, & Tach, 2012). Culturally bound economic insecurity is a slightly different than the term of poverty, because it describes those perceptions and emotions about an economic condition. A more comprehensive definition of economic insecurity is the fear of facing financial circumstances that are seemingly impossible to overcome (Bossert & D’Ambrosio, 2013). The true essence of being impoverished is indescribable to those individuals who are economically secure and suitably resourced. The road to eradicating those tensions that epitomize culturally bound economic insecurity is complex in nature mainly because its pathway is not one of linearity.

Culturally bound economic insecurity is the continual feeling of financial hopelessness, helplessness, strain, and confusion. It is a near debilitating phobic response to presumably overwhelming monetary hurdles/ hindrances. Black Americans impaired by culturally bound economic insecurity are incapacitated by their fear of financial collapse. Culturally bound economic insecurity describes the fright that parents hold because they are unable to provide their child with vital resources. The overwhelming frustration that characterizes culturally bound economic insecurity can consume the modern impoverished family. One of the many costs of economic insecurity is the emergence or worsening of mental health problems and perhaps a decrease in family functioning.

Economic insecurity is far greater in more recent times (Western et al., 2012). Shapiro, Meschede, and Osoro (2013) reported that the gap in total median wealth existing between Black Americans and White Americans had more than tripled from $85,000 (1984) to $236,500 (2009) upon tracking the wealth accumulation (based on years of home ownership, family income, college education, or inheriting funds) among a sample of families for 25 years.

[Black] Americans have been denied access to traditional methods of wealth accumulation such as home ownership beginning with the wholesale theft of their labor in slavery, Jim-Crow restrictions on hiring, the economically exploitative system of share cropping, housing discrimination, the redlining of [Black] American neighborhoods, confiscatory lending practices by banks, disparate education and access to health services. (Barbarin, 2015, p. 49; see also Coates, 2014)

This ever-widening chasm of wealth inequality reinforces the anxiety that is typical of culturally bound economic insecurity. A crude mixture of baseless policies, systematic barriers and limited opportunities exist within educational institutions, places of employment, and communities that reinforce the profoundly entrenched racial nuances of gathering and building wealth (Shapiro et al., 2013). McKernan, Ratcliffe, Steuerle, and Zhang (2013) noted that White Americans had nearly six times as much wealth when compared to their Black American counterparts. Black America has been shown to have some of the lowest incomes among groups in the United States (Barbarin, 2015; Holden & Xanthos, 2009). The latter circumstance has emerged due in part to a seemingly predetermined trajectory for Black Americans rigged with systemic and widespread societal inequalities. Bullard (2005) states that impoverished individuals and their low-income communities are given the erroneous option of in one respects having zero employment or development while on the other hand, dangerous low-paying jobs in addition to suffocating levels of pollution.

The third conceptual component of obstructed use is culturally bound economic insecurity. The financial costs and fees of physical or mental health care can be immeasurably burdensome. Economic insecurity for Black Americans is culturally bound and further obstructs their consideration of using formal mental health care for themselves or their children. The members of this community must prioritize expenditures rooted in those insecurities about their economic situations. Black American parents consistently sacrifice seeking mental health care for their children in order to supply them with suitable nourishment, shelter, clothing, and physical health–related prescription medications.

Cultural Mistrust: Adaptive Response to Historic and Contemporary Threat

The fourth element of obstructed use is cultural mistrust. Cultural mistrust is often identified as a contributor to the low rates of mental health utilization by Black Americans (Gonzalez, Alegría, Prihoda, Copeland, & Zeber, 2011). Accordingly, the collective cultural memory of historical trauma has generated a conditioned cultural resistance to formal mental health services for many Black Americans. Cultural mistrust has been explained as the “healthy reaction” of Black Americans to these historically perpetuated institutional inequalities as well as a sound cultural response to copious amounts of unsolicited prejudice (Grier & Cobbs, 1992, p. 161; see also Nickerson et al., 1994; Terrell & Terrell, 1981; Townes et al., 2009; Whaley, 2001). This idea rests on a rationale that cultural aspects of paranoia can be considered as nonclinical; therefore, being a healthy expression (Whaley, 2001). Grier and Cobbs (1992) conclude that Black Americans have developed an enormous level of resiliency amid the prolonged impacts of institutional racism. The adoption of skepticism in response to historical oppression has produced this elasticity, thus freeing Black Americans from being labeled as paranoid (Grier & Cobbs, 1992). Cultural mistrust can be understood as an adaptive response to harmful or horrific events when viewed in a historical trauma context and the neurobiology of toxic stress.

Black Americans are petrified of seeking formal mental health care because of a history of negative experiences within mental health service institutions (Suite et al., 2007). Townes et al. (2009) found that high levels of cultural mistrust predicted participants’ preference for Black American mental health practitioners. Disturbingly, Black Americans only account for a minute 2% of psychiatrists, 2% of psychologists, and 4% of social workers (Holden & Xanthos, 2009). The proportion of clinically trained personnel is similar in emergency room settings where a large percentage of Black Americans are initially treated for mental health issues (Bailey et al., 2009).

Black Americans who are leery about their everyday interactions with White Americans maintains an equal amount of mistrust for a therapist who is member of this population (Whaley, 2001). This presumption emerges because a Black American person anticipates that formal mental health systems of care along with their mental health practitioners (i.e., psychologist, psychiatrist, social worker, or counselor) will replicate the prejudice or oppression, which they experience daily and is considered to be a permanent part of our larger societal fabric.

Cultural mistrust can influence Black American attitudes and behavior about mental health service use (Holden & Xanthos, 2009; Whaley, 2001). Cultural mistrust can potentially elicit negative feelings among Black Americans about the initiation or continuation of a therapeutic relationship with a White American mental health provider (Anglin et al., 2008; Suite et al., 2007). These less than favorable attitudes may reflect a Black American fear that the help that they receive from a White American mental health provider would be less important, influential, or satisfying (Nickerson et al., 1994).

When considering potential strategies for addressing mental health service seeking experiences of Black Americans living in environmentally toxic urban neighborhoods it is important to grasp that this process is trauma-informed. Some necessary criteria for mental health practitioners when treating Black American mental health consumers who may exhibit cultural mistrust starts with acknowledging its presence through accepting that institutional racism and its deleterious effects are a catalyst for this response (Holden & Xanthos, 2009; Suite et al., 2007; Whaley, 2001). Cultural mistrust often directly dictates the mental health (help-seeking) behavior and experiences of Black Americans. It can be described as a protective response that is transferred through racial socialization from Black American parents to their children and therefore affects the response of a child to mental health care professionals employed in their schools.

Cultural mistrust is the fourth and final component of obstructed use. This adaptive response by Black Americans often directly dictates their mental health (help-seeking) experiences. Cultural mistrust obstructs use as it constitutes the fervent desire of Black Americans to avoid those reminders and memory activators of lived experiences. Black Americans are scared that seeking formal mental health help will subject them to further scrutiny and discrimination; a gamble that is not worth taking.

Implications

Obstructed use is proposed as a new logistical map of the mental health (help seeking) experiences for underresourced Black Americans residing in environmentally toxic urban neighborhoods. The emergent construct integrates four core components: historical trauma, environmental toxicity, culturally bound economic insecurity, and cultural mistrust in order to inform practice, policy, and research agendas.

Practice

Anglin et al. (2008) urges for a renewed focus on teaching mental health–based practitioners, individuals, and various communities about the continuum and spectrum of mental illness or disorders in general, but particularly for Black Americans. The latter is majorly important for underresourced, Black American children and their families residing in the environmentally toxic neighborhoods. Suite et al. (2007) note that the presence of cultural mistrust among Black Americans coupled with their historical and contemporary experiences with institutional racism should propel mental health providers to implement more nonbiased, multifaceted, contextually based treatments or interventions. Holden and Xanthos (2009) insist that mental health providers must acknowledge the role that systemic racism and discrimination play in the mental health (help-seeking) behavior of Black Americans. The key to successful mental health practice involves developing a formidable bond, which cannot exist if the practitioner does not acknowledge the culturally candid and historically based mental health help-seeking experiences of underresourced Black Americans. An integral step in fortifying a meaningful rapport rests with these professionals admitting and owning the impact that their personal cultural bias has on an overall therapeutic relationship (Atdjian & Vega, 2005).

Mental health practitioners must recognize that multicultural counseling competency is valuable because it concedes the possible presence of racism, discrimination, or prejudice within clinical interactions between Black American consumers and other mental health care professionals who do not identify with this cultural group (Buser, 2009). Any mental health provider (e.g., psychologists, psychiatrists, social worker, counselors, etc.) can potentially increase patient trust, minimize their fears or anxieties, or enhance the overall therapeutic relationships with Black Americans through considering this construct of obstructed use and its vital components. The mental health clinician who possesses a culturally relevant knowledge base will have an improved capacity to develop productive practice philosophies as well as effective preventions and interventions that are consistent with this construct. They will also be in a position to advocate for policy changes rooted in trauma-informed care within their employing organizations, thus establishing an agency that is culturally sensitive to the reality of obstructed use.

Policy

An ardent declaration that historical trauma, culturally bound economic insecurity, environmentally toxic spaces empathetically pose as formidable impediments for underresourced Black Americans living in physically contaminated urban neighborhoods will materialize if organizational policies are informed by obstructed use. Ignoring this emergent construct means that countless institutions, agencies, or organizations will continue to implicitly or explicitly support retraumatizing, exclusionary, culturally insensitive, and ineffective practices. The recent application of trauma-informed care approaches toward shifting organizational cultures among several human service agencies can offer a useful foundation for policymakers to structure legislation that includes those core elements of obstructed use (Bath, 2008; Huckshorn & LeBel, 2013; Ko et al., 2008).

Research Agendas

This article calls for qualitative and quantitative examinations to consider obstructed use as a viable concept that describes those mental health (help-seeking) experiences for underresourced Black Americans residing in environmentally toxic urban places. Thurston and Phares (2008) suggest that emerging research must continue to examine the rates of underutilization of mental health services by ethnic/racial groups. Researchers concerned with need, access, and use of mental health services should focus on developing tactics that reduce structural barriers to mental health care and mental health help-seeking (Owens et al., 2002). The presenting conceptual argument will be beneficial for researchers. Their efforts toward practice, policy, or program evaluation may be redirected to investigating the possible mitigation of obstructed use.

Conclusion

One goal of this article was to demonstrate how the four theoretical concepts of historical trauma, environmental toxicity, culturally bound economic insecurity, and cultural mistrust, are definitive obstacles to accessing, and therefore, receiving mental health services by underresourced Black Americans residing in environmentally toxic urban neighborhoods. The primary components of obstructed use provides a more realistic topography of those mental health (help-seeking) experiences for this population. In essence, this researcher contends that unveiling a more historically based and culturally candid depiction of the Black American mental health (help-seeking) experiences is necessary. The present conceptual piece is aimed at improving a growing knowledge base that begs for an extensive understanding of those disparities in access, need, and use of formal mental health care among underresourced Black Americans dwelling in environmentally toxic urban neighborhoods. Researchers, historians, practitioners, and policymakers are encouraged to facilitate meaningful changes that inform their respective tasks concerning the innumerable complexities about the mental health (help-seeking) experiences of Black Americans, particularly guided by obstructed use. The development of more culturally sensitive examinations and resolutions is essential for improving the mental health (help-seeking) experiences of this population.

Footnotes

Author’s Note

The present article was crafted in fulfillment of a required comprehensive examination mandated by the doctoral program in Social Work and Social Welfare Research at Portland State University. The department requires its doctoral students to develop a piece of scholarship worthy of publication according to those guidelines asserted and maintained by an esteemed academic journal. This article also serves as the conceptual foundation for an emergent and culminating dissertation examination.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

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