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Working with African Americans in Mental Health

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Title: Working with African Americans in Mental Health


1
Working with African Americans in Mental Health
  • Developed by members of the Multicultural and
    Diversity Committee of the VA Psychology Training
    Council (2012-2013)
  • Angelic D. Chaison, Ph.D.
    Jamylah Jackson, Ph.D.
  • Michael E. DeBakey VAMC, Houston, TX
    North Texas VHCS, Dallas, TX
  • Helene Cook, Ph.D. Melanie Scott, Ph.D.
  • VA Gulf Coast Veterans Health
    West Haven VAMC
  • Care System (VAGCVHCS), Biloxi, MS
    Connecticut

2
Multicultural Diversity Committee Members
  • Committee 2012-2013
  •  
  • Daryl Fujii Ph.D., Honolulu (Co-Chair)
  • Linda Mona, Ph.D., Long Beach (Co-Chair)
  • Angelic Chaison Ph.D., Houston
  • Jamylah Jackson Ph.D., ABPP , Dallas
  • Monica Roy Ph.D., Boston
  • Sam Wan Ph.D., San Francisco
  • Melanie Scott, Ph.D., West Haven
  • Rex Swanda, Ph.D., Albuquerque
  • Helene Cook, Ph.D., Biloxi (Postdoctoral Fellow)
  • Gilberte Bastien, M.A., Bay Pines (Intern)
  • Denise Rodriguez De Ybarra, M.A., Albuquerque
    (Intern)
  • Philip Sayegh, M.A., Northern California (Intern)
  •  Contact persons
  • Daryl Fujii Ph.D., Honolulu (Daryl.Fujii_at_va.gov)
  • Linda Mona, Ph.D. (Linda.Mona_at_va.gov)

3
Overview
  • Heterogeneity among African Americans
  • Healthcare Disparities
  • Racial/Cultural Identity Models
  • Cultural Mistrust
  • Clinical Implications Providing Treatment
  • Case Example
  • References

4
Heterogeneity among African Americans
5
Heterogeneity
  • Ethnicity
  • Regional
  • Religion
  • Educational attainment
  • Income

6
Ethnicity in Veteran Population
  • In 2009, there were 21.9 million veterans in the
    United States
  • African American 2.3 million
  • Hispanic 1.1 million
  • Asian-American 258,000
  • American Indian or Alaskan Native 153,000
  • Native Hawaii or Other Pacific Islander 30,000
  • Non-Hispanic White 17.7 million
  • Female Veterans 1.5 million

US Census, 2010
7
Heterogeneity Within the Black Population
  • In 2010 the total U.S. population was 308.7
    million, according to the U.S. Census
  • 42 million people identified as
    Black/African-American. This number represents a
    15.4 increase since the 2000 census and
    indicates that those self-identified as
    Black/African American make up 13.6 of the total
    population.
  • 12.6 (38,929,319) report being Black or African
    American alone.
  • 1.0 (3,091,424) report being Black or African
    American in combination with another race.

US Census, 2010
8
Regional Diversity
  • The population of individuals who identified as
    Black/African American alone is largest in the
    southern regions of the US, increasing by 16
    since the 2000 census.
  • Individuals who identified as being Black/African
    American in combination with another race were
    more dispersed, they also were more likely to
    live in California.
  • An overall increase in the Black/African American
    population (alone or in combination) was evident
    in every state across the U.S.

US Census, 2010
9
Heterogeneity in Religion
  • Though the US is generally viewed as highly
    religious, African Americans were found to be
    markedly more religious as a whole.
  • Compared to other ethnic groups, African
    Americans were
  • More likely to report being affiliated with a
    formal religious organization.
  • More likely to engage in prayer.
  • More likely to report that religion was an
    important part of their lives.

US Census, 2010
10
Heterogeneity in Educational Attainment
  • Educational attainment among the Black population
    is lower than among White and Asian groups.

White () Black () Asian () Hispanic ()
High School Grad 89.4 80.1 85.8 60.6
Some College 58.8 45.8 68.0 32.4
Bachelors Degree 30.5 17.3 49.5 12.5
Advanced Degree 11.3 5.8 19.6 3.9
US Census, Educational Attainment in the US
2007, 2009
11
Heterogeneity in Income
  • Total income of households for Black alone or in
    combination in 2009.

Total Income Percent
Under 5,000 6.6
5,000 9,999 7.8
10,000 14,999 9.0
15,000 19,999 8.0
20,000 24,999 7.4
25,000 34,999 13.4
35,000 49,999 14.5
50,000 74,999 15.2
75,000 99,999 8.7
100,000 and over 9.4
US Census, 2010
12
African Americans and Cultural Disparities in
Health Care
13
Cultural Health Disparities
  • The burden of illness in the United States is
    higher in racial and ethnic minorities than
    Whites.
  • In the US, African Americans have shorter overall
    life expectancies and higher rates of
    cardiovascular disease, cancer, infant mortality,
    birth defects, asthma, diabetes, stroke, adverse
    consequences of substance abuse, and sexually
    transmitted diseases.
  • Racial and ethnic disparities in health care
    exist even when insurance status, income, age,
    and severity of conditions are comparable
  • Poor somatic health likely takes a toll on mental
    health status
  • Bias, stereotyping, prejudice, and clinical
    uncertainty on the part of health care providers
    may contribute to these disparities

US DHHS, 2000 Smedley, Stith, Nelson, 2002
14
Mental Health Cultural Disparities
  • African Americans are
  • less likely to seek MH treatment
  • more likely to wait until symptoms are more
    severe
  • less likely to seek MH specialists (typically
    seen in Primary Care)
  • more likely to be diagnosed with SMI vs. other
    mental health diagnoses
  • more likely than White patients to refuse
    treatment

US DHHS, 2001
15
Mental Health Disparities cont.
  • While some indications suggest racial disparities
    are decreasing on almost every health index,
    Black Americans suffer in relation to White
    Americans and often in relation to other racial
    and ethnic groups
  • African Americans may also be hesitant to seek
    mental health treatment because of a wealth of
    personal and cultural coping resources these
    resources may serve as substitutes for
    professional mental health assistance and may
    proliferate social norms about the irrelevance of
    such service

Griffith, Neighbors, Harold, Johnson, 2009
Buser, 2009
16
Health Disparities in Depression Treatment
  • Persons who self-identified as African American
    were less likely than whites to use therapy if
    they had minor depression, even after adjusting
    for potentially influential variables including
    age, cognitive functioning, and whether the dose
    of antidepressant was adequate
  • Older African Americans with minor depression
    were less likely than whites to use
    psychotherapy.
  • Targeted strategies are needed to mitigate the
    disparity in use of psychotherapy.

Joo, Morales, de Vries, Gallo, 2010
17
Cultural Disparities Treatment of SMI
  • Spending on psychotropic drugs, mental health,
    and all health was 0.970 percent lower for
    Blacks and Latinos than for Whites. With the
    exception of Blacks with substance use disorder
    co-morbidity.
  • People of color were less likely than Whites to
    use psychiatric inpatient services.
  • Psychiatric inpatient spending among users did
    not differ by race/ethnicity.
  • With the exception of psychiatric inpatient
    utilization/spending, trend analyses showed no
    change or modest reductions in disparities.

Horvitz-Lennon, McGuire, Alegria, Frank, 2009
18
Racial/Ethnic Identity Models for African
Americans
19
Introduction to Racial/Cultural Identity
Development Models
  • Several racial and ethnic identity models have
    been proposed for visible racial and ethnic
    groups (VREG) and published in multicultural
    counseling handbooks and journals.
  • Understanding racial identity for African
    Americans is important because of the
    relationship between racial identity attitudes
    and psychological well-being among African
    Americans (Worrell, 2008).
  • Kwan (2001) points out that racial and ethnic
    identity models
  • Inform mental health professionals of the
    sociopolitical influences on VREG members
    identity experiences and potential resulting
    psychological conflicts
  • Provide tools to understand identity differences
    within racial and ethnic groups
  • Provide a framework to conceptualize
    cross-cultural dynamics in the therapist-client
    relationship

20
Nigrescence Theory and Racial Identity
Development (Cross, 1971, 1991, 1995)
  • A well-known, and well-documented model of Black
    identity development comes from the work of W.E.
    Cross who described psychological Nigrescence, or
    the process of developing Black consciousness.
  • The original Cross model (1971) described 5
    stages of racial identity development in which an
    African American individual shifts from a White
    frame of reference to a positive Black frame of
    reference. The stages occur at an individual
    level and include
  • Pre-Encounter
  • Encounter
  • Immersion-Emersion
  • Internalization
  • Internalization-commitment
  • Cross assumed that progression from the
    Pre-encounter stage to the Internalization-commitm
    ent stage signified healthy psychological
    development for African American individuals.

21
Nigrescence and Cross Racial Identity Development
cont.
  • Stage 1 Pre-Encounter
  • African American individual devalues his/her
    Blackness and views White ways and values as
    ideal and are preferred.
  • Individual experiences self-hate, low
    self-esteem, and poor mental health and desires
    to assimilate and acculturate into White society.
  • Stage 2 Encounter
  • Individual is exposed to a significant
    race-related event that challenges the
    individuals previous way of thinking about Black
    and White identity.
  • Individual and experiences guilt about previously
    preferring White culture and begins to
    reinterpret the world with a greater racial
    awareness and interest in developing black
    identity.

22
Nigrescence Cross Racial Identity Development
cont.
  • Stage 3 Immersion-Emersion
  • Individual withdraws from White culture, immerses
    himself/herself in Black culture, and develops a
    sense of pride in being Black.
  • Towards end of stage, the individual feels less
    guilty/angry and moves toward internalization of
    a new Black identity.
  • Stage 4 Internalization
  • Individual resolves conflicts between his/her old
    and new identities and anti-white feelings
    decrease.
  • Individual becomes more flexible and tolerant and
    develops a bicultural/multicultural identity.
  •  Stage 5 Internalization-commitment
  • Individual commits to promoting and advancing
    social change, social justice, and civil rights
    in words and in actions.

23
Cross Racial Identity Development Model Revised
  • Cross revised the nigrescence model in 1991 and
    1995. The revised model retains many of the
    features of the original model but also differs
    in some ways.
  • The revised Pre-encounter Stage includes the
    notion of race salience , or the degree to which
    race consciousness is integral to the
    individuals identity or way of life.
  • Pre-encounter stage is comprised of 2
    identities instead of one
  • Pre-encounter assimilation individual has low
    race salience and neutral valence towards
    Blackness.
  • Pre-encounter anti-black individual hates Black
    people and hates being black.

24
Cross Racial Identity Development Model Revised
(cont.)
  • Immersion-emersion stage now includes 3
    identities
  • Anti-white
  • Pro-Black
  • Anti-White/pro-Black
  • Internalization-commitment were collapsed into
    one stage internalization. It is characterized
    by Black self-acceptance and has 3 identities
  • Black Nationalist high black positive race
    salience
  • Biculturalist Blackness and fused sense of
    Americanness
  • Multiculturalist multiple identity formation,
    including race, gender, sexual orientation, etc.
  • Cross and associates have developed the Cross
    Racial Identity Scale which has been well
    established and validated (Vandiver, Cross,
    Worrell, Fhagen-Smith, 2001).

25
Racial/Cultural Identity Development Model
(R/CID Sue Sue, 1990, 1999)
  • Sue and Sue identified 5 stages that oppressed
    people progress through as they attempt to
    understand themselves in terms of their own
    culture, dominant culture, and the oppressive
    relationship between the 2 cultures.
  • Each level of identity is described in terms of
    the individuals beliefs and attitude towards
  • Self
  • Others of the same minority
  • Others of another minority
  • Dominant group
  • R/CID Stages (based on the individual)
  • Stage 1 Conformity Prefers and feels positive
    about dominant culture lifestyles, value systems,
    and cultural/physical characteristics and either
    depreciates ones own culture or the persons
    culture has little salience in his/her daily
    life.

26
Racial/Cultural Identity Development Model
(R/CID Sue Sue, 1990, 1999) cont.
  • Stage 2 Dissonance Questions and challenges
    attitudes/beliefs in the conformity stage and
    begins to appreciate aspects of their culture
    while growing distrustful of dominant culture,
    values, and beliefs.
  • Stage 3 Resistance and immersion Embraces
    ones own culture, values, beliefs, and rejects
    dominant culture, values, beliefs, seeing them as
    oppressive. Growing desire to eradicate
    oppression.
  • Stage 4 Introspective awareness Begins to
    question the rigid embrace of minority culture
    values with little emphasis on personal autonomy.
  • Stage 5 Integrative awareness Appreciates
    unique aspects of ones own culture and the
    culture of the dominant group. Adopts a
    multicultural perspective and objectively examine
    the values, beliefs, etc. of their own and other
    cultures before accepting or rejecting them.
    Commitment to eliminate all forms of oppression.

27
Cultural Mistrust among African Americans
28
Attitudes toward Mental Health Treatment among
African Americans
  • Diala et al., 2000
  • Analyzed data from the National Comorbidity Study
  • Prior to the use of mental health services,
    African Americans had more positive attitudes
    towards seeking mental health treatment than
    Whites.
  • After African Americans utilized mental health
    services they held more negative attitudes about
    mental health treatment and were less likely to
    use MH treatment again than were Whites with
    comparable needs/issues.

29
  • What accounts for African Americans change in
    attitude from pre to post treatment?

We still do not have a solid understanding, but
consider the following factors
30
Schizophrenia is over-diagnosed among African
Americans
  • Early studies erroneously suggested that Blacks
    had higher rates of schizophrenia than Whites.
  • Numerous recent studies have well established
    that schizophrenia is over-diagnosed among
    African Americans while mood disorders are
    under-diagnosed (Barnes, 2004).
  • Paranoid schizophrenia is the most frequent
    diagnosis given to African Americans
  • Clinicians tendency to attribute more
    paranoid/suspicious behavior to African
    American psychiatric patients than non-African
    American counterparts

Barnes, 2004 Neighbors, et al., 1999 Surgeon
General, 2001 Treirweiler et al., 2000
31
Psychotic Disorders and African Americans, cont.
  • Why are there high rates of misdiagnosis of
    psychotic disorders among African Americans?
  • Possible explanations
  • Racial bias and clinical stereotyping by
    clinicians
  • Lack of cultural understanding between clinicians
    and patients
  • Racial differences in the presentation of
    symptoms
  • Inadequate access to care leading to more severe
    symptom presentation upon admission
  • Lack of attention to the influence of a patients
    sociocultural background on psychotic-like
    symptom presentation

Barnes, 2004 Jarvis, 2007 Earl, Williams,
Anglade, 2011
32
Other ConsiderationsViews of Paranoia
  • Research on paranoia and its relation to
    psychiatric diagnoses has advanced in 2 important
    ways
  • There is greater recognition of the fact that
    there are cultural variations in the
    manifestation of paranoid symptoms.
  • Acknowledgement that paranoia can be thought of
    as a continuum from mild symptoms (e.g.,
    mistrust, self-consciousness, suspiciousness) to
    pathological (e.g., severe delusions and
    hallucinations).

Whaley, 2001, 2002
33
Assessment of Cultural Paranoia
  • Initial assessment requires the clinician to
    separate cultural aspects of paranoia from true
    pathology
  • Cultural Mistrust Inventory (CMI Terrell
    Terrell, 1981) measures the degree to which
    Blacks mistrust Whites in various settings based
    on past and contemporary experiences with racism
    and oppression
  • Example items
  • It is best for Blacks to be on their guard when
    among Whites.
  • A Black person can usually trust his or her
    White coworkers.
  • Whites will say one thing and do another.
  • Psychometrics
  • CMI total scale is a reliable measure.
  • Demonstrated convergent validity with a measure
    nonclinical paranoia
  • Demonstrated discriminant validity with measures
    of self-esteem and social desirability

Whaley, 2001, 2002 Terrell Terrell, 1981
34
Cultural Mistrust and Treatment Expectations
  • Cultural mistrust has been linked to
  • Premature termination from treatment (Terrell
    Terrell, 1984 Townes, Chavez-Korell,
    Cunningham, 2009)
  • Higher preference for Black clinicians (Townes,
    Chavez-Korell, Cunningham, 2009)
  • More negative attitudes toward white clinicians
    (Whaley, 2001)
  • More negative attitudes toward seeking
    psychological help (Duncan, 2003)
  • Negative general attitudes about seeking help
    from clinics lacking racial diversity (Nickerson,
    Helms, Terrell, 1994)

35
Clinical Implications Providing Mental Health
Treatment for African Americans
36
Build a Therapeutic Alliance Early
  • Building a trusting rapport early in the
    counseling relationship is important. It would
    be helpful to understand the concept of healthy
    mistrustand its impact on relationship
    development (Kelly, 2006).
  • Recognize the high rate of early termination
    among African American clients, particularly when
    clients (Kelly, 2006)
  • Do not trust the therapist or the therapeutic
    process
  • Do not perceive the therapist as empathic and
    authentic
  • Racial/cultural identity models may help explain
    premature termination rates for minority
    individuals (Sue Sue, 2008).
  • Minority individuals reactions to therapy may be
    a function of their cultural/racial identity and
    not simply because of racial group membership.

37
Build a Therapeutic Alliance Early cont.
  • Due to prior experiences, clients may be
    skeptical of the therapist and/or the possible
    benefits of psychotherapy. Sue and Sue (2008)
    recommend the following when working with African
    Americans
  • Determine how the client feels about counseling
    and its usefulness
  • Explain the process of counseling to the client
    and promote an egalitarian relationship with the
    client. Some self-disclosure may be helpful in
    establishing a collaborative working
    relationship.
  • Discuss how the client feels about having a
    counselor of a different or same race. Discuss
    issues of trust directly in an open, authentic,
    and empathetic manner.
  • Identify any biases you have about counseling an
    African American client and how your own feelings
    might affect the counseling relationship.

38
Case Conceptualization Tips
  • Familiarize oneself with the culture ,
    attitudes, beliefs, worldviews of African
    Americans (Brown et al, 2012) BUT do not assume
    that because the client is African American,
    he/she has the same values and beliefs as other
    African Americans. Discuss the clients personal
    worldview(s) (Kelly, 2006 Sue Sue, 2008).
  • Consider where clients may be in their racial
    identity development and identify their
    counseling needs from that perspective (Kelly,
    2006 Sue Sue, 2008).
  • Explore how the client views the problem, which
    may vary based on cultural beliefs and values. Do
    not dismiss clients assertions that racism,
    discrimination, and/or oppression contribute to
    their presenting problem (Kelly 2006 Brown et
    al., 2012)).
  • Determine positive assets and cultural strengths
    that the client brings to counseling, such as
    family, friends, community resources, religion,
    etc. (Kelly, 2006 Sue Sue, 2008)

39
Intervention and Practice Tips
  • Some clients may prefer a more directive approach
    to therapy and may request assistance with
    identifying alternative means of solving
    logistical problems using problem-solving and
    time-limited approaches (Brown, Conner,
    McMurray, 2012 Sue Sue 2008).
  • Kelly (2006) highlights advantages of culturally
    responsive cognitive-behavioral therapy with
    African Americans, including collaborative
    problem-solving, strengthening natural support
    systems, and empowering clients by helping them
    build strengths, supports, and skills to meet
    their goals.
  • Consider incorporating clients natural support
    systems (e.g., elders, extended family, church
    family,) into treatment (Kelly, 2006)
  • Help clients identify ways of addressing
    perceived and/or actual racism (Sue Sue, 2008).

40
Case Example
41
Case Example
  • Darrell is a 63 year old African American,
    Vietnam veteran referred to mental health for
    anger problems after his wife told his PCP that
    Darrell is always mad and never wants to leave
    the house except to go to work as a truck driver.
  • Darrell is on his 4th marriage and the
    relationship with his wife is rocky. He has 3
    adult children from previous marriages but does
    not talk to them very often because his children
    say he is mean.
  • Darrell began the 1st therapy session by saying
    that he is not crazy and the only reason he is
    coming to treatment is because his wife gave him
    an ultimatum to get some help or she would
    leave. He does not see how therapy will help,
    stating that he does not trust anyone, especially
    White people, recalling how he fought in
    Vietnam for his country as an American but had to
    deal with White soldiers calling him racial
    names. He also described distrust of the
    government who sent him to fight in Vietnam but
    then rewarded Vietnamese people who fled to
    America financial benefits that he was not able
    to receive .

42
Discussion Questions
  • 1. What are your initial impressions of
    Darrells case and how could you approach the
    initial session?
  • 2. What are some potential salient issues to
    explore in conceptualizing is Darrells
    presenting problems and diagnosis?
  • 3. What would be some cultural considerations/
    adaptations to consider?

43
References
44
References
  • Atkinson, D. R., Morten, G., Sue, D.W. (1998).
    Counseling American Minorities (5th ed.). Boston
    McGraw Hill.
  • Barnes, A. (2004). Race, schizophrenia, and
    admission to state psychiatric hospitals.
    Administration and Policy in Mental Health,
    31(3), 241-252.
  • Brown, C., Conner, K.O., McMurray, M. (2012).
    Toward cultural adaptation of interpersonal
    psychotherapy for depressed African American
    primary care patients. In G. Bernal and M.M.
    Domenech Rodriguez (Eds.), Cultural adaptations
    Tools for evidence-based practice with diverse
    populations (pp. 223-238). Washington, DC
    American Psychological Association.
  • Buser, J. K. (2009) Treatment-seeking disparity
    between African Americans and Whites Attitudes
    toward treatment, coping resources, and racism.
    Journal of Multicultural Counseling and
    Development, 37(2), 94-104.

45
References
  • Cross, E.W., Vandiver, B.J. (2001). Nigrescence
    theory and measurement Introducing the cross
    racial identity scales (CRIS). In J.G. PotBlow,
    F.C., Seber, J.E., McCarthy, J.F., Valenstein,
    M., Gillon, L., Bingham, C.E. (2004) Ethnicity
    and diagnostic patterns in veterans with
    psychosis. Social Psychiatry and Psychiatric
    Epidemiology,(39), 841-851.  
  • Das A.K., Olfson M., McCurtis H.L., Weissman,
    M.M., 2006. Depression in African Americans
    breaking barriers to detection and treatment.
    Journal of Family Practice, 55, 30-39.
  • Department of Health and Human Services
    http//www.hhs.gov/
  • Diala, C. et al., (2000). Racial differences in
    attitudes toward professional mental health care
    and in the use of services. American Journal of
    Orthopsychiatry, 70(4), 455, 464.

46
References
  • Dressler, W. W., Oths, K. S., Gravelee, C. C.
    (2005). Race and ethnicity in public health
    research Models to explain health disparities.
    Annual Reviews of Anthropology, 34, 231252.
  • Duncan, L.E. (2003). Black male college students
    attitudes toward seeking psychological help.
    Journal of Black Psychology, 29(1), 68-86.
  • Earl, T., Williams, D., Anglade, S. (2011). An
    update on the mental health of Black Americans
    Puzzling dilemmas and needed research. Journal
    of Black Psychology, 37(4), 485-498.
  • Griffith, D.M., Neighbors, H.W., Johnson, J.
    (2009). Using national data sets to improve the
    health and mental health of Black Americans
    Challenges and opportunities. Cultural Diversity
    and Ethnic Minority Psychology, 15(1), 86-95.

47
References
  • Hays, P. (2009). Integrating evidence-based
    practice, cognitive-behavior therapy, and
    multicultural therapy Ten steps for culturally
    competent practice. Professional Psychology
    Research and Practice, 40(4), 354-260.
  • Horvitz-Lennon, M., McGuire, T. G., Alegria, M.,
    Frank, R.G. (2009). Racial
  • and ethnic disparities in the treatment of a
    Medicaid population with
  • schizophrenia. Health Services Research,
    44(6), 2106-2122.
  • Joo, J.H., Morales, K.H., de Vries, H.F.,
    Gallo, J.J. (2010). Disparity in use of
    psychotherapy offered in primary care between
    older African-American and White adults Results
    from a practice-based depression intervention
    trial. Journal of the American Geriatrics
    Society, Vol 58(1), 154-160.

48
References
  • Kelly, S. (2006). Cognitive-behavioral therapy
    with African Americans. In P. Hayes and G.
    Iwamasa (Eds.), Culturally responsive
    cognitive-behavioral therapy Assessment,
    practice, and supervision (pp. 97-116).
    Washington, DC American Psychological
    Association.
  • Kwan, K. (2001). Models of racial and ethnic
    identity development Delineation of practice
    implications. Journal of Mental Health
    Counseling, 23(3), 269-277.
  • Neighbors, H.W., Trierweler, S.J., Munday, C.,
    Thompson, E.E., Jackson, H.H., Binion, V.J., et
    al (1999). Psychiatric diagnosis of African
    Americans Diagnostic divergence in
    clinician-structured and semi-structured
    interviewing conditions. Journal of the National
    Medical Association, 91, 601-612.

49
References
  • Nickerson, K.J., Helms, J.E., Terrell, F.
    (1994). Cultural mistrust, opinions about mental
    illness, and Black students attitudes toward
    seeking psychological help from White counselors.
    Journal of Counseling Psychology, 41(3), 378-385.
  • Ridley, C. (1984). Clinical treatment of the
    nondisclosing Black client. American
    Psychologist, 39(11), 1234-1244.
  • Smedley B.D., Stith A.Y., Nelson A.R., (2002).
    Unequal treatment Confronting racial and ethnic
    disparities in health care. Washington, DC
    National Academy Press.
  • Sue, D.W. Sue, D. (2008). Counseling the
    Culturally Different Theory and Practice. John
    Wiley Sons, Inc. 5rd Edition.

50
References
  • Surgeon General Mental Health (2001). Culture,
    race and ethnicity- A supplement to mental
    health A report of the Surgeon General.
    Rockville, MD US Dept of Health and Human
    Services.
  • Terrell, F., Terrell, S.L. (1981). An inventory
    to measure cultural mistrust among Blacks.
    Western Journal of Black Studies, 5, 180-184.
  • Terrell, F., Terrell, S.L. (1984). Race of
    counselor, client sex, cultural mistrust level,
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