Therapy isn’t easy. Living with schizophrenia—possibly the most misunderstood and stigmatized condition there is—isn’t either.

Yet, therapy is cited again and again by experts who treat schizophrenia, as well as those who have the diagnosis, as a key to symptom management and a good way to avoid hospitalization. Living well with schizophrenia is about recognizing and managing symptoms, taking medication as prescribed, and learning how to cope with stress and other triggers to help you avoid future episodes of psychosis, a temporary break with reality. Therapy can help with all of these pieces.

The trouble is that Black people are less likely to seek out traditional forms of therapy, including talk therapy like cognitive behavior therapy  (CBT) due to both socioeconomic barriers and stigma.

Alicia Hodge, PsyD, a licensed clinical psychologist with over 10 years of experience providing therapy to adolescents and adults, including those with schizophrenia, says that thinking is understandable given the history of racism in healthcare. The fallout from the infamous Tuskegee Syphilis Study—a study of 600 Black men, conducted between 1932 and 1975 by the CDC, without their knowledge or consent—in part may explain why so many Black people are distrustful and suspicious of healthcare providers.

“The biggest thing driving all of this is the stigma surrounding mental health,” says Dr. Alicia. “Being part of the Black community, you’re already othered. There’s already stigma and bias. To take on another stigma and label is so much harder. Identity-wise, that can be difficult to accept.”

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Today, Black patients continue to face systemic discrimination, including socioeconomic disparities, health care provider shortages, and discriminatory diagnosing.

In fact, Black patients presenting symptoms of mood disorders or post-traumatic stress disorder (PTSD) are more likely to be misdiagnosed with schizophrenia (which has a poorer long-term prognosis). While these concerns are legitimate, they can get convoluted when simultaneously dealing with psychosis, the hallmark of schizophrenia.

“People worry that if they have an issue, they’re going to have to get medical treatment and enter into a system that they’re, at minimum, a little concerned about,” Dr. Alicia explains. “They tend to know at least one person who has been misdiagnosed or mistreated or overmedicated and they become fearful.”

Over time, these barriers have grown into cultural stigmas and avoidance of professional care in favor of keeping mental health problems inside the family and faith communities. In one study, 63% of Black people said that they believe mental illness is a sign of weakness.

With a customized, comprehensive plan and the help of culturally aware providers, you can move past those barriers and find the right treatment for you.

Here, a look at the best therapy options for Black people with schizophrenia and other mental health issues who might be mistrustful of traditional mental health services.

Why Medication Compliance Is Important for Schizophrenia

Medication is a necessary cornerstone when it comes to treating major mental illnesses like schizophrenia and psychosis (a severe mental disorder when the mind is overtaken by hallucinations and/or delusions).

“The main thing is helping people understand that these are diseases,” says Cynthia Major Lewis, MD, director of adult psychiatric emergency services at Johns Hopkins. “We can’t just talk away psychotic illness or look at it as something we can avoid. This [schizophrenia] is a major mental health problem that affects the brain.”

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Long-acting injectable (LAI) antipsychotic medications have a notable edge over oral antipsychotics, because they are administered by a doctor on a monthly basis (patients typically get an injection every one to three months), rather than taking a daily pill.

The Black Community and Distrust of Antipsychotics

This guaranteed consistency improves adherence for those who either forget or temporarily quit their meds. While LAIs have been around since 1966 and become more popular in Europe, they have yet to gain the same prevalence in the US where noncompliance remains a major reason for relapse.  According to Dr. Major Lewis, the Black community has additional reasons to reject LAI antipsychotics.

“It’s a never-ending cycle in the ER,” says Dr. Major Lewis explaining that medication non-compliance contributes to hospitalization. “If we had more patients on long-acting antipsychotics, that would be less of an issue. But it’s hard to persuade someone who might be ambivalent about any treatment to begin with to put something in their body that lasts one to three months, especially if you add in concerns about the history of experimentation and discriminatory practices.”

Despite this skepticism, there’s good reason to work with providers, therapists, and others you trust to decide if LAI antipsychotics are right for you. Used properly, they have been shown to reduce hospitalization and risk of treatment failure.

Psychotherapy’s Many Forms: It’s Not Just About Talking

Psychotherapy, also known as talk therapy or other names, plays an essential role in schizophrenia and psychosis treatment. Essentially talk therapy gives people struggling with their mental health an opportunity to explore their thoughts and feelings and the effect they have on their behavior and mood. Options for psychotherapy can exist outside the traditional framework of talking one-on-one with a therapist. Yet Black Americans are less likely to seek treatment, due to both socioeconomic barriers and stigma.

“I do believe that culturally, the Black community is not traditionally open to speaking about problems to outsiders,” says Dr. Alicia. “By outsiders, I don’t even mean people who aren’t the same race. I mean people outside their homes or families. The idea of going to a stranger and talking about personal issues is like, ‘Why would I do that? Why would I pay to talk to someone I don’t know?’”

Cultural Barriers of Talk Therapy for The Black Community

That perception is gradually changing thanks to the work of both well established and new groups like Therapy for Black Men (whose tagline is “Strength Still Needs Support”),  Black Psychiatrists of America, Black Emotional and Mental Health Collective (BEAM), Black Mental Health Alliance (around since 1983) and Therapy for Black Girls, which offer space and resources tailored for the Black community to learn more about mental health care and therapy.

“If you feel like something is actually for you and you can trust in your providers, you will see the benefits and you’re more likely to maintain the treatment,” Dr. Alicia says. While many patients do better when they feel aligned with a same-race clinician, Dr. Alicia has found that it’s not always required–as long as the relationship is built on trust and the provider is culturally sensitive.

“All therapists should have received formal training around racial sensitivity, but they should also be aware of the dynamic in the room. Therapists should never make assumptions. Instead, they should ask questions so the patient understands that race is not a taboo topic,” she says.

There are a number of psychotherapy options for treating schizophrenia and psychosis. It should be noted that storytelling, meditation, music, and affirmation can also be utilized in therapeutic ways to heal and provide you with insight into your condition (more on that later). Where a patient starts largely depends on their ability to communicate and their level of insight into their illness. Your therapist may combine elements from several different styles of psychotherapy; most don’t tie themselves to one approach but will instead blend elements from different approaches based on what you need. The following list explains different psychotherapy approaches:

Supportive Therapy

When someone is experiencing a period of psychosis, their relationship with reality is impaired, making it impossible to engage in most types of talk therapy. However, they will still benefit from supportive therapy, which aims to improve self-esteem, regulate negative thinking, and cope with emotional distress. Supportive therapists encourage patients to vent (if necessary) and develop their own resources. Like other forms of therapy, it aims to build self-esteem, improve functioning, strengthening coping skills, and reduce anxiety. Supportive therapy can serve as a first line of defense against marginalization and social isolation.

Cognitive Behavioral Therapy (CBT)

Because of barriers like disorganized thinking and a low level of insight into their illness, many people with schizophrenia will benefit from help identifying and changing destructive thought patterns. CBT for psychosis is a way of challenging flawed thinking. For example, if someone with schizophrenia feels paranoid that the government is watching her every move, the therapist might respond by asking if they can see cameras or why the government might be interested in their thoughts to help them see there might be something else (psychosis) going on. This type of CBT helps a patient identify when symptoms are flaring up, and become better equipped to know how to manage symptoms.

Acceptance and Commitment Therapy (ACT)

ACT is generally thought of as more action-oriented than CBT, because it encourages people to accept their thoughts and feelings as the appropriate responses rather than question them. For this reason, Dr. Alicia finds ACT particularly helpful for patients dealing with psychosis and race issues. “I find some people only default to is that true or not,” she says. “I am a big fan of ACT, because sometimes I think CBT can get fuzzy on topics about race. Was it rational or irrational? What is distortion? Do you think they really meant that? It becomes a tug of war. It’s easier to say, ‘We know bias exists. That’s really awful. How do we deal with that?’”

Alternative Approaches to Psychotherapy

While medical interventions are necessary with schizophrenia and other psychotic disorders, they aren’t the whole story. A number of alternative treatment options, including creative arts therapy and somatic therapy, have become popular ways to complement the physical healing provided by antipsychotic medication. Because people with schizophrenia frequently have less social support and endure stigmas such as forced hospitalizations, it’s often necessary to also address trauma and holistic treatment.

“The reason why people go into therapy to begin with is to address the bigger issues,” says Nala C. Turner, LCAT-LP, creative arts therapist and ceramics artist. “What is the trauma? What is the obstacle? What is the thing you’re processing that’s making life difficult in addition to your mental health?”

Different types of alternative therapy can play an important role in treatment.

What Is Psychoeducation

Psychoeducation aims to break down the stigmas of schizophrenia by teaching people about their mental health conditions and disorders. Whether it’s through a formalized program or alongside talk therapy, psychoeducation has been shown to reduce rehospitalization rates, teach patients to think more critically about their symptoms and develop coping skills. Often, it also involves family intervention, helping to create a healthy support network of friends and family who understand your illness. The National Alliance on Mental Illness (NAMI) runs a type of psychoeducation therapy they call family to family. For more information visit https://www.nami.org/Support-Education/Mental-Health-Education/NAMI-Family-to-Family

“Sadly, with schizophrenia one of the things that contributes to lack of getting care is lack of insight, says Dr. Major Lewis. “It’s really about educating them [the patient], pointing out someone they trust, and saying even if you don’t believe me the provider, how about your sister or your brother or your parents who just want to see you do well? It definitely takes a village.”

When everyone is on the same page, Dr. Major Lewis says, it’s easier to ensure that patients take their medication, stay away from drugs, and get the emotional backup they need. “It’s really a support therapy to help people stay engaged with treatment so their symptoms can get better controlled.”

Support Group: Learning Through Peers

Schizophrenia treatment emphasizes community and often requires wraparound services to ensure that the patient is getting the medication and help they need. Support groups can be an effective way of achieving that connection with peers, as well as helping a patient who might feel nervous or embarrassed to share without fear of stigma or judgment.

“It eliminates the power dynamic and connects you with people who empathize,” says Dr. Alicia. “In support groups, it’s easy to open up to the root of what’s going on and encourage self-acceptance.”

Black Mental Health Resources

Here, some resources that focus specifically on Black mental health (each one has a support group):

Because the Black community has historically sought support from faith communities, Dr. Alicia also notes that she’s seen a great effort amongst providers in the last couple of years to reach out to clergy and educate them on mental health.

Assertive Community Treatment (ACT) Teams

Sometimes, patients require a higher level of care than friends, family, and support groups can provide. That’s where ACT teams come in. These 24/7 teams offer treatment, rehabilitation, and support services to people with serious mental illnesses such as schizophrenia. Considered a medically monitored non-residential service, each ACT team offers continuity of care from a hospital to an outpatient practice.

ACT teams typically follow a holistic approach to treatment and include a psychiatrist, social workers, nurses, occupational therapists, and peer support specialists. These professionals help their clients with psychiatric services, substance abuse issues, representation at court hearings, ordering medications, and more. In one study, ACT was shown to reduce psychiatric hospitalization by 78%, increase housing stability (67%), and improve quality of life (58%). Contact your state’s department of mental health to be connected to ACT teams.

Social cognition and Interaction Training (SCIT)

It’s not unusual for those suffering from schizophrenia to feel out of place or struggle with social interactions. Increasingly, experts believe this is because schizophrenia patients exhibit impaired social cognition (the ability to understand social cues in real-world situations). SCIT behavior therapy, which consists of weekly, hour-long group sessions held by clinicians, teaches communication and other skills that help improve emotional perception. Because social cognition is an important driver in the functional success of schizophrenia patients, developing these skills is a critical part of treatment.

“I like it [SCIT behavior therapy] because it teaches people how to feel safer and integrated in society,” says Dr. Alicia. “If you have schizophrenia it can be difficult to read people’s emotions. It teaches people almost step-by-step how to interact with others and break down social interactions.”

Creative Arts Therapy

For a schizophrenia patient who struggles with verbalizing their thoughts and motions, creative arts therapy in the form of art, music, dance, or drama, might offer some relief. Some studies have even found that it can increase self-esteem and reduce emotional and social withdrawal.

“Sometimes the things we experience just can’t be explained through words,” says Turner. “So being able to use art to process and express yourself can be really valuable, especially when it comes to those who are lower functioning or talking just isn’t their forte.”

For many, art therapy offers accessibility that more traditional methods lack. While paying for and remembering to attend talk therapy appointments may be challenging for some, art therapy can be performed in your own home once you have the initial skillset. Turner also prizes its ability to reach patients who might be reluctant to open up or hesitant to talk to a therapist.

“What’s powerful about it is I can meet with a client who might be very guarded and say, “‘I don’t want to do therapy and I definitely don’t want to talk to you.’ But in creating, they then are able to allow themselves space to be more vulnerable than they are on a day-to-day basis. There aren’t many people who don’t connect to art in some form.”

Somatic Therapy

Somatic therapy is a body-centered therapy that acknowledges the connection between the mind and the body for a holistic treatment style. While there are multiple types of somatic therapy (including yoga, dance, vocal work, and massage) a session typically involves a combination of deep breathing, relaxation exercises, and meditation as a therapist helps the patient recall painful experiences and tie them to specific physical responses, such as facial expressions and posture. By developing an awareness of these connections, the patient can work with the therapist to release their tension and negative emotions.

While not typically used specifically for schizophrenia or psychosis, somatic therapy can be extremely useful to help address the trauma, stress, anxiety, and depression that so many schizophrenia patients face.

In her art therapy work, Turner has found that clay allows for a similar, albeit less formalized experience.

“Because it’s naturally responsive, I think there’s this power in clay that allows us to actually feel an experience and bring up the things that stay with us that are felt in our body, whether it was happy or extremely traumatic,” she says.

To learn more about racial trauma, visit Mental Health America. To learn more about why Black people are diagnosed more frequently than white people, read Psycom’s report, Schizophrenia in Black People: Racial Disparities, Explained.

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Last Updated: Jun 29, 2021