Victor Ekuta

Harnessing Cultural Competency in Schizophrenia to Address Anti-Black Racism in Mental Health

“The function, the very serious function of racism is distraction. It keeps you from doing your work. It keeps you explaining, over and over again, your reason for being. Somebody says you have no language and you spend twenty years proving that you do. Somebody says your head isn’t shaped properly so you have scientists working on the fact that it is. Somebody says you have no art, so you dredge that up. Somebody says you have no kingdoms, so you dredge that up. None of this is necessary. There will always be one more thing”.-Toni Morrison


On May 1, 2023, a grisly murder unfolded within the confines of a New York Subway train, shattering the lives of those involved. Witnesses and video testimony recount the chilling moment when Jordan Neely, a 30-year-old homeless Black man battling mental illness, boarded the F train and unleashed his anguish: “I don’t have food, I don’t have a drink, I’m fed up.” Neely then went on to exclaim “I don’t mind going to jail and getting life in prison. I’m ready to die.” What followed was a disturbing display of violence as Daniel Penny, a white 24-year-old Marine veteran, and others restrained Neely in a chokehold for a reported 15 minutes until he succumbed to unconsciousness and death.

In the aftermath of this harrowing incident, countless questions have arisen, demanding answers. Was Daniel Penny’s response truly appropriate, and to what extent should Jordan Neely bear responsibility for his tragic demise? However, embedded within these discussions lies a profound and unsettling truth—the ultimate perpetrator accountable for Jordan Neely’s untimely death is none other than systemic racism itself.

Amidst the sorrow and despair, we must confront the stark reality of how anti-Black racism in mental health intertwines with catastrophic consequences, not only in isolated incidents but throughout our society. Mental illness, homelessness, racism, and poverty should never have conspired to bring about Jordan Neely’s demise. Yet, our collective failure to address these intersecting oppressions continues to perpetuate preventable tragedies for those who bear their weight.  Jordan Neely’s death serves as a visceral reminder of the manifold ways in which the mental health system has failed Black individuals, revealing an urgent need to rectify the pervasive grip of anti-Black racism in mental health.

Understanding Racism in Mental Health

Sadly, the death of Jordan Neely represents merely one ghastly symptom of an insidious malady—systemic racism—that plagues the very heart of mental health care. Today, an overwhelming abundance of data illuminates the myriad ways in which anti-Black racism permeates the field of mental health, contributing to biased diagnoses, woefully inadequate treatment, and the cruel denial of access to essential mental health services.

Anti-Black racism in mental health manifests in various ways.


Moreover, any discussion of anti-Black racism’s manifestations in mental health would be incomplete without addressing how it impacts the brain, giving rise to troubling mental afflictions. As we have discussed previously, racial stressors contribute to increased allostatic load and weathering, impacting the brain and worsening health outcomes . Similarly, Psychiatric sciences have long acknowledged the fact that stress is causally implicated in an enormous range of mental disorders, referring to the “stress-diathesis model” of mental illness. This model incorporates the well-documented fact that chronic stressors, including poverty, political violence, and discrimination, intensify the likelihood of developing mental disorders ranging from depression to schizophrenia. Moreover, this chronic elevation of stress hormones has downstream effects on the neural architecture of the brain’s cognitive and emotional circuits.

Together, all of this evidence points to the urgent need of a solution to rectify these disparities.

Cultural Competency as a Tool for Combating Racism in Schizophrenia

Cultural competency stands out as a powerful tool for combating systemic racism, but understanding its true potential requires delving deeper into the construct of mental disorder diagnoses. Take for instance, the disease of schizophrenia. According to the Diagnostic and Statistical Manual, considered by many to be the bible of psychiatric diagnosis, the following criterion are needed to make a diagnosis of schizophrenia:

  1. Two or more of the following for at least 1 month (or longer period of time), and at least one of them must be a 1, 2, or 3:


  • delusions
  • hallucinations
  • disorganized speech
  • grossly disorganized or catatonic behavior
  • negative symptoms, such as diminished emotional expression


  1. Impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance: Work, interpersonal relations, or self-care.


  1. Some signs of the disorder must last for a continuous period of at least 6 months. This six-month period must include at least one month of symptoms (or less if treated) that meet criterion A (active phase symptoms) and may include periods of residual symptoms. During residual periods, only negative symptoms may be present.


Notably absent from this definition is any mention of the culture and the context, a misstep with deadly consequences. A culturally competent approach recognizes the influence of culture and politics in defining what is considered pathology. As Alvin Pouissant, a clinical professor of psychiatry at Harvard Medical School, astutely notes,

Victor Ekuta - Harnessing Cultural Competency in Schizophrenia to Address Anti-Black Racism in Mental Health

This very issue unfolds within the definition of schizophrenia. Consider the case of a delusion, defined by the DSM-5 as “fixed beliefs that are not amenable to change in light of conflicting evidence.” Let’s imagine a patient expressing the belief ‘I don’t want to die like Trayvon Martin.’, I encountered such a scenario during my own psychiatry training. Would this qualify as a delusion? Here, a clinician must make a judgment call.

Perhaps a clinician deems it a delusion because no amount of reassurance can convince the patient that this outcome won’t occur. But what if the patient is Black, residing in a neighborhood where death by police is tragically not an uncommon occurrence? Does this perspective still qualify as a delusion? The answer to whether this belief constitutes a delusion begins to shift dramatically.


Thus, there is no denying that cultural context and cultural competence play a pivotal role in distinguishing a delusion from a patient’s lived experience and making an appropriate diagnosis. The very fabric of our diagnostic framework must recognize and account for the influence of culture to ensure that we don’t pathologize genuine reflections of an individual’s reality. By embracing cultural competency, we can dismantle the barriers that hinder accurate diagnoses and ensure that mental health care truly acknowledges and respects the diverse experiences of those we aim to support.


How then can we adequately incorporate culture into our diagnostic framework?


  1. Revising diagnostic criteria: We need to critically examine existing diagnostic criteria and make necessary revisions to ensure they account for cultural influences. This entails engaging with diverse communities, cultural experts, and mental health professionals to gather insights and perspectives that inform more comprehensive and culturally sensitive criteria.
  2. Collaboration with diverse communities: Engaging with diverse communities is vital in shaping a culturally inclusive diagnostic framework. Collaborative efforts involving community leaders, advocacy groups, and individuals with lived experiences can provide invaluable insights and ensure that cultural perspectives are adequately represented. Community partnerships can facilitate ongoing dialogue, feedback, and mutual learning to inform diagnostic practices.
  3. Culturally sensitive assessment tools: Developing culturally sensitive assessment tools and measures can help capture the nuances of mental health experiences across diverse cultures. These tools should consider language, cultural symbolism, and relevant life experiences to ensure accurate assessments. Culturally adapted screening tools and questionnaires can also facilitate better communication and rapport between clinicians and patients.
  4. Multidisciplinary and diverse research teams: Encouraging multidisciplinary research teams that include diverse perspectives is essential for advancing culturally competent diagnostics. Collaboration between psychologists, psychiatrists, anthropologists, sociologists, and other experts can provide a comprehensive understanding of the complex interplay between culture and mental health. It is through diverse research approaches that we can challenge biases, uncover new insights, and develop culturally appropriate diagnostic guidelines.
  5. Diversifying providers: When merely 2 percent of the estimated 41,000 psychiatrists in the U.S. are Black, and just 4 percent of psychologists are Black, the Supreme court’s recent decision to end affirmative action in medical school puts lives at risk. Thus, there is a need for new and innovative approaches to increase the number of mental healthcare providers from diverse communities. This could include specially tailored mental health pipeline and mentorship programs designed to attract early education students to the field of mental health (K-12). Such programs could also provide students with scholarship support, simultaneously reducing the financial burden that can often serve as a deterrent to members of these communities.

By implementing these strategies, we can foster a diagnostic framework that respects and incorporates culture as a vital aspect of mental health assessment. Ultimately, our goal should be to move away from a one-size-fits-all approach and embrace a culturally nuanced understanding of mental health, ensuring that diagnoses reflect the true experiences of individuals from diverse backgrounds. Through this transformation, we can establish a mental health care system that is equitable, inclusive, and responsive to the needs of all.


On May 1, 2023, Jordan Neely, a poor Black man, tragically lost his life on a New York subway train. A court of law will determine whether Daniel Penny should be held legally responsible for his death. Yet, beyond the trial, a haunting truth persists—Jordan Neely was already dead long before he stepped onto that train. Navigating the trauma of repeated encounters with the criminal justice system, mourning the loss of his mother who tragically and eerily died from strangulation, and disregarded by numerous bystanders, Neely’s death was the culmination of societal neglect and the absence of cultural understanding.


We all face a choice—actively prevent the mental decline of individuals like Jordan Neely or passively contribute to their suffering. Jordan Neely should still be alive today, reminding us of the imperative to address anti-Black racism in mental health care. We must take a stand against the pervasive biases and injustices that perpetuate these tragedies. In doing so, we can forge a path towards healing and a mental health care system that upholds the dignity, equality, and well-being of all individuals, regardless of their race or background. The choice is ours, and the time for change is now.




  1. Cramer M, Marcius CR. Man Dies on Subway After Another Rider Places Him in Chokehold. The New York Times. Published May 2, 2023. Accessed July 13, 2023.
  2. What we know about the chokehold death of Jordan Neely on a NYC subway. NBC News.
  3. Williams DR. Stress and the Mental Health of Populations of Color: Advancing Our Understanding of Race-related Stressors. Journal of Health and Social Behavior. 2018;59(4):466-485. doi:
  4. Barnes A. Race, Schizophrenia, and Admission to State Psychiatric Hospitals. Administration and Policy in Mental Health. 2003;31(3):241-252. doi:
  5. Verbanas P. African-Americans more likely to be misdiagnosed with schizophrenia, study finds: The study suggests a bias in misdiagnosing blacks with major depression and schizophrenia. ScienceDaily. Published 2019.
  6. Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services. Psychiatric Services. 1996;47(3):282-286. doi:
  7. Panchal N, Saunders H, 2022. How Does Use of Mental Health Care Vary by Demographics and Health Insurance Coverage? KFF. Published March 24, 2022.
  8. Dalencour M, et al. “The Role of Faith-Based Organizations in the Depression Care of African Americans and Hispanics in Los Angeles.” Psychiatric Services. 2017. 68(4):368-374.
  9. Wang PS, Berglund P, Kessler RC. “Recent care of common mental disorders in the Unites States: Prevalence and conformance with evidence- based recommendations.” J Gen Intern Med. 2000. 15(5), 284-292.
  10. – Mental Health Disparities: Diverse Populations.
  11. Hawthorne WB, Folsom DP, Sommerfeld DH, et al. Incarceration Among Adults Who Are in the Public Mental Health System: Rates, Risk Factors, and Short-Term Outcomes. Psychiatric Services. 2012;63(1):26-32. doi:
  12. Victor Ekuta – Tackling Racism in Alzheimer’s Disease Research: A Model for Advancing Equity in Neurology Part 2. Published May 11, 2023. Accessed July 14, 2023.
  13. Monroe SM, Simons AD. Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders. Psychological Bulletin. 1991;110(3):406-425. doi:
  14. Substance Abuse and Mental Health Services Administration. Table 3.20, DSM-IV to DSM-5 Psychotic Disorders. Published June 2016.
  15. Who Was Trayvon Martin?! CLOSLER. Published May 26, 2022. Accessed July 14, 2023.
  16. Eakin E. Bigotry as Mental Illness Or Just Another Norm. The New York Times. Published January 15, 2000.
  17. O’Malley L. Addressing the Lack of Black Mental Health Professionals. INSIGHT Into Diversity. Published November 17, 2021.
  18. Washington JF Utibe R. Essien, Donna L. The Supreme Court’s affirmative action decision puts lives at risk. STAT. Published June 30, 2023. Accessed July 14, 2023.
  19. Louis E. Jordan Neely Was Already Dead. Intelligencer. Published May 6, 2023.
  20. 20. Jordan Neely: Homeless man killed in chokehold on NYC subway was “shattered” after mom’s brutal murder. MEAWW. Accessed July 14, 2023.
  21. Mote J, Fulford D. Now Is the Time to Support Black Individuals in the US Living With Serious Mental Illness—A Call to Action. JAMA Psychiatry. Published online July 17, 2020. doi:
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The mission of the Boston Congress of Public Health Thought Leadership for Public Health Fellowship (BCPH Fellowship) seeks to: 

  • Incubate the next generation of thought leaders in public health;
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It is guided by an overall vision to provide a platform, training, and support network for the next generation of public health thought leaders and public scholars to explore and grow their voice.