Behavioral Health Innovations during COVID in Black and Hispanic Communities

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSpecial Report: Hispanic Community and COVID-19—Addressing Health Inequalities Can No Longer Be DelayedHector Colon-Rivera, M.D.Hector Colon-Rivera, M.D.Published Online:23 Jun 2020https://doi.org/10.1176/appi.pn.2020.7a28AbstractThe Hispanic community in this country, which has long been underserved with regard to health and mental health care, is experiencing additional barriers to maintaining their health and mental health and getting the care they need during the pandemic.The values of a community are reflected in individuals' willingness to secure well-being and vitality for all. I envision a day when preventable death, disabilities, and health disparities are eliminated. This transformation will occur only by examining the causes of health inequities and social determinants of health and directing more interventions to collaborate in health promotion and disease prevention.The socioeconomic status of Hispanics in the United States is considerably lower than that of non-Hispanic whites due to several specific characteristics of the Hispanic population, including their lower family income, more limited educational attainment, and lower-paying occupations.Hispanics are more likely to work in agriculture, construction, domestic and food services, and other low-wage occupations with inadequate health insurance coverage. Limited formal education may impair people's ability to navigate the complex health care delivery system. Additionally, Hispanics are more likely to live in impoverished communities, in close living conditions, and cities with less-developed trash and sewer infrastructures. Most foreign-born Hispanics and Puerto Ricans primarily speak Spanish, and most of the health-related instructions and materials are in English, so non-English speakers don't have access to them.Despite the disparities in employment, education, and income, Hispanics have lower age-adjusted mortality rates than African Americans and, in many cases, lower rates than non-Hispanic whites. One possible explanation is the social support and traditional values of the families and community as they tend to stay together.This action makes it hard for communities with extended families who highly value family contact to get through difficult situations when asked to stay away from each other because of the pandemic. A loss of cultural values in family members who are U.S. born or assimilated to the culture can lead to intergenerational stress that undermines family relationships and lowers expectations about academic performance, mental health, and well-being.These socioeconomic differences of Hispanic communities continue to be valid during the COVID-19 pandemic. Of course, all human beings have a right to know when and how to seek care. But data continue to show that African Americans and Hispanic people are dying from COVID-19 at higher rates than whites, even though they make up a smaller percentage of the population.iStock/rightdxThis situation is similar to the Spanish flu in 1918, cholera pandemic of 1961 to 1975, and the H1N1 swine flu outbreak in 2009. People with limited ability to communicate because of language differences and limited social and economic options do not receive adequate health information and services, which ultimately exacerbates health disparities. We must learn from our past mistakes.Closing places of trust for our communities like churches, barbershops, and community parks has left a gap in communication channels in minority neighborhoods across the country. Without culturally relevant communication strategies, many cities were lost.The Centers for Medicare and Medicaid Services and other federal and state regulatory bodies waived specific requirements for telecommunications, which has allowed many Americans to continue to get health care services. While based on my colleagues' and my experiences during the pandemic, telehealth is not the optimal solution for every patient, these changes are important to not only ensure but also increase access to care. In addition to physicians and nurses, other health care professionals, including psychologists and social workers, can provide telehealth services. I have been practicing telemedicine for more than four years, and this is the first time I have seen such policy changes. Telehealth has been promoted as an innovative approach to bridging the health care delivery gap by increasing access to services for medically underserved communities for decades.Unfortunately, it was not until the pandemic affected both white and non-white communities that we saw a loosening of the rules. That loosening increased access to resources that could have been the salvation, for so long, of socioeconomic revitalization, connectivity, and technology infrastructure development to address health equity for underserved communities. The same effect was seen when the life expectancy of the U.S. white population declined mainly due to the opioid epidemic. Specific treatment options were marketed primarily to suburban communities, whose residents can pay for treatment.The spread of telehealth services during the pandemic and increased medication access for assisted treatment during the opioid epidemic have a lot in common. They illustrate how racially different health policies and health care practices make those vulnerable even more vulnerable in the face of inadequate attention to public health.Case Examples of Impact of Pandemic on Hispanic CommunityLet's take the experiences of some of my patients. I am using pseudonyms for both of the cases discussed to protect the patients' identities.Gilberto was doing well; his diabetes and opioid use disorder were well controlled. He was working and taking care of his family. After the pandemic hit, the restaurant where he was working was forced to close. He did not have health benefits or accumulated days off, so his boss let him go. He started eating junk food, which affected his sugar control. Poor glycemic control is a risk factor for severe infections, and adverse outcomes of infection with COVID-19 and other diseases, including bacterial pneumonia, are more likely without reasonable glycemic control.Gilberto was admitted to the hospital for glycemic control and discharged home to quarantine after testing positive for COVID-19 because he was asymptomatic. His wife called my office after he relapsed on heroin after three years of sobriety on buprenorphine. Gilberto then told me that he was ashamed of calling me as he had "failed."Stigma and shame associated with mental illness and lack of information reduce the utilization of services. But we know that a fact in recovery culture is that a substance use disorder is a disease of isolation, and, in every possible way, what we are asking people to do during the pandemic is to isolate.For people struggling with a substance use disorder and chronic illness, virtually all of the services and treatments available to them have been disrupted by the COVID-19 epidemic. People are told to stay home, which directly contradicts the need to go to clinics to obtain services. Without in-person meetings, remaining sober is difficult for some individuals, and it is difficult for our communities to call for help.Unfortunately, there are countless stories of patients struggling with similar situations. Having clinics provide their services over the phone presupposes that there are physicians who are healthy and certified to prescribe every medication and that the pharmacies and doctors' offices are functioning. Additionally, rehabilitation facilities have limited new admissions, canceled programs, or even shuttered their doors for fear of spreading the virus.Another patient was Marla, an undocumented Guatemalan woman who worked in a pizzeria "under the table." She never stopped reporting to her job, even after she began coughing and feeling ill. Her condition quickly deteriorated. She was admitted for treatment and discharged two weeks later. However, her mother became sick while Marla was in the hospital. After her mother began gasping for air, Marla's husband rushed her to the hospital. Marla and her mother could not see each other due to COVID restrictions, and her mother died from COVID-19. Marla feels guilty about what happened, saying that finding support and accepting loss of her mother have been hard without seeing her psychotherapist and me, her psychiatrist, in person.We need to make extra efforts to maintain social bonds during this time of enormous stress and social isolation. Healthy social conditions can ensure that the most vulnerable members of society benefit from the same fundamental rights and opportunities as more affluent citizens. We need to ensure that all residents have equal access to quality health care and essential community services that preserve and protect health.How to Strive to Understand the Social Determinants of HealthFor providers, the complexity of social health determinants paired with the medical field's challenges and organizational priorities make it hard to know where to start focusing, but determining the "who," how," "where," and "what" of the underlying factors impacting minority communities is critical. Food security, jobs, education, and quality of housing are four determinants of a secure link to health and are common areas of focus for health care organizations.Understanding market-specific population issues should lead our health systems and private practices to focus on increased access to behavioral health services and virtual telehealth offerings as part of overall growth strategies. Shifting individuals' and organizations' mindset around can better inform the way we create services aligned to health equity and the communities' preferences and needs.Social Determinants of Health Go Beyond Racism and ColorismThe coronavirus is not a racist disease. It has no eyes, and its only goal in life is to replicate inside the living cells of an organism. There are no biological reasons why Black and Hispanic people should be getting sick with and dying of coronavirus more than white people. Skin color continues to serve as the most apparent criterion in determining how a person will be assessed and treated in our country. The racial categories in the United States for our phenotypically ambiguous population are limited. According to the U.S. Census, you are white, Black, American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific islander, or multiracial. The privileging of light skin over dark affects where you live, what you eat, where you work, and other environmental factors.What Can We Do?Improve education and leadership programs in the workforce: Without a doubt, the future workforce will have an increasingly Hispanic identity. We need to improve the access of Hispanics to education and eradicate the root causes for the shortage of Hispanics' advancement into leadership. Less than 5% of corporate leaders and physicians are Hispanics. For one, there is still outright prejudice and bias in the workplace. A fair and equitable work environment creates a competitive system. Those who do well get promoted, and issues of race, ethnicity, and gender do not matter because merit is all about performance. For the most part, Hispanic individuals have been closed out of the health professions, and supporting them would create a pool of potential health care workers in the United States.Create flexible and culturally competent policies and payments: Culturally specific guidelines for mental and substance use disorder treatment programs must be created so that Black and Hispanic people can access treatment and get high-quality care.Tailor communication channels: Public health information changes rapidly, and timely guidance to minority communities is critical. Public health concepts are not readily understandable across cultures. Concepts such as social distancing, flattening the curve, self-quarantining, wearing face masks, and washing hands should be explained in a culturally appropriate manner. The dissemination of news and information through mainstream and social media should also be done in a culturally appropriate manner.Partner with communities, nonprofits, and community leaders: Community leaders are trusted messengers and influencers to their communities. They know their community's needs. They often have diverse partnerships and collaborations with schools, local businesses, law enforcement, and medical personnel. Mental health professionals are critical for outreach, engagement, and linking Blacks and Latinos with mental and substance use disorders to treatment. As medical professionals, we should promote and educate patients about lifestyle factors associated with disparities, including preventive care; dietary behavior; physical activity; use of tobacco, alcohol, and other substances; and sexual practices. Screening and treatment are particularly crucial for the control and prevention of many conditions. Knowing where to find treatment facilities with cultural competence and resources for Hispanics is essential to obtain preventive care and treatment and avoid the progression of disease and worse outcomes, including death.Collect and release data to improve resources to improve health disparities: All states and municipalities need to collect and release the demographic data on who is being affected with coronavirus in both the Hispanic and Black communities. The more we understand about the virus, the better equipped we will be to determine the resources and funding needed in these communities. The COVID-19 pandemic has common ground with the Black Lives Matter movement. These bring opportunities for our country to make investments that will help revive our national potential for productivity by promoting the health of minority communities and targeting disparities in population health. An increased focus on chronic disease prevention and control programs that engage Latino communities in addressing environmental, policy, and behavioral changes is needed.Supporting our international medical graduates (IMGs) colleagues: Join advocacy efforts and groups supporting non-U.S. citizen international medical graduates (IMGs) who are practicing or otherwise lawfully present in the country. Given workforce demands during and probably after the pandemic, there is an urgent need to take these opportunities for fast-tracking immigrant and bilingual people into the health care force, especially in areas of the country with higher rates of poverty and chronic disease such as minority communities.The trends in health disparities are demographic and based on socioeconomic inequalities that create high-risk conditions for Hispanic communities. We can reduce health disparities by addressing inequalities, but we need to deliberately change our focus from thinking only of white-type patterns of health care needs and use. Such thinking ignores other groups who may have different needs. The change is possible only if the efforts of federal, private, and state health agencies are coordinated and include benchmarks to hold them accountable and ensure that Hispanic individuals are getting the care they need. If we do fail to achieve equality in the health care system and law enforcement, we will continue to leave Hispanic communities and others vulnerable in the face of harmful social determinants of health. ■ResourcesAPA offers a number of resources on working with Latino/a and Hispanic patients on its website:"Guide on Best Practice Highlights Latino/as and Hispanics.""Working with Latino/a and Hispanic Patients" with Lisa Fortuna, M.D."Mental Health Facts for Hispanics and Latinos/as"."Stress & Trauma Toolkit for Treating Hispanics in a Changing Political and Social Environment"."Engagement Interview Protocol" that helps psychiatrists work with patients from different cultural backgrounds and understand the meaning of symptoms based on patients' cultures and traditions."Psychosis Literacy Among Latinos With First-Episode Psychosis and Their Caregivers".APA members interested in joining the Caucus of Hispanic Psychiatrists should go here and click on "Join" on the right side of the webpage.Hector Colon-Rivera, M.D., is medical director for APM Inc., a nonprofit that serves the communities of North Philadelphia with behavioral health, housing, foster home, and education services. He is also a faculty member at the University of Pittsburgh Medical Center and the Einstein Medical Center, the president of APA's Caucus of Hispanic Psychiatrists, and the Area 3 representative to the APA Assembly. ISSUES NewArchived

Women with severe mental illnesses face high rates of violence victimization, yet little is understood about the unique needs and challenges these women present to the domestic violence and behavioral health agencies that serve them. To help address this knowledge gap, focus groups were conducted with 28 staff members from local behavioral health and domestic violence service agencies. Results from this exploratory study suggest that women with severe mental illnesses who experience intimate partner violence face additional challenges that exacerbate behavioral health and domestic violence issues and put these women at greater risk for continued victimization. DV and behavioral health agency staff experience individual-, provider-, and system-level barriers to serving this high-risk, high-need population. Recommendations and implications for domestic violence and behavioral health providers are discussed.

The frequent police killings during the COVID-19 pandemic forced a reckoning among Americans from all backgrounds and propelled the Black Lives Matter movement into a global force. This manuscript addresses major issues to aid practitioners in the effective treatment of African Americans via the lens of Critical Race Theory and the Bioecological Model. We place the impacts of racism on Black families in historical context and outline the sources of Black family resilience. We critique structural racism embedded in all aspects of psychology and allied fields. We provide an overview of racial socialization and related issues affecting the parenting decisions in Black families, as well as a detailed overview of impacts of structural racism on couple dynamics. Recommendations are made for engaging racial issues in therapy, providing emotional support and validation to couples and families experiencing discrimination and racial trauma, and using Black cultural strengths as therapeutic resources.

Context: In recent years, due to an alarming increase in the number of opioid-related overdose fatalities for White, Non-Hispanics in rural and suburban communities across the United States, they have been considered as the face of this epidemic. However, there has also been a staggering rise in the number of opioid overdoses in urban, minority communities, which have not been thoroughly addressed by the literature. Methods We reviewed deaths where opioid-related substances were reported as the leading cause of death to the Centers of Disease Control Multiple Cause of Death database from 1999 to 2017. Deaths were analyzed by year, State, drug type, and race and ethnicity. Results There were 399,230 total opioid-related deaths from 1999 to 2017 amongst all ethnic groups in the U.S. During this timeframe, approximately 323,939 total deaths were attributed to White, Non-Hispanics, while 75,291 were attributed to all other ethnicities. Examination of opioid-related overdose death data by ethnicity reveals that while White, Non-Hispanics have experienced the largest numbers of opioid-related overdose deaths in the U.S with up to 37,113 deaths occurring during 2017, there has also been a sharp rise in the number of opioid-related overdose deaths for minorities. opioid-related overdose deaths for Black, Non-Hispanics climbed from 1130 deaths in 1999 to 5513 deaths in 2017, while opioid-related overdose deaths for Hispanics climbed from 1058 in 1999 to 3932 in 2017. According to the Centers for Disease Control and Prevention, over the past 19 years, age-adjusted opioid-related deaths for Hispanics have climbed from 3.5 overdoses per 100,000 in 1999 to 6.8 overdoses per 100,000 in 2017. However, greater increases have been reported for Blacks during the same 19-year timeframe with age-adjusted rates of 3.5 overdoses per population of 100,000 in 1999 to 12.9 overdoses per population of 100,000 in 2017. Conclusion While Opioid-related overdoses have overwhelmingly plagued rural and suburban White, Non-Hispanic communities, there has been a surge in the number of deaths in Black and Hispanic Minority communities in recent years. Although there have been significant increases in the number of opioid-related overdose deaths in Black and Hispanic communities, the media narrative for this epidemic is often portrayed as a White, Non-Hispanic rural and suburban crisis. As a result, intervention strategies and policies have failed, both, to assess the severity of the problem in minority communities and to offer culturally sensitive preventative and treatment solutions. In this paper, the impact of the opioid epidemic on Black and Hispanic minority communities will be presented. Racial disparities in the U.S. Government’s current approach to an epidemic, which plagues rural and suburban White America, will be compared to its past criminal justice response to drug pandemics in urban minority communities. Culturally sensitive policy considerations and recommendations that can be used to, both, mitigate and offer treatment options for the opioid epidemic in these minority communities will also be addressed.

Transgender and gender-diverse (TGD) individuals are at a greater risk for various poor mental and behavioral health outcomes than cisgender individuals, including higher rates of suicide, psychiatric diagnoses, and behavioral health problems. For example, research has documented a seven-fold increased risk for lifetime suicide attempts among young TGD people, compared with the general population. Less is known about the age of onset of such mental and behavioral health disparities and how these disparities may vary across other intersectional socio-demographic variables. It has been well-documented that trans and gender-diverse individuals often encounter discrimination and transphobia across various social, educational, professional, administrative, and healthcare settings. This discrimination, as highlighted in the literature, frequently poses obstacles to accessing both general and trans-specific healthcare services due to experiences of discrimination (e.g., misgendering, refusal of care, lack of adequate services). The right and ability to self-determine and the accessibility to gender-affirming care without discrimination are key to closing the gap in TGD individuals’ mental and behavioral health outcomes, and for them to live authentically and thrive. Tailored and affirming mental and behavioral health interventions to reduce these health inequities are pivotal for TGD individuals to achieve the highest attainable standard of physical and mental health: a key fundamental human right. Considerable gaps in the literature remain concerning the onset and determinants of gender identity-based health disparities and healthcare approaches that are respectful, inclusive, non-pathologizing, and grounded in human rights principles for TGD individuals. This workshop intends to address these knowledge gaps by delving into the mental and behavioral health needs of TGD individuals. The workshop seeks to further foster dialogue on strategies to overcome resistance to implementing approaches that uphold the human rights and well-being of these communities. Dr. Richard Bränström (Karolinska Institutet) will present a study that explores the age at which gender identity-based disparities in psychiatric diagnoses and treatment can be first identified. Dr. Gonzales (Vanderbilt University) will examine disparities in mental health and social determinants of health among TGD individuals with private insurance. Dr. Moleiro (Lisbon University Institute) will review TGD persons’ ways of identifying with the choices and trajectories in social, legal, and affirmative healthcare processes in Portugal. Dr. Lelutiu-Weinberger (Columbia University School of Nursing) will present findings from a study that assessed tobacco use and cessation attitudes, facilitators, and barriers to quitting, and intervention components and delivery modality acceptability among TGD individuals, as well as sexual minority individuals, in Romania to inform a tailored and affirming smoking cessation intervention. Key messages • Transgender and gender-diverse are at increased risk for a variety of poor mental and behavioral health compared with the general public. • There is a critical need to foster healthcare services for transgender and gender-diverse individuals that are tailored and affirming.

“The Great Resignation” refers to the large numbers of people who were quitting or changing jobs in the aftermath of COVID-19. This qualitative study was conducted with twenty-seven social service and behavioral health agencies in early 2022. The study sought to understand how behavioral health and social service agencies fared during the Great Resignation. Agency managers interviewed in this study discussed six themes including: 1) Loss of Staff & Burnout; 2) Pressure & Increasing Need; 3) Retention & Workplace Culture; 4) Salary; 5) Benefits; and 6) Recruitment Challenges. Practice and policy implications include the need for higher reimbursement rates and the importance of employee benefits and workplace culture to retention.

This study investigates the perceptions of safety among entry-level doctoral occupational therapy (OT) students during their Level II fieldwork and capstone experiences. The significance of safety, defined as emotional comfort and the ability to express oneself authentically, is emphasized in fostering learning outcomes and mental health. The paper highlights that institutions providing safe spaces enhance acceptance and conversely, a lack of emotional safety, often due to microaggressions, adversely affects student retention and mental health. An author-created survey was utilized at the conclusion of the program to 45 third-year OT students. The 10-item survey assessed perceived physical and emotional safety during fieldwork/clinical rotations and capstone, occurrences of microaggressions, and possible solutions to improve student's sense of safety. The majority of respondents reported feeling physically (95%) and emotionally (72%) safe overall. However, Level II fieldwork/clinicals was identified as the setting where students reported the most frequent lack of safety. Six main themes impacting safety perceptions were identified: expectations, reflection/advocacy, education/preparation, communication, coping strategy, and the acknowledgment that some students may not require interventions. Findings suggest that allied health academic programs should take steps to ensure that the safe spaces created during didactic portions of the curriculum extend into clinical and experiential settings. This approach will not only improve learning outcomes but also support students' mental health and their ability to provide quality healthcare. Future research should focus on evidence-based practices to support student safety in clinical education.

Perceptions of a safe and supportive school environment are imperative to the well-being of all students. Positive perceptions of school safety and supports may be especially important for students attending boarding schools, given that many of these students live on school grounds. However, these experiences have rarely been studied for boarding school students. The current study aimed to address this gap in the literature by investigating relations among perceptions of school-wide bullying and physical and emotional safety among a sample of students from one boarding school (N = 358). School mental health supports were also examined as a moderator in the relation between school-wide bullying and school safety. Results indicated that school-wide bullying was significantly related to both emotional and physical safety—although more strongly related to physical bullying—for both male and female students. School mental health supports were a significant moderator, or buffer, in the relation between school-wide bullying and emotional safety for males. Further research is needed with larger and more diverse samples of boarding students to increase generalizability of these findings. Impact Statement A positive school climate is essential for the well-being of students attending boarding schools, yet this has rarely been studied among boarding students. The findings of this study contribute to this important gap in the literature and suggest that boarding students’ perceptions of school-wide bullying are related to feeling both physically and emotionally unsafe. Male, but not female, students who perceive the school supports students’ mental health reported feeling emotionally safe at school regardless of prevalence of bullying.

BackgroundRacism and discrimination are among the factors perpetuating the persistent disparities within the Canadian health sector and related social and community services. Addressing issues of racism in Canada is crucial to reducing the mounting mental health disparities that subsequently impact the psychological well-being of diverse groups of people, particularly racialized and Black individuals. While some research has been conducted on mental illness–related stigma, very few peer-reviewed studies have attempted antistigma interventions to address mental health disparities in Black families and communities in Canada.ObjectiveThis study aims to generate critical knowledge to reduce mental health disparities and mental illness stigma experienced by Black families and communities and engage them in cocreating a best-practice model to guide policy and programming. Our study intends to engage individuals living with or affected by mental illness, service providers, and community leaders in Black communities who are interested in stigma reduction activities and advocacy in Ontario, particularly in the Greater Toronto Area (GTA), including Durham and York Regions, London, Ontario, Brampton, and Ottawa.MethodsInformed by population health promotion approaches, critical race theory, and an intersectionality framework underpinned by social justice principles, this mixed methods study will engage individuals of Caribbean and African descent in 5 cities in Ontario. We will use online self-reported surveys with Black individuals (335/431) to assess depression, anxiety, stress, mental health knowledge, racial discrimination, and mental health stigma. We will also engage Black individuals (40/431) and service providers and community leaders (16/431) in focus groups and individual interviews (10/431). Results from the survey and focus groups will inform concept mapping activities with cross-sector leaders, decision makers, and community advocates (30/431) to cocreate a best-practice model to improve mental health outcomes in Black families and communities. Quantitative data will be analyzed using descriptive and inferential analyses through SPSS (IBM Corp). Qualitative data will be transcribed verbatim, and NVivo software (Lumivero) will be used for data management. We will apply Braun and Clarke’s framework of 6 phases in thematic analysis.ResultsAs of September 2024, the study has received ethical approval in Canada. We have completed data collection for phase one of the study and plans are far advanced to start recruitment for phases 2 and 3. Results from the study are expected in the last quarter of 2025 and the first quarter of 2026.ConclusionsThis project will generate a novelty of knowledge to contribute to effective ways of addressing mental illness stigma and promoting mental health literacy in Black families and communities and other vulnerable populations. In addition, the knowledge gained from this study will be taken back to Black communities to empower affected individuals and their families.International Registered Report Identifier (IRRID)DERR1-10.2196/66851

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Reduction and elimination of African American health disparities, a major challenge of our society for the past 20 years, has not been realized, although empirical studies, clinical practice and policy initiatives have made progress in their attempt to achieve this goal. Behavioral health risks are a significant component of such disparities. In this paper the authors maintain that the precise lack of understanding of how much behavioral health is influenced by worldview, and the importance of historical roots of African American people, and the challenges they face in the 21st century need to be explored and understood within the context of worldview. Specifically, the allocentric worldview should be considered an essential component in discussions surrounding behavioral health disparities. This paper argues that anything less than an historical assessment of the conditions leading up to behavioral health ills in African American urban and rural communities today will be incomplete, inaccurate and fall short of achieving the goals of reducing behavioral health disparities in this population. The purpose of this manuscript is to present the allocentric worldview and explore how its adoption is critical to behavioral health recovery among African Americans today. It is proposed that knowing and adopting a cultural and historical worldview that is indigenous to African descended peoples may significantly improve motivation and action among African Americans to adopt healthier behavioral health life styles.