When Jinneh Dyson was 17 and a doctor prescribed medication to treat depression that had plagued her since the death of her mother three years earlier, her friends and family persuaded her not to take it.
"They said: 'That's going to make you crazy. You've just got to pray and have faith,'" recalled Dyson, who is black and the daughter of a Baptist minister. "They said, 'That's the way of the white man, poisoning you.'"
Four years later, Dyson was a student at the University of Texas at Austin and still battling debilitating depression. A friend, who was biracial, urged her to seek counseling.
"I said, 'Girl, we don't do that ... that's your white side,'" said Dyson, now 31. But she eventually agreed to meet with the university's only black counselor. Her treatment was so transformative that she now splits her time working as a senior manager at the National Alliance on Mental Illness in Arlington, Va. and as a life coach and motivational speaker on mental health and other issues in Houston.
Many people, regardless of race, have a hard time talking about mental illness. But for many blacks, the topic has carried particularly negative connotations -- to the point where it's easier to talk about drug or alcohol addiction than depression or anxiety. In 2008, whites received mental health treatment or counseling at nearly twice the rate of blacks, and whites received prescription medication for mental health-related issues at more than twice the rate of blacks, according to the 2010 National Healthcare Disparities Report.
However, blacks' acceptance of therapy has been rising over the past decade, providers say, particularly among the young and those with more education and in those urban areas with large black populations.
There have been no large-scale studies about the recent shift, but providers interviewed said they have seen it in their work and in their communities.
"I've seen an increasing number of African Americans who feel increasingly less stigmatized about coming in and seeking therapy and who also recognize the healing power of therapy," said Jeffrey Gardere, a psychologist in private practice and assistant professor of behavioral medicine at Touro College of Osteopathic Medicine in New York City, adding that in the past 10 years he has seen a 20 percent to 25 percent rise in blacks seeking therapy.
"The attitudes have changed," said Lisa Whitten, an associate professor of psychology at the State College of New York at Old Westbury, noting that more black students are studying psychology and "taking that message home ... that this is something a broad range of people do and it doesn't mean you're disintegrating."
But change comes slowly.
"There's some shame and embarrassment," said Damian Waters, a marriage and family therapist whose clients at his practice in Upper Marlboro, Md. are predominantly blacks. "You'll tell someone that you went to the doctor, but you won't tell that you went to the counselor or psychiatrist. Also, there is the idea that their faith should carry them through, though often their problems are larger than that."
The notion, dating back to slavery, that one should endure life's difficulties without complaint or appearing weak runs deep in African American culture.
"People kind of expect, 'Gee, you should pull yourself up by your bootstraps, get yourself together, there's nothing wrong with you,'" said Annelle Primm, deputy medical director of the American Psychiatric Association and director of its office of minority and national affairs. "We were always taught: 'Don't put your business in the street. Don't put your family's issues out in front of strangers.'"
As a result, "many African Americans have gone without needed care, and when they have sought care it has been at the crisis stage, which is not optimal."
Blacks have also tended to distrust the medical professions, Waters said, especially after the Tuskegee experiment in which the U.S. Public Health Service knowingly withheld syphilis treatment from black men to watch the disease run its course.
The dismal state of black hospitals during segregation fueled their suspicion, as did blacks' high rate of involuntary commitment into institutions. While they are underrepresented in outpatient therapy, they are committed to inpatient care at twice the rate of whites, sometimes against their will, Waters said.
"It's been documented, the amount of distrust many blacks have toward the health professions," Primm said. Especially if the provider is of a different racial and cultural background, "they may have expectations that they're not going to be treated well."
Part of this has to do with communication styles, she said, adding that standard approaches to therapy, in which the provider stays quiet and listens, can be off-putting to blacks.
"In the African-American community there's more of an expectation of give and take, maybe in the pattern of call and response," she said. "Culturally competent care does require some flexibility on the part of the provider, to understanding where people are coming from, what their needs are."
The cultural dissonance has abated somewhat as more African Americans go into the field as providers. The 2007 American Psychological Association's Doctorate Employment Survey found that 22 percent of new doctorates in psychology were members of a minority group, up from 15 percent in 2000.
"The door was virtually slammed shut through the 1960s," said Halford Fairchild, professor of psychology at Pitzer College in Claremont, Calif., adding that blacks began entering the field in larger numbers starting in the 1970s.
As more blacks pursue higher education, the stigma lessens.
"The more educated you are and the more you understand your disorder, the more you're likely to get it treated," said Donna Holland Barnes, director of the Suicide Prevention Action Group at Howard University. "The more educated you are, the more you understand this is a normal part of life."
Other factors include gender -- women are more likely than men to seek help -- and money. Many psychologists and psychiatrists do not accept insurance, and the cost can be prohibitive for those with lower incomes.
Age also plays a role -- younger people tend to be more open to therapy, said Sonja Williams, a marriage and family counselor who shares a practice with Waters in Upper Marlboro.
"In the last 20 years there's a lot more television programming that is much more accepting of seeking mental health services, so it's made it, in some populations, more trendy," she said, adding that celebrities such as Oprah Winfrey talk openly about it. "Probably amongst the younger crowd it can be a little trendy to say, 'Oh, I'm seeing a therapist.'"
Not all young people feel comfortable opening up.
"We as a culture have not overcome post-slavery," said a 28-year-old black woman in the District of Columbia who sees a therapist but did not want her name used. "I think that in the black community we have to be strong and we cannot be perceived as weak."
The woman said she has told close friends, but not family members, about her therapy. "I'm at a place where my peers are like-minded, but I think the older generation tends to think that it's not needed."
For many older people, a church, rather than a counselor or psychiatrist, is the natural place to turn for psychological healing.
"There's no stigma going to a pastor, it doesn't cost any money, and they know you because they see you every Sunday," Barnes said.
Some churches have perpetuated people's distrust in mental health services. "Many churches see therapy as antagonistic to some sort of spiritual calling," said William Lawson, professor and chair of psychiatry and behavioral sciences at Howard University.
But increasingly, black churches are forming partnerships with mental health providers and requiring their own ministers to get some training in counseling. At Zion Baptist Church in the District of Columbia, Lawson and other mental health care providers give regular talks on topics such as depression and anxiety disorders.
"The black church can no longer be used for so-called one-stop shopping," said Sherry Molock, an associate professor of psychology at George Washington University and co-pastor of the Beloved Community Church in Accokeek, Md., where she offers therapy to parishioners.
"Prayer and connection to the church are all very beneficial, but it's going to take more than that for someone who's suffering from depression," she said. "You do a disservice to your congregation to believe that you can treat people with serious mental illness" without professional help.
More churches in the Washington area are requiring their clergy to be trained in mental health counseling and referring parishioners to mental health professionals, she said. "In reality, we're a team, and everyone has a role to play."
Since her first visit to her university counselor, Dyson has gone from someone who used to hide the fact that she was in therapy to someone who makes a living talking about it.
Her family didn't really understand until this year. "They came and heard me speak, and it clicked," she said. "They said, 'We didn't know how much pain you were in.'"
Her father, the Baptist minister, still doesn't talk about it. But, she said, "he tells me he is extremely proud of me.'"