Daily Archives: 24 February, 2010

Shame and Blame with African-Americans and Mental Health: Let the Circle Be Unbroken

Recently, U.S. Surgeon General Dr. Regina Benjamin kicked off a national campaign to tackle mental health in the African-American community. Benjamin explained why a focus on African-Americans is needed: “Mental health problems are particularly widespread in the African-American community. In 2004, nearly 12 percent of African Americans ages 18-25 reported serious psychological distress in the past year. Overall, only one-third of Americans with a mental illness or a mental health problem receive care and the percentage of African Americans receiving services (nearly 7 percent) is half that of non-Hispanic whites.”

Programs focusing on addressing underrepresentation of minority groups in mental health care tend to focus on outreach to and education of the underrepresented group (while this post focuses on historical and structural barriers to African-American participation in the mental health system, these larger concepts are likely applicable to other racial and cultural minorities throughout the world.). The theory seems to be that if individuals knew that they might be experiencing mental health systems and understood how the mental health system could treat and benefit them, they’d start accessing it in droves. This kind of outreach and education is clearly an important part of increasing minority representation in mental health care, but the exclusive focus implies that the primary barriers are the attitudes of individuals who would change their minds if they just had more information. This ignores a lot of problems and lets a lot of bad actors off the hook for institutional barriers and exclusions. In the particular instance of African-American engagement in the mental health system, it is these long-standing oppressions and exclusions which are perhaps most to blame.

A primary issue is that African-Americans are more likely to be subject to a number of forces of oppression and discrimination which can increase trauma and vulnerability to mental health disorders. “Owing to a long history of oppression and the cumulative impact of economic hardship, African Americans are significantly overrepresented in the most vulnerable segments of the population. More African Americans than whites or members of other racial and ethnic minority groups are homeless, incarcerated, or are children in foster care or otherwise supervised by the child welfare system. Proportionally, 3.5 times as many African Americans as white Americans are homeless. African Americans are especially likely to be exposed to violence-related trauma, as were the large number of African American soldiers assigned to war zones in Vietnam. Exposure to trauma leads to increased vulnerability to mental disorders.”

To me, that does not suggest that the primary solution is increasing African-American representation in mental health treatment – it suggests that a primary solution would be to address the structural inequalities that are making African-Americans “significantly overrepresented in the most vulnerable segments of the population.” Maybe a program that focuses on homelessness in the African-American population. Maybe addressing the sentencing disparities for crimes involving cocaine and crack cocaine, and how that contributes to disproportionate and longer incarceration of African-Americans. Or how felony disenfranchisement prevents a staggering number of African-Americans (13% of black adult males!) from participating in our democratic political system. Without addressing these ongoing problems, a disproportionate number of African-Americans will continue to experience trauma and increased vulnerability to mental disorders.

A second and key issue is the long history of how the psychiatric profession has treated African-Americans in the United States. Diagnoses and treatments for African-Americans have long been rooted in the structural racism of slavery, with early diagnoses of “Negritude” and “Drapetomia” for slaves who fled their masters and recommended treatment of whipping as therapeutic intervention. In 1895, a Georgia psychiatrist popularized the idea that “structured lives led by slaves served as protective factors against insanity” and that slavery protected African-Americans from freedom that would literally make them insane. In the late 1800s and early 1900s, there were separate “colored” institutions for African-Americans, who received little if any treatment services and were subject to horrific tortures and sexual assaults.

A glance at the current mental health system makes it clear those historical problems have not been eradicated. African-Americans are much more likely to be diagnosed with schizophrenia than with affective (mood) disorders, even when displaying the exact symptoms of a white patient diagnosed with affective disorder. This is true even when the diagnosing clinicians included African-Americans well trained about the bias towards schizophrenia diagnoses. Studies suggest this is because clinicians apply entirely separate decision models when diagnosing African-American patients, likely drawing on stereotypes of paranoia and violence that aren’t actually associated either with African-Americans or people with schizophrenia.

There are also significant knowledge gaps in how psychoactive medications affect African-Americans. There is almost no research on ensuring adequate racial representation in psychopharmalogical research, nor on how to ensure that participating patients from various cultural and racial groups give informed consent. This lack of knowledge is affecting the effectiveness of treatment, as existing research shows that “a greater percentage of African Americans than whites metabolize some antidepressants and antipsychotic medications slowly and might be more sensitive than whites,” and can lead to faster responses and more severe side effects when African-Americans are treated with doses commonly used for whites. Despite this, clinicians in psychiatric emergency services commonly administer “both more and higher doses of oral and injectable antipsychotic medications to African Americans than to whites.”

To me, all of this suggests that the psychiatric profession hasn’t really figured out how to provide psychiatric treatment and care of the African-American population with the African-American individual’s best interests in mind. History speaks to using psychiatry to control, torture, sedate, and oppress African-Americans, even creating fictionalized diagnoses to help support the structures of slavery. Add to all of this the multiple barriers preventing access to mental health care even for those who enthusiastically wish to access it – lack of parity for mental health care, lack of health care coverage at all, societal sigma around mental health – and instead of wondering why there’s underrepresentation of African-Americans in the mental health system, I start wondering why there’s as many as there are.

Clearly, a solution focused only on outreach and education to individual African-Americans is doomed to be unsuccessful, because it overlooks the underlying structural issues making African-Americans particularly vulnerable to mental health problems and the historical reality of their exploitation by the mental health system. Even more troubling, though, is that when the access problem is framed as an issue of education to an individual, it allows the blame to be placed squarely on that individual – even if these other, more serious, structural barriers are ignored. That kind of blame is just another addition to the complex system of forces making African-Americans more vulnerable to mental disorders to begin with.

Recommended Reading for February 24th

Warning: Offsite links are not safe spaces. Articles and comments in the links may contain ableist, sexist, and other -ist language and ideas of varying intensity. Opinions expressed in the articles may not reflect the opinions held by the compiler of the post. I attempt to provide extra warnings for material like extreme violence/rape; however, your triggers/issues may vary, so please read with care.

Mark Bekir in a First Flight Crew T-shirt

Image: Marky Mark (Mark Bekir) in a black First Flight Crew T-shirt.

accessibleARTS: First Flight Crew breaking into the scene:

The eight piece hip hop crew from all over Sydney is managed by Accessible Arts’ Creative Programs Coordinator, Alison Richardson and was formed in 2009 as a result of a series of workshops with Victorian based music organisation Club Wild, further development with Powerhouse Youth Theatre and all under the guidance of hip hop artist, Morganics.

Wheelchair Dancer: Passing By:

At the studio where I take classes when I am in NYC, the elevator isn’t ADA accessible: it’s painfully small. So small that there is always a line, well, a press of people waiting to go upstairs. It continues to amaze me that hyperable-bodied dancers who are about to go and dance for hours on end take the elevator. But they do, and so, when I was using my previous (wider) chair, I had to get there even earlier than the rest; I had to stand up, dismantle my chair, limp in, hold the door, drag the pieces in behind me and then reassemble the thing. It’s the sort of disability performance I didn’t want people to see.

staticnonsense: at I Am Not: A Punishment:

I am not a punishment to be bestowed upon anyone, much less my caring and supporting family. I know your beliefs strongly state otherwise, but they do not represent the reality of the situation.

My mother’s medical decisions and past choices are hers. They are not anyone else’s business. It is not our place to judge her for her decisions, especially when one does not know or one doesn’t need to know the reason why. No matter her decisions in the past, she is an infinitely caring person that has been behind me every step of the way through the trials and tribulations of my life.

IP at Modus Dopens: Why separate resources ain’t good enough:

There’s a pervasive myth that annoys the hell out of me, and I hope you’ll excuse me while I get it out of my system: it’s the idea that it’s ok for an institution to put in new inaccessible facilities as long as it also has some accessible ones elsewhere.

Really, no.

Why why why do we have to have one set of facilities for the “normals” and another set for the “freak show”? It’s humiliating, and it’s not even useful. If you’re putting in a facility from scratch, it’s often the case that you can put in something accessible for the same cost as something inaccessible. So it’s not even easier to put in two sets of facilities rather than just the one. This is just another way that we center the experiences of currently non-disabled people

PS News: Red tape cut enables disabled veterans:

Ex-Service personnel with disabilities who access income support are to be spared medical reviews at Centrelink for their Disability Support Pensions. […] Mr Griffin said TPI pensioners currently had to endure repeated Job Capacity Assessments to keep their Disability Support Pensions.
He said these assessments were “unnecessary”, as the veterans had already been through a rigorous assessment process to access DVA benefits.

Brisbane Times: When the ability to act is what counts :

Actors with a disability playing characters with a disability have been particularly prominent in Australian films this year, including Matthew Saville’s feature Noise and Clubland, which stars Brenda Blethyn. […]

Rick Randall, director of The Other Film Festival, Melbourne’s trail-blazing festival of “New cinema by, with and about people with a disability”, says roles remain few and far between in Australia. “There are a few films with minor roles played by people with disabilities, but there’s still a long way to go. The major problem, though, is that we’ve got a shrinking film industry so it’s really hard for new players to get a foothold.”

Young agrees, adding that it’s vital that disabled people are making the work as well as starring in other people’s. “When we write about our own experience, we bring something to it that non-disabled people rarely manage to capture,” she says.

New York Times: Doing an About-Face on ‘Overmedicated’ Children :

[Judith Warner] sallied forth to interview all the pushy parents, irresponsible doctors and overmedicated children she could find — and lo, she could barely find any. After several years of dead ends, missed deadlines and worried soul-searching, she was forced to reconsider her premise and start all over again.

“We’ve Got Issues” is the product of that unusual cycle. Journalists who cobble together enough anecdotes to support a preset agenda are all too common, and presumably Ms. Warner could have managed to do just that. Instead, she actually let her research guide her thoughts.