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Stigma: The Often Silent Obstacle To Mental Health and Substance Abuse Care Among African Americans

By: Lorna J. Hines, LCSW, ACSW

am certain that there are those of you who possess the courage and interest to read beyond the title of this article will recall that memorable film “Soul Food”. Besides the main character, “Big Momma”, there was also brief depictions of a gentleman, the brother of “Big Momma”, who remained alone in his room. No one saw him coming or going however family members knew he was there. Periodically, family members delivered food outside of his room, however rarely did we see him. In many ways this depiction of being “strange” and “hidden” in character symbolizes an image of mentally ill persons within African American culture. Further, it is cultural that caring for and keeping the secret of a mentally ill person is part of the family’s responsibility and more importantly, the family learns to cope with yet simultaneously, not discuss this “strange” behavior.

One of my most poignant experiences regarding African American culture was shared with me by an African American minister who had not been trained in mental health, and had not seen it as a significant part of his ministry. However, he was forever changed when, on one sunny afternoon, one of his male parishioners called him in crisis, stating he had a knife and was going to kill himself. This parishioner was suffering from symptoms of Major Depression, and did not see a way out of his debilitating feelings as he became suicidal.  He was, after long battling mental illness, in a life threatening crisis. This experience led this pastor to assume leadership in finding ways to bring mental health services to his parish life and to raise awareness amongst other ministers regarding the significance of mental health in our community.

In my own life, growing up in the South Bronx in the 60’s, it was clear that the mentally ill in our community were strange (as they both looked and acted differently), and were, at times, subjected to ridicule, jokes, and other devaluing experiences. Additionally, during my childhood, my sister fell to mental illness in her late teens, and this fact was held secret among the immediate family. In retrospect, it was never made clear to me why this happened; it was never explained and I did not have the courage to ask. I, now, wonder if family secrecy would have been the culture if she suffered from heart disease or diabetes? Or perhaps, if she became pregnant without being married.

Unfortunately, the private mental health system, of which we were a part, did not believe that an African-American teenager could suffer from a Bipolar disorder, and she

was misdiagnosed while under their care. This stigmatization and misdiagnosis is perhaps another reason why African Americans are reluctant to seek mental health care.

There are similar scenarios of cultural secrecy regarding substance abuse and addiction within the African American community. Again, in my own family, addiction was kept silent until there were legal ramifications. Our family focused on “managing the situation”, leading to financial loss; but, ultimately through strong advocacy and calling in favors we were able to help addicted family members to obtain substance abuse treatment. Many black mothers and grandmothers silently support the drug habits of their sons, daughters,grandsons and granddaughters, while feeling powerless to manage seemingly impossible situations. This desperate coping strategy may be the best way they know how to keep their loved one out of prison.They are often placed in the situation where they feel compelled to lie, pay off the drug dealers, or seek other resources within their community.

I have professionally counseled a client suffering from severe rheumatoid arthritis who lived on her benefit check, but supported her son’s drug habit through crocheting blankets.  Once, twice, or three times when she had clients on payment plans she had to immediately ask for the money because her son needed a fix and she was frightened. This cultural reality was also depicted in the terrorizing story of a family’s coping with substance abuse, Jungle Fever, 1991 ( the Spike Lee classic where the father, played by Ossie Davis, is angry and fed up with supporting his son’s drug habit, and fatally shoots him while his mother is crying hopelessly).

The term stigma is a thoughtful choice for this subject matter. Its’ derivation, according to Merriam Webster dictionary, is Greek or Latin. It “Indicates a mark or brand especially one that marked a slave marking the person as inferior” (Merriam Webster Dictionary). Often times,stigmas are not visible, but are reading perceived and “felt”, such as a person with a history of incarceration or a disability of mental illness. The stigmas in mental health and substance abuse are clearly hidden or kept in secret, and is associated with emotionally potent feeling of shame and isolation. Central to understanding stigma is the idea that it is a socio political and socio economic construct based on particular societal and cultural norms. It is very much based on environmental and community culture. Therefore, a stigma in the United States culture may not be a stigmatizing influence in other cultures.

Clearly, when we examine the history of African Americans here in the United States, as opposed to our glorious African past, we see clear evidence of the development and evolution of the stigmatization process. During the 1840 census, for example, researchers noted increased rates of insanity and psychosis among freed Blacks in the North. This “research” was utilized to justify the need for African Americans to be enslaved, reasoning freedom caused insanity among freed African Americans(Academic .Udayton.edu, An Early History-African American Mental Health, Vanessa Jackson). In 1851, the imminent physician from Louisiana, Dr Samuel Cartwright, who was a supposed expert on the medical needs of “Negroes”, “identified a mental disorder among slaves…Drapetomania , a disease causing Negroes to run away from their slave owners. Further, he felt the treatment intervention for slaves evidencing this disorder was whipping (Ibid Academic. Udayton.edu). And, as we examine this concept from a historical view, we note medical genocide in the infecting of and denial of treatment of syphilis to African Americans in the Tuskegee Syphilis Study, and the unlawful and immoral use of the cells belonging to Henrietta Lack.

One may ask at this point, how does this information exert a stigmatizing effect on the access of mental health and substance abuse services among African Americans?

More than twenty years ago, a monumental report was issued by the then Surgeon General of the United States, Dr. David Satcher. In that seminal report, dated 1999, Dr Satcher focused on the public health nature of mental health and the tragedy of stigma that negatively impacts access to care ( www.psychosocial .com). First and foremost, the existence of stigma relates to the ongoing mistrust of African Americans towards various institutions especially medical and mental health care. Many feel their best interests, care and concerns will not be met. This combined with the glaring lack of African Americans physicians and clinicians, as well as the lack of cultural competency (both institutionally and among practitioners) exerts a unwelcoming environment for those in need. We must be aware of the glaring health disparities among African Americans. Therefore, the larger mental health environment in the U.S., through both its institutions and clinicians, perpetuate a stigmatizing climate which closes the opportunity for the unsure and perhaps conflicted African American to have their mental health and substance abuse needs met.

I would be neglectful in fully exploring this topic if I did not fully articulate the extent to which some African Americans engage in self stigmatizing with respect to accessing mental health and substance abuse services. In African American culture, is the belief that seeing a therapist is seen as a sign of weakness. Some even go to the extent that our ancestors were slaves, and what we have experienced is not akin to enslavement, so we should be able to endure it without intervention or therapy. For many, including some in my own family, accessing mental health care was seen as something that

would look bad on their record and prevent them from getting a job. The idea of having a mental health diagnosis is seen as terribly stigmatizing. Other beliefs have stated accessing mental health and substance abuse indicates a poor reflection on the family’s ability to handle problems, indicating failure. Many who are religiously or spiritually focused indicate that fasting and praying will handle all difficulties. Although religious and spiritual practices have found to be helpful in both mental health and substance abuse treatment, fasting and praying alone may not be the sole interventions to address a pressing need for someone suffering mental illness or substance abuse. Those African Americans who may be suffering from a major clinical depression describe their clinically sound symptoms simple as the “blues” and suffer in silence many debilitating symptoms such as despair, sadness, insomnia, hopelessness,helplessness, guilt and for others, anger, agitation and physical symptoms such as pain, headaches, etc.  I have seen a pattern where self medicating is the course of action in these circumstances leading to addiction to alcohol and other dangerous drugs. The ongoing use of these substances is justified culturally as healthy coping mechanism, when in fact there are serious life threatening consequences.

Our culture must acknowledge the psychological effect of traumatic experiences as expressed subconsciously in our body, mind and spirit. We do not need to de emphasize traumas such as childhood sexual, physical, and experiences of neglect and maltreatment. We must clearly examine the causes of suicide, especially among young African Americans. We need to intervene early in the path that leads them to seek self harm as a means to cope with the ending of feelings and thoughts that may be unceasing in a spiral of hopelessness. When we split off important part of ourselves, which may be negative and also impact our mind, body and spirit often these experiences express themselves in parts of our of lives. It is essential that we pay close attention to aspects of, not only our physical health, but mental health and use of substances.

What are the paths that African Americans can seek to eradicate stigma?

Both on a community and personal level obtain the facts. Do you engage in self stigma? Be honest with yourself and those around you. Have you prevented yourself or members of your family from obtaining much needed mental health care or counseling? The computer affords us access to information about physical and mental healthcare, If you don’t have access to a computer visit your local library. Speak with healthcare professionals you trust and obtain information. Your primary healthcare provider can be your first access to care and a possible referral. Insure you have confidence and trust in your primary care doctor to ask all and any questions. If you have private insurance be aware of what is covered. Most insure plans have adopted parity for physical and mental health care. If you do not have health insurances many communities have ways to access care through public care. Get the facts

Begin to raise awareness about these issues. Shame and fear renders the need for mental health and substance abuse services unmet in our community. I applaud the efforts of well known celebrities who have openly discussed their mental illness and substance abuse. All of us belong to churches, civic and social organizations. Consider doing a health fair and inviting mental health and substance abuse clinicians to participate. Outreach to your local Mental Health Association. substance abuse services, and other resources can engage mental health activities in our organizations and community events. Engage participants in your community in something that is needed and positive. They too will have an opportunity to learn.

Consider the opportunity to engage in Mental Health First Aid Training. This is a wonderful training opportunity that demystifies mental health and substance abuse problems and ways in which citizens who do not have a background in this area can obtain knowledge and skill. The training is not designed to have you treat conditions. It is focused on helping individuals to obtain the help they need from a professional. You should contact your County or State Mental Health Department for information about this excellent training.

Please be aware of ways in which you may perpetuate the stigmatizing process. Don’t use language that denigrates those with mental health and substance abuse problems. Don’t use a diagnosis that you are not trained to use, i.e. schizophrenia, bipolar, etc. Let people know when they are stigmatizing.

Utilize your faith and/or spiritual community to help identify resources. A church in my community developed a resource guide with names, address, and specialities of mental health and substance abuse clinicians, many of who were African Americans.

These are just a few steps towards eradicating stigma in the African American community. Be assured it starts with the power and perspective of one person to eradicate this self-defeating and disempowering phenomenon.

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