By C. S. Williams, Fountain House Education Unit
“Social determinants of health” are buzzwords floating in nearly every circle of public health these days. And they should be, as there is mounting evidence that environmental exposure shapes human disease. In 1998, the Centers for Disease Control released its landmark study on adverse childhood events (ACE), drawing links between childhood stressors, disease, social concerns and risk of early death.
The ACE study has been emphasized in trauma-informed work in the mental health sector, yet it was conducted on individuals who were predominantly White and middle-class. No similarly scaled study has ever been conducted with African-American youth or adults.
The one study I found on low-income urban youth included just 119 participants, of multiple races (compared to 17,000 in the ACE research) (Wade et al, 2014). That’s problematic. Any person who has ever worked with predominately African-American populations, especially low-income people, know that our lives are full of adverse events—whether experienced at home, in the community or within institutions. We need to look at these determinants of African-American mental health if we are to support recovery, healing and hope.
Last year, when I first learned about the ACE study, I decided to take the 10-question survey that was used by its researchers. I easily scored 9 out of 10 possible points. I was born in rural South Carolina in the late 1970s. My biological parents and my stepfather all had direct experiences with Jim Crow segregation laws, Klan violence and domestic violence, before I was born. I was raised by highly traumatized people to begin with. When we moved to the South Bronx in 1982, it was literally on fire. Divestment, the proliferation of drugs and “White Flight” caused the Bronx to collapse into urban decay. Our city-owned apartment was dilapidated, infested with vermin. We lived on less than $10K a year. Though my mother came here to escape racism, my K-8 schools were both segregated and under-funded. The violence I experienced and witnessed began early. When my family refused to let dealers sell drugs in our building, they attempted to kill us. I was just five years old. We had to pass the bullet holes they left in the door and outside walls every day. Community shootings occurred so frequently that all the kids in my neighborhood were trained to hit the floor as soon as we heard gunshots to avoid stray bullets. I witnessed significant numbers of people succumb to the crack-cocaine and HIV epidemics, including relatives. Intravenous drug use was so commonplace, it was difficult not to step on needles when walking down the street. Even worse, I suffered sexual assaults by multiple perpetrators before the age of 18.
Since I was labelled “smart,” I was expected to educate my way out of that hellish life. My family believed that was the only solution towards success. No one ever offered counseling or support. Instead, I was subscribed to a rigorous schedule of traditional and supplemental education--early morning school; day school; after-school; Saturday school; summer school; and my grandfather’s Black history free schools. It was designed to help kids like me catch up on instruction already provided to wealthy white students, so we could get into elite schools (which would lead to a better life). The expectation was that I always make A’s, practice good behavior and good manners, so I could “make it”. This pretend life came with a cost. I had my first episode of depression at age 7. By 8th grade, my grades began to slip. That was met with contempt. I still managed to get into the Bronx High School of Science. There, I faced overt racism for the first time and became demoralized when I realized that none of my previous schooling prepared me for success at all. I stopped going to class. That was met with a year’s grounding. After two years of failure at Bronx Science, my mom placed me into an alternative school and said “you have a second chance. You better not blow it.” I pulled myself up by my bootstraps and completed four years of coursework in only two, graduating at the head of my class. By the time I got to Hofstra University on a full scholarship, mental illness hit me like a ton of bricks. I descended into a “can’t get out of bed or eat or clean” episode of depression. I earned an abysmal 1.7 GPA that year. I lost my scholarship and had to return home, defeated. The lesson I learned was that individuals cannot empower themselves out of broad societal afflictions, not on their own.
Give or take some details, my story is not unique. More than 23 years of non-profit work experience with marginalized people has taught me that. The intersection of structural racism, poverty and violence has a far greater impact than most people can imagine. As bizarre as it sounds, I was lucky in many ways. I didn’t wind up in foster care nor jail like so many African-Americans with similar childhoods. I’ve never self-medicated with drugs nor contracted HIV. But I worked with too many people who did not fare well. I am committed to shifting those outcomes.
Not all African-Americans are poor. Not all African-Americans grew up in the ghetto. However, wealthy Black folks also report racial stress and trauma that is disruptive to their lives. For example, Chris Rock has repeatedly criticized his local police department for harassing him, just for driving in his own neighborhood. Last year’s #BlackWomenAtWork discussions on Twitter revealed a disturbing pattern of racialized sexism directed at Black lawyers, professors and business executives. No matter your personal disagreements with NFL players who “take a knee,” it cannot be understated that they face death threats for exercising their constitutional rights. These are the types of stressors that CDC and Harvard researchers indicate lead African-Americans to early death.
All these concerns are preventable. Yet, our healthcare infrastructure is not set up to manage them. In fact, it contributes to the problem. Researchers have advocated interventions for complex trauma since 1993 but it was only recognized in the ICD-10 this past October. It has yet to be included in the DSM. Renowned expert Dr. Bessel van der Kolk has said that mental health practitioners are rarely trained to treat complex trauma. Furthermore, cultural competency coursework is often taught as an elective, when it should be integrated throughout the graduate-level curriculum. There are several other issues. According to the Kaiser Family Foundation, African-Americans are less likely to be insured than White or Asian Americans, despite higher rates of disease in our community. That’s true even since the passing of the Affordable Care Act. Health discrimination remains rampant even for Black patients with great insurance. A 2016 Princeton University study found that a middle-class Black man was 16 times less likely to receive a callback from a potential therapist than a middle-class White woman. The National Association for the Mentally Ill (NAMI) asserts that African-Americans are more likely to be diagnosed with schizophrenia when presenting with the same symptoms that would be diagnosed as depression or anxiety in a White-American patient. Too many Black people who live with mental illness are criminalized rather than treated. Activists often refer to the Rikers Island Detention Center as the world’s largest psychiatric hospital. A 2016 University of Virginia study found that 50% of White medical residents and students (who happen to be the clinicians that are most likely to treat poor Blacks) believed African-Americans were impervious to pain. When doctors don’t take medical complaints seriously, it has grave consequences for treatment and survival. I experienced this first hand, when I had an allergic reaction to a post-ECT medication regimen. It disrupted my ability to walk and talk. My psychiatrist refused to listen when I requested a medication change. My mother demanded a second opinion and that doctor changed the regimen. My faculties were restored immediately.
The health system does not bear blame alone. Too many mentally ill African-Americans have been told to pray away mental illness, by well-meaning loved ones. African-Americans have always relied on religion as a survival strategy to cope with unspeakable injustice. But that can be maladaptive, causing further harm. We are not possessed by unseen forces. The irony is the first psychiatric hospitals were founded by African Muslims and Christians. We need to reclaim those traditions and educate our religious communities. Other survival tactics involve “strong Black woman and mammy mythology,” which teaches Black girls and women to take care of everyone they know instead of attending to their own pain. Both philosophies are rooted in American slave culture. It is 2018. We must learn to engage in self-care, to build communities of recovery.
So, what can we ALL do now? “It takes a village,” as the old African proverb states. This is not a Black problem. Everybody hurts when any member of our society suffers. We all benefit when we design a health culture that operates from margin to center. We must mobilize for social justice to end racism. We must creatively invest in urban communities to create jobs, build infrastructure, protect affordable housing and design supportive schools. We must advocate for systemic transformation in public health that incorporates more comprehensive research; prevention; early intervention; universal health coverage; training for healthcare professionals; and MORE CLUBHOUSES, especially in poor neighborhoods. We must implement mental health education programs across Black communities. Finally, African-Americans must be willing to share our testimony to advocate for change. We must become peer workers, social workers, therapists and psycho-pharmacologists. There can be no change if we don’t take our seats at the decision-making table.
For further reading, please check out the following resources:
CDC-Kaiser Permanente ACE Study Website https://www.cdc.gov/violenceprevention/acestudy/index.html
“Adverse Childhood Experiences of Low-Income Urban Youth”
“Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part I: Assessment & Part II: Treatment”
Kaiser Family Foundation’s Report “Disparities in Health & Healthcare: 5 Key Questions and Answers” https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/
“The Disturbing Reason Some African-Americans May Be Undertreated for Pain”
“Former Rikers Island Mental Health Worker Details Experience of Inmates Going Mad, Abuse in New Book”
“Black Women’s Truth & Reconciliation Commission” (written by me!)
NAMI’s Sharing Hope: A Guide to African-American Mental Health https://www.nami.org/getattachment/Extranet/NAMI-State-Organization-and-NAMI-Affiliate-Leaders/Awareness/AKA/Mental-Health-Fact-Sheets/Sharing-Hope-2014_FINAL.pdf
Author C. S. Williams teaches in-house classes on African & African-American Studies at Fountain House.
This blog has been updated on June 6, 2018. The original post stated that the ACE study was conducted with 17,000 children; however, the original CDC-Kaiser study was conducted with adults, ages 19+ who were asked about childhood experiences. Subsequent state studies have been conducted on children.