By Jocelyn Leung, Community Engagement Program Associate, Nexus Community Partners
Mental illnesses are generally unspoken but remain pervasive. Just going off what is reported, around 1 in every 5 adult Americans will experience mental illness(es) in a given year (“Mental Health By,”2015). The probability of living with mental illness(es) increases when additional environmental factors are layered on top of the common stresses and disappointments associated with regular life. Such environmental factors include but are not limited to:
1) racism and discrimination in a host country;
2) undocumented immigrant status or other immigration statuses that are at risk for deportation;
4) unemployment and underemployment;
5) social isolation;
6) lack of access to healthcare and particularly, mental healthcare;
7) responsibility for taking care of multiple generations and sending money home;
8) traumatic passage to a host country;
9) stress from acculturating to a new society and dealing with language, religious, cultural, etc. barriers;
10) intergenerational conflict as not all age groups acculturate at the same rate or level;
11) and the aftereffects of living through war, refugee camps, persecution, natural disasters, etc. (Johnson, 2016).
Because of the trauma many have gone through, refugees are especially at risk for PTSD, depression, schizophrenia, and other psychoses (Izadi, 2016). Nonetheless, these environmental factors don’t exist in isolation from each other. A recently resettled refugee holding an advanced degree might not find a job in their profession because American institutions don’t recognize the degree and yet, that person feels anxiety over the prospect of earning enough for family living here and in refugee camps (Oni, 2016). Or an elder feels increasingly isolated living in a car-dependent neighborhood and separated from her rich social network of friends speaking the same language, back at home. Every day, she has more problems relating to her children and grandchildren, who through school, work, and the ability to drive are more immersed in American society. We also see that groups who are disproportionately overrepresented in mental illnesses tend to be the same groups that American society systemically overstresses, discriminates, and/or ignores the needs of. For instance, there is an alarming rate of suicides among Black Lives Matter activists, who constantly see “black death,” when the black community is already 20% more likely to experience mental health problems than the general public (Stankiewicz, 2016). All of the above environmental factors inform the lived-in experiences of residents in the Bottineau corridor and with whom I work with in my VISTA service on the projected light rail project.
For the last two years at Nexus Community Partners, I have provided administrative and research support to the Health Equity Engagement Cohort (HEEC), a group of 16 community and community based organizations (CBOs) representing African Americans; Latinos/Hispanics; West Africans; Southeast Asians; and other minority residents. This is an especially diverse transit corridor running from North Minneapolis to Brooklyn Park. Many of our organizations work directly with undocumented immigrant, refugee, and asylee populations. North Minneapolis is home to a vibrant black community and an ever growing LGBTQIA+ community. The suburban cities that the projected light rail will pass through are more ethnically diverse than greater Minnesota, the metropolitan area, and Hennepin County (Myslajek, 2013). However, if we compared the areas along the corridor with the highest percentages of minority populations to those with the lowest (i.e. predominantly Caucasian areas), the diverse areas would see a drop of 10 to 15 years in life expectancy and approximately 53% drop in annual income (Myslajek, 2013). With this context in mind, HEEC is dedicated to integrating community engagement and health equity into the development of light rail station area plans for the METRO Blue Line Extension. HEEC not only recognizes the health disparities that fall on racial/ethnic lines but also the existing richness of communities, and the future potential this light rail project can unlock for them. Reliable mass transit, and the accompanying economic development it tends to spur, plays a positive role in people’s health in a variety of ways ranging from making it easier for low-income families to have reliable transportation to medical appointments to increasing the number of job opportunities in the area. HEEC members have bridged community engagement with health equity by asking over 900 community members on how light rail could improve their health and quality of life. I have had the privilege of combing through and analyzing a good chunk of this input.
What I didn’t expect to happen was that my own understanding of health equity would widen from reading community members’ words. I had always followed the definition of health equity as, “When every person has the opportunity to realize their health potential—the highest level of health possible for that person—without limits imposed by structural equities” (“Health Equity Terminology”). But I never made the firm link between mental health and one’s highest health potential despite having my own personal experiences with clinical depression. Part of my ignorance was due to the literature; mental health is at best referred to in passing with health equity but never given the attention that mental health deserves, even though its physiological effects (e.g. obesity from stress eating and substance abuse as coping mechanisms etc.) demonstrably shorten life expectancies. When I read our community members’ words, I was surprised at how frank they were about mental illness despite the stigma it continues to hold over many communities of color. African community members provided very sophisticated analysis on why many African men they knew were suffering from depression. They talked about how there is a cultural expectation for African men to be successful breadwinners, and when these men have to take low-income jobs they are overqualified for, they become vulnerable to depression. West African, Hmong, Lao, and other communities were very honest in discussing the civil wars and/or traumatic situations their community members escaped from and PTSD’s impact on their communities. One of our HEEC members was able to capture an ask made by community members for ways to break the mental illness stigma so that people could talk about it and get help. This ask wasn’t prompted and just came about organically through a discussion on light rails and health equity. When I talked to HEEC members about this ask, I was cautiously given the green light but was reminded that mental illness remains a sensitive topic and must be approached from a culturally appropriate perspective. They realized that if people are to give meaningful input on how mass transit can help their communities attain better mental health, we have to work first on language.
Their advice changed how I researched. I found ways that were kinder and more committed to the emotional truth of affected individuals than I would have otherwise. There isn’t room to do justice here but I’ll attempt a rough sketch. Firstly, even though many cultures still treat mental illness as a taboo, moral failing, and/or source of shame to one’s family, American culture also contributes to the stigma. Despite some progress, American culture remains uneasy talking about mental illness without judgement, and the white majority culture continues to unreflectively pressure minorities. When these are combined, Monnica Williams, the director of the Center for Mental Health Disparities at the University of Louisville, explains, “[…] we’re going uphill trying to fight all of these negative stereotypes about us, and the last thing a lot of black people want to do is give people one more reason to look down on us” (Stankiewicz, 2016). Any mental health intervention has to build in constant self-reflection and reexamination to prevent furthering these harmful, ubiquitous stereotypes. Empathy, the recognition that all fellow human beings deserve the opportunity to truly live life instead of soldier on under the cloud of mental illness, is a keystone (Aldhous, 2015). For institutions, this can begin with “cultural humility” (Aldhous, 2015). Cultural humility works against many mainstream approaches to psychiatry, social services, etc. which can be quick to dismiss information and/or treatments that don’t fit neatly into the Western scientific paradigm (Aldhous, 2015). Hendry Ton, the medical director of the Transcultural Wellness Center in Davis, California, talks about cultural humility running “both ways”; he has seen patients get better after shaman rituals, “and it doesn’t matter to him that science has no good explanation for that” (Aldhous, 2015). If different cultures are to work together for the common goal of helping people get better, then western institutions have to break the false dichotomy between spirituality and science. It is very likely a combination of medicine, counseling, and traditional or alternative methods (e.g. trauma yoga) will help stabilize a person. Creating an alliance between psychiatrists, government planners, etc. and community is another way to achieve cultural humility. Oftentimes, working with cultural, community, and/or religious leaders, who have earned the trust of their communities, is a good tactic because they are often the first group that people reach out to for help. These community leaders can also be a crucial source of information for topics like common expressions (e.g. heaviness of heart) that people use to express pathological, emotional distress or how to distinguish behaviors that are aberrant from those that are spiritually acceptable (e.g. talking to dead ancestors) (Aldhous, 2015).
Empathy also provides some guidelines for individuals working through these conversations. Without an adequate grasp on cultural practices, mannerisms, beliefs, and the lived-in reality that a minority must navigate in the US, there is no guarantee that people will trust you enough to tell you what’s happening or that you can listen effectively (Garrett-Akinsanya, 2016). At a minimum, understanding the cultural norms that dictate how dangerous it is for someone to come out with mental illness(es) will tell you what level of confidentiality you need to operate on. But going deeper, empathy stresses patience—listening to someone’s story the way they choose to tell it and in their own time. A relatively easy conversation starter if someone is coming to you with troubles is talking through what is stressing them out. Combined with cultural context, such conversations can frequently lead to tangible triggers, stressors, and symptoms of psychiatric disorders, like sleep deprivation, which are important to finding treatments to help someone get better (“Sleep,”2009; Oni, 2016).
Nonetheless, this might not be enough to cut through the fear that feeds into stigma, especially if people are internalizing multiple cultures’ fears of mental illness. To address that complexity, it is essential to listen carefully to a person and/or their family’s concerns. Are people scared that they will never be cured and nothing will ever be normal again after the diagnosis (Johnson, 2016)? Do people condense the multitude of psychiatric disorders to being “crazy” and those “running around naked” (Johnson, 2016)? In their minds, can a person only be sane or insane (Johnson, 2016)? These concerns are legitimate and can be mitigated by what we know about mental health (i.e. its biopsychosocial etiology and how treatments can lessen/treat overwhelming symptoms of mental illness) (Johnson 2016). Common themes are likely to run through their questions like the anxieties that mental illness is permanent, mental illness is uncommon, and those with mental illnesses are defective and/or have brought it on themselves. All of these make mental illness feel very isolating. Normalizing mental illnesses through statistics, stories, and a relatable definition of mental health can help make mental illnesses less scary. People, who live (or have lived) with mental illness(es), can reveal personal information related to shared experiences and show that it is possible to live a good, successful life even while managing mental illness(es) (Johnson, 2016). The World Health Organization has an excellent definition of mental health where it is described as “a state of wellbeing in which every individual realizes [their] own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make contribution to [their] community” (“Mental health: a state”, 2014). At the moment, most of us are not at that level and that is because we are likely to be somewhere on “health-to-illness continuum, always seeking a return to wellbeing” (Baron, 2012). Seeing mental health as a spectrum helps to close some of the distance between those who can function normally with those overwhelmed by mental illness. When a depressed person talks about living under a thick fog of intense self-loathing that drains their energy and makes it impossible to focus on anything, we might not understand the intensity and entirety of their experience. But we can relate to moments, perhaps while mourning, when we feel something slightly similar. There will always be mental illnesses that are beyond the understanding of most of us. But through empathy and seeing each other’s humanity, we can bring down that stigma and unite in helping everyone make that journey back to mental stability.
Aldhous, P. These Incredible People Are Changing How Isolated Asian Groups Deal with Mental Illness. (2015, December 12). BuzzFeed NEWS. Retrieved February 20, 2017, from https://www.buzzfeed.com/peteraldhous/transcultural-wellness?utm_term=.jbNKKgxxM#.fnd22lJJQ
Baron, M. (2012). Calling in Crazy: Why We Must Normalize Mental Illness. The Huffington Post. Retrieved Februrary 22, 2017, from http://www.huffingtonpost.com/mary-walker-baron/mental-illness-stigma_b_1301514.html
Garrett-Akinsanya, B. (2016). Going the Distance, Not Far Enough: The Essential Role of Culture in Mental Health Interventions. Personal Collection of Dr. BraVada M. Garrett-Akinsanya, Ph.D., LP, 2nd African Mental Health Summit, MN
Health Equity Terminology (n.d.). Minnesota Department of Health. St. Paul, MN. Retrieved February, 20, 2017, from http://www.health.state.mn.us/divs/chs/healthequity/definitions.htm
Izadi, Elahe. (2016). For Refugees, another risk: Schizophrenia. The Washington Post. Retrieved February 22, 2017, from https://www.washingtonpost.com/news/worldviews/wp/2016/03/16/for-refugees-another-risk-schizophrenia/?utm_term=.f01906d340ed
Johnson, D. (2016). Culturally Sensitive Diagnostic Interview Protocol for Somali Immigrants/Refugees. Personal Collection of Dr. Dasherline Cox Johnson, Psy.D., 2nd African Mental Health Summit, MN
Mental Health: a state of well-being. (2014). World Health Organization. Retrieved February 22, 2017, from http://www.who.int/features/factfiles/mental_health/en/
Mental Health By the Numbers. (2015). NAMI: National Alliance on Mental Illness. Arlington, VA. Retrieved February 20, 2017, from http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers.
Myslajek, C. Bottineau Transitway Health Impact Assessment Final Report. (2013). Hennepin County Public Works. Minneapolis, MN. Retrieved February 20, 2017, fromhttp://www.hennepin.us/-/media/hennepinus/residents/transportation/documents/hia-final-report.pdf
Oni, R. (2016). Welcome and Opening Remarks. Personal Collection of Dr. Richard Oni, Ph.D., 2nd African Mental Health Summit, MN
Sleep and mental health. (2009). Harvard Mental Health Letter. Cambridge, MA. Retrieved February, 20, 2017, from http://www.health.harvard.edu/newsletter_article/Sleep-and-mental-health
Stankiewicz, W. L. (2016, February 16). 'My Demons Won Today': Ohio Activist' Suicide Spotlights Depression among Black Lives Matter Leaders Suicide Spotlights Emotional Strains in Black Rights Circles. The Washington Post. Retrieved February 20, 2017, from https://www.washingtonpost.com/news/post-nation/wp/2016/02/15/my-demons-won-today-ohio-activists-suicide-spotlights-depression-among-black-lives-matter-leaders/?utm_term=.d12a0c092eaa