Category Archives: race and mental health

On MLK Day 2023: With Gratitude to Dr. King, from a Desi Doctor

In February 1959, Dr. Martin Luther King, Jr. arrived in India for a five week trip to learn firsthand the South Asian history and strategies that informed the US battle for Civil Rights. Nine years after Gandhi‘s death, Dr. King wrote that he was deeply struck by direct observation of the Indian caste system and the parallels in American conceptions of race. Over 60 years later, caste-based discrimination continues in India, and, exponentially, in Muslim communities In India.

If you get a chance, read Dr. King’s words about his impressions of India, just profoundly beautiful.

Related: Caste book summary by Isabel Wilkerson

South Asian health professionals in North America need to express gratitude for the activism that has reduced racist structures but also to acknowledge the privilege afforded to us by education and profession. Indian, Pakistani and other South Asian physicians and mental health must lead that charge. Asian physicians make up the second-largest majority of all health professions within the United States. South Asian doctors fall around the 15% range. Of these, for example, greater than 60,000 physicians and approximately 10 to 12 percent of entering medical students are estimated to be of Indian heritage in this country.

Like many of our first and second-generation colleagues, our parents were primarily part of a migration from India, Pakistan, Bangladesh, and Sri Lanka. It began around 1965 and increased through the early nineties, thanks to relaxed immigration legislation and increased employment opportunities, many brought about by the Civil Rights Act of 1964, the Voting Rights Act of 1965, and The Fair Housing Act of 1968. The large number of South Asian immigrants who arrived during those years did so as either recent university graduates, or with the scholarship or family funds to obtain an education here on U.S. soil. As a result, South Asian immigrants have been prominent in fields that require extensive and often expensive training, such as medicine and technology.

We the first and second generation children of immigrants can use our education and position to advocate for change. The first thing to do is speak out against racism within our own communities. Although this statement often angers my South Asian community, it would be dishonest to state that we did not witness growing up with elderly community members, outwardly spewing racist propaganda; particularly condemning engaging in romantic relationships or close friendships with Black women or men. I work with a large number of Desi clients, and many feel they must keep their personal lives secret from family, a practice which is painful and ego-dystonic.

Related, see Dr. Siddique in The Meaning of Difference, McGraw Hill.

As healers, South Asian medical and mental health professionals, must be part of solutions to tackle health inequities for our Black patients. Health disparities in medicine are prevalent in all fields of medical practice. Coronavirus is still claiming the lives of Black Americans at a rate almost 2.5 times greater than Whites or Asians. Black men continue to have a substantially lower life expectancy. As a health community, we must set the goal to help narrow the disproportionate gap in Black Americans’ deaths from coronary artery disease, stroke, diabetes, and cancer. At the least, we should take our skills and funds to contribute to organizations that will help abolish the health inequities that we see daily in our line of work.

South Asians have endured discrimination. Our names are mispronounced, our office lunch mocked, we are stereotyped as doctors or convenience store clerks on many popular shows. We continue to endure micro aggressions from patients, administrators, and supervisors based on who we are. Of the utmost importance now is that we take some of the burden for fighting for persons of color away from our Black colleagues and patients, so they can take a timeout or at least rest.

Additional reading:
Microaggressions are a Publc Health Crisis.
Why Representation Matters: Media and Mental Health

Indigenous (AI/AN) Mental Health

Artwork: Dr. Siddique private collection

The Western concept of mental health illnesses may often not correspond with the beliefs and interpretations of AI/AN cultures. For example, the words “depressed” and “anxious” are absent from some native languages where alternative expressions such as “ghost sickness” or “heartbreak syndrome” are present. The context is crucial for treatment by mental and medical health professionals.

Many tribal cultures embrace the notions of interconnectedness; balancing the mind, body, and spirit. Highlighting one’s well-being is entwined with cultural identity, family, nature and earth, and a connection to the past. Research suggests that indigenous persons with symptoms of anxiety and depression may seek help from other sources; including traditional and spiritual healers.

The shared history of trauma caused by colonialism for the indigenous and native populations is believed to be a factor in the reports of 2.5 times more experiences of serious psychological distress in AI/AN populations compared to non-indigenous populations. Having an accurate and non-defensive understanding of colonization is necessary in understanding the unique place that Indigenous communities hold in history and how this can impact mental health and medical care.

Although numbers vary by tribe, the suicide death rate for AI/AN populations between the ages of 15-20 is more than double the rate of all other racial-ethnic groups at that age group. Elevated risk factors of suicide may be influenced by the fact that 26% of AI/AN communities are living in poverty, have higher rates of alcohol and drug abuse compared to all other ethnic groups, have comorbid medical problems such as diabetes at a much higher rate, and suffer the impacts of historical trauma, alienation, acculturation, discrimination, community violence, lack of access to treatment, financial hardship, family separation (a large number of indigenous children and adolescents were forcibly removed from their families and placed in boarding schools by the government), and accumulated micro-aggressions.

To approach healing, mental health programs for indigenous persons should address community and traditional knowledge, and designate historical, inter-generational, and racial incident-based trauma symptoms as legitimate injuries to mental health.

See also, “The Healing Power of Heritage.”

(Sometimes I go about in pity for myself, and all the while, a great wind carries me across the sky. Ojibwa/Chippewa saying).

Trauma is not a Life Lesson

Please stop describing trauma as a life lesson or badge of honor that people survived or it made them stronger.

-What doesn’t kill you can dysregulate your nervous system, That includes your mood, sleep, eating habits, and daily functioning.

-What you survived can impair your ability to have attachments or trust people. Your relationships.

-What you endured can make you sick. Trauma can contribute to chronic diseases such as type 2 diabetes, heart disease, and rheumatoid arthritis.

-What you “tough out” changes your brain. Trauma changes brain chemistry and structure from the hippocampus (which is your memory functioning), to your amygdala (your ability to manage stress and emotional responses) and your prefrontal cortex (problem-solving and reasoning).
Trauma sucks. Don’t glorify it.

Also see Racial Trauma and Mental Health

Why representation matters: Media and mental health

Growing up as a Brown Asian Canadian/American child first generation immigrant in Nova Scotia, Queens, Virgina, and Michigan, I never really saw anyone who looked like me in the media. The TV shows and movies I watched mostly concentrated on blonde-haired, white, or light-skinned protagonists. My two best friends, who were Black and Syrian, and I, the Desi girl, played Charlie’s Angels, about the whitest show ever made. Of our friend group, my Syrian friend, Mohja, had the lightest hair and skin, so she was always Farrah, the one we all aspired to me. She is now a feminist , award winning Middle Eastern poet and tenured Professor, who pokes fun at patriarchy, both Western and Middle Eastern.

Shows hardly ever depicted things that reflected my everyday life. Desi characters were actually caricatures, such as convenience store clerks, nerds with calculators, or seductive women wearing kajal. It was equally odd and fascinating that people on TV didn’t eat rice at every meal; that their parents didn’t speak with accents; or that no one seemed to navigate a world of daily microaggressions. I was frequently called a camel driver followed by requests to instruct boys about the Kama Sutra as I got older, Idiosyncratic images.

Despite these experiences, I continued to absorb this mass media—internalizing messages of what my life should be like or what I should aspire to be like.  I spent an entire high school year wearing Polo and Izod with khakis and dock siders. Because that’s what all the girls were wearing. There is nothing less interesting or flattering in the entire fashion world. My delicious curries, lentils, and Biryanis that I grew up with were teased and mocked by classmates eating their Oscar Mayer bologna, mayo, and velveeta sandwiches on Wonder Bread. Ironically, present day, some of the top Michelin starred restaurants in the country are Indian. My henna hand designs raised eyebrows, my desire for beautiful blingy jewelry was extra, and the pronunciation of my family names and everyday terms were massacred by tongues far from mellifluous. I speak six languages fluently and I will never tolerate anyone making fun of somebody’s accent. Also, you cannot shorten someone’s name without their consent because you can’t pronounce it. Practice.

Fact:
Every immigrant has the familiar experience of having their name mispronounced as they sink at their chair, their packed lunch made fun of, and even the dearest traditions mocked.I have Hindu friends who were told that the dot on their head was for target practice. Now Beyoncé wears a fake Bindi in her videos. I found it ironic when I was in college at Duke and Virginia Tech, two very Southern colleges, that all the girls came by to borrow my clothes and jewelry. Virtually every spelling bee in the United States and Canada is won by somebody from India. We know your language but you don’t know ours. Most countries in the world including the tiniest like Belgium have multiple national languages.

The Research:
Clinical psychology research clearly indicates that people desire realistic, non stereotypical representations of their own culture. About six in ten parents (57%) say it is important for their children to see people of their own ethnicity/race in the media they consume. But it’s most important to Black parents, 75% of whom say representation is important. Also, 70% of parents want media that exposes children to more about their family’s culture, religion, or lifestyle. The melting pot ideal is not something that is conducive to loving your own culture and is not associated with a strong sense of self-esteem or identity.

The research also clearly indicates that people want stories that are inspirational and aspirational. About two in three parents (65%) feel that media has a big impact on their children’s professional aspirations, which underscores the importance of providing positive role models for Black, indigenous, and children of color. They want diversity because it teaches acceptance and inclusion. Almost 6 in 10 (57%) parents say that the media their child consumes has prompted conversations about diversity, and 63% of parents believe that media has an impact on the information children have about people of other races, ethnicities, religions, and cultures.

Media is slowly changing. Many of you may know that I write for several media outlets. I insist on accompanying photos in any article that I write depict POC. We are vastly underrepresented in all Western advertising forums, from print to media.

Check out shows like Ms. Marvel on Disney+. It actually made me tear up, because nostalgia is not allowed when you are being assimilated (Borg reference for my fellow star trek geeks). Watch a Bollywood flick, listen to some music from South Asia or Africa, have conversations with people who don’t look like you. It is amazingly beautiful.

I love being Brown, I love my food, I love all my languages, art, music, jewelry, architecture, appearance, apparel, history, ancestor stories, I love the scents, sounds, and customs. Take a look at us. You won’t regret it.

You should read:  poetry from Dr. Mohja Kahf and Dr. Siddique’s chapter in The Meaning of Difference, Published by McGraw-Hill, New York.

Causes of Mortality in US Teens and Children

In 2020, firearm-related injuries became the leading cause of death for children and teens, an age group defined as ranging from 1-19 years. From 2019 to 2020, the relative increase in the rate of firearm-related deaths of all types (suicide, homicide, and unintentional) among children and adolescents was 29.5%, a significant uptick.

In addition, drug overdose and unintentional poisoning increased by 83.6% from 2019 to 2020 among children and adolescents, becoming the third leading cause of death in that age group. Motor vehicle accidents remained the second cause of death.

Although the USA suicide rate dropped overall from 2019 to 2020, there were increases among young adults/teens that affected different demographic groups differently.

According to a study published in the Journal of the American Medical Association (JAMA Psychiatry) that examined racial differences in suicide in 2020, suicide mortality among Black young people doubled. The evidence pointed to the pandemic having a heavy impact on Black Americans in significant areas including more hospitalizations, deaths and bereavement, job loss, and housing instability.

(Stats: New England Journal of Medicine: NEJM,May 19, 2022; JAMA, psychiatry; December 2020 ). 

Diabetes and Mental Health

37.3 million Americans—about 1 in 10—have diabetes.

About 1 in 5 people with diabetes don’t know they have it.

96 million American adults—more than 1 in 3—have prediabetes.

More than 8 in 10 adults with prediabetes don’t know they have it.

For the past three years, approximately 1.5 million new cases of diabetes were diagnosed each year. Many more go undiagnosed.

For people aged 10 to 20 years, new cases of type 2 diabetes increased for ALL racial and ethnic minority groups, especially Black teens.

This past week, the House of Representatives passed a bill capping the cost of insulin on Thursday night with unanimous Democratic support, a mere 12 Republicans voted for the legislation, with 193 voting against it (five didn‘t vote at all). The House (Democrats) voted to cap the price of insulin at $35. (The bill will go to the Senate after Easter).

FACT: The cost of insulin for patients WITH insurance ranges from $334 to $1,000 a month.
FACT: The manufacturing cost for a vial of insulin is approximately $10.
FACT: Many diabetes patients ration their medicines or discontinue them because of the cost.

NEUROPSYCHOLOGICAL AND MEDICAL IMPLICATIONS

  • uncontrolled diabetes is implicated in a threefold increase in vascular dementia
  • uncontrolled diabetes drastically increases the chance of stroke, which also brings an entire set of cognitive and physical consequences
  • untreated diabetes and prediabetes results in impaired attention and concentration, brain fog, fatigue, headaches, learning problems, and lethargy
  • diabetics have a much higher level of clinical depression and anxiety, medical related worries, financial hardship, and overall stress
  • diabetics are at higher risk for secondary events, such as car accidents, work disability, and falls
  • people with prediabetes are at far greater risk for long-term cognitive decline and memory problems because they most often walk around without any diagnosis or treatment
  • most people will have/will have a loved one, family member, colleague, or friend who suffers from diabetes and related sequela in their lives. As such, diabetes affects everyone
  • BIPOC individuals have a significantly higher rate of diabetes, with the highest group being Black men, women, and children
  • diabetic medical consequences that affect daily life include vision problems, neuropathy, chronic pain, kidney problems and possible renal failure, memory weakness, increased risk of hypertension, sexual dysfunction, tooth/gum problems, and foot/mobility problems
  • individuals with diabetes have a much higher chance of long-term consequences from COVID-19
  • the consequences of untreated or undertreated diabetes will create an added strain on the medical and mental health system, which is already under severe pressure. This, in turn, has a trickle-down effect on treatment of other conditions
  • as a psychologist, management of diabetes, medication regimen, diabetic self-care, nutrition, and related stressors are often a focus of treatment

(Data sources: Kaiser Health, WebMd 4/22, CDC, 1/22)

Black History Month, Heroes in Psychology

Olivia Hooker, PhD (1915-2018)
As a child, Dr. Hooker survived the Tulsa race massacre of 1921. She and her siblings hid behind a kitchen table while watching the destruction. She described the trauma as life-long, but it didn’t hold her back. Dr. Hooker was the first Black woman to enlist for active duty (Coast Guard) and the only Black woman in her Ph.D. class at the University of Rochester, graduating with honors.  She previously attended TC at Columbia University, where she obtained her master’s in psychology. She was told she was ‘not intelligent enough’ to proceed to the doctoral program, and subsequently transferred to the University of Rochester for her doctorate.

She began her mental health career at a prison in New York, counseling and supporting women with learning disabilities. For decades, she continued to work with neurodivergent people who had intellectual and developmental disabilities and established Division 33 of the American Psychological Association, which focuses on neurodiversity. She was also a distinguished professor of psychology at Fordham University, where she was a mentor to both students and faculty. She was a tireless voice for justice and equality, especially for neurodivergent individuals. Dr. Hooker died in 2018 at the age of 103.

Microaggressions are a public health crisis

In clinical psychology, microaggressions are defined as brief and relatively commonplace daily verbal, behavioral, or environmental indignities and incidents, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color.

Individuals may engage in acts such as avoiding eye contact on the street or making assumptions about someone’s intelligence or mental state. This ‘subtler’ type of discrimination negatively impacts health outcomes. Microaggressions have been described as “death by a thousand cuts.”

Microaggressions tend to be harder to identify than overt racism, more difficult to confront or address, or both, because victims of microaggressions may have different perceptions and racial realities than those who enact them.

An emerging body of research has found that people of color experience an array of microaggressions, ranging from being assumed to be a criminal, being presumed to be cognitively inferior, being exoticized, or being treated as a second-class citizen. From locking of a car door when approached, to stepping away from someone in an elevator, being singled out by security at an airport, a supercilious tone of voice from those in authority positions, to being trailed around the store while shopping… these actions are injurious to the mental health of those who are being aggressed against and they have a cumulative affect on medical and mental health.

The connection between microaggressions and health
An alarming set of data shows that perception of racial discrimination from doctors is associated with reduced trust in mental health professionals/physicians, as well as reduced adherence to treatment regimens among Black American adults suffering from chronic disease. In fact, individuals who perceive their doctors as engaging in microaggressions generally do not return to treatment. With anyone.  See Dr. Siddique’s series of seminars: Minority Mental Health: Everyday Traumas and Microaggressions

Lack of trust in providers due to discrimination is also related to lower levels of screening for cancer, heart disease, and diabetes in Black Americans. Racial discrimination is linked to unhealthy behaviors such as overeating, consumption of fatty and fast foods, and decreased exercise. Repeated exposure to discrimination has also been linked to substance use, including marijuana, alcohol, and tobacco among Black American teens and adults.

The connection between microagressions and mental health
Research on microaggressions provides strong evidence that they lead to elevated levels of depression, anxiety, and trauma among minorities. In several large studies, depressive symptoms were the link in the relationship between racial microaggressions and thoughts of suicide.

Finally, one recent study showed that Native/Indigenous Americans diagnosed with type 2 diabetes experienced racial microaggressions from their mental health care and medical providers. Among those sampled in the study, a correlation was found between microaggressions and reported histories of heart attack, depressive symptoms, and hospitalizations.

What to do?
So, as professionals in health care, how can we work to minimize the physical and psychological harm of overt racism and microaggressions? First, workplaces and health care training programs (such as medical and clinical psychology training programs and nursing schools) can provide better training to employees and students. Such training must include information on the impact of racism and microaggressions on health outcomes and should also increase awareness of one’s own biases. Training should include dialogues and language designed to promote mutual understanding.

This should be facilitated by training experts and focus on the impact of overt racism and microaggressions. Supervision matters, with peer groups, clinical directors, instructors, and program heads. As I have spoken and written about elsewhere, intake processes for new patients very rarely assess for contextual and racism factors in the past.

Active inquiry about microaggressions in the daily and overall life of our patients is mostly missing and absolutely crucial.

Second, health care institutions can create online resources for employees, students/interns, and patients. For example, The New School University’s Health Services created a microaggressions site that assists students with understanding the nature and impact of microaggressions.  As a student, intern, and resident of several excellent programs, I received no training in this area. I had to cobble it together and seek at my own mentors. This should become absolutely mandatory for training and continuing education requirements.

Third, policymakers should consider creating policies that address IRL microaggressions. Similar to sexual harassment policies, racial microaggressions policies can be created to protect individuals/students/employees from experiencing micro-aggressions.

The Psychological Importance of Juneteenth

Juneteenth not only celebrates the freedom of Black Americans from slavery, but it also is a time when achievements are noted and continuous self-development is encouraged.

People dress with pride to show spirit, sometimes in African garments. This day of national pride is celebrated with food, music, games, and other activities to promote cultural awareness and community cohesiveness. Memories are shared for passing down to generations.

Black Mental Health and Juneteenth
From the clinical psychology research on Black mental health: (1) messages focused on instilling a sense of pride and learning about the history of one’s racial group (i.e., cultural socialization); and (2) messages focused on increasing youth’s awareness of racial discrimination and skills to manage it (i.e., preparation for bias) are BOTH powerful psychologically.

Overall, cultural socialization messages are associated with positive psychological and academic outcomes for youth. Preparation for bias messages are sometimes linked with positive outcomes, but there are mixed findings indicating these messages in isolation may not be consistently helpful for youth. One reason for these mixed findings may be because youth need a combination of messages that prepare them for racial discrimination along with messages that instill racial self esteem and pride. For example, if parents only provide messages about racial bias without messages focused on pride, it may lead youth to feel worried or hopeless. A combination of racial pride and knowledge and conversations about racial bias led to stronger mental health outcomes.
(For a great review on the research, see  Umaña-Taylor & Hill, Journal of Marriage and Family, 2020).

Additional ways to celebrate Juneteenth:
Vote.
Every time, every election.

Buy Black.
By buying black, people are also assisting in strengthening local economies and positive effects like the creation of more jobs.

Representation.
Promote Black images and experiences in advertising, social media, movies and shows, podcasts, and webinars.

Share resources.
Share information about housing, job opportunities, banking and loans, medical resources and clinics, agencies, and educational opportunities.

Intergenerational conversations.
Build relationships and communication between younger and older adults.

Destigmatize mental health.
Black people are far less likely to seek mental health care. Statistics show that about 25% of Black Americans seek mental health care, compared to 40% of white Americans. Unequal access to health care is one major contributor to this disparity. The lack of cultural sensitivity by health care professionals, feeling marginalized, a history of exploitation by the medical field, the reliance on family, community, and spiritual support instead of medical or psychiatric treatment are others.

Culturally responsive mental health treatment is one way of addressing the disparities in psychological wellbeing in the Black community. Finding and sharing information about culturally informed and responsive mental health professionals and agencies is vital. Also see Racial Trauma and Mental Health.

Strengthen Community.
Conversation around what people can do together that they cannot do apart should be mindful, intentional and strategic.

Racial Trauma and Mental Health

Meta-analysis reviews of racial trauma research unequivocally demonstrate symptoms that mirror post-traumatic stress disorder (PTSD):

  • Mental Health.
  • Psychologically, racial trauma can cause symptoms of post-traumatic stress disorder (PTSD).
  • Arousal: higher reports of somatization when distressed (e.g., stomach aches, headaches, rapid heartbeat).
  • Anger and disruptive behavior: more behavioral problems in children and teens
  • Chronic Stress: depression, anxiety, low motivation.
  • Hypervigilance: reduced ability to trust or form social connections.
  • Avoidance: less willingness to take academic risks, higher school drop-out rates after racial discrimination is perceived.

These negative psychological outcomes are not only present in adults, but have been found to appear as in children as early as 12 years of age. However, the toll of racial trauma and stress is not limited to psychological outcomes. The negative effects of racial trauma also affects physical health outcomes. These symptoms are often exacerbated by lack of access to adequate medical services.

Physical symptoms can include:

  • Physical pain
  • Cardiovascular Disease
  • Hypertension, with spikes in blood pressure following exposure to racist stimuli; blood pressure remains elevated after.
  • Respiratory Complications
  • Higher Allostatic Load (the wear and tear of the body caused by chronic stress) When the body is in a state of distress, it activates the stress response system, which helps us fight or get out of the stressful situations (a.k.a. fight, flight, or freeze). However, when experiences of stress are consistent and chronic, the stress response system becomes taxed and hormones can be unbalanced, exacerbating the physical illnesses and conditions listed above.
  • Digestive issues

See:
APA (American Psychological Association) Guide on the Effects of Stress on the Body
Racism, racial discrimination, and trauma: a systematic review of the social science literature, K.Kirkinis, August 2018. 
Mental Health and Black Patients: Survival and Stigma

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