Three years ago, Victor Armstrong, MSW, Vice President of Behavioral Health at Atrium Health, launched Let’s Talk, a platform for in-person discussions on the intersections between organizational culture, implicit bias, and mental health crises. At the time, the Charlotte, NC, community was reeling after police officer Brentley Vinson killed Keith L. Scott on September 20, 2016, and tensions began to rise around the issue of race and the use of deadly force by police officers. The strain was exacerbated by heated political rhetoric stemming from the 2016 presidential race. Silence, says Armstrong, wasn’t going to improve the situation. Initially, his objective was to open up dialogue on how these events were affecting staff at Behavioral Health Charlotte, the Atrium Health facility that Armstrong oversees. Since then, he has taken the conversation on the road, traveling throughout the community and into other states to provide a safe space for behavioral health stakeholders to have vital conversations about assumptions and beliefs. The dialogue doesn’t just include mental health professionals but also healthcare providers and police officers. The challenge, says Armstrong, is that talking about implicit bias—automatic connections stored in people’s minds outside of their conscious awareness—is not easy. “How do we talk about our implicit biases when we aren’t aware we have them or even what they are?” The first step, he says, is recognizing that all humans have biases and that society plays a significant role in how we develop them, particularly when it comes to cultures we are not members of; though Armstrong is quick to point out that people can be implicitly biased against their own marginalized group and even themselves.
When examining implicit bias and the trajectory of people in crisis, Armstrong says experts can’t ignore how a person of color enters the system. He says people of color often don’t have access to crisis services within their neighborhood, which makes it more likely that they will end up in the nearest emergency department or encounter law enforcement, entry points where implicit bias can produce and compound negative outcomes. Putting together heatmaps of crises and zip codes, Armstrong and his colleagues discovered a crescent that runs from the eastern side of Charlotte and rainbows across the north of the city over to the west: they are all areas in Charlotte that are economically deprived. “When we identified where people who frequent emergency departments reside, and then we laid it atop of the crescent area, we discovered they were nearly identical. Yet our hospitals and outpatient medical care facilities are not based in those areas, and neither are our outpatient behavioral health providers.” The patients these hospitals are serving often live in the crescent area, but the providers they need are elsewhere. The reason, says Armstrong, is that hospitals and community resources are typically built in safer, more affluent neighborhoods where they have increased access to resources. “We are driving marginalized patients who are un- or under-insured into our emergency departments because they don’t have any other options.”
Armstrong says an intersection where implicit bias can be particularly dangerous is when a person of color in crisis encounters law enforcement. He says while officers are increasingly trained in crisis intervention, those assigned to communities of color tend to be younger and have less experience. Police officers participating in Let’s Talk conversations have shared that seasoned officers are often able to choose where they police and generally prefer beats in safer, wealthier areas. “That means inexperienced officers, who are more apt to be reactionary and less sure of themselves, are assigned to socio-economically deprived communities. This creates the perfect storm when marginalized people of color experience a behavioral health crisis and come into contact with less experienced officers who are more likely to be in a hyper-vigilant state and default to whatever implicit biases they may have, which can impact life-altering decisions he or she makes within a fraction of a second.” He says it’s not that police officers are somehow predisposed to having implicit bias but that officers, just like everyone else, are part of society as a whole where implicit bias is prevalent.
Even professionals in the mental health sphere trained on cultural competency have implicit bias. Armstrong says that one of the earliest Let’s Talk discussions revealed a perception by Armstrong’s teammates that behavioral health professionals they worked with were more likely to give sedative injections to Black males in crisis than any other population who came into their psychiatric emergency department. When peeling back why, participants said their colleagues perceived an increased need to calm a Black male down quickly before he escalated to the point where he could be violent or difficult to control. Armstrong says what was even more shocking is that some of his colleagues acknowledged that some who succumbed to the fear-based preemptive measure were themselves people of color. “Implicit bias runs deep, and it even affects our thoughts on people within our own population. While clearly anecdotal, I realized if this happened here with a diverse group of mental health professionals, including those of color, well, it no doubt was happening elsewhere.”
Lack of Representation and Difference in Communicating Symptoms
Armstrong says implicit bias of people of color is particularly problematic in the behavioral health field where there is a dearth of diversity among mental health professionals, resulting in a lack of representation and cultural competency. In 2015, eighty-six percent of psychologists in the United States were Caucasian, four percent were Black, five percent were Hispanic, and five percent were Asian. “The percentage is about the same for Black social workers but even less among psychiatrists at around two percent. During a behavioral health crisis, people of color are going to a psychiatric or medical emergency department where the people treating them likely don’t look like them.” Armstrong highlights that research on psychopathology and medication management has been based on European models, specifically White males, and has not, for the most part, included minority populations. Without awareness of how people of color may describe their behavioral health symptoms, clinicians are more apt to misdiagnose them, which can have dire consequences. “Providers and their clients of color don’t describe symptoms in the same way, which has resulted in clinicians misdiagnosing Black males with Schizophrenia or antisocial personality disorder more than any other ethnic group.” Armstrong says a Black man may describe the pressures he’s facing by talking about current politics, employment issues, and violence in his community. He says the patient may sound like he’s coming from a position of anger or even paranoia, but, instead, he’s merely communicating the experience of a Black man in the United States. Women of color are more apt to describe physical symptoms of depression, such as stomach aches and headaches. “What clinicians need to ask themselves is, ‘How do we hear the information the patient is sharing?” The patient may be describing his or her symptoms of anxiety or depression but may not talk about it in those terms. Armstrong says this is because of mental health stigma within the Black community. “We don’t talk about mental health issues or depression and think that since we survived slavery, we can survive anything and are supposed to be more resilient.”
Mental Health Stigma in Communities of Color
Armstrong says it’s essential to look at mental health stigma in minority communities and the impact on when and how a person of color enters the behavioral healthcare system. He says that while Blacks are 20% more likely to report psychological distress, they are less likely to initiate treatment and more likely to end treatment prematurely. In the 1990s, a public opinion poll revealed that 63% of Blacks surveyed believed depression to be a sign of weakness. “People of color may not seek help until they are in crisis, which means the entry point is most likely to be the emergency department or by encountering law enforcement. They are being introduced to the system at an entry point that’s not most conducive for optimal outcomes.” More recent studies illustrate there has been a shift where Blacks are more likely than Whites to believe mental health professionals can help people with mental illness but also perceive that mental health problems can resolve on their own. As a result, Armstrong says they are less likely to use mental health services, which is exacerbated by a lack of representation in the mental health profession. “These two issues play upon one another, impacting the comfort of people of color seeking help before they get to the point of crisis.”
Fortunately, dialogue on mental health in minority communities is increasing. Armstrong says when he speaks to people in his community, focusing on statistics has been helpful to move the needle. “When I share that suicide among our children, ages 5 to 12, is twice that of White children, it gets people’s attention and helps to dispel the myth that we aren’t impacted by suicide or depression.” Armstrong says that vocal celebrities sharing their Lived Experience has helped chip away at stigma, including Serena Williams on her experience with Postpartum Depression and Taraji P. Henson on struggling with anxiety and depression. Henson founded the Boris Lawrence Henson Foundation (https://borislhensonfoundation.org/) to eradicate mental health stigma in the Black community, naming it after her father, a Vietnam war veteran who experienced PTSD and Bipolar Disorder.
Faith-based Partners in Communities of Color
Armstrong says there is an understandable lack of trust of White paternalistic attitudes in communities of color. “Implicit bias draws from the historical context of slavery, Jim Crowism, racial segregation, socio-economic disadvantages, and housing disparity. All of which drive a chasm between the provider and patient.” That’s why Armstrong works alongside faith leaders in churches, mosques, and synagogues to facilitate conversations because often it is they who their members may turn to before anyone else. He’s found that focusing dialogue on the terminology mental wellness instead of mental illness has helped engage more participants. There is a movement toward integrative behavioral health, collaborating with general medicine, social services, and law enforcement, but Armstrong says what must also be included is finding ways to amalgamate behavioral healthcare into the community. “How do we integrate these resources into the churches, YMCAs, and community centers?” He notes that people of color are more likely to keep a therapy appointment if they can do so from the safety and comfort of their church. “They are more likely to hop onto a computer from their church than to get on a bus and go across town to speak with their clinician.” Not only might faith leaders be the first to potentially identify a member experiencing a crisis but also by getting people the care they need earlier, and where they are more apt to access it, Armstrong says it can also keep people from entering the behavioral healthcare system through law enforcement or the emergency department.
Check Your Bias
Countering implicit bias takes training and forethought. Armstrong says law enforcement and people in the medical community are taught to be people of action who address what’s in front of them. The environment is often too quick paced for people to immediately breakdown discrepancies in their behavior, and that’s why people need to address their biases beforehand. “Take steps to learn your biases before you’re in a work situation where they can harm the person in crisis you’re supposed to be helping.” He says that in the mental health field, only 10 percent of what impacts outcomes occurs inside treatment facilities, which means clinicians often miss a large part of what brought the person there in the first place. “You have to be Trauma-Informed and examine the person holistically, looking at what happened to bring him or her to that particular moment.” He says that checking biases also means slowing down enough to anticipate what may trigger trauma in patients or understand why a person who has been disenfranchised and discounted may reject being told what to do, even if that suggestion may appear to be in his or her best interest.
Armstrong says a Trauma-Informed approach is a counter to implicit bias. He says that in addition to a clinician examining his or her biases, it’s critical to also look at where a patient is coming from with compassion as opposed to what’s wrong with him or her. For example, a patient may show up late for an appointment, and the clinician doesn’t want to see him, requiring that he reschedule. “That clinician isn’t taking into account that the patient had to take three buses in the rain to get to her. If we don’t consider those challenges, we are often retraumatizing our clients just by how we treat them when they’ve made every effort to show up.”
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