Abstract
Using a narrative approach, this study explored how African American men became mental health advocates. This ancillary study is part of a formative within an ongoing community based intervention program that was designed to promote mental health of African Americans (AMEN) project within an ongoing community based intervention program that was designed to promote mental health of African Americans (AMEN) project. Narrative research techniques were used to analyze and synthesize the data. Analysis generated one major theme (interdependence) with four supporting sub-themes (credibility, social depression, stigma, and calling). These findings and insights through this qualitative study guided the AMEN project team to formulate effective communication strategies in establishing working relationships with community partners and wider stakeholders as well as crafting culturally tailored messages for African American participants.
Mental illness affects one in five (46.6 million) Americans each year (National Institute of Mental Health, 2017). The prevalence rates among African Americans (AAs) for any mental illness is similar to other ethnicities (Substance Abuse and Mental Health Services, 2017). Some research, however, indicates that treatment rates for AA with mental illness is only 1:3 (Dalencour et al., 2017), and when they do seek treatment, they suffer from poorer mental health (MH) outcomes (APA, 2017). Lack of awareness about MH and lower MH literacy are two causes cited for MH disparities (APA, 2017). Research has been conducted to understand why MH treatment/utilization rates are lower among AAs, however, little attention has been payed to race-concordant MH advocates, and no studies were found on how MH advocacy arises in the AA community. The purpose of this research is to better understand the process and motivation of AA men who became lay MH advocates by conducting narrative interviews with MH advocates currently working in AA community.
These interviews do not focus on the outcome (i.e. being a MH advocate) but rather on the events, motivations, and processes of becoming a MH advocate. Advocacy is defined as ‘the act or process of supporting a cause or proposal’ (OED, n.d.). Advocacy may be directed at political or institutional powers, or at raising public or community awareness. This current study grew out of an ongoing multilevel community based program designed for promoting mental health and wellness among African Americans (AMEN). The long term goal of the AMEN project is to reduce health disparities through comprehensive community-based programs designed to improve mental health and physical wellness outcomes of African Americans (AAs) with limited access to quality care. AMEN is an academic-community partnership designed to find effective, sustainable, and community-owned ways to address mental health. This narrative study grew out of deliberate conversations with AA mental health advocates who partnered with the AMEN project, and reflects our desire to listen, learn, and share the insights gleaned from attending to their stories. The men interviewed in this study are important bridges between MH treatment providers and the AA community, and may be crucial keys to understanding how to reduce MH disparities. Partnerships among advocates, researchers, clinicians and those affected by MH morbidity hold the keys to clarifying contradictions in the literature, and improving MH outcomes in AA communities.
Method
A narrative approach was used for this formative investigation to generate actionable data to improve mental health of African Americans. The narratives obtained from participants help to inform the details and nuances surrounding these men’s motivations to become MH advocates in their communities. This study is important because it offers practical insights into why each man’s MH advocacy arose. Making the decision to use one’s time, talents, energy, and other resources for the benefit of one’s community is a narrative worth knowing.
Sample
This qualitative study utilized purposive sampling, recruiting from a large city located in the Southwestern United States. Purposive sampling was chosen because of the specificity of the research question and the need to find participants who met the inclusion criteria. Inclusion criteria included AA ethnicity, male gender, and functioning as a MH advocate in the AA community. Exclusion criteria for this study included anyone currently experiencing psychotic symptoms, and anyone under the age of 21. Prior to enrollment in the study, potential study participants were contacted by email to assess interest, willingness, and availability to participate. Potential study participants were contacted based on current involvement in local mental health advocacy for AAs. in Basic demographic data was collected (age and education) but no personal health information was collected. Pseudonyms are provided in this study to protect the privacy of the participants. Interview participant #1 (‘Frank’) was in his 20s with 2 years of college. He came from a single-parent home in a very large inner city. His mother committed suicide when he was 19 years old. His father is serving life in prison. He formed his own organization to promote MH and suicide prevention. Interview participant #2 (‘Mark’) was in his 50s and is a PhD student and works for community MH organizations. He has a history of mental illness and numerous incarcerations. He also has his own nonprofit organization that focuses on substance abuse treatment. His interview was conducted by telephone because of Covid-19 while the other two interviews were conducted in person. Interview participant #3 (‘David’) was in his 40s, has a PhD, is a full-time pastor and civic leader in a large American city in the Southwest.
Procedure
The whole AMEN protocol including this formative study was reviewed by the Institutional Review Board (IRB)at the University of Texas at Austin deemed this exploratory project did not needed an IRB oversight.
Narrative is a form of naturalistic inquiry that involves asking participants to tell their own lived experience. The commonplaces of narrative inquiry were elicited through semi-structured interviews with an emphasis on open-ended questions. The initial temporality question for each semi-structured interview was: ‘Tell me what happened in your life to cause you to become a MH advocate?’ Follow-up questions were used to elicit the personal, social, and, physical commonplaces pertinent to the narratives. The interview included a semi-structured interview guide and lasted from 45 to 120 minutes. Two of the three interviews were conducted face-to-face while one was conducted by telephone due to the Covid-19 pandemic. Interviews were audio-recorded with a hand held recorder and with an additional smart phone voice recorder as a back-up. Observational notes were taken after completion of each interview. Each audio recording was transcribed verbatim into a Word document. Data was stored on a password protected computer and only accessible by the researcher. Interview recordings were destroyed after completion of writing. Trustworthiness of data management and analysis was enhanced by a computer program, (ATLAS.ti, Version 8), designed for qualitative research, and used to create an audit trail of how data was managed.
Data analysis
After identifying features of each narrative interview, themes related to process and becoming were compared across the interviews. Each field text transcript became an interim research text through coding according to seismic events (turning points), essential themes, and specific responses. After this, key ideas across the three sets of research texts were analyzed (by SY) through immersive readings and were categorized into themes that revealed psychological, familial, social, larger cultural contexts. Initial themes were discussed with the methodological expert, and with co-authors. Authors SY and MK discussed the research texts and the relationships among the themes and agreed upon the synthesis presented in this study. Upon completion of coding and analysis, the interim research text became the research findings of the study. Additionally, analytic memos were completed throughout the process of reading and comparing texts. These analytic memos provided a record of the process of identifying the theme and subthemes. Thematic analysis is not driven by a concrete set of analytic rules (Riessman, 2008). Thematic analysis illustrates ‘how stories can have effects beyond their meanings for individual storytellers, creating possibilities for social identities, group belonging, and collective action’, (Riessman, 2008, p. 54). The research texts were permeated with the importance of collective identity and belonging. This meta-finding was called ‘interdependence’ by the authors. Sub-themes were all seen to emanate from the primary theme.
Validity of the interpretation was managed by close and holistic reading/rereading of the interviews, testing texts against proposed interpretations (and co-interpretations), and through an expert consultant. The expert consultant is a qualitative research expert who provided guidance on methodology and interpretation of narrative texts. Additionally, because narrative is situated within each interviewee’s life, culture, and historicity, the researcher strove to be as context sensitive as possible. This is commonly referred to as reflexivity. Disciplined reflection of personal subjectivity and reflexivity was vital because this researcher’s nosology of mental health, community, and the act of becoming was limited by a different set of experiences, culture, and ethnicity. For example, I explained to research participants that I am a white, female, psychiatric clinician who shares no insider knowledge of being male, AA, or becoming a MH advocate.
Findings
Narrative data in these interviews consisted of three kinds of information: thick, thin, and omitted. Thick information was richly detailed (Geertz, 2003). Thin information was summary and lacking in detail (such as, ‘I went to school’, or ‘I lived in a socially depressed neighborhood’). Omitted information was simply what was left unsaid. Omission was less noticeable across a single interview than across several interviews. The participants each described their experiences growing up as an AA male in the United States. Each described the events that defined their sense of self, of racial identity, of place (community), and of purpose. The process of identifying the salient themes in these three narratives involved following the richer, thicker stories in the same way that a hiker might cross a stream by hopping from larger stone to larger stone. The commonly shared ‘thick’ descriptions became the theme and subthemes. One overarching theme (interdependence) and four subthemes (social depression, credibility, stigma, and calling) emerged from the data. These illuminated the motivations for becoming a MH advocate.
The interview participants had different experiences with MH/illness. One described his personal experience with mental illness. Another participant described a close proximal experience (MH problems arising within the immediate family). The third participant described his advocacy as stemming from vicarious experience (MH issues within a community). Becoming an advocate, therefore, did not depend upon a personal experience of mental illness. MH/illness emerged as a construct in each advocate’s world differently. The way each man’s world was affected by mental illness became a motive for his advocacy. Their individual advocacy is a form of translational partnerships between each man, and a broader community. The theme (interdependence) and subthemes (social depression, credibility, stigma, and calling) are presented and supported by narrative excerpts and have direct bearing on becoming a MH advocate.
Interdependence
Interdependence emerged as a prominent theme in the interviews because of the richly layered descriptions of life in their respective AA communities growing up. Dependence is a word that may have negative connotations because it implies being controlled by someone or something else. However, the word interdependence seemed to the authors to best reflect and honor the mutuality that was described. More significance was given to describing family, neighborhood, and other important communities (church, athletic, and educational) than to internal/psychological elements. The narratives depicted their journeys as socially rather than individually psychological. Interdependence considers ‘the relationships between people as important as the people themselves’ (Van Lange et al., 2014, p. 488). Interdependence was chosen because it best captures the synthesis of depending upon, belonging to, and participating in community. This paper does not attempt to apply interdependence theory to this analysis but rather elucidates the theme of interdependence which formed both the background to, and the motivation for becoming a MH advocate.
The AA neighborhoods that each grew up in contained numerous interconnected social support systems (family, neighborhood, schools, athletic organizations, and church/fellowship groups) which formed his social and psychological architecture. The interdependent community was a potent source of knowledge about how to respond to life’s challenges. Sometimes, however, dependence on the knowledge and values of the larger community functioned to limit the understanding of MH. For instance, seeking MH treatment was not socially sanctioned, whereas praying, going to church, playing sports were adaptive and accepted responses to MH needs, and drinking alcohol, smoking marijuana, or taking drugs were less adaptive responses to MH needs.
Interdependence describes the complex social matrix that both supported and limited knowledge. Mark described coming from a ‘strong’ family, but ‘. . . If a child seemed like they might have a little difficulty or, uh, uh, as
God and the church were the community-sanctioned referral source for a child with ‘a little difficulty’. One of the reasons interdependence upon a collective local network emerged as a high level theme to help solve problems stemmed from how hard life was socially and economically. Parents, who were spread-thin by working, depended on locally sourced, trusted partners (such as the church) when a child ‘had a little angst’. Mark later explained how time was a limiting constraint on treatment-seeking: So, mental health. . .Ain’t nobody got no time to, to, to go in there and complain about what you have and don’t have. And ‘I don’t need no medicine. I just need to work. I need to be able to pay my bills. I need to take care of these little kids’. . .The social determinants of health, uh, really affect those in the lowest social economic environment, especially those of in, in minority populations.
Parents were both poor and busy, and collectively depended upon one another to solve problems by relying upon socially prescribed answers (sending the child to talk to the pastor or praying more).
Thus, since interdependence was valued and important, Mark further described socially accepted ways to manage psychological pain through athletics, alcohol, drugs, and sex.
I went through, um, uh, what would be considered a sexual assault, um, as a child, um, so those things had, had changed me quite considerably. . . my mom just said that I was always angry, and she didn’t know what it was. And she just said that I needed more, more Reverend D., more, more church. There was no way that they could talk to me about it. Um, so, uh, naturally, I’m not gonna go talk to anybody because what you do is when you talk about it, you reveal. When you reveal, um, that makes you weak. And you have to remember, right? From the neighborhood, you can’t be weak. You can’t show a form of weakness. . . I was dealing with my difficulties, uh, from a mental health perspective and. . .from trauma. . .That eventually, uh, turned into substance use. . . I was able to find the thing that gave me comfort and it was
This lengthy quote illustrates how solutions to problems were generated by an interlocking network of communities (family, neighborhood, church, school, sports). Church and athletics were powerful ontological and epistemological sources of self-mastery, but other answers included drugs and alcohol. Because MH was not discussed Mark used the means available to him: church, drugs, and athletics.
In this next interview, Frank described how his advocacy was shaped by a highly interdependent group. His experience with MH was shaped by his mother who suffered from MH problems and who committed suicide when he was 19 years old. His mother overcame drug addiction by participating in an addiction recovery group. He described the social support he and his mother received from this community:
And we grew up going to these meetings with her consistent like every Thursday would probably be like two, maybe three times a week that we – it was always a place like church. . .It was minority-driven, and you know, what I would consider a trench of [our city]. . .So, it was really what I call a ‘culture of support.’ The. . .people, who I’ll call on ‘Uncle’ or ‘Aunt’ today, are people who my mother met through the fellowship. . .these
Notice, Frank does not say that they are ‘like’ family, but rather, they ‘are family’. He described an intentionally created community that served as a stabilizing force during his childhood and adolescence. His mother’s MH difficulties remained largely untreated psychiatrically, but this group was his extended family, and they provided critical support for him, and ultimately became the model for his own advocacy work.
Social depression and interdependence
Frank also echoed the influence of larger social factors on his path to becoming a MH advocate. He coined a term ‘social depression’ to describe the pervasive conditions he experienced growing up and which continue to influence the lives of many AAs. He articulated the argument that social depression precedes and obscures the capacity of many AAs to see mental illness as a disease state that exists only in an individual.
My mother was about 18 years old, and really just a product of her time. I’ll probably say this a lot, but what I call ‘
Social depression shares some features with the mental illness called depression (defined as: experiencing sadness/irritability, anhedonia, changes in sleep, appetite, energy, feelings of worthlessness, and suicidal ideation most days for 2 weeks [APA, 2013]). Social depression, however, is a phenomenon that exists broadly within a community over a long span of time. Given that the AA community has experienced sadness/irritability, anhedonia, and feelings of worthlessness across generations, it might be hard for many AAs to understand any idea of depression that is confined to an individual over a period of only 2 weeks. This concept of social depression appears to be related to why interdependence is so important. If ‘you’ve got a whole culture of people who are just trying to survive’, then it is easy to understand why the men interviewed kept returning to the importance of their groups. They echoed the old saying, no man is an island. This may be particularly true in communities where survival is more difficult and being part of a group helps to create safety by sharing burdens and resources.
David shared how vicarious experience with MH led to becoming an advocate. This participant serves as a pastor caring for parishioners with MH care needs as well as in civic leadership with the larger city-wide AA community. He described holding his city accountable for meeting the MH needs of the AA community. His journey to advocacy arose from the many roles he has within his communities. He also saw depression as more than an intrapsychic MH phenomenon. When asked about the most pressing MH needs in the AA community, David stated:
I would probably say depression would be a big one that I hear because again, I think, depression is
David identified depression not simply as an individual-level neuropsychiatric problem but one that comes from the ‘constant and a continuous being beat down’. Because he saw a connection between MH among minorities and the broader social determinants of health, he became civically engaged.
Credibility and interdependence
The second subtheme, credibility, was folded into the matrix of interdependence, with two reasons supporting each person’s MH advocacy. First, these participants believed that mainstream MH institutions lack credibility among AAs. Second, these participants have gained a hard-won understanding of MH care, and are thus credible community advocates. Each participant described how credibility was determined by his community. Credibility is not so much an issue of trustworthiness but about the perception of trustworthiness. For instance, although vaccines may be a scientifically trustworthy way to prevent disease, there are some groups/individuals who nevertheless do not trust the credibility of vaccines. The inverse is also true, a person or organization may present as completely credible and yet be untrustworthy. The US Public Health was a credible organization that proved to be untrustworthy during the unethical 40 year study of syphilis (Gamble, 1997). These participants described how their communities held overt and tacit perceptions about credibility and MH care.
Additionally, Mark and David discussed the legacy of family and cultural memory as important sanctioners of credibility. They did not overtly attribute their perceptions of the lack of credibility of MH care to a legacy of racial inequity in the US or to the trauma of slavery. However, ‘the trauma. . .[of] slavery, [is] not as institution or even experience, but as collective memory, a form of remembrance that grounded the identity-formation of a people’, (Eyerman, 2019). The MH care of AAs in the US has both implicit and explicit memories and antecedents that go back generations.
Skepticism of two cultural institutions were mentioned in these interviews: the police, and MH. According to Frank, MH earned a lack of credibility. ‘I think that’s
So, you take my-my situation, right, my mother, right?
Frank equated fear of MH treatment as being on par with fear of the police. He stated: So, now you’ve got
The beliefs held about MH care by the older generation were compellingly suffused with mistrust and skepticism that came from personal, familial, and historical events. Thus, while the scientific community may work very hard to produce evidence-based treatments for mental suffering, this may lack credibility within AA communities.
Mark compellingly juxtaposed credibility and mistrust, describing his experience with his own MH crisis. He described his concern about medication as stemming from a cultural memory of the unethical ‘scientific’ experiments known as the Tuskegee syphilis experiments conducted on AA men in the 1932 to 1972s in Alabama. The participant explained: ‘From the Black experience, there’s a distrust. There’s a, there’s a distrust and, “Why are you gonna give me that? I know what they do with those Tuskegee men.”’ (The Tuskegee test participants were AAs who suffered from syphilis. They were not made aware they were participating in an experiment, and many never received treatment for the syphilis even after penicillin was discovered.) These experiments profoundly contributed to the mistrust among AA of scientific research (Gamble, 1997).
Mark illustrates the tension felt by the interviewee between being told he had a MH condition that warranted life-long medication, and the trusted memory of his grandmother telling him he ‘aint got to do nothing but go to church’. Who should he believe? Who is credible?
‘You ain’t gonna give me that! Does this mean that we’ll be on this the rest of my life?
Pharmacological treatments for MH conditions was elaborated upon as lacking credibility. The following excerpt continues from above highlighting the trust/mistrust dynamic.
I remember, um, saying, ‘Fuck this. I will never take another medicine in my life. I will never tell anybody that I have anything to do with mental health. I will, I will reinvent myself, and that’s it,’ and that’s when I stopped. I stopped completely, uh, taking medicine. I stopped seeking assistance. I stopped reaching out.
The tension was between taking a medication (scientifically trustworthy) and ‘Jesus is my doctor’ (credible belief from his grandmother). About the prospect of achieving ‘homeostasis’ solely through MH medication, Mark stated: ‘If maintaining that success means they’re gonna take these pills the rest of my life, “Ma’am, I don’t know if I could trust you that that much.”’
In addition to the lack of credibility of medications for MH treatment, seeing a psychiatrist is also seen as negative. Mark stated:
While I was there, I spoke to a psychiatrist who. . .
Thus, at a particularly vulnerable place in Mark’s life, when his ‘tool kit’ was no longer working, he began to interact with the MH system. Even if the psychiatrist provided evidence-based care, he was not perceived as trustworthy because he did not seem to care. The experience left this participant feeling dehumanized and objectified. The gap in care may come from a lack of understanding of how psychological health is determined and defined by AAs. David discussed how the experience of being AA in the US shapes a different understanding MH.
What does it mean to understand, to deal with the racial implications of being an AA in the city? What does it mean to still experience racism? So, if I’m coming to a counselor who has none of those experiences and can’t relate, then you may be a well-qualified psychologist or psychiatrist but if you don’t understand the experience then I think there’s still going to be a gap.
This next quote will transition from interdependence and credibility to interdependence and stigma. Mark posed a compelling question: ‘And so now, my question is truly, is the, uh, low utilization service utilization of AA and Latinos in the field because of stigma,
Stigma and interdependence
Stigma emerged as a complex subtheme within interdependence. Stigmatization is defined as a socially assigned mark that designates (unclean, unsafe, suspicious) and devalues (Goffman, 1963). Because stigmas are shared at the group level, they are part of the interdependent understanding of MH described in the interviews. Some stigmatization of MH treatment was described as protective and derived from personal, family, and cultural memories of abuses suffered by AAs who received MH treatment. Additionally, however, stigma was also described as a painful barrier that prevented solutions to MH from outside the interdependent community. In this next vignette, Frank explained how intricately stigma and MH care were embedded into the psyche of AA community.
She (his mother) just has severe emotional imbalance. Um, and I think she, if she did get some medication, which I think made it worse. . .She should’ve gotten. . .checked in somewhere. . .Oh, my God! That was something that she did not want to do because she had been in treatment facility. She had been in rehab before. So, she knew that, at least in her mind, she was-she was worried about that. And if you want to go down to
This excerpt links the dread his mother felt about MH medication/treatment. Frank elaborated that for clinicians and researchers to ‘blame’ AAs for not seeking MH care is a form of victim-blaming. This quote illustrates the perception that stigma is protective and not just prohibitive. If AA communities share a collective belief that MH treatment is dangerous, this knowledge was derived from personal and collective experience. In the example above, his mother had her own memories of MH care. This quote is compelling as he wondered why the MH conversation is about what AAs are not doing to help themselves mentally (not taking medication nor seeking counseling). Frank asked why MH clinicians are not asking AAs: ‘What have you been doing to keep yourself strong against all odds for all this time?’
Stigma is cited by Mark as something like the straw that broke the camel’s back. He described multiple aspects of stigma emanating from numerous sources:
And that’s why I told you the story. . .about not wanting to take medicines. Well, it was how, um, I was treated whenever I was talking to the psychiatrist. It was how I was treated when I went to court. . .It was how I was treated by, um, the, uh, child’s mom and his grandmother and his family about, ‘Oh, well, you’re on medicine now.’ Before it was like, ‘Oh, well, you just smoke a little weed and do a little cocaine. Just stop that and you’re okay.’ Now, ‘Ooh, you’re on meds?’ You know what I mean? So, there’s multiple aspects of, of
MH diagnosis was thus associated with feeling devalued. Stigma was an important subtheme identified in these interviews because the participants understood how stigma is both protective and burdensome. The next section will discuss the relationship between interdependence and calling. These participants understood the stigma of mental illness (personally, or vicariously) which has contributed to their calling as MH advocates.
Calling and interdependence
The final section of the findings section details the sense of calling each participant felt prior to becoming a MH advocate. Calling is defined by the Oxford English Dictionary (n.d.) as ‘a profession devoted to the service of God. . .any profession or way of life which a person feels called or destined to pursue’. Receiving a calling can thus arise from God, a community, or an inward response to service. Calling, discussed in each interview, was rooted in interdependence (family, neighborhood, community, and church). This exerpt described Mark’s calling to advocacy as way of sharing his experience with others: I developed a ‘Wham Plan. And I, I developed a, a, a group of individuals that we liked and should call Recovery Capital and Human Capital. And today, I have found that I don’t have to take medicines anymore because I have other holistic ways of dealing with some of the challenges that I’ve had in the past. But I do know that I can always go back to that if I need it. Do you know what I mean?
Through ownership of his own journey and utilizing numerous tools (medication, accountability, cessation of drug use, social support, etc), he found a way to be mentally well. He became the ‘someone’ that others could rely upon. However, Mark’s journey took longer and was harder because he felt so alone, stating: ‘But not once did I ever, um, talk to or see anyone who looked like me that can tell me that they went through an experience that was similar to mine’. Because he never interacted with an AA MH professional, he wanted to help others:
I’ve always wanted to go work in a prison for a short time just because, uh, again, I wanna give back, but I also want that experience to be able to take into an
The calling felt by this advocate was implicit rather than explicit. He experienced the absence of race/gender concordant help when he was struggling with his own MH problems. Mark’s calling thus came from experiencing a void of like-minded help, and wanting to share his own experience with others.
Frank felt called to advocacy by God to honor his mother. He started an organization in memory of his mother to offer support for other AA males affected by suicide.
So, I knew that I needed to, we needed to plant a flag. We needed a legacy builder. We needed something or she would be forgotten. . .I started thinking about mental health, just different things. . .So, I started the group in her name. . .I’ve been able to speak about my neighborhood, right. And I-I envisioned my life, even well before she passed, as somebody who will speak into masses, who was speaking to people. And then I realized that this is the vessel. This is it for me. This was –God gave me these cards, you know, in this way. And I mean He-He just put everything in front of me and just took some time for me to actually be able to see what it was.
Frank’s advocacy was the dual call: (1) to honor his mother, and (2) to help other men in the AA community who have been affected by the suicide of a loved one.
The final vignette in this section described David’s calling to serve as a civic leader. In his role as a civic leader, he has been able to advocate on behalf of the AA community to a large civic municipality.
I’m looking at. . .trying to find the discernment process of AA pastors who have felt their call to ministry is into civic leadership. How do you pastor full time and also fulfill that calling to be a civic leader. . . It started here with a member. . .who came to me one day and said, ‘Hey listen, there’s a commission for the city that is concerned about the quality of life for AAs and I think you would be perfect to serve.’ I knew nothing about it, didn’t know what it was about and trying to figure out why they thought I should do it. After talking with him, I went ahead and said, ‘I’ll give it a shot and I’ll see what it is.’
The subtheme of calling emerged as an important aspect of interdependence and becoming a MH advocate. Mark, Frank, and David were deeply connected to a community. Each man gained important understanding about MH care, and desired to share his knowledge with his community. These narratives described the process of becoming a MH advocate in their AA community. In the discussion section, we will discuss why we believe MH clinicians should attend to their stories.
Discussion
This study offers MH clinicians and researchers valuable insights into the complex MH landscape inhabited by the study participants. The most important preliminary finding gleaned from this small pilot study was the discovery of the theme of interdependence. Interdependence is a theoretical construct developed by (De Lange, 1980) and used in social psychology to explain/understand the complexity of social life. Interdependence, the thematic superstructure, captured the role of community and social connection related to four subthemes: credibility, social depression, stigma, and calling. Together these concepts revealed the themes behind becoming a MH advocate.
Interdependence, accords with an Afro-centric worldview consisting of a fundamentally interconnected universe, with the collective forming the most important element of existence, and communal self-knowledge holding the keys to MH (Nobles, 2013). Optimal AA psychological functioning is derived from the unity of the family, community, nation, and race, along with the need of AA people to speak for themselves (Mattis et al., 2016).
King and Nobles (1997) coined the term, ‘culturecology’ to help explain the role of both culture and physical milieu on humans and to help researchers understand the role of health disparities in the AA community (Nobles et al., 2009). The culturecology model posits that people are cultural agents who develop a sense of efficacy, wellness, and humanity that is culturally defined (King & Nobles, 1997). The results of this study indicate that AAs have their own culturecology of efficacy, wellness, and MH. The MH care ‘establishment’ is outside the interdependent milieu of many AA communities.
Some of the complexities regarding AA and MH care will be briefly summarized. Their negative collective experiences with MH may also stem from the fact that AAs avoid seeking care when MH problems are more manageable, and thus have higher rates of psychiatric emergency visits and in-patient treatment (Bolden & Wicks, 2005). Psychiatric emergencies and forced in-patient hospitalization are more traumatic and this may contribute additionally to an overall fear of MH treatment among AAs. For these reasons, AAs possess their own culturecology of MH management. This study additionally confirmed the importance of AA memory complexes derived from personal, family/community, and cultural memories/historical events such as ‘Tuskegee’ (Gamble, 1997). These create problems with the credibility of MH treatments.
This study also found that current social conditions (including social disparities of health) influence the view that MH is partially a collective phenomenon and not solely intrapsychic and individually neurobiological. Frank coined the term ‘social depression’ to describe this collective phenomenon of ‘mental fatigue and immobilization’. Mainstream MH institutions posit psychiatric disease as an individual-level, intrapsychic disease that is best addressed by psychiatric care. The participants depicted a more collective and socially determined understanding of MH supporting the possibility that AAs may be suspicious of the idea that MH is solely neurobiological and best managed by a pill. Participants indicated that AAs may not have a siloed and privatized sense of MH. Because the etiology of mental illness, however, was not discussed in these interviews, any inferences about etiology cannot be drawn from this study. More recent research, however, has indicated that AA do correlate depression with psychosocial or neurobiological problems (Murphy & Hankerson, 2018). This study indicated that Mark saw the importance of psychosocial influences, describing MH as inextricably bound to the larger factors (stress, poverty, community, busyness, mistrust of MH institutions, faith, and social determinants of health). ‘The social determinants of health, uh, really affect those in the lowest social economic environment’.
These findings offer MH clinicians the opportunity to consider a different way to understand MH problems. These interviews challenged us to consider that seeing depression from the lens of the DSM is yet another way of discounting how profoundly the social determinants of health put entire communities at risk of social-level mental illness. Offering a pill to cure this could be seen as a truncated act that ignores the important social factors that contribute to mental unwellness. As Mark said, ‘Ain’t nobody got no time to, to, to go in there and complain about what you have and don’t have’. If many AAs experience the effects of collective social depression, it may be difficult to discern the individual-level mental illness defined by the APA as depression.
Thus, this small pilot study affirms the vital importance of interconnectedness. Not only does it inform the process of becoming a MH advocate, this study reveals how each advocate’s credible self-knowledge holds keys to improving communal MH. This study concords with other findings in the literature. Such as, if language is a potential barrier to understanding the MH experiences of AAs (Mitchell et al., 2017), then race-concordant MH advocates can help clinicians to better understand the concerns and symptoms of their AA patients. Additionally, this study affirms the role that the values of community in AA’s self-understanding of MH (Watson & Hunter, 2015). These study participants confirmed that communal values contributed to avoiding acknowledging MH problems. Additionally, Haynes et al. (2017) and Sullivan et al. (2017) both found that community members have deep insights into the MH needs and barriers. These MH advocates offered insights consonant with those studies.
The results of this study also add to the complexity of what is known about stigma by suggesting that MH stigma is both protective and prohibitive. This study affirms previous research that AAs hold more negative beliefs about mental illness (Alvidrez et al., 2009, 2010). Mental illness among AAs is associated with higher levels of stigma and lower levels of MH treatment-seeking behaviors (Link et al., 2017; Sirey et al., 2014). These differences in beliefs held by AAs may cause them to seek MH care at reduced rates (Gonzalez et al., 2011; Jimenez et al., 2013). However, the protective features of stigma have been less studied and stem from concerns voiced by Mark about historical abuses of AAs for MH research: ‘I know what they do with those Tuskegee men!’
This study additionally suggested that ‘calling’ functions as a feedback loop into the interdependent AA communities. Each advocate experienced MH problems directly or vicariously whichled to ‘insider knowledge’ of mental illness, suicide, MH treatment, etc. Each advocate now functions to bring his own knowledge back to his interdependent community by speaking about MH to other AAs.
This small pilot study offers glimmers of insight into how MH is seen by AAs and is part of a larger community-academic partnership. Future interviews on advocacy and community leadership roles will be conducted with community health workers trained by the AMEN project. Future interviews that include AA women who are MH advocates would also be necessary to clarify and challenge the findings from this study.
Limitations
The limitations of this pilot study include the small, intentionally homogenous study sample. The participants were adult AA men who are MH advocates. Because the population used for this study was restricted to males, the findings do not reflect why a female might become a mental health advocate. Additionally, interviews with each participant lasted only 60 to 120-minutes. The lack of follow-up interviews is a limitation of the findings. The sample size limits the generalizability beyond the AA men who participated in this narrative research pilot project in the year 2020.
Conclusion
These compelling narratives from three AA men who became MH advocates are important for MH providers/clinicians. MH clinicians who provide care for AAs must strive for cultural competence. Understanding AAs’ perceptions of psychiatric morbidity aligns with the Healthy People 2030’s key objective of preventing, screening, assessing, and treating mental disorders and behavioral conditions. (U.S. Department of Health and Human Services, 2020). AA MH advocates are important sources of knowledge about how MH care is understood within their communities. Improving clinicians’ understanding of AA perception of MH may be an important first step toward reach AAs who need MH treatment.
How can we best do this? One well-known MH researcher (Corrigan, 2016) suggested that policies and actions must be formed in partnership with those most affected. AA MH advocates must be heard because they possess the lived experience of the social conditions that produce the MH disparities. They offer researchers and MH clinicians important understanding of how to better care for AA clients. Corrigan (2016) recommends that clinicians and researchers learn ‘by getting into the back seat. People with lived experience need to be driving the effort to erase the stigma of mental illness. Nihil de nobis sine nobis (“Nothing about us without us”)’. Partnerships between clinicians and communities are the key to improving both understanding and outcomes in MH care for AAs. MH disparities are complex, and efforts to address them require conciliant and sustained efforts among the stakeholders: the community, healthcare, social services, academics, and local governments.
