For the past nine weeks, WFAE’s series “Fractured” has been exploring problems with North Carolina’s mental health system. Inequities in the system include disparities in access and quality of care. People of color often face barriers when seeking treatment.
We’ve invited Vic Armstrong to discuss this issue. He’s the former director of the Division of Mental Health for North Carolina’s Department of Health and Human Services and a former vice president of Behavioral Health for Atrium Health.
Now he’s the director of Soul Shop for Black Churches. It provides culturally-relevant training for pastors and lay leaders in dealing with suicide.
Marshall Terry: So my first question, explain "culturally-relevant training," and why is it that you feel there's a need for this type of training?
Vic Armstrong: I guess I would take a step back because as we talk about culturally-relevant training, the thing that usually comes to people's minds is trying to provide culturally-competent training. And I think culturally-competent training is something that's really been overused because we tend to think about culturally-competent training more in terms of speaking the language or learning the buzzwords or learning what not to say.
Culturally-relevant training, to me, it's really more about taking into account the lived and living experience of a particular group, as you try to educate and infiltrate and talk about things that are relevant to that community.
Terry: And why do you feel the need for this type of training?
Armstrong: Well, we look at suicide or mental health services in general. One of the things that we don't often consider is that people don't come to this conversation from the same place. They don't come to with the same readiness to talk about it. And so when we have one approach, we forget sometimes that these are conversations that may be far into certain segments of the population, at least in the context of how we talk about them.
You know, for example, when I grew up in rural North Carolina as the son of a pastor, we didn't talk about mental health. We didn't talk about suicide. If we did talk about suicide, it was simply that Black people don't die by suicide, that it was a white problem, and that if you did die by suicide, you were destined for help. That was the bulk of the conversation. We didn't talk about depression and we didn't talk about anxiety because we were socialized to believe that if you were Black, you were resilient and that you should be able to overcome depression and anxiety because we come from people that have overcome slavery.
So you should be able to overcome anything, which in turn means that for a lot of young people growing up in Black and brown communities, the message that they have received all their lives is that you don't have the right to be depressed. You don't have the right to experience anxiety. And if you don't come to the conversation with that context and understanding, you can lose people in trying to educate people about mental health services.
Terry: Is there a greater stigma in the African American community or communities of color, for that matter, of having a mental health diagnosis than there is in the white community?
Armstrong: I would characterize it as greater, but I think it is definitely safe to say it's a different kind of stigma. Oftentimes in the Black community, mental health challenges are associated with moral or spiritual weakness. Depression is perceived as just a part of getting old. There's also this perception that people in Black and brown communities oftentimes don't recognize anxiety or depression in the same way that people in other communities do. In part, it's because, it's not that we don't necessarily recognize depressive symptoms, but we normalize them because so much of what we've been socialized to accept in the Black community and brown communities is that there will always be things that will be difficult for us.
I think also, you know, for me as a Black man, I've been socialized all my life to believe that the way that you survive in America as a Black man is you keep your mouth closed, you keep your head down. That is not something that lends itself very well to being open and honest about being vulnerable to mental health challenges.
Terry: Well, you brought up equal access there a moment ago, and that's where I want to go next. African Americans are disproportionately more likely than other groups to not have access to mental health care. Why is that and what is the impact of that?
Armstrong: Mental health services are not usually being carried out and conducted simply because is the right thing to do. It's like other things. It's a business. Businesses locate in places where they feel that they have access to the most profitability. So for a lot of providers, they don't choose to locate in Black and brown communities if those Black and brown communities are perceived as being higher crime areas. They want to locate in safe, well-lit neighborhoods.
There's also this perception, real or otherwise, that people of color don't access services. We know statistically that Black people are less likely to initiate services and more likely to terminate services prematurely. So there is a perception that you don't get as much specialization of your business if you locate in Black and brown communities.
But there are also things like the fact that Black and brown people are much more likely to be uninsured or underinsured. But I think the other piece that we have to think about is that access is not just about physical proximity to traditional resources. Access is about resources that are relatable to my life experience, resources that I am willing to utilize.
And so I think when we think about how we create more access to resources in Black and brown communities, I think we need to think very differently about what access is and what access should look like. One of the things that we learned from the COVID pandemic — I was working for the Department of Human Services — and one of the things that we learned very clearly from COVID, when we saw the disproportionate impact on Black and brown communities, even when we sought to try to address those concerns, we found that there was not a trusted relationship with those communities. It was not until we were willing to take a step back and look at 'How do we need to partner with communities and provide access in a way that makes sense to those communities?'
It wasn't until then that people really began to access those resources. We had to think differently about the media outlets that we utilized. You know, we use urban radio differently than we had in the past, periodicals and newspapers that occur in different communities and segments of the community.
We had to think differently about not only what was a trusted message, but who was a trusted messenger.
Terry: We've talked about the lack of insurance being a barrier. We've talked about stigmatization being a barrier. But what are some of the other barriers that you see with African Americans and other people of color in getting mental health treatment?
Armstrong: I think we cannot overstate the importance of access. When you think about the fact that, you know, Black people, in particular, don't access mental health services at the same rate as our white counterparts and that we are more likely to terminate services prematurely, I think part of what you also have to think about is the fact that if you have to take three buses to get to your initial appointment, you are going to be much less likely to keep that appointment. And if you keep that appointment, you're going to be less likely to come back for subsequent appointments.
The other thing that I think we have to think about — a couple of things — one, is that we, in this country, don't have a lot of providers of color. So one of the challenges is when I don't see someone who looks like me as a resource for me or as an option for me, I'm going to be much, much more likely to want to go someplace where I think people understand my history, my culture.
Some of the most recent data I've seen is that only about 4% of psychologists in America are Black and only about 2% of psychiatrists. You know, I am a clinical social worker by training, so I am the first to tell you that I believe a good clinician is a good clinician. I believe that you can treat people who don't look like you. But we also have to think about the fact that for those communities of color, it's not just about whether or not that provider is willing to see a person of color. That provider can meet that person of color where they are. There's also the question of 'Can that community meet their provider where they are?'
You know, as a 50-something-year-old Black male, it would be very difficult for me, the first time, to walk into the office of a blonde-haired, blue-eyed, 20-something-year-old white female clinician and sit on her couch and tell her, 'I cry all the time, I don't feel like getting out of bed in the morning or my sex drive is low.'
Those are difficult conversations to have with anyone, let alone when you're being asked to have that conversation with someone who you don't believe really understands or appreciates what even you're setting foot in her office means to you.
