Excerpt: The Intersection of Mental Health, Communities of Color, and Suicide
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The Intersection of Mental Health, Communities of Color, and Suicide
Recently, I was invited to Sacramento to address the Mental Health Services Oversight and Accountability Commission’s public hearing on suicide prevention. This oversight body makes key statewide policy decisions on how mental health services in California are funded. Specifically, the commissioners were interested in hearing about my personal experience as a suicide attempt survivor, my research on suicide in communities of color, and culturally responsive strategies for prevention and intervention that may address suicide in diverse communities.
During my presentation, I told the commissioners that while there are many things communities of color share, each community has a unique way of handling mental health and trauma. Therefore, I could not speak on behalf of all of these diverse communities, but instead I would speak from my own experience as a Black woman and suggest to include more diverse voices in the overall conversation. Below is my response to the questions raised, and recommendations for policy makers on suicide prevention approaches in communities of color in California. However, I believe this is relevant to a needed nationwide conversation on suicide prevention with marginalized groups.
More attention needs to be paid to how suicide/suicide attempts are experienced in communities of color. For many reasons, suicide is underreported in communities of color. There is a widespread misconception among many mental health professionals and researchers that suicide is not a problem in Black communities. However, this is not true. Recent studies show that nationwide, suicides among Black children under eighteen are up 71 percent in the past decade, rising from 86 in 2006 to 147 in 2016, the latest year such data is available from the Centers for Disease Control and Prevention.
The truth is, we don’t talk about suicide in the Black community, and if we do there can be consequences. When I was struggling as a teenager with suicidal ideations and eventually attempted, I heard a lot of problematic messages from my community. Black people don’t have mental health issues. We don’t try to kill ourselves. Get over yourself. Stop being so dramatic. Pull yourself up by your bootstraps. Pray it away. Take it to Jesus. Mental illness is a “white problem.” None of these messages were helpful. Eventually I started pretending that everything was okay so that I wouldn’t disappoint anyone or be rejected by my community. There is a huge myth that the mere mention of suicide plants the idea of suicide in someone’s head. This is not true, but could be one of the many reasons why people would want to avoid the conversation altogether. People are also afraid of saying the wrong thing. However, I know that because of the silence around suicide many people suffer in isolation.
Most of the time Black people are missing in the data around suicide, and “traditional research” does not always accurately capture our stories. During my work as a researcher and peer advocate, I interviewed Black communities in San Bernardino County with the African American Mental Health Coalition about suicide and mental health recovery. Young Black men told me stories of losing their friends to blue suicide. They explained that because they grew up in the church, and because faith-based communities warn of the “spiritual consequences” of suicide (e.g., eternal damnation), friends and family members who were struggling with thoughts of self-harm opted to intentionally antagonize police officers as a means to dying. This is called blue suicide. This concept came up across many interviews, because this neighborhood had lost several Black community members (mainly young Black men) to blue suicide. Community members shared that someone on the outside looking in would categorize these deaths as homicides, which demonstrates how suicide in the Black community is underreported. We have to get more culturally responsive approaches to data collection for communities of color to accurately reflect what’s really going on.
Trauma and the Label of Strong Black Women
For many Black women, like myself, there is a disbelief that we are struggling because we are “so strong” and “present well.” According to a recent New York Times article, Black women are more likely than white women to have experienced post-traumatic stress disorder resulting from childhood maltreatment and sexual and physical violence, and are more likely to have stress related to family, employment, finances, discrimination, and/or racism. Yet fewer than 50 percent of Black adults with mental health needs receive treatment. Barriers include mental health stigma and shame. Black women also prefer Black mental health care providers, and there are not enough. Many of us suffer silently, because we have to keep our families together, hold it down at work, and show up for our communities. Even though many of my Black sisters have experienced trauma, discrimination, and racism, many are more focused on taking care of others, and not their own self-care. If we could shift the paradigm that asking for help is a strength not a weakness, we might be able to reduce suicide attempts. However, when we are ready to reach out for help, the help needs to be there ready for us. When I was struggling with suicidal thoughts after a traumatic experience, I sought help at a psychiatric hospital. Unfortunately, the staff thought that because I was able to articulate my suicidal thoughts and depression, I couldn’t be struggling. They were “culturally irresponsible.” They ignored my mental health crisis, because I didn’t look or act like some cast member of a Lifetime movie. I, like many Black women, “present well” and look put together. This means my pain often goes unseen. Shortly after being dismissed from needing care for being too “high functioning,” I was sent back to this very hospital after a suicide attempt: the very thing I was trying to prevent.
How Communities of Color Present in a Crisis
For many communities of color, mental health and crisis present differently. What someone may view as “angry” or “aggressive” might actually be trauma. There is a high correlation/connection between trauma and suicide attempts and deaths by suicide (youth and adults). There is also a high correlation between experiencing racism and traumatic stress. Because of a myriad of reasons (e.g., implicit bias) if communities of color cannot access mental health services because they aren’t presenting in a way that is recognized by providers, they are at risk for receiving mental health services in emergency room settings or in the criminal justice system. Trauma-informed approaches across the life span can address the issues driving suicidality. Trauma-informed approaches first acknowledge trauma and respond by fully integrating knowledge about trauma into policies, procedures, and practices to actively resist re-traumatization. Trauma-specific treatments such as eye movement desensitization and reprocessing (EMDR), somatic experiencing, and Intentional Peer Support teach a trauma-informed relational approach. Additionally, supported decision-making and collaborative approaches to care are needed. I’ve personally benefited from trauma-informed therapy. I used to think recovery meant not ever being in a dark place again. I was wrong. Recovery, for me, is about the choices you make when you are in those spaces. For me, healing was developing boundaries, seeking trauma-informed therapy, removing toxic people from my life, increasing connection, poetry, and singing. I have created a safety net to catch myself.
Recommendations for Policy Makers
As a mental health advocate who has benefited from connecting with mental health advocates statewide, I thought it would only be appropriate to include them in this conversation about what should be considered in the suicide prevention plan. The following are culturally relevant strategies for prevention and intervention that may more effectively address suicide and suicide attempt in diverse communities. Thank you to all of the peers, family members, therapists, crisis intervention service providers, suicide prevention hotline workers, suicide attempt survivors, and suicide loss survivors who contributed to this response.
CULTURALLY RELEVANT STRATEGIES FOR SUICIDE PREVENTION
• Consider employing culturally specific mental health ambassadors to support suicide prevention planning. While there are many things that communities of color share, each of these communities has a unique way of dealing with mental health and trauma. Include people from these diverse communities as mental health ambassadors and connectors to learn more about what works for them (e.g., art and healing, culturally specific practices).
• Involve the voices of suicide attempt survivors and suicide loss survivors. Each county should have consumers and family members representative of their “isolated and underserved” communities involved in suicide prevention planning. It is important in communities of color to also authentically engage suicide attempt survivors of color (e.g., clear roles and responsibilities) to mitigate the experience of “tokenization.”
• Develop culturally specific suicide prevention outreach tools that feature communities of color. Suicide prevention needs faces of color and messages that will speak to these diverse communities. PSAs, social media, billboards, radio ads can help normalize the conversation and let people know that suicidal ideation is something that many people experience. Include messaging that says they are not the only one or not alone and resources for help, and ensure these messages are available in many languages.
• Create opportunities for people of color (POC) with lived experience or survivors to connect and share their experiences in safe spaces like support groups. This may help decrease stigma and isolation, increase knowledge of wellness tools, and normalize the conversation around suicide in diverse communities.
• Alternatives to 911. For many communities of color, calling police can escalate situations, and many may avoid seeking help through this venue. Can the suicide prevention plan build networks of mutual aid and crisis support from the community? This should include outreach materials that provide information on alternatives to 911.
• Strengthen discourse and 5150 education for law enforcement. A careful assessment is needed when writing a 5150.4 Sometimes an individual may appear to be a harm to themselves or others because they are intoxicated, which can lead to a 5150. In other cases, where individuals are suffering in silence and hopelessness and potentially a rapid cycling in and out of psychiatric hospitals, their needs are not addressed, and they are not given the support they need. Oftentimes putting people on 5150 and placing them in a locked psych unit exacerbates the issues. What can we learn as a community around this topic?
• Recognize that “outcome-based/evidence-based practices” are not always responsive to what consumers need in the moment. Develop culturally responsive research that includes what is working right now and what consumers need from people on the front line, such as crisis, warm line, and hotline workers. (A warm line is an alternative to a crisis line that is run by peers.) Involve consumers in how they measure their own success.
• Increase overall capacity for county crisis support services. Statewide, crisis support services like warm lines, hotlines, crisis text, and crisis clinical services are seeing a severe increase in both need and calls (e.g., Alameda County Crisis Support Services had 457 calls in January, and in March of 2018 had 832 calls). In order to meet the needs of these services (many of which are volunteer run), these nonprofits need more human resources, funding, and sustainability approaches to attract and maintain staff. Additionally, these groups need bilingual and bicultural staff to respond to the linguistic needs of diverse communities to provide a better option than tele-interpreters.
• Strengthen data collection on suicide deaths by incentivizing partnerships with coroners’ offices.
• Financially incentivize and hire more diverse peers and other behavioral health providers. This also includes members from the LGBTQ+ communities.
• Partner with primary care doctors and faith-based congregations/ leaders on how to recognize early warning signs and connect their members with mental health support. Learn from existing national and local models like Mental Health Friendly Communities (training for faith leaders).
• Create clinical support training for first responders like EMS/ EMT and ER nurses who often interface with mental health consumers after a suicide attempt but don’t have training on how to triage or support them.
• Provide information and resources to family/friends/loved ones helping someone who is suicidal. Providing support to the loved ones of those who are suffering is important. We need to educate and be more supportive of family members, caregivers, and friends who are supporting the individual who is at risk for suicide. Include wellness and self-care resources for the families that may be experiencing secondary trauma.
• Develop several options for suicide prevention trainings. Provide options for brief training on suicide prevention, from “what to say to someone who is suicidal” to more intensive training like “assessment tools.” Ensure trainings are free to the community, and host suicide prevention trainings for adults and youth of color.
• Establish Statewide Peer Respite Centers. Many mental health consumers are traumatized by their experiences in hospital settings. Peer respite centers can offer a homelike environment that can be an alternative in a crisis. Consider investing in crisis respite programs to divert from the emergency rooms, and decrease reliance on inpatient locked facilities.
• Integrate the Zero Suicide model in all inpatient hospital programs.
• Partner with universities to integrate mandatory intensive and robust suicide prevention training into the curriculum for all providers interfacing with mental health consumers, including clinical interns. Trainings should include the intersectionality of systematic oppression, classism, racism, sexism, historical trauma, transphobia, and homophobia as risk factors for suicide. Provide ongoing support for providers’ professional development.
• Provide more education and training on assessment for suicide risk; ensure it includes cultural considerations. More educational support around assessment for suicide risk is needed. Individuals at risk for suicidal ideation, intention, or completion of suicide look different. There are cultural differences in relation to religious beliefs about dying and worldviews related to individuals’ racial identity. This will aid clinicians in providing more thorough assessments as well as other service providers and officials who may come into contact with an individual who is at risk. Suicide is preventable, and it starts with how we assess for suicide risk.
We have to normalize the conversation about suicide in diverse communities and create a culturally informed safety net to catch people. If we create a responsive mental health system and also decrease the stigma of suicide, maybe more people will speak out when they are in pain. Maybe more people will stay. It is a difficult and worthwhile fight, but I trust that each community has its own solution within. If policy makers are truly interested in investing in the mental health of diverse and marginalized communities, they need to trust that these communities have wisdom and follow their lead into tangible results.