a critical approach to stress-related disorders in african ... - NCBI

A CRITICAL APPROACH TO STRESS-RELATED DISORDERS IN AFRICAN AMERICANS Jacqueline S. Matfis, PhD, Carl C. Bell, MD, Robert J. Jagers, PhD, and Esther Jenkins, PhD Ann Arbor, Michigan and Chicago, Illinois This article outlines an integrative, dynamic approach to stress and is, in part, a response to emergent debates within social science research and practice that suggest that African Americans are currently experiencing the reverberating psychological effects of slavery and oppression. It is the product of the work of an African-American mental health think tank situated at the Community Mental Health Council, Chicago, Illinois. We suggest the need to attend to biopsychosocial, environmental, and cultural factors that inform both exposure and responses to stress. Finally, consideration is given to matters of resiliency. (J Natl Med Assoc. 1 999;91 :80-85.)

Key words: post-traumatic stress disorder * stress * African Americans Over the past six decades psychologists and psychiatrists have attempted to explicate the impact of systematic social, political, and economic marginalization on African Americans.' Recently, a number of mental health professionals have proclaimed that as a result of slavery and its sequelae, African Americans collectively suffer from post-traumatic stress disorder (PTSD).2 Many of these historic, psychological approaches have been too simplistic. Nonetheless, they have raised important questions about the psychological and physiological effects of acute and sustained exposure to stress. Further, the increasing attention being paid to these historic-psychological approaches highlights the need for a critical, integrative approach to stress. In this article, we endeavor to weave together a number of existing approaches to the study of stress in the lives of African Americans. Hence, we proffer an From the Departments of Psychology and Women's Studies, University of Michigan, Ann Arbor, Michigan; and the School of Medicine and the Department of African American Studies, University of Illinois, and the Department of Psychology, Chicago State University, Chicago, Illinois. Requests for reprints should be addressed to Dr Jacqueline S. Mattis, University of Michigan, Dept of Psychology, 525 E University Dr, Ann Arbor, Ml 48109-1109. 80

approach to stress that appreciates the dynamic interplay between culture, environment, family, community, and the individual well-being of African-American people. It is not our goal to provide a critique of the slavery-PTSD hypothesis. Instead, we offer this work as both an alternative to that hypothesis and as a caution to social scientists who overemphasize slavery while underemphasizing the significance of current stressors in the lives of contemporary African Americans. Excessive stress refers to any event or experience that taxes the cognitive, physical, or psychological resources of an individual.3'4 Within mental health research and practice, racism often has been privileged as the form of stress that is most important in shaping the psychological experiences of African Americans. The effects of racism and other forms of oppression should not be underestimated. However, several problems are associated with the tendency to identify oppression (particularly racism) as the sole or most important cause of despair faced by many African Americans. First, the virtually exclusive attention to the deleterious effects of racism undervalues the effects of other stressors including environmental and social stressors. Second, traditional treatments of racism often obscure the fact that race and racism do not have the same manifestations, meaning, importance, or salience for all African-American people (Sellers R, Smith M, Shelton J, Rowley S, unpublished data, 1996). Finally, traditional treatments of racism ignore the hetJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 2

AFRICAN AMERICANS & STRESS DISORDERS

erogeneity of African Americans. These approaches shift attention away from individual-level differences in experience and status (ie, differences in biopsychosocial status) that help to explain the broad range of responses that African Americans have to stress.

EXPOSURE TO STRESS Environmental factors such as family context, social support networks, and neighborhood conditions have important implications for individuals' exposure and responses to stress. For example, toxins (eg, lead) encountered in the home, at school, or in the community may affect an individual's psychological functioning and the ways that they respond to stressful events.5 In addition, exposure to violence, including neighborhood violence, places individuals at risk for developing a range of stress-related disorders including learning disorders, somatic complaints (eg, stomachaches), anxiety, depression, PTSD, and brief reactive psychosis.6 Such disorders are responses to stress. However, they also mitigate a person's ability to effectively respond to stress. Neighborhoods and families that experience high rates of violence may provide chronic reminders of stress and victimization. Some neighborhoods also may serve as contexts for repeated exposure to environmental stressors (eg, exposure to toxins such as lead, toxic fumes that emerge from proximity to highway traffic, and improper waste disposal) that eventually have a cumulative, deleterious impact on individuals. In contrast, neighborhoods and families that are safe (or those perceived as safe) may give individuals who are exposed to excessive stress time to recuperate from their stress before they are faced with more trauma.7 Safe environments also may provide for healthy interpersonal exchanges (eg, caring and sharing), which may promote positive outcomes. The proximity (direct versus indirect), duration (acute versus chronic), and quality (traumatic versus nontraumatic) of exposure to stress are important valences along which to evaluate the impact of environmental stressors. Chronic, indirect exposure to nontraumatic stressors (ie, repeated exposure to gruesome stories about a relative's death) may have different psychological ramifications than acute, direct exposure to traumatic stress (ie, a single event in which an individual is shot while being robbed). It may be tempting to argue that direct, chronic, and traumatic exposures will lead to the poorest psychological and physical health outcomes. However, it is important to remember that an individual's health outcomes are determined by exposure and by that individual's ability to make meaning JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 2

out of an event, and effectively mobilize internal and external resources to facilitate healing and coping. It is important to be aware of the social and economic stressors that marginal families and communities may be exposed to for long periods before intervention is sought or received.8 These individuals and families also may have fewer avenues through which to effectively mediate the stressors they experience.9 Limited access to employment, poor or inadequate health care, and inadequate transportation also may affect the proximity, duration, and quality of stress experienced by these families and individuals.

RESPONSES TO STRESS Besides exposure to stress, there is a need to attend to the factors that affect African Americans' responses to stress. Individual responses to stress are informed by biological and psychological factors, family values and norms, environmental factors, personal/individual values and norms, cultural values and norms, social location, and the levels and types of stress experienced by the individual. Biological factors, whether permanent (eg, human immunodeficiency virus infection) or transitory (eg, fatigue), genetic (eg, genetic vulnerability to alcoholism) or acquired (eg, a head injury that causes frontal lobe damage), can either facilitate or prevent effective responses to stress. Similarly, some acquired biological conditions (eg, top physical fitness) and some genetic factors (eg, natural immunity to particular illnesses) might enhance rather than diminish an individual's response to stress. Psychological factors present before exposure to stress also have an impact on responses to stress. Personality style is one factor that may play a crucial role in individuals' response to stressful events.'0 The quality of early attachment between African-American infants and their caregivers is another important psychological variable relevant to their ability to tolerate stress. The experience of being raised in a nurturing early environment may allow for secure bonding and for opportunities to successfully and confidently negotiate new situations. These qualities may be crucial to positive responses to stress. Responses to stress may be classified as immediate (short-term), intermediate or long-term, pathological or nonpathological, or emotion-focused or resolution-oriented. Short-term responses help individuals achieve stasis. Long-term responses reflect more stable changes that help individuals anticipate and protect themselves from the deleterious effects of future encounters with stress. Short- and long-term responses to stress may be associ81


ated with varying levels of pathology. Pathological reactions to stress are distinguished from nonpathological responses in that the forner lead to levels of distress that exceed expectations and cause significant impairment in social or occupational functioning. How people think about their ability to control the outcome of stressful experiences has implications for their responses to stress. Individuals who perceive themselves as having little control over the outcome of the stressful event may rely on palliative (emotion-focused) responses to stress; individuals who believe that they have control over the outcome of stress tend to rely on resolution-oriented (problemfocused) responses.4 Cooley-Quille et all' suggest that long-term responses to acute (ie, non-recurring) trauma are different from long-term responses to chronic (ie, high-frequency) traumatic stress. Exposure to acute violent incidents is associated with "internalizing problems" (eg, psychological disorders characterized by symptoms of fear and anxiety, depression, helplessness and hopelessness, emotional withdrawal, and somatic symptoms). In contrast, exposure to chronic violent incidents is associated with "externalizing problems" (eg, impaired social relationships, increased general activity and restlessness, and conduct problems). These findings are supported by Jenkins and Bell12 who note that chronic exposure to community violence leads to serious high-risk behavior including drug and alcohol use, carrying knives and guns, defensive and offensive fighting, and trouble in school. Defense mechanisms (eg, denial, repression, and regression) as described by psychoanalytic theorists offer models of short-term response to stress. Some defensive strategies that have physiologic manifestations (eg, fainting) also may reflect immediate or intermediate responses to (traumatic) stress.13 The Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition (DSM-IV)14 also provides an effective system for classifying these and other short- and long-term responses to stress. Among the diagnostic categories that reflect short-term responses to stress are acute stress disorder and adjustment disorder. Symptoms characteristic of bereavement and major depressive disorder (eg, feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss) also may represent immediate responses to stress. Brief reactive psychosis has been recognized as an immediate and severe response to traumatic stress. In addition, Bell1516 has proposed that among African Americans, alterations in states of consciousness represent short-term responses to exposure to stress. There are many psychiatric disorders that reflect longterm responses to stress. The DSM-IV categories that rep-

No exploration of the role of stress in the lives of African Americans would be complete without some attention to the impact of racism. Pierce22 asserts that terrorism, torture, and disaster are effective analogs for the stress that results from exposure to oppression and discrimination. He argues that in exploring oppression and discrimination, we must pay attention to the subtle but pernicious degradations (micro-aggressions) to which women and people of color are often exposed. Perpetrators of micro-aggressions (like perpetrators of macro-aggressions) achieve their goals by attempting to control the space, time, energies, and freedom of movement (STEM) of oppressed individuals. Pierce22 suggests that victims of micro-aggressions may experience stressful microterrors, microdisasters and microtortures. These forms of stress result from victims' efforts to gauge, titrate, regulate, and express legitimate outrage about the control of their STEM. Pierce argues that individuals who are chronically exposed to acts of oppression (including micro-aggressions) often adapt a cognitive style that is defensive, tentative, apologetic, and deferential. He suggests that such cognitive adaptations produce more stress because often the victim's plight is to possess defensive responsibility without commensurate authority, liberty, or power.

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resent long-term responses to traumatic stress include: post-traumatic stress disorder (PTSD), dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, anxiety disorder, somatization disorder, panic disorder, generalized anxiety disorder, conduct disorder, attachment disorders of infancy, depressive disorder not otherwise specified (NOS), learning disorder NOS, communication disorder NOS, disruptive behavior disorder NOS, and impulse control disorder NOS.17 The phase of life in which traumatic stress is encountered affects an individual's response to stress. Children exposed to stress in early childhood may endure psychological difficulties that cause particular problems in coping with stress as an adult.15,18 However, individuals who encounter stress at a time in their development when they have mastered language, or at a time when they have already internalized models of effective functioning and acquired mechanisms for coping will differ in their ability to tolerate exposure to stress.19'20 Among the DSM-IV categories that may represent long-term responses to trauma that are originally experienced during childhood are personality disorders, sexual dysfunctions, paraphillias, post-traumatic depression and disorders of extreme stress NOS.21

STRESS AND OPPRESSION


Empirical research has shown that encounters with racism and the suppression of anger in response to racerelated stressors may play a role in the pathogenesis of hypertension for African Americans.23 However, research conducted by Armstead suggests that it is not soley exposure to racism that decides health outcomes. Instead, outcomes are mediated by factors such as racial identity (Harrell S, unpublished data), the meaning and centrality of race to the individual (Sellers S, Smith M, Shelton J, Rowley S, unpublished data, 1996), the meanings constructed about the racist event, and the availability of safe outlets for the expression of the emotions (eg, rage) that such events engender. These findings are crucial because they underscore the reality that exposure to oppression does not lead to a uniform set of psychological or physical health outcomes. Further, these studies indicate that responses to oppression are determined by a variety of factors. Pierce22 argues that many characteristics are predictive of positive, resilient outcomes following exposure to oppression, micro-aggression, threat, or danger. These characteristics include the ability to gather and effectively use relevant information, the ability to assess rigorously and honestly an individual's response to the stressful event, strong personal convictions, the willingness to serve as both leader and follower, and confidence that support will come from intimate others. These factors that are important to positive outcomes among oppressed individuals are consistent with the communal and affective orientation identified by Jagers et a124 and with research that suggests that role flexibility is important to positive life outcomes. One neglected area of attention among mental health service providers is the impact of enculturative or acculturative stress on African Americans.25 Enculturation refers to the process by which individuals acquire the contents and perspectives of their indigenous culture without explicit instruction or training.26 Acculturation refers to the processes associated with a minority group's participation in a dominant culture.26 Researchers and practitioners must pay attention to the intrapsychic tension (ie, stress) that arises from difficulties in defining and acquiring the contents of an individual's own culture (enculturative stress). Attention also must be given to the stress that occurs when there are disjoints between individuals' available or preferred style of functioning (ie, learning styles) and contextual demands (acculturative stress). At present, research on acculturative stress has focused almost exclusively on immigrant populations. However, there is a critical need for attention to acculturative and enculturative stress in African-American communities. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 91, NO. 2

RESILIENCY IN THE AFRICAN-AMERICAN COMMUNITY We must be mindful that exposure to stress can result in resiliency (ie, in positive changes in the values and beliefs of individuals). Among the factors that facilitate individual resiliency are efforts to care for and share with others who are less advantaged.27 Consistent with this finding, research on African Americans suggests that spiritual, affective, and communal values are central to resiliency. Children who perceive their families and friends as more spiritual, affective, and communal express greater empathic concern for others and avoid such antisocial activities as gang-related activity, school rejection, and delinquency.24'28'29 In contrast, children who perceive themselves or their friends to be more individualistic are more likely to engage in delinquent and aggressive behavior (Jagers RJ, Mock LO, Smith P, unpublished data). These children may be particularly likely to know someone who is a victim of violence, to directly witness acts of violence, or to personally engage in violent or delinquent behavior. Bell6 suggests that children and adults who are thus exposed are at risk for developing a panoply of stress-related disorders. Communal values and norms may promote a sense of connectedness and unaloneness in times of danger, and may promote psychological skills (eg, cooperative problem-solving) that facilitate coping. An affective family environment in which intimacy is cultivated through members' sensitivity to verbal and non verbal expressions of thoughts and feelings may provide an important buffer against stress. This kind of affective acuity within the family can elevate levels of trust, cohesiveness, and security among members, and can mitigate against the negative effects of stress. There are many family characteristics, values, and norms that may influence resiliency. Among these are family size, egalitarian patterns of interaction between adult family members, education orientation, selfreliance, role flexibility, employment (including a history of continuous employment), and racial pride.30'3' Strong family bonds, adaptability of family roles, achievement, and religious orientation clearly are also helpful in coping with a broad array of social stressors.32 Family socialization goals and related practices are important points of consideration as well. Finally, research has shown that supportive sibling and peer relationships facilitate resilient responses.33

CONCLUSION Much remains to be understood about the ways in which individual-level and social stress affect the well83


1. Fanon F. Black Skin White Masks. New York, NY: Grove Press; 1967. 2. Abdullah S, Kali G, Sheppard L. Post-Traumatic Stress Disorder: A Diagnosis for Victims of the African Holocaust United States ofAmerica Component. The African Principle: Essay Series, Vol. 1, No. 2. Chicago, IL: African World Community Press; 1995. 3. Folkman S, Lazarus R. Analysis of coping in a middle-age sample.JHealth Soc Behav. 1980;21:219-239. 4. Folkman S, Lazarus R, Gruen R, DeLongis A. Appraisal, coping, health status and psychological symptoms. J Pers Soc Psychol. 1986;50:571-579. 5. Bell CC. Taking issue: doesn't anyone remember the dangers of lead? Psychiatr Serv. 1996;48:273. 6. Bell CC. Stress related disorders in African American children.JNatl Med Assoc. 1997;89:335-340. 7. Bell CC. The psychiatric implications of violence in the African American community. Psychiatric Times. 1992;10:23-27. 8. McLoyd V. The impact of economic hardship on black families and children: psychological distress, parenting, and

socioemotional development. Child Dev. 1990;61:311-346. 9. Klinkenberg WD, Calsyn RJ. The moderating effects of race on return visits to the psychiatric emergency room. Psychiatr Serv. 1997;48:942-945. 10. Bell CC. Racism, narcissism and integrity. J Natl Med Assoc. 1978;70:89-92. 11. Cooley-Quille MR, Turner SM, Beidel DC. Emotional impact of children's exposure to community violence: a preliminary study. JAm Acad Child Adolesc Psychiatry. 1995;34:1362-1368. 12. Jenkins EJ, Bell CC. Violence exposure, psychological distress and high risk behaviors among inner-city high school students. In: Friedman S, ed. Anxiety Disorders in African-Americans. New York, NY: Springer Publishing; 1994:76-88. 13. Fenichel 0. The Psychoanalytic Theory of Neurosis. New York, NY: WW Norton; 1945. 14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-IV Washington, DC: American Psychiatric Press; 1994. 15. Bell CC. States of consciousness. J Natl Med Assoc. 1980;72:331-334. 16. Bell CC. Black intrapsychic survival skills: alteration of states of consciousness. J Natl Med Assoc. 1982;74:1017-1020. 17. Jenkins EJ, Bell CC. Exposure and response to community violence among children and adolescents. In: OsofskyJ, ed. Children in a Violent Society. New York, NY: Guilford Press; 1997:9-31. 18. Bell CC. The need for psychoanalysis is alive and well in community psychiatry.JNatl Med Assoc. 1979;71 :361-368. 19. Davidson J, Smith R. Traumatic experiences in psychiatric outpatients.J Trauma Stress. 1990;3:459-475. 20. Bell CC, Jenkins EJ. Traumatic stress and children. J Health Care Poor Underserved. 1991;2:175-188. 21. Davidson J. Issues in the diagnosis of post-traumatic stress disorder. In: OldhamJM, Riba MB, Tasman A, eds. Review of Psychiatry. Vol 12. Washington, DC: American Psychiatric Press; 1993. 22. Pierce CM. Stress analogs of racism and sexism: terrorism, torture, and disaster. In: Willie C, Rieker P, Kramer B, Brown B, eds. Mental Health, Racism and Sexism. Pittsburgh, PA: University of Pittsburgh Press; 1995. 23. Armstead CA. The relationship between anger control, hostility, anger suppression and cardiovascular responsivity to racial and other stressors among black and white women. Dissertation Abstracts InternationaL 1993;54:1126. 24. Jagers RJ. Afrocultural integrity and the social development of African American children: some conceptual, empirical and practical considerations. Journal of Prevention and Intervention in the Community. 1997;16:7-34. 25. Anderson LP. Acculturative stress: a theory of relevance to black Americans. Clin Psychol Rev. 1991;1 1:685-702. 26. Berry JW, Poortinga YH, Segall MH, Dasen PR. CrossCultural Psychology: Research and Applications. New York, NY: Cambridge University Press; 1992. 27. Apfel RJ, Simon B. Psychosocial interventions for children of war: the value of a model of resiliency. Medicine and Global SurvivaL 1996;3:A2. 28. Jagers R, Mock L. Culture and social outcomes among inner-city African American children: an Afrographic exploration. Journal ofBlack Psychology. 1993;19:391-405. 29 Jagers R, Smith P, Mock L, Dill E. An Afrocultural social ethos: component orientations and some social implications.

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being of African Americans. However, theories that situate African Americans' experiences of and their responses to stress exclusively in the context of oppression inevitably will be narrow. Overgeneralizations and oversimplifications of the effects of slavery and institutionalized oppression do little to clarify the effects of current stressors on the psychological or physical wellbeing of African Americans. Further, historic-psychological theories consistently fail to account for the vast array of factors that inform individual responses to stressful events. We must be sensitive to the fact that African Americans are a heterogeneous population. Members of the African-American community have a broad range of experiences and a wide array of definitions and conceptualizations of what constitutes a threatening or stressful event. These definitions and conceptualizations, along with a person's response to stress, are determined by situational, biological, psychological, and personality factors. If we are to grasp the complexities of African Americans' responses to stress, we must be aware that African Americans attach a broad array of meanings to the events that they experience. African Americans live in diverse environments and are exposed to a gamut of social and environmental factors that affect responses to stress. Finally, we must pay attention to the complex ways in which culturally derived notions of caring, sharing, and the interdependence of individuals, families, and communities affect African Americans' resilient responses to stress. Researchers and practitioners must examine these various issues if we hope to yield an accurate understanding of the impact of stress on African Americans.

Literature Cited


Journal of Black Psychology. 1997;23:328-343. 30. Gary L, Beatty L, Berry G, Price M. Stable Black Families: Final Report. Washington, DC: Institute for Urban Affairs and Research, Howard University; 1983. 31. Willie CV. Black Families. Bayside, NY: General Hall;

32. Hill R. The Strengths of Black Families. New York, NY: Schocken Books Inc; 1974. 33. Graham-Bermann S, Banyard V, Coupet S, Egler L, MattisJ. Interpersonal relationships and adjustment of children in homeless and economically distressed families. J Clin Child Psychol. 1996;25:250-261.

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