Hello and welcome. My name is Jordan White, and I'm the Director of Social Determinants of Mental Health at the American Psychiatric Association. I'm pleased that you are joining us for today's Striving for Excellence series, Coping While Black, Racism's Impact on Mental Health. Next slide, please. On this slide, you will find the funding and disclaimer statement for today's presentation. Next slide, please. This webinar has been designated for one AMA PRA Category 1 credit for physicians. Credit for participating in today's webinar will be available for 60 days. Next slide, please. The PDF of the slides will be available in the chat tab of the Zoom feature. Captioning for today's presentation is available, and to enable captions, click Show Captions at the bottom of the screen, click the arrow, and select View Full Transcript to open the captions in a side window. And please feel free to submit your questions throughout the presentation by typing them into the question area found in the Attendee Control Panel. We'll reserve 10 to 15 minutes at the end of the presentation today for questions and answers. Next slide, please. And finally, Dr. Brianna Brownlow is our speaker today. She is a clinical psychologist currently in a postdoctoral role in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. In this position, she splits her time between engaging in community-based research, teaching, training, and providing clinical work on both the inpatient and outpatient level. Dr. Brownlow's research broadly focuses on how racism gets under the skin and impacts Black Americans' physical and mental health. She explores this through the lens of psychophysiology and emotional regulation. Her work on this topic has been featured on TEDx Talks. Dr. Brownlow received her bachelor's degree in psychology and philosophy at Spelman College in Atlanta, Georgia, and her master's and doctoral degrees in clinical psychology from The Ohio State University. Dr. Brownlow. Thank you. I appreciate the introduction. And so before I begin, just want to give some acknowledgements and special thank yous to those that I've worked with that have helped to produce a lot of what we'll talk about today. So Dr. Jennifer Chevins, Dr. Michael Vasey, Dr. Julian Thayer, who are my former mentors at Ohio State, and Dr. LeBaron Hill and Dr. Duane Williams, are both colleagues and friends who really inspired this work. And then Dr. Andrew Case in his lab here at UNC Charlotte, who's also helped a lot to test some of the things that we're going to be talking about today. So I wanted to start with gratitude, and I'll jump straight in and set a bit of agenda for what we'll be focusing on today. So I'll start with really defining racism and racialized stress. So we're all talking and thinking from the same realm. Then discuss a little bit about the physical and mental health disparities that Black Americans are facing and contextualize those. And then spend a good amount of time talking about how coping with experiences of racism can help us to understand those health disparities and really the mechanisms that might be underlying them. And then last but not least, talk about, so what does this mean for treatment? What does this mean for clinical work and the implications that this body of work can really have for how we go about thinking about culturally responsive clinical care? So jumping straight into thinking about racism and racialized stress, I love to use this image. And so here is an image of Ruby Bridges, who was the first Black person to desegregate schools in Louisiana. And a reason why this image stands out to me is a couple of things. But when I was a child, there was a movie based on Ruby Bridges that my parents had me and my brothers watch. And I remember it was like my first kind of salient image of racism to see a little girl around my age being screamed at, spat on, and having to literally have a police escort to go to school. Really just, it kind of blew my mind at thinking about how racism could impact someone in that way who looked just like me and at that time was around the same age as me. But the other part that stood out about the story of Ruby Bridges beyond her being the first example that I got of racism was she's the same age as my mother. And I'm sure my mom doesn't love me sharing that because now I've shared her age. But that also stood out because it was like, this could have been her. Racism wasn't that long ago. It was something that I could see right in front of me. And so in some ways, we talk about racism as these distinctive, salient, overt experiences like that of Ruby Bridges, like the examples of police brutality that we can name. But it didn't take long for me to realize that these images that we have, it goes beyond those distinctive experiences and their systemic structural racism that's really baked into nearly all aspects of society. And it's inescapable. Because it's baked in, we can't quite get it out. And so it's not just these distinctive experiences of racism that impact Black Americans. It's also the threat in the air, right? It's embedded in our everyday life. It's woven into the fabric of our society. And so racism goes beyond those experiences and those time-limited events to just racialized stress. And that was important to kind of separate in my mind, both personally and professionally, to think about how just living in America and really just living in a Black body means that you're going to experience racialized stress. And this goes beyond these individual experiences and these distinctive images that we've learned about that are happening then and still happening now. And so with that in mind, racialized stress in this way has three kind of important components. One is that it's unique. And so what this means is that it's additive to the day-to-day stressors that everybody's experiencing. So we all have stress, right? We all have different kinds of things that weigh us down, just being human beings moving through the world. But for those who have marginalized identities, they also have additive stressors to those general stressors that then require additive effort. So you have to push against not just the things everybody's facing, but things that are unique to Black experience. And racialized stress is also chronic. So it's something that's happening pervasively because it's built in, because it's embedded in our systems and our structures. It's institutionalized and maintained, so it's chronic. It's not something that you can kind of come in and out of. It's always present. And a big piece of why it's chronic is because it's socially constructed. And so what this means is that the origins of this country in and of itself coincided with the construction of race as a tool of oppression. And given that it's embedded in our society, our processes, our structures, it goes beyond the individual. So even if we removed every racist person in the world or in the country, it wouldn't get rid of racism or racialized stress because it's built into the system and it doesn't require individuals to function. It's a part of how we have been socialized. And so all those things make racialized stress unique in and of itself. Another thing though that makes racialized stress unique is this lack of perceived control. And events where you don't have control or you feel like you don't have control are more stressful when you feel like there's nothing I can do or there's no way that I can cope with this challenge. And racialized stress in particular has that feature because it's socially constructed and a lot of Black Americans can identify with this and those who are other marginalized identities, that there's this sense of helplessness, that this is so big and it's so daunting and it's so embedded that it does feel like there's nothing I can do. And that sense of helplessness amplifies the stressful nature of it. And the other part, the chronicity of it is important too because we know that chronic stressors lead to greater psychological and physical symptoms compared to more acute events, like a breakup or the death of a loved one. Those things are really, really stressful and you have a quick stress response. They're time limited though, whereas chronic stressors, even though they might seem small in the grand scheme of things, if you're holding them for too long, it becomes more and more taxing. And so I always use the example of like if I was holding a cup of water initially, super light, but if I had to hold it for hours on end, eventually my arm would almost feel like it was going to fall off. And that's a great way of thinking about how the chronicity of a stressor can wear you down over time because it's this burden that you can't quite get off of you and your body still has to cope and respond on a day-by-day basis. And so with that in mind, it leads directly into the concept of allostatic load. Allostatic load in a nutshell is the wear and tear on our body when we're exposed to repeated or chronic stress. And so anytime we're exposed to stress, our sympathetic nervous system kicks in and it does what it needs to do to give us the physiological resources to regulate. And so what happens is that once the stressor is over, we go back to baseline. But if the stressor keeps happening over and over again, you eventually never quite go back to baseline before you have to use your resources and have to regulate again. And over time, that wear and tear effect leads to allostatic load, a new allostasis point. And we see that this cumulative burden of managing chronic stress and the stressors that we're exposed to over time, the stressors that we're exposed to in stressful life events, particularly for Black Americans, they have the higher levels of allostatic load. And Black women in particular have highest levels of other groups of allostatic load because of this exertion. And it really creates what we call a weathering effect, right? It's taxing over time because you never quite can return to homeostasis or baseline before you're having to exert that effort again. And it has downstream impacts on the body because that stress becomes embodied. And so in that way, it is not surprising that racialized stress, we can connect it directly to the well-documented health disparities that we see that Black Americans face. And so I'll kind of give an overview of this, starting with physical health disparities. And so what we see here, so recent data have shown us that people of color, but particularly Black Americans, fare worse than their white counterparts. For Black Americans, virtually across any measure of health status that you can come up with and across the lifespan. So this includes from the time of conception, so Black Americans have its higher infant mortality, greater rates of low birth weight babies, which has complications down the, across the lifespan, higher rates of pregnancy-related deaths. So we're seeing a lot of discussion about that now where the Black maternity, maternal crisis. We also see a higher prevalence of childhood chronic conditions like asthma, but also adult chronic conditions like hypertension, cardiovascular disease, higher rates of mortality and morbidity later in life. And so all of these things combined also contribute to some of the more recent data that's come out that show that Black Americans have had a reduction in life expectancy. This was particularly during 2020 in the pandemic, where at the time Black Americans were exhibiting higher infection rates, higher, like there was racial disparities in deaths related to COVID, although that shifted across time. But all those things combined, right, we see that Black Americans are dying early of most causes than any other group. And so given that, we know that there's something happening here. And oftentimes when we talk about these physical health disparities, they feel really bleak. But it's important for us to contextualize these and not just say that Black Americans are more likely to die early. That's not just because of the color of our skin. It's because of racialized stress and racism, both directly and indirectly, and how that impacts our ability to live, thrive and survive. So it's important that we finish the sentence and not just say that there are these physical health disparities without also naming that they come from somewhere. They're not just because of Black Americans as a group or our skin color. It's because of the experiences that are unique to us, in this case, systemic oppression. And so a lot of times the physical health disparities are more pronounced or more prominent or talked about, but we also know that Black Americans are experiencing mental health disparities. And so when you look at the decades of research, usually what you find and you see like data like this that shows that people of color tend to report less mental health related symptoms. And this is, we've seen it across decades where they also data that says that Black Americans are reporting greater flourishing and are less likely to meet diagnostic criteria for many of the mental health diagnoses. But this is important to also consider, one, that these are oftentimes coming from epidemiological studies, which commonly use household surveys, which often exclude vulnerable populations like those who are unhoused or incarcerated or in residential treatment centers where people of color tend to be overrepresented. So that's one reason to take these kinds of data with a grain of salt. The other thing though that comes to mind is this oftentimes doesn't quite capture for Black Americans the other ways in which they're overrepresented. And one of the big ways is when we think about inpatient. So Black Americans are coming to the emergency department and are hospitalized at a greater rate than white Americans. And so that also kind of obscures this puzzle of sorts of we're saying that they're experiencing less mental health, mental health related concerns. And at the same time, they're overrepresented in the emergency room and in inpatient settings while simultaneously being underrepresented in outpatient therapy settings, as well as underrepresented in regards to who's actually being prescribed medication or support around managing mental health related concerns. So all those things, what they suggest is that we can't just look at those numbers alone and take those at face value. And this is also further complicated by the literature that has found racial disparities in mental health, particularly there's multiple studies that have found that Black Americans when they are reporting mental health issues are exhibiting a greater burden of disability from those symptoms. So they're reporting more impairment, they're reporting more dysfunction, they're reporting greater severity, and it's getting in the way of their ability to function, they're calling out of work, things like that. So they're exhibiting a greater burden of disability. And of course, we can think about how this might be compounded by the lack of access to resources that could help them to manage those symptoms when they arise. So it's both a report of greater burden, while simultaneously on a system level, less access. And there's also copious work that's been done that's linked racial discrimination to poor mental health outcomes, particularly depression, there's a body of research that's focused on that. And in fact, there are longitudinal studies that have found that racial discrimination precedes the onset of depression later in life. And the more racial discrimination a person's been exposed to, subsequently, the greater rate of depression and suicidal ideation they will report later in life. And so we can kind of directly link racial discrimination as a predictor or risk factor for mental health concerns for Black Americans. And more recently, a study came out in 2020, that talked about or 2022, excuse me, that talked about how Black Americans during the pandemic, so during the year of 2020, exhibited increased mental health burden compared to other groups. So they were reporting greater increases in depression and anxiety during this period of time. And this was also exacerbated by times of increased racialized stress. So in this case, what they were looking at was, how did these symptoms change before, during and after the murder of George Floyd, which also coincided with the murder of Breonna Taylor, which occurred beforehand, but there was greater media attention, and Ahmaud Arbery. So all of these different ways in which police brutality was being put more on center stage than it had been. And so what they saw was that during this period of time, Black Americans were reporting increased depression, anxiety and trauma related symptoms in the context of these increased racialized stressors. And you compound that with the fact that Black Americans were also exhibiting more of an impact from the pandemic on their livelihoods, right? So either having to continue to work, because they're in blue collar jobs, which increases their rate of being exposed, or be more likely to lose income and to suffer at a greater rate during these periods of times. And so when you kind of take into account both system level and individual level factors, we know that there are racial disparities in mental health across kind of all those levels. So the question that I have, and that a lot of my colleagues have, is wanting to understand, so how is racism impacting Black Americans' health? That inspired my area of research, too, of like, really wanting to think through, we know that racism relates to Black Americans' health. Like there's a body of literature that supported that racism negatively impacts the health of Black Americans. My question became how? So how is racism actually getting under the skin? How is it seeping under the surface and actually changing or shifting the health outcomes that we have later in life? So really wanting to understand, what are the mechanisms at play here so that we can figure out how do we actually intervene in thoughtful ways? So before I talk a little bit more about the ways in which we're trying to answer this question and the evidence that we have so far, I just kind of want to highlight a way that we're thinking about this, right? So we think about social determinants of health. We want to consider, we know what the downstream health effects are. We see these physical health disparities. We see these mental health disparities. The effort is, what are the upstream impacts? So what are the seeds that are planted across time that lead to this downstream health effect? And in what ways does that, those upstream, like how, what are the things that are happening that lead to racism and to racial discrimination? And how does that lead to racism in turn, really shortening the lives of Black Americans? And so really trying to get more evidence and more understanding of what are the upstream factors that can help us to better understand what we're seeing downstream? And so one prominent model that has looked at this and tried to make sense of, okay, so how are we getting from racialized experiences to this morbidity and mortality, both in a physical health realm, but also stress-related psychopathology? And so here we have James Jackson's environmental affordances model. And what he really kind of, and his colleagues suggest here is that for Black Americans, it's the social context in which they operate, their environments afford them different things. So if you think about the ways in races intertwined with SES, as well as geography, and you enter the intersection of gender and all these different contextual factors, how they come together is first, there's increased chronic stress, right? So if you think about the ways in which black Americans are navigating like redlining and all these different things, right? We already know that there's chronic stressors, those in and of itself can lead to poor health behaviors. And so in this case, they're suggesting that both the social context that they're operating and chronic stress can lead to maladaptive forms of coping like emotional eating or physical inactivity or the use of substances. And this is also, they were taking into account, like if you think about the environments that they're navigating like food deserts and also the war on drugs, all these different things might contribute to these maladaptive health behaviors that in turn are why we see some of these physical health disparities and may also contribute to stress-related psychopathology, but also could mitigate those because people are coping in ways that might essentially kind of numb their mental health kinds of symptoms. And that might help us to understand that paradox of what appears in the literature of greater physical health, but less mental health related concerns. But as I've mentioned that we know that's not necessarily fully the case that black Americans' mental health is better than their physical health. But nonetheless, what this model really highlights is we have to take into account the role of coping and self-regulation. And so this model was pivotal to thinking about what are those pieces of the puzzle that help us to get from the environmental forces of racialized stress to long-term health outcomes. One of the challenges here though, is that there's not data to support that black Americans use substances at a greater rate than white Americans. And the other part of this is that it in some ways puts the onus on black Americans and their use of maladaptive health behaviors that we're not even sure if that adds up. And so an alternative to this model and a complimentary way of thinking about this is considering adaptive styles of coping, right? That the ways in which racism impacts our day-to-day life requires us to cope in ways that actually are often adaptive and warranted. And that might be one way to think through a mechanism by which these experiences are impacting our health. So before I talk a little bit more about alternative theories here and introduce some new work that we have that is trying to connect these dots, I wanna be very clear here that no culture is a monolith. And so, although oftentimes we talk in over generalizations for simplicity sake, it's important to be very clear that black Americans are not a monolith, we're not a homogeneous group. And so in that way, we're not all coping in the same way. And so what I'll talk about is a style of coping that a lot of black Americans and other marginalized groups are using, but it's not the only way that black Americans are coping. So I wanna be very clear that this is not meant to say that this is the definitive or the standard, but just one pathway that we might be able to explore given its prominence. So got the disclaimer out of the way. So when we think about adaptive styles of coping and moving more into that realm, one culturally based style of coping, and some of you may be familiar with is John Henryism. So for those who are less familiar with John Henry and the story of this folklore of sorts. So John Henry, as the folklore story goes, was a railroad worker who was the best in all the land. And around the time he was doing this work, they created a machine who could do the work of a man. And all the people were like, John Henry, you should race the machine. You'd definitely beat it. So John Henry agrees. And he races the machine and spoiler alert, he wins. But as the story goes, he dies with the hammer in his hand because his heart gave out. And so this story is connected to the real life experiences. And in fact, I was informed by the experience of a farmer whose name was also John Henry. And what we were seeing was these black Americans and they were focused on black men initially, but we know this is related to black Americans generally, was the striving against the odds, this pushing and pushing, this being resilient, not appearing weak, having to have like high levels of self-control and engage in high levels of hard work and at the expense of your physical and mental health. So in the beginning, John Henryism was connected to a lot of cardiovascular outcomes. So greater hypertension, greater cardiovascular disease, but since been connected to mental health outcomes that we know that this hard work, this pushing, this having to fight against the system and to overcome social and economic barriers was emotionally taxing and physiologically taxing as well. So now we think about John Henryism as a style of active coping where to this day, black Americans are still engaging in that striving against the odds, even when it's causing damage to the body and to the mind, because you don't have a choice. Thinking about this from an intersectional perspective though, is we know that race is one thing, but for those who are at the intersection of multiple identities, that informs the ways, not only that they're coping, but the kinds of experiences that they're coping with. And so it's important to take into account how that might vary as a function of these different identities and as thinking about like what Kimberly Crenshaw said, like sometimes an accident happens at one intersection, sometimes it happens at another, and sometimes it happens because of the multiple ways those streets are intertwining. And so with that in mind, to think about John Henryism in a more intersectional way, this is where Sheryl Woods-Giscombe and others have thought about a similar style of coping, but thinking about black women's experiences uniquely. And so in this case, the superwoman schema captures a similar style of coping as John Henryism, where black women are filling this obligation to manifest strength, to suppress their emotions, to not be vulnerable or dependent, to succeed even in the face of limited resources. And at the same time, the gendered part of this is there also this obligation to help others, to take care of the family, to make something out of nothing. And we hear like phrases like black girl magic and all of these different things where black women are really carrying the brunt, the burden of not only their race, but their gender. And so a lot of this was informed by the fact that even in the civil rights movement, black women were experiencing sexism. And in the feminist movement, black women were experiencing racism. And so these compounding effects also inform the ways in which black women have had to push and push. And so you think about the strong black woman syndrome or superwoman schema, these all come from the same place. And so you'd see the similarities between John Henryism and things like superwoman schema. And if you think about just styles of coping or emotion regulation across the spectrum, you can think about how some of these factors that we're discussing kind of fall on this side. And so under controlled, just to kind of orient you all to this, under controlled are things where a person is, like we see high levels impulsivity, low levels of self-control and inhibition. And so you might have people to come to mind who are like kind of fly off their handle, right? And they're less controlled, less regulated in that way. So that's when we think about the spectrum of emotion regulation and coping, we have some folks who are more under controlled. On the other side of the spectrum is over controlled. So this is high self-control, really high levels of inhibition, emotionally constricting and restraining, being really hypervigilant. So we think about this spectrum, it uses the words under and over. And historically within mental health, we've thought about psychopathology as being connected to under controlled, right? So a lack of self-control, a lack of emotional control is what might contribute to what some of the mental health related concerns we see. But more recently people have also conceptualized how being on the other end, being overly controlled, being rigid, being perfectionistic can also lead to psychopathology. And so the use of the language here over, I'll talk a little bit more about how that doesn't quite fit, but just thinking about these as concepts, something that stood out to me at least was that a lot of times black Americans are engaging in strategies that fall more in that over controlled realm. So to kind of talk a little bit more and zoom in on over control, what we see here is Tom Lynch and colleagues came up with a model that really captured over controlled styles of coping from a neurobiosocial perspective, came up with some elements to really kind of say like, who are the over controlled people? Like what are the elements that contributes to that style of over controlled reaction towards the world or stance towards the world? And so from a nature perspective, just there are some biological predispositions where some folks are more likely to be hypersensitive to threat, exhibit, have more ability to inhibit, and also more ability to kind of pick up on those details. That in turn, when you put them in an environment where they're taught that mistakes are intolerable, they can't make a mistake, they should avoid appearing vulnerable, right? Like you have to kind of put on a face and they have to have high levels of self-control that that's important, it leads to a style of coping where they're masking their inner feelings, they're avoiding unplanned risks, they're very cautious, and that sometimes comes off as aloof and distant because there's so much rigidity. So this model was meant to kind of capture trans diagnostically, a group of people who were engaging in over controlled stances related to things like treatment resistant depression, obsessive compulsive personality disorder, anorexia, nervosa, right? That it was supposed to think about how these styles of coping were considered to be maladaptive and how we can intervene on people who are on the other end. And something that stood out to me when I was kind of taking this in is that it looks very similar to a lot of the styles of coping that black Americans have used across generations. And so the work that was done here was really culturally translating this model of over controlled coping to think about how does this shift when we think about the cultural context that people are occupying? And what I mean here by cultural context is not the culture, black Americans' cultural context, but the cultural context of existing in a space that's embedded in the history of white supremacy, right? So if you're living in a society where racism is inherent, that's the culture that you're navigating. And that culture for black Americans has compelled them, has required them to cope in a particular way given the life and death threat of racialized stress. So in this way, cultural translation refers to how does the meaning, the function, and the consequence of using quote unquote over controlled coping strategies change when we consider how black Americans exist and cope within a culture of systematic racism? And so what this looks like is that black Americans, what it means for them to be hypersensitive to threat looks very different than what somebody with a privileged identity being hypersensitive to threat is. Because for us, the threat is indeed present. So it's not even hyper as much as it is a required level of vigilance. So this also takes into account that there's been intergenerational transmission across our culture of how do you actually cope, right? Where we're taught indirectly and directly to use these kinds of strategies. And the other part of this to name is that this doesn't mean that black Americans can't be naturally over-controlled. What it means is that whether you're under-controlled or over-controlled, you might still be compelled to engage in this regardless of your biological predispositions or your temperament or your preferred style of coping, right? So high inhibitory control here looks like I need to be able to inhibit if I'm being pulled over by the police or if I'm in a meeting and I'm the only black person there and I don't wanna come off as the angry black woman. I need to have high detailed focus processing to look out for both threat and safety. We are taught that mistakes are intolerable when you think about the school to prison pipeline, when you think about the harsher kinds of punishments that black Americans are experiencing. We are taught that you need to avoid appearing vulnerable because people can take advantage of our weakness, right? We're taught that self-control is imperative. This here is John Henryism and superwoman schema in a nutshell. And masking inner feelings is something that's a part of our culture too. You can even think back to Paul Laurence Dunbar who's one of the first black poets whose poem, we wear the mask, where he talks about having to put on this mask where behind it you're suffering but you have to put on a face literally to keep yourself safe. And then avoiding unplanned risk. And oftentimes this looks like coming off a Lufen distant where people oftentimes have a hard time reading black people's faces. There's data to support that because they have to put on this mask. They have to restrict and restrain oftentimes in the face of threats that can either, if not life or death can at least impact their ability to thrive. So these are things that are both compelled but also reinforced. So with that being said, this style of coping that we're calling cultural compelled coping really can be thought of as a pathway by which we can understand how racism gets under the skin. So since we're embedded in this culture of white supremacy, so you see it kind of as this enveloping force that directly impacts the ways that we learn to regulate the chronicity in the ways that we have to regulate and our health. But for black Americans, because we're embedded in this culture of white supremacy this directly relates to chronic racial stress. And this experience of racial stress means that we learn indirectly and directly how to cope. So directly, my parents taught us what to do if we're pulled over by the police. We were literally taught to inhibit. They taught us what to do if people were getting in trouble in school, they're like, you're the only black child, you're probably gonna get in more trouble. So they literally taught us how to cope directly. But we also learned indirectly both through the media and observing the people around us. I saw how my parents would code switch and would shift in certain environments. I was able to pick up on these messages. You see these messages in the media, right? Even when you learn about the history of black Americans, you hear these stories of black Americans literally having to swallow their pain as a form of survival, not being able to express their anger or to retaliate or to really have any kind of behavioral response for fear of retribution. You see this when you look at the images of the civil rights movement where people literally had to put on a mask and not kind of allow somebody to provoke them. And that takes so much inner fiber and moral fiber and strength to be able to do that. But you're learning that this is how, in some ways that people move through the world as a black person. And so you learn this regulatory strategy. In this case, we're talking about culturally compelled coping styles. Again, not the only style, but this style in particular is socially adaptive because it can reduce negative consequences, right? And so in that way, it becomes reinforced and it becomes cyclical. And because you're having to use this chronically because racialized stress is pervasive, over time that has downstream physical and mental health effects because it is not easy to have to inhibit, to have to hold back, to have to restrain in this way, to have to constantly be on guard, to have to be like kind of always have this in the back of your mind. One of my patients described it as having apps open in the background and they're not actually on the, you're not using them, but they're draining your battery, right? And so thinking about culturally compelled coping in that way. And so the question is, I believe this model, we have anecdotal evidence to support it, but how can we actually test that? How can we provide empirical evidence to support that this might be one pathway by which racism is getting under the skin and impacting health outcomes? So I'll touch on a little bit of preliminary data and then talk a bit more about clinical implications of this. But one of the ways that we can actually test what is the style of coping this emotion regulation strategy doing is considering psychophysiology. So what's happening under the surface when a person is coping this way. So I've already described a little bit just how much effort this takes both physically, mentally, and emotionally. And so one way to think about this an important measure is heart rate variability. And so what heart rate variability is is that there's variability in between adjacent heartbeats. And what that variability is between that kind of individual heartbeats, what it tells us is the brains control over the heart. So particularly the parasympathetic nervous system because what the parasympathetic nervous system is all about is conserving energy. It's when the body is at rest. And what it does on the heart is it tries to keep it at homeostasis at baseline. So when parasympathetic is in there, right? Our heart rate is slower, but it also controls whether or not the sympathetic nervous system kicks in. So when the sympathetic nervous system kicks in or a fight or flight response kicks in, that activates the heart rate and our heart rate increases. And so the more variation in those intervals, those heart rate intervals tells us that there's better parasympathetic activity. Another way to say that is the more variability that is, the more sensitive your brain is to know when to speed up the heart, when to slow it down, right? And basically think about it like a break, right? And so when the parasympathetic activity is higher, when you have better parasympathetic activity, it knows when to let up off the break and when to keep the foot on the brake, when to conserve energy and when to allow the sympathetic nervous system to kick in. So that variability between heartbeats shows us just how sensitive someone's able to regulate. And we can think about this actually as a biomarker of emotion regulation and cognitive control because people have different resting states of heart rate variability. And so in this way, it's a really important measure to thinking about how are people regulating, but also how are people using those resources to regulate? Because some of us naturally run on the lower side of heart rate variability, where we're just more sympathetic activated, right? We're more likely to go into a panic, we're more likely to just kind of like fight or flight kicks in, where other people are more parasympathetic activated, where they're able to kind of be a little bit more sensitive to knowing when to let the sympathetic kick in and when to pull back and hold it in. And so all of this for me connects directly to how black Americans are engaging, where oftentimes we kind of do have to hit the brakes, even when there might be a reason to let our fight or flight act, but we don't want fight or flight sometimes, adrenaline can be dangerous, right? And so having that parasympathetic activity or in this case, higher heart rate variability is an indicator of greater parasympathetic control. And this is important because higher heart rate variability is related to better health outcomes, both physically and mental, it's related to better emotion regulation, both emotion regulation being more successful, but also emotion regulation being more flexible in the face of a demand. So it's an important kind of marker of thinking about how people are using their regulatory resources under the surface. Importantly, what we found is that black Americans actually exhibit higher heart rate variability than white Americans. So a meta-analysis was done and we see across the lifespan, across gender, black Americans exhibit higher heart rate variability than white Americans. At the time that was paradoxical because we also know that black Americans exhibit worse physical health disparities. And for most, like most times that means that heart rate variability is lower, but that's not what we're seeing. And so one way to make sense of this is that higher HRV for black Americans may actually reflect a greater need of and a greater use of resources to regulate. So why we might see that black Americans have higher HRV on average than their white counterparts might be because they need to hit the brake more often. And so that might be something that's intergenerationally transmitted that because we need those resources, we exhibit it, but we're also using them at a greater rate. So you can think about that as really having a long, like downstream health effects. If I'm constantly hitting the brakes, my brakes are going to wear out over time, even if my brake pads are thicker as it were. And so in this case, when we think about culturally compelled coping and health, so going back to the surface, we've been able to connect culturally compelled coping to heart rate variability. And there's this question of, is it protective or is a risk factor? And in some ways, it's protective, right? Because if I'm using my resources to inhibit and cope in this way, it can keep me safe and it can allow me to maintain safety and status in other ways. And at the same time, it's a risk factor in the longterm because if I'm constantly having to do this, it's going to undermine the protective health benefits of higher heart rate variability for black Americans. So as one of my mentors put it, if you're able to engage in this style of coping and you're able to do things like inhibit your anger, it can literally keep you alive, right? Like if I'm getting pulled over by the police, it can prevent me from dying, right? But if I can't do that, right, if I'm expressing my anger, if I'm allowing my emotions to flow, which is good for my health, I could literally get killed. But the thing about inhibiting our anger is that we could die slowly as it were, because we're constantly having to use our physiological resources in ways that are taxing and in the longterm undermine our health. And so it's kind of a damned if you do, damned if you don't, because you need to move in this way. And at the same time, it's costly. So there's a bit of a double-edged sword there because it's culturally adaptive and warranted, but it also, and at the same time, it's taxing. So in this way, one of the ways that Black Americans are coping and have to cope in the face of chronic racial stress may be a mechanism for how racism's getting under the skin and impacting both mental and physical health outcomes. And we have some preliminary data to support that it is impacting things like depression. So to wrap up, a part of this work is thinking through, so what does this mean for how we approach mental health treatment for marginalized populations? The important thing before I talk about some of the ways that this impacts treatment is that it's not on Black people to change how they're coping with a racist society. Engaging in culturally compelled styles of coping, even if they are taxing, we're doing that for a reason. It's not on us to change how we're coping because what's causing us to cope in that way is the problem. And if the problem is not solved, it's not safe to say, oh, this type of coping is taxing, stop doing it. When we're doing it for a reason, it's required of us. And so the only way to really kind of shift the downstream health effects is to address the root of the problem, which is why I have to cope like this in the first place. And so in that way, though, that doesn't mean that this is where the kind of the lack of perceived control comes in because we can't change systems overnight. And so while we're still working on higher level system level changes, cultural level changes, there are still things that we can be doing on a clinical individual level. And some of this is if we think about culturally compelled coping and how coping with racialized stress impacts health, what does this mean for assessment? Who are we missing with our current measures? Because if the point of what we're talking about with culturally compelled coping is that the goal is to function even when you can't, even when you don't feel it inside, more than likely, people are going to appear as if they're not suffering, right? Because that's the whole function of culturally compelled coping is that I have to keep going, even if I can't, I have to keep pushing. And so are our assessments sensitive enough? And like, are they actually getting asking the right questions to capture the kinds of what would actually appear as your stress? And so there's also data to support that Black Americans are less likely to report feeling hopeless when they're depressed. So in what ways are we assessing and using tools that don't actually assess for the kind of distress that Black Americans might be exhibiting? And who are we missing given that these styles of coping serve the function of obscuring mental health related concerns, because you can't ever let your guard down. So we have to think through what are the kinds of ways we can assess more thoughtfully and more like contextually think about the culture that Black Americans are navigating. Another part here is what does this mean for treatment? How does this shift what we approach as interventions, as targets for treatment? How does this shift what we might be targeting that shouldn't be targeted, right? So like a classic example of this is changing somebody's thoughts or approaches is not helpful, it's invalidating. And it also means that if we're treating only symptoms and individual level factors, what are we missing that's more contextual? What does this mean about how we approach intervention? Are there other ways that we should be doing this? And I'll talk a little bit more about that before I wrap up. And more importantly, what would prevention look like? Because what these results imply and what this work implies is that if Black Americans could actually express their emotions, it wouldn't be as taxing as restraining and holding them in, right? But we have to think about going beyond individual efforts and considering system level changes that would allow for that kind of freedom and flexibility that would get at the thing that's actually contributing to this, to these health outcomes. So I want to touch a little bit on treatment before we wrap up. And so here, thinking through a big part of the implications of this coping model, the culturally compelled coping model, is that we have to go beyond coping and move into healing. So coping is, how do I survive? How do I kind of survive within an oppressive society? But healing is, how do I thrive? And so the radical healing framework talks a lot about moving into the space of centering that healing requires not just wellness, individual wellness, but justice as well. And so it's not just about symptom reduction in this case, it's about how do I actually thrive and heal and not just survive and get by? And one way we can do that is take a dialectical approach. And what this means is that two things that are opposite can be true at the same time. And the dialectic that they talk about in the radical healing framework is, how do I hold both sides of resisting oppression and the despair of oppression and moving toward freedom and the imagination of possibilities? Because if I'm only on one side, if I'm only resisting oppression and experiencing the despair, that is so demoralizing. And in many ways, it kind of contributes to the sense of disempowerment if I'm just constantly feeling the weight of what it feels like to be in the systems that we're in. But if I'm on the other extreme, where I'm only moving towards freedom and imagining the possibilities, that invalidates the reality that we are in currently. And so in some ways, the ways that we can access healing is to be able to exist in the dialectic of, I can experience the despair of oppression and at the same time imagine new possibilities. What that means for the clinical role is that when people come into our office who are experiencing racial trauma and navigating these systems, we can help to balance them out of, if they're on one side more than the other, how do we kind of get them to the balance of holding both sides without having to choose one or the other? And that in and of itself can be healing and freeing, not kind of having to pull against that tension. Another broad implication of this culturally compelled coping model is that community matters. We have to go beyond the individual and honor that Western interventions are individualistic in nature. And the African diaspora is a communal tradition. So how can we leverage community spaces? This is one reason why people go to historically Black colleges, like I went to Spelman. Just being in a community space where people look like me, the kind of camaraderie and the collective struggle and the collective healing that occurred there, even when we weren't talking about our experiences, was a way that we could leverage that community space for healing, right, where we could use, could kind of understand the common collective struggle as a way, as a vehicle for healing and relief, that camaraderie offered refuge in the context of ongoing racism. So how can we leverage more community approached interventions that can, when we heal a community, we also heal individuals. And it expands our conceptualization of coping. Healing requires more than just you. And last but not least, all of these things highlight that anti-Black racism is a public health crisis. If there's something that's happening in a society that's negatively impacting the health of a particular group, that is the definition of a public health crisis. We have so much evidence to support that racism is impacting health, and now we have even more theories and models that show that having to cope and to move through the world is one way that that's impacting our health. And it's not enough for us to think through how we can, you know, do individual efforts if we're not also thinking about what this means for policy and advocacy. Because for me as a clinician, I can meet one-on-one with a person, but I'm not actually doing my job if my goal is to help them, if I'm not also engaged in social justice. It's a requirement because the things that I'm doing are not actually helping them. So I'm not actually doing my job. So the thing that's causing their suffering goes beyond them, and if that's my job to help treat that, then I also have to treat the root. And the root here is a system-level thing. So it's a part of our job description in clinical spaces to be engaged in policy and advocacy work so that we can go beyond these ways in which right now are band-aids of sorts. And so with that, I want to say thank you both to you all, everybody for listening. Yeah, and open it up to Q&A minutes. Thank you, Dr. Brownlow. And this is a reminder to everyone on today's session to submit your questions via the Q&A area of the attendee control portal. And after the webinar ends, please do complete your post-event survey. You can visit the link or use the QR code that's at the end of this presentation. So I do believe we have a few questions in the chat. And so I'm going to take the liberty, Dr. Brownlow, to go ahead and read and articulate this question to everyone just in case folks cannot see it. And this question asked is, is it only Black Americans or all persons of color? Because when I walk into a room speaking English, I am viewed as a Black American person based on my outer appearance. So Dr. Brownlow, I think this question is asking, do the implications of racism and its impact on coping, are those relevant for other persons of color or only for Black Americans? Yeah, absolutely. So this model right now has been applied to Black Americans, but we've actually expanded it to other groups. I'll talk a bit more about that in a second. But this absolutely applies to anybody experiencing systemic oppression, because the culture of white supremacy isn't just directed at Black Americans, it's directed at anybody who doesn't fall within that privileged identity. This includes just phenotypically how you appear in the world. So we know that colorism is a thing here, so it's layered. So it happens at the intersection of multiple identities, but it also happens across the spectrum of color. So we have some data that looked at this in Brazil, and what it found is that these results were exacerbated the darker the color of someone's skin. So we know that's a thing. We also know that other marginalized groups, other people of color are navigating the culture of white supremacy in different ways for those who are immigrants. And there's all these different things that require you to kind of use that over-controlled style of coping. And so it's both taxing individually, but the culture that we're occupying impacts people of color in similar ways, albeit different. So it's not the same across every cultural group. And as far as severity and the different ways and the different kinds of stereotypes and discrimination that people are navigating, we know that there are nuances there, and people of color in general are impacted by their marginalized identities, even if they're in a power dynamic by various factors. And that's where the intersectionality piece comes in. And we did expand this data to LGBTQ folks and found a similar thing that we were seeing the same kind of physiological thing underneath connected to the culturally compelled styles of coping. And you can think about that as compounded in a Black American who might be queer and navigating both a Black environment and a white environment and a homophobic environment. All those things will require you to have to restrain and inhibit and be on the lookout for danger. And so we know these things impact marginalized groups as well, whatever that might be, and those who have the compounding effect of being at the intersection of multiple marginalized identities. Yeah. And Dr. Brownlow, you mentioned earlier this concept or this framework of radical healing as a process, right, moving beyond the process of understanding the outcomes of implications of COVID to the healing. And I wonder if you might be able to expound upon that and maybe some of the cultural implications or the racial and ethnic implications that you think might be relevant, particularly for psychiatrists and for other mental health professionals who might be on today. Yeah, absolutely. So I bring up the radical healing framework for multiple reasons, one of which I didn't mention is that, so the model that we translated, the over-controlled coping model was originally informed to create radically open dialectical behavior therapy. And so that was kind of the point of that model was to support a treatment that could help intervene. And so dialectical is in there. And so, and I'm also trained in dialectical behavior therapy. And one of the things I like about the approach is that it balances acceptance and change. So oftentimes a lot of our strategies are about how can we change your experience? And when you're navigating something where it's, you're doing that for a reason, I don't actually want to change your experience. I also want to help you to acknowledge reality as it is. That does not mean resignation, but if I'm constantly pushing against my reality, that ups my suffering. And so this radical healing framework talks about basically being in the dialectic of like, absolutely you're suffering, right? Absolutely. This is painful. And at the same time, being just there ups, the suffering, but only being in imagining new possibilities, change, change, change, change, change, right now you're suffering. And so the role of a clinician is like, there are interventions that you can actually use with the radical healing framework, but I think about it more as an approach. I'm constantly thinking about how am I balancing that dialectic? So if somebody is coming in and they're just like, I have to fight, fight, fight, fight, fight. I might lean forward with validation that they're also suffering right now. If somebody is coming in and they're just suffering, suffering, suffering, I might lean in and say, and validate that. And what can we do to imagine new possibilities? What would that even look like, right? If things were different. And so that's kind of how you can think about the radical healing framework as a, both an interpersonal kind of connection, but also something that can in and of itself be an intervention of like, if you don't have to be on one side or the other, that in and of itself just kind of turns down the volume on the suffering where I'm not completely disempowered, but I'm also not completely consumed. I can be kind of, and it also helps you to help people to get into activism and social justice and figure out what are the vehicles for change that we miss or on one end or the other. I'm not sure if that got at the question. Well, I think that was an excellent answer to that question. As someone who reads and studies and thinks about dialectical behavioral therapy and also has an interest in radical healing, I think it's important for us to think about the implications for providers and for other professionals who are supporting persons who are presenting with these issues and who are going through these processes. And many of our members at APA are going to be thinking about what are the implications for me as an individual psychiatrist who's seeing patients are practicing in my community and what can I do in my group or my organization or my region beyond the work of policy level factors. And so this is one approach, as you say, to critically think about it that moves us into a progressive space around both addressing and acknowledging the aspects of the harm and discrimination and the negative impacts of discrimination on health, but also the process of how we move forward and promote resilience within this population. So I think it was a great answer. And I want to do a check in with our APA staff colleagues and see if we're at time or if we have a minute or two for one more question. But I do think that we can do one more, it looks like. So I'm going to take the liberty to double check to make sure I'm not looking over anybody in the chat. So apologies, I'm not trying to skip over any questions. So I'm going to ask one more question, Dr. Brownlow. You also mentioned today this idea of, or this concept and this framework of, you know, thinking about discrimination and its implications on population health, and that essentially it has a negative harmful effect. And again, thinking about the work of psychiatrists and our members beyond radical healing approaches, what might be assets or resources that we could, I know this is like the toughest question, how might we begin to think about promoting the health and well-being of individuals who are coming into these settings and bringing forth issues around discrimination and racism and race-based discrimination that are impacting and influencing, right, health and social health? What types of resources beyond the therapeutic context might be relevant here as we have this sort of interdisciplinary discussion today? Yeah, absolutely. I mean, some of it is coming to talks like this, right, where it helps to lift the veil a bit of like being able to see these things happening. Because oftentimes when people learn about culturally compelled coping, they're like, oh yeah, I see myself engaging in that, I see others engaging in that, and just being able to kind of capture some of those more nuances of like how like the permeating effect of structural racism also gives you an ability to be able to intervene more. And so one of the big things, I'll talk two ways and then I'll wrap up. On a professional level, everybody's embedded in a system. So even if you're not the type to go fight, you know, the government or the policies, we all are embedded in our systems, our micro and macro systems. So we can make changes there, right, that inform those, have the trickle-down effect, right, of how this impacts the people in our little mini globe of sorts. So this can happen in my job at Duke, like I don't have to go to the head of whoever, I can do this in my little systems, in my work groups, in my clinics. So that's one way to do policy and advocacy. The other thing is that the other side of this work is that if you don't have to police your emotions and your behaviors, it is good for you. And so how do we create walking safe spaces? So even if, like in your personal life, how do we create spaces where people can express the fullness of their emotions, of their sorrow, without being policed, but also without the fear that it could be, it pose a threat to their safety or status. So that can happen in a clinical space, but it also happens in an individual and personal space. If we have more walking safe spaces, that creates more room for people to not have to wear a mask, not have to restrain, not have to code switch and do all these things that we know have downstream health effects because they're taxing. That's another way to live this work, even outside of, you know, our jobs in our clinical spaces. We can do that in clinical spaces. We also can be a part of a world that allows people to not have to, in some areas, right, put on this mask. Right. Well, thank you, Dr. Brownlow. I do believe that we are now at time. On the next slide, it's Dr. Brownlow's contact information. If you have additional questions, you can email her at briannabrownlow at duke.edu. And so, and again, we want to thank everyone for joining us for today's session, and we look forward to seeing you all again soon.

Coping While Black

webinar

racism

mental health

racialized stress

Black Americans

culturally compelled coping

John Henryism

Superwoman schema

heart rate variability