Health Equity: A Conversation With Victor Armstrong, MSW

health equity

Share a few words with Victor Armstrong about his profession, and one thing is immediately clear: He’s truly driven by his passion for the mental health space. With a master’s degree in social work, a formative career in rural regions struggling for health resources, and his own perspective as a black man in the United States, Armstrong’s call to advance health equity runs deep and is more nuanced than most.

Today, Armstrong serves as the Chief Health Equity Officer at North Carolina’s Department of Health and Human Services. He’s seen firsthand how the healthcare industry has misunderstood the unique needs of black and brown communities, with damaging outcomes. Armstrong believes there is a path forward by approaching minority mental health differently and normalizing the conversation with everyday positivity — often through thought-provoking messages on his T-shirts.

Cori McMahon, PsyD, NCCE, Tridiuum Vice President for Clinical Services, spoke with Armstrong to gain his insights on how behavioral health professionals can better connect with overlooked communities.

 

MCMAHON: You’ve got such a great perspective from your background in behavioral health. Would you share with us the work you’re doing now and the path that brought you to this role?

ARMSTRONG: That’s a great question. In my early career a lot of my work focused on community mental health. Raising awareness, reducing stigma, and trying to improve access was always part of that. I work through an equity lens and think about people who live with mental health challenges, are developmentally delayed, or have a traumatic brain injury or substance use disorder.

I always saw those groups as marginalized because they face so much discrimination, including in housing and employment. This takes equity out of its typical context. People usually want to make it about race and ethnicity, but I come to this role with experience that tells me it’s more. It’s about people with physical disabilities, it’s about urban versus rural…there are so many nuances to how someone can be historically marginalized. I think my experience helped prepare me for the role I sit in now, while my passion still is and will always be mental health.

MCMAHON: I know you have a master’s degree in social work. Can you share something about the clinical roles you’ve held?

ARMSTRONG: I started my career managing outpatient clinics for an area mental health program in North Carolina. Back then, the mental health structure was a little different, and the program covered five eastern rural counties. The population of the counties combined was only about 94,000 people, and there was a time when I was the only clinician covering three of those counties! I saw kids and adults, provided substance use treatment, ran a DWI group, worked with men who were court-ordered for domestic violence and with women who were victims of domestic violence…because that was all there was.

I was able to really connect with people and gain perspective on the social determinants I was seeing and on generational trauma. Since then, I’ve worked in a couple social services departments, managed care organizations, and hospital systems. It all gives me a unique perspective in my role now and the ability to understand the challenges that different groups of people bring to the table.

MCMAHON: With this discussion, we’re hoping to shine a light on disparities in mental health care as they impact the black community in the United States. Can you define the term ‘disparity’ as it relates to mental health care?

ARMSTRONG: In general, when you talk about disparity, you talk about a difference — a measurable difference. There is a measurable difference when it comes to behavioral health, yet there is not a difference in terms of susceptibility to mental illness for black and brown people. There is no evidence to show that you are more likely to experience mental illness if you are black or Hispanic as opposed to being white.

What the evidence does show is that blacks in America are 20 percent more likely to report psychological stressors. When you think about suicide as an example: It is not a disease. It is the worst possible outcome of a culmination of very complex things. That means there are multiple points at which we could intervene before a person reaches the point of suicide.

The challenge for black and brown communities is that often those resources are not available and accessible, so it limits the ability to intervene. What ends up happening is that for black and brown men, their introduction to the mental health system is from the back of a police car or in an acute care bed. They often don’t enter the system until they’ve reached the crisis point. This does not create a good relationship with the mental health system and is not conducive to good outcomes.

Statistically, blacks are less likely to initiate treatment and more likely to terminate treatment prematurely. If you don’t have access to services in your community and must take three buses to get to that first appointment, even if you get there once, you are not likely to return. We also know that black people access telehealth at lower rates than white people. There are so many obstacles to accessing services that tend to create a lot of these disparities.

So, the black experience is different. If a clinician’s perspective is one-size-fits-all, they may not understand, appreciate, or acknowledge the experience of being black in America. It’s very difficult and can become a traditional paternalistic relationship where the provider is saying, ‘I know what’s best for you,’ when it’s not necessarily the right fit. We often hear the myth that black men don’t want mental health treatment. I think that black men do want mental health treatment that accounts for their personal experience.

Consider this example: you invite me over for dinner, and I’m hungry and really want to eat. When I get to your house, I see you’re serving okra. Now, I don’t eat okra. Can’t swallow it. Can’t stand it. I am going to tolerate it, then leave and not come back. People of color might be hungry for help, it’s just that the help that’s available to them might be offered in a way that they cannot digest. Once I leave that okra dinner, I am going to look for something that I can eat. This is why a lot of people of color turn to their faith leaders, or the church, and are more likely to talk with their pastor than with a psychiatrist. The pastor understands their experience.

Watch the full interview here:

 

MCMAHON: This reminds me of something I hear a colleague often say. She is a community mental health leader and, in reference to how we can better reach people when it comes to healthcare, she always says we need to meet people where they eat, shop, and pray.

ARMSTRONG: That’s right! You have to understand someone’s perspective, their context. It will hit much better than trying to fit them into this box that has been created. Adding to that, there just are not enough black and brown clinicians, let alone black or brown male clinicians. So I appreciate it when providers are thoughtful about what they can do to better understand the patient’s perspective.

MCMAHON: I understand, based on the literature, that we might see less disparity when it comes to diagnosis of mental health conditions. Prevalence of disorders are not higher among minorities, per se, but reported psychological symptoms tend to be higher among minorities. Is this your understanding, and would you help us make sense of the factors that might be involved?

ARMSTRONG: Yes, and I think there is more to it. Statistically, black people are more likely to report psychological distress, and black males are four times as likely to be diagnosed with a psychotic disorder than white males. Hispanic males are about three times as likely.

If I am talking about things I have experienced as a black man in America, what you hear is paranoia. What you hear is complaining. What you hear is anger. I am much more likely to get a diagnosis than a white man because he might be heard differently. I think that is part of the bias because we don’t hear the experience that comes along with the presenting factors. We don’t hear the pain of systemic racism. We don’t hear the experience of generational trauma.

I could go into the barber shop on any given Saturday and hear black men talking about people lying or talking behind their backs. If I took it out of context, I could diagnose a personality disorder. But giving that a label just puts the person at a disadvantage, instead of simply providing a safe space to talk. As we see an increase in suicide rates, primarily among young black males, there is even more reason to normalize the conversation and provide the right space for it.

MCMAHON: So, it’s a big question, but how can we do better? What are some things that you are working on to make a difference in disparities for the black community?

ARMSTRONG: First, we have to think about the fact that mental health is health. So we have to think about this in the same way as health disparities. We saw early in the pandemic that there was a disparate impact on black and brown communities as they were more likely to get sick and to be hospitalized. Some of the reasons for that were comorbidities like high blood pressure, diabetes, and heart conditions, which all resulted from longstanding health disparities.

In North Carolina about a year ago, only 3 to 5 percent of the COVID-19 shots were going to African Americans. Today, we are at roughly 18 to 20 percent of those shots, and given that African Americans make up approximately 22 percent of the population in North Carolina, we have significantly closed that gap. We had to look at how to build trust and relationships in those communities, and that meant bringing folks to the table who could speak for the community to help us understand the challenges it faced.

We are more likely to accept things from people who look like us, so using community representatives is the best way to mitigate a historical lack of trust in health care. We can use that same strategy when it comes to mental health. We need to go into the community and partner differently than we have before, including aligning ourselves with the faith-based community.

The second thing we did was look at access. We had to be intentional about where to set up vaccine sites that were not just in places white people frequent. One of the first large vaccine sites we had in North Carolina was at the NASCAR racetrack. While that’s great, not nearly as many black people are fans of NASCAR, or even know where the track is, as white people. To address this, we needed to look at community-based organizations and work with black and brown vendors to educate people at vaccine and testing sites.

With mental health, we need to do the same. Be mindful of how many black providers we have in our networks and how to give them access to the resources they need in these communities, for example by partnering with HBCUs (Historically Black Colleges and Universities). I also think a lot of churches would open their doors and provide space, knowing that people might be more comfortable seeking services where they already feel safe. I think we need to be more intentional about taking seriously the fact that one size does not fit all.

MCMAHON: You are a wonderful and very present mental health advocate on LinkedIn and Twitter. You frequently share important data, educational posts, and resources for those in need or in crisis.  I look forward to your ‘Easy like Sunday Morning’ posts where you share motivational messages from your workout in the gym and the other messages you wear on your T-shirts! What inspired you to get started and what keeps you going?

ARMSTRONG: I think it started for a couple of reasons. One, behavioral health is my passion. I don’t think I’ve missed a day posting for years now. When I first started, much of my focus was on the connection between physical and mental health, so I would post pictures at the gym. One of my hashtags is #weightliftingismytherapy because that is really what I do to stay grounded. Then it evolved into the ‘Easy like Sunday Morning’ posts because that’s one of my favorite songs, and Sunday morning happens to be the time when I make videos. I think the song might have even been playing at the gym when I first used that title.

I am trying to encourage people living with mental health challenges and to reduce some of the stigma around it. Then it evolved to include T-shirts that go along with the message. Now, people sometimes message me and ask me my size so they can send me a shirt to wear in my video posts!

The biggest reason I make these posts comes back to my own mental well-being. For me, I need to feel like I am putting something good out into the world and mental health is what I know. So, this is kind of a social justice issue for me. This way, I can remember that no matter what challenges I am facing, there are people out there who are fighting the good fight every day, living with severe depression, anxiety, or suicidality. I just want to do my part to encourage them to keep going.

MCMAHON: As a mental health professional, I’ve found myself over the years working against the commonly held myth that if you talk about suicide, it is somehow contagious. I appreciate even more that you are putting yourself out there every day and openly talking about suicide.

ARMSTRONG: Yes, and it’s important for people who look like me to see someone else who looks like them talking about it. That’s why I often talk about the power and strength in being vulnerable, and just saying, ‘I’m struggling,’ and being willing to open up. It’s the human condition. I do have days when I feel like I don’t have the energy to do the things that I need to do, just like everybody else. Most of us can realize that if we get through today, tomorrow will be better. I want those who are having trouble to know that too.

MCMAHON: Do you have some final thoughts or an area you’d like to emphasize when it comes to mental health disparities in black and African Americans?

ARMSTRONG: Yes, I think we need to focus on reducing stigma in the black community. I grew up the son of a pastor who led a church for 48 years. I was raised and socialized in the church. I was taught that black people don’t die by suicide, and that if you were experiencing anxiety or depression, then you just needed to pray harder. People were often described as mentally or morally weak.

I think we can do a much better job of communicating and improving that messaging in the black community. The only way we’re going to eradicate that kind of thinking is if we normalize the conversation and open our doors to people in the mental health profession who want to talk to church congregations. The more we are out there talking about it, the better chance we have to eradicate the stigma. For that, the faith-based community can be a source of enormous strength.

To learn more about Victor Armstrong’s work in behavioral health, follow him on LinkedIn, or on Twitter @1of2vics. Watch the full conversation on our YouTube channel.