“When poverty creates the need for mental health care and then limits access to it, untreated mental illness shapes lives.”

Text: Dr. Sarah Y. Vinson

You would think that in the course of completing 10 years of training after undergraduate and studying for and passing three national board certifications, I would have learned about the important stuff. Not so. I never had one class on one of the biggest single issues in black mental illness and criminal justice involvement: poverty. 

I am both a psychiatric care provider and a psychiatric forensic expert. Sometimes my role is to help people get healthier, and sometimes my role is to help courts understand the impact of a psychiatric issue in a given legal case.  As a healthcare provider, the families I serve are in three distinct settings: a juvenile justice facility (jail for kids), a boutique private practice in a wealthy neighborhood, and a public clinic in one of Atlanta’s poorest neighborhoods. In the majority of clinical cases, biology is not the major driver of symptom presentation and treatment plan development. The key players are environmental: local community programming, housing stability, health insurance status, and caregiver resources, both monetary and human. 

As a forensic psychiatrist, I’ve consulted federal criminal defense teams in six different states, helping the court understand the biological, psychological and social context of the defendant’s criminal actions. This requires a detailed evaluation of the defendant, interviews with family members, and reviews of educational, health, correctional and/or child protective records. Each incarcerated defendant of color I have interviewed was facing 20 years or more in prison, and in some cases even the death penalty. Every single one of them had experienced childhood poverty. 

It is obvious that poverty limits access to mental healthcare, but what is overlooked is that all too often poverty creates the need for that care in the first place. Mental illness, like many health problems, typically strikes when  biological vulnerability is coupled with exposure to a stressor. Poverty, simply defined, is when a household has insufficient resources to reliably meet its basic needs. This constant threat to one’s very survival most certainly qualifies. Poverty in and of itself is traumatic, especially during periods of brain and identity development.  It also creates vulnerability to additional traumas – both inside and outside of the home. For example, families with limited resources can get stuck in neighborhoods with high rates of community violence and disproportionate contact with the criminal justice and foster care systems. Additionally, financially dependent poor women and their children are especially vulnerable to perpetrators of domestic violence and child abuse. Staying means ongoing abuse. Leaving means risk of hunger and/or homelessness.

When poverty creates the need for mental health care and then limits access to it, untreated mental illness shapes lives. Mental health impacts relationships, academic progression and employment opportunities. Irritable moods alienate and distress loved ones. Hopelessness from depression makes seeing the big picture and finding motivation to complete school work feel impossible. Avoidance from anxiety undercuts work productivity. The list goes on. As the Adverse Childhood Experiences (ACE) studies have well documented, even childhood trauma survivors who reach the middle class as adults are not immune from poverty’s reach. Early traumatic exposures increase the risk of depression, addiction, and even suicide in adults. Furthermore, black people who make it out of poverty have less of a familial safety net and are at greater risk of falling back into it.

Because of the well-documented psychological phenomenon of intergenerational trauma, black people who do not grow up in poverty themselves, but have parents who did, can still be at risk. As a result, non-traumatized children can display psychological scars similar to that of the traumatized parent. Early trauma can activate certain genes and this activation pattern can be inherited. Additionally, parents shape children’s development, both by example and by what they explicitly tell them. Therefore, the children’s mentality can mirror their parents’, which was molded by the parents’ own childhood trauma.

Poverty threatens mental well-being and as such, black people are exceptionally threatened. Per the U.S. Census Bureau, in 2016 22 percent of black people and 30 percent of black children lived below the poverty line. These numbers likely understate the problem’s reach. For one, they do not include the incarcerated or those in foster care, both populations in which blacks and people of lower income/no income are over-represented. Secondly, the Census Bureau defines poverty as having an income below the poverty line, and these lines are set strikingly low, especially in light of rising housing and healthcare costs.  It is a mere $24,563 for a family of four; $16,543 for a two-person household including one child; and $12,486 for a single person. 

Our society literally makes poor people sick, and a disproportionate number of black people are poor. Access to quality care absolutely matters when it comes to mental illness and mental health.  A secure environment, having basic needs met, and reliable access to food and housing simply matters much more. As a highly trained medical provider, it was a sobering realization that much of what hurts my patients and much of  what is needed to heal them has absolutely nothing to do with the practice of medicine; however, this perspective also has an upside. It expands the pool of potential mental health advocates far beyond patients and providers. Anyone with a voice or a vote can support programs, policies and personal practices that combat poverty, and in so doing join the fight for black mental health.