In 2015, two Princeton University economists, Anne Case and Angus Deaton, published a study in the Proceedings of the National Academy of Sciences of the United States of America that made a shocking claim: After decreasing for decades, the mortality rate for white non-Latinx middle-aged Americans was actually increasing. They ascribed this reversal of fortune in part to what they dubbed “deaths of despair” caused by an increase in alcohol abuse, opioid use and suicide. Their findings grabbed headlines and fueled furious debate in the public health and other research communities, particularly when they published a follow-up report in 2017 in the Brookings Papers on Economic Activity. Some researchers questioned the authors’ interpretation of mortality data. Other experts argued that the factors contributing to the rise in suicide rates and in opioid and alcohol abuse were too complex to be attributed to “despair.”
However, despite their narrow focus on a particular demographic slice, Case and Deaton were perhaps tapping into a greater sense of instability among the American populace. Since 2007, the American Psychological Association (APA) has conducted an annual nationwide survey — Stress in America — gauging both the overall level and leading sources of stress in the United States. The 2017 report revealed that two-thirds of the 3,440 adult Americans surveyed that August were significantly stressed about the future of the country. More than half of those surveyed — a group that spanned generations — said they considered the current time to be the lowest point in U.S. history that they could remember. Nearly 6 in 10 adults reported that the current climate of social divisiveness was a serious source of personal stress. Other significant sources of worry included money, work, health care, the economy, trust (or lack thereof) in government, hate crimes, conflicts with other countries, terrorist attacks, unemployment/low wages and climate change/environmental issues.
Although Americans may not be drowning in despair, research such as APA’s report indicates that many people are feeling more insecure than ever. That sense of walking a tightrope without a safety net can cause significant psychological distress, which can in turn lead to health problems and mental illness. Many experts say the burden of general societal unease is often magnified for disenfranchised groups such as communities of color or those of low socioeconomic status. And trauma — whether caused by being a member of a disenfranchised group or by a history of abuse or violence — takes an even more significant toll on health and well-being. Any or all of these issues may be related to the rise in opioid addiction and suicide across the U.S.
A poverty of health and well-being
To some degree, most people in the so-called 98 percent — those not in the top 1-2 percent of individuals possessing the majority of the nation’s wealth — worry about money: affording a mortgage, sending the kids to college, saving for retirement. The Great Recession may be over, but recent research from the Federal Reserve Bank of San Francisco (FRBSF) indicates that the economy hasn’t fully recovered. In its Aug. 13 economic letter, the FRBSF states, “A decade after the last financial crisis and recession, the U.S. economy remains significantly smaller than it should be based on its pre-crisis growth trend.”
The letter goes on to speculate that this is due to substantial losses in the economy’s productive capacity post-crisis. These losses were so significant, FRBSF researchers assert, that they could result in a lifetime income loss of $70,000 for each American.
This is staggering news for most Americans, but for those who live in poverty — 40.6 million Americans according to a 2016 U.S. Census Bureau study — such an amount is catastrophic. The poverty threshold is broadly defined as any single individual younger than 65 earning less than $12,316 annually and any single individual 65 or older living on less than $11,354 annually. The poverty threshold for two people under the age of 65 living together is $15,934, and the threshold for two people over the age of 65 living together is $14,326. For a family of three — one child and two adults — the poverty threshold is $19,055. For a family of three with one adult and two children, the threshold is $19,073.
For people who have never been impoverished, it can be difficult to comprehend all the ways in which poverty can affect health and well-being. Forget vacations, higher education and saving for retirement. People living in poverty are often unable to access basic needs such as safe shelter, food and, in some cases, even running water, says Chelsey Zoldan, a licensed professional counselor (LPC) practicing in Youngstown, Ohio. She has also counseled clients in the rural, impoverished Appalachian region of Ohio.
“I’ve worked with many clients over the years who have had their utilities turned off and lived in homes without water, heat or electricity,” says Zoldan, an American Counseling Association member. Missing that foundation at the bottom of Abraham Maslow’s hierarchy of needs, these clients struggle to stabilize their mental health symptoms, she explains.
People living in poverty often have to reside in low socioeconomic status areas with higher levels of violence and crime. Zoldan says many of her clients have lived in supportive housing and regularly heard gunshots in their neighborhoods at night. Although some clients seemed to get used to it, others — particularly those with trauma histories — had trouble feeling safe in their own homes.
Those who live in poverty also often lack access to quality health care. “Not only are individuals limited in terms of health care coverage, but they may also struggle to obtain transportation to get to health-related appointments,” Zoldan says. “In my area, there was such a high demand for medical transportation to appointments that they stopped providing door-to-door transportation and only provided bus passes.”
Instead of a 15-minute ride to appointments, Zoldan’s clients now had to navigate public transportation, which could take up to two hours each way with a change of buses. Riding the bus also poses another significant challenge — having to walk numerous blocks to the stop, which during winter in northeast Ohio means navigating “tons of snow” and double-digit subzero windchills, Zoldan says. Even in more clement weather, many of Zoldan’s clients were unable to devote two to four hours a day to traveling to health-related appointments, so they stopped receiving services.
Self-care can also prove challenging for those living in poverty, and it doesn’t include vacations or nights out. Zoldan works with individual clients to identify free activities that they enjoy and can engage in at least weekly, such as taking a bath, attending a Bible study, going for a walk in the park, meditating, and reading books or magazines at the library. Unfortunately, some of these activities may not be available to all clients, either because they live in rural areas with few resources or because they are unable to arrange child care, Zoldan points out.
Zoldan advises counselors working with this client population to get outside the walls of their offices. It is critical that counselors make community connections, she says, so that they can help clients access resources such as shelters, housing authorities, food banks, clothing providers, programs that offer financial assistance for utilities, medical transportation and vocational services.
“In connecting our clients with these resources, we can work to build a safety net for our clients and create some more stability in their lives so that they can thrive,” she says.
The legacy of racism
Racism happens on both a micro and macro level, says Cirecie West-Olatunji, a past president of ACA. Microaggressions are more nuanced and under the radar and involve everyday interactions with individuals who exert privilege. It might be the shop clerk who ignores an African American person in favor of a white shopper or a student of color who is consistently not called on, despite raising her hand. Macroaggressions are overt and meant to intimidate members of a group, such as neo-Nazis marching in the nation’s capital and people openly using racial slurs. Together, the macro- and microaggressions create pervasive, chronic stress that is handed down through intergenerational trauma, explains West-Olatunji, an associate professor at Xavier University of Louisiana and director of the Center for Traumatic Stress Research.
Over the past 20 years, researchers have been studying a phenomenon they first witnessed in some of the grandchildren of Holocaust survivors. Despite not having experienced the Holocaust themselves, and instead having grown up in a middle-class environment in the U.S., these individuals displayed survivor-like trauma symptoms. The findings were startling but have proved not to be unique. After 9/11, researchers studied children who had not been born at the time that their parents served as first responders at one of the attack sites. Like the grandchildren of the Holocaust survivors, these children of 9/11 trauma survivors displayed corresponding symptoms despite not experiencing the trauma themselves, West-Olatunji says.
Chronic, pervasive stress and trauma can be seen in changes at the DNA level, she says. Some researchers believe that these DNA changes play a part in handing down the trauma from generation to generation.
For African Americans, the trauma is also handed down on a systemic level, West-Olatunji says. “It is evident in social structures, education, lack of power and aggressive acts that threaten the psyche of individuals who are culturally marginalized,” she says. Slavery still casts a long shadow, its legacy evident in the school-to-prison pipeline, the number of African American children who are in low-resource schools, their overrepresentation in special education and the disproportionate diagnosis of behavioral disorders. “Children are being tossed out of the American dream by a lack of resources,” she says.
The effects of openly expressed racism are also manifesting in society, West-Olatunji says. “We’re anxious and irritable and feeling less hopeful about the world,” she says. These “symptoms” match those displayed by culturally marginalized groups.
Courtland Lee, also a past president of ACA, believes the effects of racism extend beyond the targeted group. In fact, he contends that racism can be considered a mental illness.
Lee began thinking of the concept of racism as mental illness after reading Stamped From the Beginning: The Definitive History of Racist Ideas in America, a book by Ibram X. Kendi that examines the intellectual roots of racism. Although many people may consider racism the purview of poor, white, rural Southerners, it has historically been handed down from the best and brightest minds in science, medicine, philosophy, religion and psychology, Lee explains. Racism is woven into our intellectual and social fiber and is used to manipulate people through fear of the other, he continues.
Lee says that targets of racist behavior are ground down by the constant micro- and macroaggressions, leading to “cultural dysthymia,” or collective low-grade depression. This collective depression is manifestly not conducive to mental health, and he argues that its effects aren’t felt solely by those who are targets of racism.
Lee believes that the fear and hatred of those who perpetrate racist acts is also mentally traumatizing — not just to those who are targeted but to the perpetrators themselves — and that the trauma must be addressed to treat the mental illness of racism. Counselors can do this on a systemic level through advocacy and on an individual level by helping people who are racist see that the agitation, irritability, hostility and hypervigilance they experience is caused by their beliefs. The challenge is getting perpetrators of racism to see that the defensiveness and fear inherent in racist thought can also bring those fears to life, Lee says.
For instance, one commonly cited reason to block immigration from Mexico is that these immigrants are stealing American jobs and damaging the economy. However, a lack of visas and fear of anti-immigrant violence have kept Mexican seasonal workers away from sectors such as the Maryland crab industry. In their absence, merchants who sell crab meat to restaurants and stores cannot recruit enough employees to clean and process their haul, even at high wages. That means the crabs cannot be sold, which is a major economic blow to the industry.
As a country, the United States needs to discuss racial issues, Lee says. Counselors, who are trained to encourage conversation, can and should facilitate these dialogues in their communities, through churches or community centers, he suggests. “We really do live in a sick society,” Lee says. “We can help people get well, but the only way to get well is to cure the society.”
As individuals, counselors can also play an important role in validating the experiences of people of color and speaking out when they witness micro- or macroaggressions, West-Olatunji says. She also urges counselors to explore non-Eurocentric methods, such as using the tradition of storytelling in the Latinx community or testifying in the African American community. Non-Western traditions can be applied effectively across cultures, making them a useful addition to any counselor’s toolbox, West-Olatunji says.
Touched by trauma
“Life is a traumatizing experience,” says Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. “It’s full of challenges, unexpected and uncontrollable events, and losses. I don’t think any of us gets through it unscathed.”
Miller, an ACA member, says trauma is on a spectrum that begins with ordinary stress and gradually progresses to completely overwhelm a person’s ability to cope. Eventually, it can even put them at risk of death.
A seminal study that the Centers for Disease Control and Prevention and Kaiser Permanente began in 1995 established a link between adult health problems and adverse childhood experiences such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household, and household members who had substance abuse problems or had been in prison.
These experiences fall on the more extreme end of the spectrum — often referred to as “big T” traumas. However, Miller cautions against discounting the “little t’s” as sources of distress. Where a trauma falls on the spectrum is individual and variable. “Some people might experience the loss of a job as stressful but wouldn’t be completely overwhelmed by it,” she explains. “Others might experience it as very overwhelming and become immobilized. So one person’s stressful event is another person’s traumatic event, and one person’s traumatic event is another person’s ordinary stressful event.”
Miller notes that mental health professionals recognize events such as the loss of a job, economic insecurity, divorce and family problems as sources of stress but often don’t accord them the same level of treatment as “real” mental illness. “It’s really a false distinction,” she says.
Someone who has lost a job or is going through a divorce is experiencing significant stress and is likely flooded with cortisol in the same way that a person who has experienced violence is, Miller asserts. “It’s really the chronic stress from either a ‘little t’ trauma or a ‘big T’ trauma that eats away at us and sets us up for depression, anxiety, anger problems, health problems and substance use,” she explains.
“There are a lot of things going on in society that could be experienced as traumatic,” Miller continues. “Globalization and automation are rapidly changing communities and workplaces, eliminating some industries and leaving workers scrambling for jobs that pay less and offer less job security. Economic inequality is growing, and housing costs keep rising. People feel increasingly insecure and like their futures are being threatened. That’s leading some people to feel helpless or hopeless. Others are angry and lashing out.”
Trauma-informed counseling is critical to recovery from both “big” and “little” traumas, Miller says, as well as for building ongoing resilience.
“I think that the biggest thing that trauma-informed counselors bring to the treatment process that less-informed counselors may not is an alternative explanation for behaviors that are often seen as purely manipulative, obstinate, oppositional, attention seeking or antisocial,” Miller says. “Trauma-informed counselors may be more likely to view a client’s reactions and behaviors as attempts to cope or protect themselves rather than chalking them up to resistance, treatment noncompliance or poor motivation. They also bring an awareness of the importance of creating a sense of safety and control for a client, and they work to create environments in which clients have as much autonomy and input into their treatment as possible.”
Miller also decries the traditional “split” between substance abuse and mental health treatment. Although she doesn’t believe that all substance abuse is caused by mental illness or trauma, she says these are often underlying factors that go untreated, which puts clients at risk of relapse.
Regardless of the cause, substance abuse is an illness that needs to be treated, she asserts. “For far too long, substance abuse has been treated as a problem of weak moral character rather than an effort to soothe emotional pain that someone doesn’t feel able to cope with,” she observes.
Miller also points to the contrasting public reactions to the crack and opioid epidemics. Whereas the crack crisis of the 1980s and early 1990s was considered a criminal problem, the current opioid epidemic is recognized as a public health problem, she notes. Miller ascribes this difference not only to the traditional judgment of substance abuse as a moral failing but also to the reality that crack was seen largely as affecting African Americans, while opioids are generally viewed as affecting white Americans. (Some researchers and commentators have also begun noting that the growing number of opioid-related overdoses and deaths among African Americans has largely been left out of the national narrative.)
Just as crack enveloped areas that were economically devastated — at the time, predominantly African American urban neighborhoods — opioids are most common in rural areas that can no longer depend on the industries that once sustained them. West Virginia is one of the epicenters of the opioid crisis, and Carol Smith, an ACA member and past president of the West Virginia Counseling Association, believes that isolation and the lack of opportunity in much of the state are helping to fuel opioid abuse.
A frequently spun narrative of the crisis is that of unsuspecting people who get addicted after being prescribed opioids for pain after injury or surgery, but those cases make up a small percentage of those who are addicted to opioids, according to Smith. Indeed, people have been using opioids for pain relief for decades without becoming addicted on a large scale, notes Smith, a counseling professor and coordinator of the violence, loss and trauma certificate of studies at Marshall University. The people who do get addicted after being prescribed opioids usually already have substance abuse problems, she says.
However they first encounter opioids, the people most at risk for addiction are those who lack good coping skills and social support, Smith says. They typically also have a certain degree of existential despair, which is only reinforced by the long-term abuse of opioids.
Smith explains that West Virginia is particularly vulnerable to this sense of despair because its topography of mountains and waterways makes building roads and installing cables prohibitively expensive. This isolates the state not just physically but virtually because of the lack of high-speed internet access, she says. This lack of connectivity discourages new economic development, further reinforcing the cycle of poverty. As a result, many of the state’s inhabitants don’t feel that they have a lot to lose or much to strive for, Smith says, leaving them vulnerable to anything that might make the day go by faster or easier.
With its emphasis on treating the whole person, counseling is integral to the effort to stem the tide of addiction, Smith says. Counselors can help clients fight despair by guiding them to regain a sense of purpose through goal setting and identifying reasons for living. In addition, counselors can aid clients in dispelling their sense of isolation by teaching them relationship skills and helping them build support networks. Smith also stresses the importance of combining counseling with medication-assisted treatment, which addresses the physiological aspects of addiction.
Dying of despair?
According to the Centers for Disease Control and Prevention (CDC), 45,000 Americans 10 years and older died by suicide in 2016, the most recent year for which statistics are available. In the June CDC Vital Signs report, the agency said that from 1999-2016, the suicide rate rose by more than 30 percent in 25 states. While acknowledging that those suicide statistics are the most accurate figures available, the American Foundation for Suicide Prevention has stated that it believes actual rates are much higher.
Case and Deaton’s study connected the rise in the suicide rate in part to despair caused by a dearth of employment and lack of opportunity, but some experts say that causation is far from clear.
“It is hard to pinpoint a specific cause,” says ACA member Darcy Granello, a professor and director of the Ohio State University suicide prevention program. “Frankly, the numbers are increasing at such an alarming rate and across so many different demographic groups that we have to be careful not to paint broad brushstrokes and assume that specific factors apply to all of these different groups.”
Granello, whose research focuses on suicide prevention, does believe that Americans are feeling more isolated and disconnected, however. “That pervasive sense of loneliness is especially dangerous for those who already struggle with depression,” she says. “We know that social connectedness, feeling supported and having a sense of belonging all are protective factors that help minimize the risk for suicide. When those are taken away, suicide risk increases.”
Granello says myriad factors may be contributing to the rise in suicide, but recent research has caused experts to question their understanding of suicide. For example, historically, 90 percent of those who kill themselves have some kind of mental illness — often undiagnosed or untreated. However, more and more people who die by suicide do not have a diagnosable mental illness at the time of their death, Granello says.
“This is challenging to everyone in the field, and it causes us to rethink much of what we know,” she says. “It means that suicide is more and more the result of people who simply do not have the resources to cope with life’s problems, whether this inability to cope is because they are living with a mental illness or simply because they are overwhelmed by life and have never developed healthy coping strategies.”
Granello urges counselors to focus on helping clients develop those strategies. Those at risk for suicide are often ill-equipped to face life’s challenges, make long-term plans and envision a future, she says. For many people, the key to survival is getting through the crisis period — that window when they are most tempted to end their lives, she continues.
Counselors can teach clients to move out of their isolation, reach out to others and develop healthy coping strategies, Granello says. But to do that, counselors need to be adequately trained in suicide prevention, assessment and intervention — something that Granello doesn’t think is happening often enough. She stresses the need to push for comprehensive, empirically supported suicide prevention training in counselor education programs and through continuing education.
“We have to do this,” Granello says. “We are, quite literally, fighting for our lives.”
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
Counseling Today (ct.counseling.org)
- “Opioid SOS” by Laurie Meyers
- “We’re in danger of losing a generation” by Bethany Bray (online exclusive)
- “Stepping across the poverty line” by Laurie Meyers
- “Facing the realities of racism” by Laurie Meyers
- “An eight-step process for implementing social justice and advocacy interventions,” by Jonnie Seay Lane (online exclusive)
- “Informed by trauma” by Laurie Meyers
- “Raising awareness of suicide risk” by Jerrod Brown and Tony Salvatore
- “Coming to grips with childhood adversity” by Oliver J. Morgan
- “Group counseling with clients receiving medication-assisted treatment for substance use disorders” by Stephanie Maccombs
Books and DVDs (counseling.org/publications/bookstore)
- A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
- Counseling for Social Justice, third edition, edited by Courtland C. Lee
- Multicultural Issues in Counseling: New Approaches to Diversity, fifth edition, edited by Courtland C. Lee
- Suicide Assessment and Prevention, DVD, presented by John S. Westefeld
ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)
- Trauma and Disaster
- Suicide Prevention
- Substance Use Disorders and Addiction
- “Counseling African-American Males: Post Ferguson” presented by Rufus Tony Spann (ACA285)
- “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
- “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
- “ABCs of Trauma” with A. Stephen Lenz (CPA24329)
- Multicultural and Social Justice Counseling Competencies
Laurie Meyers is the senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
Letters to the editor: email@example.com
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.