mental health AIDS

Spring 2005 Newsletter

Addressing Historical Trauma Among African Americans as an HIV Intervention

"During 2000-2003, more than half of new HIV/AIDS diagnoses in 32 states were among blacks, although blacks represented only 13% of the population of those states. "

- Centers for Disease Control and Prevention, 2005, p. 89

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Klonoff and Landrine (1999) conducted a door-to-door written survey involving 520 black adults in 10 randomly selected middle- and working-class census tracts in San Bernardino County , California . Nearly 27% of respondents agreed with the statement, "HIV/AIDS is a man-made virus that the federal government made to kill and wipe out black people." An additional 23% of respondents were undecided about this statement. Importantly, endorsement of this belief was unrelated to age or income, but was associated with higher levels of education. "Blacks who agreed that AIDS is a conspiracy against them tended to be culturally traditional, college-educated men who had experienced considerable racial discrimination" (p. 451).

More recently, Bogart and Thorburn (2005) conducted a telephone survey regarding HIV/AIDS conspiracy beliefs and their relation to condom attitudes and behaviors with a random national sample of 500 African Americans between the ages of 15 and 44. The HIV/AIDS conspiracy beliefs presented to respondents were based on earlier research studies. A selection of these beliefs follows:

• A lot of information about AIDS is being held back from the public. (58.8% of respondents agreed "somewhat" or "strongly")

• There is a cure for AIDS, but it is being withheld from the poor. (53.4%)

• HIV is a man-made virus. (48.2%)

• People who take the new medicines for HIV are human guinea pigs for the government. (43.6%)

• The government is telling the truth about AIDS. (37.0% overall; 31.6% among male respondents) 1

• AIDS was produced in a government laboratory. (26.6% overall; 30.5% among male respondents)

• AIDS was created by the government to control the black population. (16.2%)

• AIDS is a form of genocide against blacks. (15.2% overall; 20.7% among male respondents)

• HIV was created and spread by the CIA. (12.0% overall; 16.1% among male respondents)

• The medicine that doctors prescribe to treat HIV is poison. (6.8% overall; 8.6% among male respondents)

• The medicine used to treat HIV causes people to get AIDS. (6.0%)

• Doctors put HIV into condoms. (1.6% overall; 4.0% among male respondents)

Consistent with prior research, these investigators found that "between 1% and 60% of the respondents endorsed specific conspiracy beliefs about HIV/AIDS. Few respondents endorsed the most extreme beliefs, such as 'Doctors put HIV into condoms.' The greatest proportion of respondents endorsed beliefs about the government's role in withholding a cure for AIDS or information about the disease itself" (p. 216).

Findings further suggest that HIV/AIDS conspiracy beliefs may act as a barrier to HIV prevention, particularly among black men. "Men held stronger conspiracy beliefs than did women, and endorsement of conspiracy beliefs was associated with more negative attitudes toward using condoms and less consistent condom use among men but not among women" (p. 217).

Given the highly disproportionate impact of HIV on the black community, these beliefs bear further examination, both from the historical perspective as well as the psychological.

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"Conspiratorial theories are particularly endemic in Black America . These theories are historically embedded and often stem from persistent mistreatment and inequality, beginning with the institution and practice of slavery."

- Parsons, Simmons, Shinhoster, & Kilburn, 1999, p. 216

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The Shadow of Tuskegee

The government-sponsored Tuskegee Syphilis Study was conducted between 1932 and 1972. Over this 40-year period, 399 African American men from Macon County , Alabama , were denied effective treatment for syphilis for the purpose of documenting the natural history of the disease. It is "the longest nontherapeutic experiment on human beings in medical history" (Thomas & Quinn, 1991, p. 1498).

Not surprisingly, "[t]he Tuskegee Syphilis Study continues to cast its shadow over the lives of African Americans. For many Black people, it has come to represent the racism that pervades American institutions and the disdain in which Black lives are often held" (Gamble, 1997, p. 1777). Conspiracy beliefs about HIV/AIDS are rooted in this social and historical context.

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"Many ... have suggested that blacks have developed a profound distrust of whites in response to ... racism and that such distrust is purposefully taught to successive generations ... and so ... may have important implications for black health. Others have speculated that such racism has led blacks to be particularly distrustful of AIDS-related information and interventions ... ."

- Klonoff & Landrine, 1999, p. 451

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Transgenerational Transmission of Trauma and Grief

In their pioneering studies involving American Indians, Brave Heart and DeBruyn (1998) describe the monumental losses of life, land, and culture experienced by peoples native to the Americas as a result of European contact and colonization. They contend that descendants of these native peoples, in response to these losses, suffer from historical unresolved grief. "Like children of Jewish Holocaust survivors, subsequent generations of American Indians also have a pervasive sense of pain from what happened to their ancestors and incomplete mourning of those losses" (p. 68). Compounding this legacy,

[p]resent generations of American Indians face repeated traumatic losses of relatives and community members through alcohol-related accidents, homicide, and suicide. Domestic violence and child abuse are major concerns among American Indian communities throughout the country. Many times deaths occur frequently, leaving people numb from the last loss as they face the most recent one. These layers of present losses in addition to the major traumas of the past fuel the anguish, psychological numbing, and destructive coping mechanisms related to disenfranchised grief and historical trauma. (pp. 68-69)

What are the theoretical frameworks used to explain transgenerational transmission? Brave Heart and DeBruyn contend that self-destructive behaviors in historically traumatized peoples are reflective of "internalized aggression, internalized oppression, and unresolved grief and trauma" (p. 70). The aggression and oppression are, in turn, acted out against the self and others like the self (i.e., fellow group members).

Brave Heart and DeBruyn also point to the concept of "identification with the aggressor." Through this identification, the individual "incorporates the harshness of the aggressive authority figure, which may be projected onto others with ensuing hostility" (p. 70). As Brave Heart and DeBruyn see it, "the high rates of depression ..., suicide, homicide, domestic violence, and child abuse among American Indians can ... be attributed to these processes of internalized oppression and identification with the aggressor induced by historical forces ..." (p. 70).

Referencing the African American experience, Apprey (1999) reaches a similar psychoanalytic conclusion regarding what he describes as transgenerational haunting, defined as "the transfer of destructive aggression from one generation to the next. In such a transfer we may witness a shift from suicide in one generation, murder in the next, followed by, let us say incest or physical abuse in a subsequent generation, and so on and so forth. It is as if the injured group has accepted the message that they do not deserve to live and therefore must die by one form or another. ... Here the [trajectory] toward one's death remains the same but ... the form of reducing oneself to nothingness, changes from one generation to the next" (p. 134).

While theoretical in nature, the concepts of historical trauma and historical unresolved grief have recently received preliminary empirical support (Whitbeck, Adams, Hoyt, & Chen, 2004) and will surely be topics of continuing inquiry.

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"Healing takes on many dimensions. The body, mind, spirit, and relationships to one's family and community are all involved in the healing process. Healing in one dimension is incomplete without the others. Integration of positive, healthy habits into daily patterns of life should be the ultimate goal. "

- Tully, 1999, p. 42

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"Overturning the Received 'Poison' of History" 2

Perspectives on the therapeutic induction of a healing process are, for the most part, consistent across writers in this field.

Bogart and Thorburn stress the importance of bringing conspiracy beliefs out into the open when conducting HIV prevention interventions.

Based on the large number of individuals who endorsed HIV/AIDS conspiracy beliefs ..., it is important for ... practitioners to integrate such beliefs into safer sex education messages targeting African Americans, especially black men. ... Further, to the extent that conspiracy beliefs stem from general mistrust of the US government and health care system, interventions that encourage frank dialogue about conspiracy beliefs in the context of historical and current racial discrimination may have the greatest prospect for success. ... In this way, we can begin to overcome barriers, such as conspiracy beliefs, that are obstacles to the ready acceptance of prevention messages and the subsequent practice of safer sexual behaviors. (p. 218)

Building on these recommendations, Apprey suggests that "[i]n working with aggrieved communities and pooled communal memories that continue to have destructive impact on the present, a description of shared communal injury must include: a) the fact of historical injury; b) the potential for transformation of that history; and c) a constant reminder that each person, family, or ethnic group must know the motivation behind the historical injury caused by the transgressor" (p. 135).

If clinicians emphasize only the urgency of remembering history, ... patients ... only get more angry. There is, as it were, a repeat of the experience of history in affective form. If clinicians only emphasize the will to change and bypass history, ... clients ... experience a sense of woundedness once again. They hear the voice of the transgressor saying that their history of devastation does not matter. However, by considering the wounds of the living, as it were, together with the will and responsibility to transform the received injury, one gets to transform the toxic ... into [the] positive ... . (p. 136)

In his view, just as destructive aggression can be transmitted transgenerationally,

[t]here is the potential to transform structures of behavior transgenerationally. In the creative arts and expressive therapies, various opportunities for dramatizing and transforming the storied texts of trauma exist.

In art therapy, narrative of who one is, where one is, and where one sees oneself as going in life can be the subject of drawing, painting and sculpting. Various degrees of transformation are potentially there to be grasped and negotiated.

In dance therapy, a clinician can explore with a client where in one's body the traumatic pain is stored ... .

In psychodrama and/or in drama therapy, life themes can be portrayed, staged, enacted, extended and transformed in the context of negotiating how one can be both separate from and yoked to one's family.

Horticultural therapies can use plants to indicate how one plant gives life to another. (pp. 139-140)

Turning to more traditional forms of talking therapy, Apprey has this to say:

There are many clinical methods for understanding and transforming the impact of historical trauma and reinventing the self in the clinical process. However the approach advocated here requires that regardless of what clinical method of intervention is chosen, a particular strand must run through the process of treatment to [produce] durable and meaningful change. This strand ... includes understanding ... the way that particular suffering is mentalized by the victimized group and subsequently reenacted by generations to come. In technical terms there must first be many profiles of understanding of the historical injury. Then there must be an understanding of how the aggrieved community has stored in [its] communal memory those psychological hurts, those feelings of humiliation and changing historical accounts of the actual injuries. Subsequently those sedimentations of historical grievances are enacted within the transference in the clinical situation where the grievances are not only staged, but re-staged, distorted or extended. Then comes the most decisive obligation the clinician has towards the ... client or community that is attempting to transform itself. That ... obligation is to ... constantly engag[e] the mandate to die or destroy oneself in order to find new and more flexible forms of adaptation. In short, to know death is to put it back where it belongs in history as well as knowing how victims may unconsciously house so much bitterness that they may uncannily carry out their own extinction without knowing it and without the assistance of their historical enemy. (p. 140)

Focusing as well on modifying destructive patterns, Tully (1999) references the work of Judith Herman (1992), positing that "since the core experience of trauma is disempowerment and disconnection, recovery is based upon reconnection to one's own power and to the fellowship of others ..." (p. 31). She goes on to identify components of African American culture that buffer the effects of trauma and support healing. These include:

• Religious faith and/or deep spirituality, which offer connection to "a powerful identity" (e.g., God, Allah) and, ultimately, reconnection to the power within;

• The communication of ideas, feelings, and social commentary through music (e.g., "the blues," rap, hip-hop) and storytelling (in forms that range from humorous to hard-hitting), inventions that repeat and allow others to bear witness to oppression but also serve to reframe trauma stories, rendering them more manageable; and

• Dedication to family and to the community, through which members experience support and commonality.

In Tully's words, "[t]he beauty, complexity, and variety in African American experiences and cultural forms are a treasure. Understanding these elements and incorporating them into interventions may provide a means to create a meaningful, healing connection. These cultural forms are evidence of the many ways people have sought to claim their right to live fully. Helping professionals can facilitate the unique processes that individuals and communities make for themselves to address their problems" (p. 39).

Speaking to the centrality of community, the underlying premise in Brave Heart and DeBruyn's healing model "rests on the importance of extended kin networks which support identity formation, a sense of belonging, recognition of a shared history, and survival of the group" (p. 70).

Similarly, Stephens et al. (1997) urge clinicians to "[e]mphasize the benefit that risk-reduction practices have for the community" (p. 86). "For the group or individual counselor, ... positive results may be obtained if health promotion and maintenance through safer sex practices can be used to give African American males health alternatives, reduce stress, and support individual decision making. Paying strict attention to ... the importance of linking HIV/AIDS prevention as a form of giving back to the community, may instill the importance of health care and HIV prevention among this group" (pp. 87-88).

References

Apprey, M. (1999). Reinventing the self in the face of received transgenerational hatred in the African American community. Journal of Applied Psychoanalytic Studies, 1 (2), 131-143.

Bogart, L.M., & Thorburn, S. (2005). Are HIV/AIDS conspiracy beliefs a barrier to HIV prevention among African Americans? Journal of Acquired Immune Deficiency Syndromes, 38 (2), 213-218.

Brave Heart, M.Y.H., & DeBruyn, L.M. (1998). The American Indian holocaust: Healing historical unresolved grief. American Indian & Alaska Native Mental Health Research, 8 (2), 60-82.

Centers for Disease Control and Prevention. (2005). National Black HIV/AIDS Awareness and Information Day - February 7, 2005. Morbidity & Mortality Weekly Report, 54 (4), 89.

Gamble, V.N. (1997). Under the shadow of Tuskegee : African Americans and health care. American Journal of Public Health, 87 (11), 1773-1778.

Herman, J. (1992). Trauma and recovery: The aftermath of violence - from domestic abuse to political terror. New York : Basic Books.

Klonoff, E.A., & Landrine, H. (1999). Do blacks believe that HIV/AIDS is a government conspiracy against them? Preventive Medicine, 28 (5), 451-457.

Parsons, S., Simmons, W., Shinhoster, F., & Kilburn, J. (1999). A test of the grapevine: An empirical examination of conspiracy theories among African Americans. Sociological Spectrum, 19 (2), 201-222.

Stephens, T.T., Watkins, J., Braithwaite, R., Taylor , S., James, F., & Durojaiye, M. (1997). Perceptions of vulnerability to AIDS among African American men: Considerations for primary preventive counseling for undergraduates. Social Behavior & Personality, 25 (1), 77-92.

Thomas, S.B., & Quinn , S.C. (1991). The Tuskegee Syphilis Study, 1932 to 1972: Implications for HIV education and AIDS risk education programs in the black community. American Journal of Public Health, 81 (11), 1498-1505.

Tully, M.A. (1999). Lifting our voices: African American cultural responses to trauma and loss. In K. Nader, N. Dubrow, & B.H. Stamm (Eds.), Honoring differences: Cultural issues in the treatment of trauma and loss (pp. 23-48). Philadelphia : Brunner/Mazel.

Whitbeck, L.B., Adams , G.W., Hoyt, D.R., & Chen, X. (2004). Conceptualizing and measuring historical trauma among American Indian people. American Journal of Community Psychology, 33(3-4), 119-130.

- Compiled by Abraham Feingold, Psy.D.

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1 All differences noted for male respondents were statistically significant.

2 Apprey, 1999, p. 139

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