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The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices

Lekas, Helen-Maria; Lewis, Crystal; Bradley, Mark V; Pahl, Kerstin
Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.
PMID: 37143336
ISSN: 1557-9700
CID: 5521572

Self-reported anxiety and depression problems and suicide ideation among black and latinx adults and the moderating role of social support

Williams, Sharifa Z; Lewis, Crystal Fuller; Muennig, Peter; Martino, Daniele; Pahl, Kerstin
Suicide is a critical public health problem. Over the past decade, suicide rates have increased among Black and Latinx adults in the U.S. Though depression is the most prevalent psychiatric contributor to suicide risk, Black and Latinx Americans uniquely experience distress and stress (e.g., structural adversity) that can independently operate to worsen suicide risk. This makes it important to investigate non-clinical, subjective assessment of mental health as a predictor of suicide ideation. We also investigate whether social support can buffer the deleterious impact of poor mental health on suicide ideation.We analyzed data from 1,503 Black and Latinx participants of the Washington Heights Community Survey, a 2015 survey of residents of a NYC neighborhood. Multivariable logistic regression was conducted to examine the effect of subjectively experienced problems with anxiety and depression on suicide ideation independent of depression diagnosis, and the role of social support as a moderator.Estimated prevalence of past two-week suicide ideation was 5.8%. Regression estimates showed significantly increased odds of suicide ideation among participants reporting moderate (OR = 8.54,95% CI = 2.44-29.93) and severe (OR = 16.84,95% CI = 2.88-98.46) versus no problems with anxiety and depression, after adjustment for depression diagnosis. Informational support, i.e., having someone to provide good advice in a crisis, reduced the negative impact of moderate levels of anxiety and depression problems on suicide ideation.Findings suggest that among Black and Latinx Americans, subjective feelings of anxiety and depression account for a significant portion of the suicide ideation risk related to poor mental health. Further, social support, particularly informational support, may provide protection against suicide ideation.
PMID: 35921053
ISSN: 1573-3610
CID: 5288082

Crisis Intervention Team (CIT) training and impact on mental illness and substance use-related stigma among law enforcement

Nick, Gilbert A; Williams, Sharifa; Lekas, Helen-Maria; Pahl, Kerstin; Blau, Chloe; Kamin, Don; Fuller-Lewis, Crystal
Limited empirical data and research exists about stigmatizing attitudes and perceptions held by law enforcement officers towards persons with mental illness and substance use issues. Pre- and post-training survey data from 92 law enforcement personnel who attended a 40-hour Crisis Intervention Team (CIT) training was used to investigate training-related changes in mental illness stigma and substance use stigma. Training participant's mean age was 38.35 ± 9.50 years, majority white non-Hispanic race/ethnicity (84.2%), male gender (65.2%), and reported job category as road patrol (86.9%). Pre-training, 76.1% endorsed at least one stigmatizing attitude towards people with mental illness, and 83.7% held a stigmatizing attitude towards those with substance use problems. Poisson regression revealed that working road patrol (RR=0.49, p<0.05), awareness of community resources (RR=0.66, p<0.05), and higher levels of self-efficacy (RR=0.92, p<0.05) were associated with lower mental illness stigma pre-training. Knowledge of communication strategies (RR=0.65, p<0.05) was associated with lower pre-training substance use stigma. Post-training, improvement in knowledge of community resources and increases in self-efficacy were significantly associated with decreases in both mental illness and substance use stigma. These findings highlight the existence of stigma related to both mental illness and substance use pre-training suggesting the need for implicit and explicit bias training prior to the start of active law enforcement duty. These data are consistent with prior reports indicating CIT trainings as a path to address mental illness and substance use stigma. Further research on effects of stigmatizing attitudes and additional stigma-specific training content is warranted.
PMCID:9949319
PMID: 36844168
ISSN: 2772-7246
CID: 5521562

Anti-Asian Attitudes in the Context of the COVID-19 Pandemic: an Exploratory Study

Pahl, Kerstin; Wang, John; Sanichar, Navin; Williams, Sharifa; Nick, Gilbert A; Wang, Lisa; Lekas, Helen-Maria
OBJECTIVE:The purpose of this paper was to measure if people with greater "structural literacy," as indicated by greater awareness of racial and socioeconomic disparities in COVID-19 impact, would hold fewer negative attitudes against those perceived to be Asian in the context of the COVID-19 pandemic. METHODS:A survey was administered between April and August 2020 to participants from two longitudinal cohorts in New York State. The survey assessed anti-Asian attitudes relating to COVID-19, awareness of racial and socioeconomic disparities in COVID-19, residential location, socioeconomic status, and other demographic information. The sample included 233 Black, Latinx, and White midlife adults from urban, suburban, and rural New York neighborhoods. Multivariable regression modeling was used to assess associations between COVID-19 disparities awareness, an indicator of structural literacy, and anti-Asian attitudes, adjusting for gender, race/ethnicity, residential location, and socioeconomic disadvantage. RESULTS:Greater awareness of disparities in COVID-19 was associated with lower levels of anti-Asian attitudes after adjustment (adj-slope =  - 0.358, p < 0.001). CONCLUSION/CONCLUSIONS:Greater structural literacy, as measured by awareness of socioeconomic and racial disparities in COVID-19 impact, was associated with fewer anti-Asian attitudes among Black, Latinx, and White adults. IMPLICATIONS/CONCLUSIONS:Increasing structural literacy may reduce anti-Asian attitudes that motivate harmful acts against oppressed groups.
PMCID:9341418
PMID: 35913546
ISSN: 2196-8837
CID: 5287842

A longitudinal pathway from ethnic-racial discrimination to sexual risk behaviors among Black women and Latinas: Ethnic-racial identity exploration as a protective factor

Pahl, Kerstin; Williams, Sharifa Z; Capasso, Ariadna; Lewis, Crystal Fuller; Lekas, Helen Maria
BACKGROUND:Black women and Latinas in their thirties continue to be at risk for HIV transmission via heterosexual intercourse. METHODS:Informed by the Theory of Gender and Power, this study investigated a longitudinal path model linking experiences of ethnic-racial discrimination in late adolescence to sexual risk behaviors in adulthood among 492 Black women and Latinas. We also tested whether ethnic-racial identity exploration served as a resilience asset protecting women against the psychological impact of ethnic-racial discrimination. Survey data from female participants in the Harlem Longitudinal Development Study, which has followed a cohort of New York City Black and Latinx youth since 1990, were analyzed. Data for this analysis were collected at four time points when participants were on average 19, 24, 29, and 32 years of age. Structural equation modeling was used to examine a hypothesized pathway from earlier ethnic-racial discrimination to later sexual risk behaviors and the protective role of ethnic-racial identity exploration. RESULTS:Results confirmed that ethnic-racial discrimination in late adolescence was linked with sexual risk behaviors in the early thirties via increased levels of affective distress in emerging adulthood, experiences of victimization in young adulthood, and substance use in the early thirties among women low in ethnic-racial identity exploration. We also found that ethnic-racial identity served as a resilience asset, as the association between discrimination in late adolescence and affective distress in emerging adulthood was not significant among women with higher levels of ethnic-racial identity exploration. CONCLUSIONS:The results provide important preliminary evidence that ethnic-racial identity exploration may serve as a resilience asset among Black women and Latinas confronting racial discrimination. Further, we suggest that ethnic-racial identity exploration may constitute an important facet of critical consciousness.
PMID: 35637046
ISSN: 1873-5347
CID: 5283392

Longitudinal predictors of male sexual partner risk among Black and Latina women in their late thirties: ethnic/racial identity commitment as a protective factor

Pahl, Kerstin; Capasso, Ariadna; Lekas, Helen-Maria; Lee, Jung Yeon; Winters, Jewel; Pérez-Figueroa, Rafael E
This study aimed to investigate predictors of male sexual partner risk among Latinas and Black women in their late thirties. We used multiple regression analysis to examine factors associated with male sexual partner risk among 296 women who participated in two waves of the Harlem Longitudinal Development Study (New York, 2011-2013 and 2014-2016). Women who experienced childhood sexual abuse had higher risk partners than those who did not [b = 0.16, 95% confidence interval (CI) = 0.06, 0.28]. Earlier marijuana use was a risk factor for partner risk in the late thirties (b = 0.12, 95% CI = 0.04, 0.27). Higher levels of ethnic/racial identity commitment mitigated this risk (b = - 0.15, 95% CI = - 0.26, - 0.04). Ethnic/racial identity commitment can be protective against male sexual partner risk among Latina and Black women who use marijuana. Further research should explore the protective role of different dimensions of ethnic/racial identity against sexually transmitted infections, including HIV.
PMID: 32965619
ISSN: 1573-3521
CID: 4605762

Trajectories of violent victimization predicting PTSD and comorbidities among urban ethnic/racial minorities

Pahl, Kerstin; Williams, Sharifa Z; Lee, Jung Yeon; Joseph, Adriana; Blau, Chloe
OBJECTIVE:To examine the effect of long-term violent victimization from late adolescence to the mid-30s on posttraumatic stress disorder (PTSD) and comorbid psychiatric disorders in adulthood among urban African Americans and Puerto Ricans. METHOD/METHODS:= 674) at 4 time points associated with mean ages of 19, 24, 29, and 36 years. Trajectories of violent victimization were extracted using growth mixture modeling and used to predict psychiatric disorders and comorbidities in adulthood. RESULTS:The sample was 52.8% African American and 47.2% Puerto Rican, with 60% females. Three trajectory groups of violent victimization were identified: high, intermediate, and low. Over half of the sample reported relatively high- and intermediate-level violent victimization experiences from adolescence to adulthood. Group comparisons showed that participants belonging to the relatively high-victimization group had greater odds of having PTSD, major depressive episode (MDE), and substance use disorder (SUD) separately, as well as comorbid PTSD-SUD and PTSD-MDE, compared with those classified as having relatively low levels of victimization. Having intermediate-level victimization experiences, compared with low-level victimization experiences, over time was associated with higher odds of PTSD and MDE separately and comorbid PTSD-MDE. CONCLUSIONS:Long-term exposure to relatively high levels of violent victimization during emerging and young adulthood is associated with PTSD and comorbid psychiatric disorders in the 30s. Social, structural, and interpersonal factors underlying the differential patterns of violent victimization in urban African American and LatinX youth need to be identified to adequately inform prevention efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
PMID: 31647275
ISSN: 1939-2117
CID: 4261852

Rethinking Cultural Competence: Shifting to Cultural Humility

Lekas, Helen-Maria; Pahl, Kerstin; Fuller Lewis, Crystal
Healthcare and social services providers are deemed culturally competent when they offer culturally appropriate care to the populations they serve. While a review of the literature highlights the limited effectiveness of cultural competence training, its value remains largely unchallenged and it is institutionally mandated as a means of decreasing health disparities and improving quality of care. A plethora of trainings are designed to expose providers to different cultures and expand their understanding of the beliefs, values and behavior thus, achieving competence. Although this intention is commendable, training providers in becoming competent in various cultures presents the risk of stereotyping, stigmatizing, and othering patients and can foster implicit racist attitudes and behaviors. Further, by disregarding intersectionality, cultural competence trainings tend to undermine provider recognition that patients inhabit multiple social statuses that potentially shape their beliefs, values and behavior. To address these risks, we propose training providers in cultural humility, that is, an orientation to care that is based on self-reflexivity, appreciation of patients' lay expertise, openness to sharing power with patients, and to continue learning from one's patients. We also briefly discuss our own cultural humility training. Training providers in cultural humility and abandoning the term cultural competence is a long-awaited paradigm shift that must be advanced.
PMCID:7756036
PMID: 33424230
ISSN: 1178-6329
CID: 4746502

Sexual Risk Behaviors Among Black and Puerto Rican Women in Their Late Thirties: A Brief Report

Pahl, Kerstin; Lee, Jung Yeon; Capasso, Ariadna; Lekas, Helen-Maria; Brook, Judith S; Winters, Jewel
In New York City, over 90% of women newly diagnosed with human immunodeficiency virus (HIV) are Black and Latina; a quarter of these infections occur among 30-39 year-olds. A survey was administered to 343 Black and Puerto Rican women (2014-2016) to examine two HIV infection risk factors: relationship exclusivity and having experienced childhood sexual abuse (CSA). A majority of male partners (69.7%) had at least one risk for HIV transmission. Women in non-exclusive sexual relationships (nESRs) had higher-risk partners, but engaged in safer sex practices than those in ESRs. Two-thirds of women in ESRs (64.8%) reported unprotected vaginal intercourse, although 33.5% had partners with a history of concurrent relationships. Among women in nESRs, having experienced CSA was a strong risk factor for HIV infection. Black and Latina women's vulnerability to HIV infection is significant, even when in exclusive relationships. Safer sex counseling should be integrated in primary care.
PMID: 30924047
ISSN: 1557-1920
CID: 3777512

Psychosocial Predictors of Mental Health Service Utilization Among Women During their Mid-Sixties

Pahl, Kerstin; Brook, Judith S; Zhang, Chenshu; Brook, David W
This prospective study examined the longitudinal pathways to the utilization of mental health services among women in their mid-sixties. Earlier educational level, psychological symptoms, cigarette use, and physical diseases and later psychological symptoms were examined as predictors of mental health services utilization. The sample consisted of a prospective cohort of women (N = 511) who were followed from young adulthood (mean age = 32) to late midlife (mean age = 65). Using structural equation modeling, the results supported a mediational model showing that earlier low educational level and greater psychological symptoms predicted increased cigarette smoking. Cigarette smoking predicted later physical diseases and symptoms. Physical diseases and symptoms were related to financial difficulty and later psychological symptoms and, ultimately, the use of mental health services by women in the mid-sixties.
PMCID:4250473
PMID: 24878632
ISSN: 1556-3308
CID: 1193932