Fresh: A Biopsychosocial Assessment In the Yakin-directed film Fresh, a 12-year-old boy -- "Fresh" -- struggles to balance school and a tumultuous home life with the drug-running activities that allow him to make and save money. Though Fresh is intelligent, ambitious, and highly motivated to rise above his current station in life, as an African-American living in the crime-driven projects, his perceived opportunities for advancement are limited. As a result, Fresh makes money in the only way he knows how; as an inner-city drug mule for the number one suppliers of heroin -- "smack" -- and cocaine, referred to as "base." The money he makes, he saves in a tin can hidden by the tracks on the city's outskirts. Says Fresh to his friend Rosie in scene two, "If I had me a million dollars, I'd get me a Porshe 959." And when Rosie says it doesn't matter because he'll never have a million dollars, "I will too," says Fresh. "Someday, I'm gonna have it" (Fresh, 1994).

Demographic, Presenting Problem and Mental Status

African-Americans account for approximately 12% of the U.S. population. Approximately 60% of African-Americans live in urban areas with elevated crime rates, while approximately 25% live in conditions below the poverty line (Baker & Bell, 1999).

As a member of this demographic, Fresh is already at risk of becoming a victim of homicide, suicide, and severe chemical dependency. As a drug runner for violent drug dealers, this risk is exacerbated. According to researchers F.M. Baker and Carl C. Bell, 53% of African-Americans are female due to the high mortality rate of their male counterparts, particularly males between the ages of 15 and 19, many of which are suicides.

Analysis of suicide rates among African-American male adolescents in the 15- to 19-year range showed that rates have steadily increased from 2.3 per 100,000 in 1960 (65) to 16.6 per 100,000 in 1994 (Centers for Disease Control, National Call Center for Injury Prevention, unpublished data, 1995). It has been proposed that the rising rate of African-American male suicide is due to the presence of major mental disorder along with sociological circumstances such as alienation and a sense of being trapped that African-American youth experience (66). (Baker & Bell, 1999)

These suicides are largely the result of the chronic stress of living in high crime environments and/or environments of prevalent drug abuse. Though Fresh himself has not yet resorted to violence or drug abuse, he is surrounded by persons who have. In the first scene of the movie, Fresh notices track marks indicative of intravenous drug abuse on the arm of a heroin supplier -- also a mother of one his classmates who offers him milk and cookies while she wraps up the "bricks." Later in scene four, Fresh turns away a young woman who offers to "suck him off" in exchange for cocaine, and in scene eight, he witnesses Jake -- one of the drug-pushers he works for -- murder his friend Rosie and another of his classmates over a basketball game (Fresh, 1994). Meanwhile, his own sister Nicole is so addicted to heroin that she's willing to trade sex for it, and his friend Chucky resorts to illegal dog-fighting for cash.

Unfortunately, this is only the beginning of the violence Fresh is witness to. In scene thirteen, he and Chucky are jumped and Chucky is shot and killed during a drug run; in the following scene, Fresh is attacked by a former friend who blames him for Chucky's death. Though Fresh doesn't say so, the fact that he feels responsible for Chucky's death is evidenced in scene fourteen when he shoots the dog he shared with Chucky. This is the first act of violence Fresh commits in the film, and is one of the first indicators that the stress of his environment is taking its toll.

Current/Previous Agency Contacts

It is suggested that Fresh and his sister were taken away from their father after their mother's death and sent to live with their aunt Francis. While not currently involved with an agency or social worker, Aunt Francis plans to send Fresh to live in the Bushwick Group Home, as his behavior has compromised her ability to care for him and his eleven cousins.

Medical, Psychiatric, and Substance Abuse History

Fresh's personal history of medical and/or psychiatric conditions is unknown. While he himself has no history of substance abuse, his father is an alcoholic and his sister is a heroin addict. It is unclear if substance abuse, medical or psychiatric conditions played a role in his mother's death, however all are possible contributors.

Current Family/Significant Others

Fresh lives with his aunt Francis and his eleven cousins. He sees his father sporadically -- typically for chess games in the park -- and his sister occasionally, typically when visiting whatever dealer she is currently living with. Fresh's mother is deceased due to unknown causes.

Analysis of Presenting Problem for Work

According to...

[Specifically,] African-American children who are witnesses to violence have been shown to experience a variety of psychiatric symptoms (8). (Baker and Bell, 1999)
Among these disorders, severe depression, anxiety, intrusive thoughts, chronic phobias, and schizophrenic delusions are the most common. Though Fresh does not initially present easily detectable symptoms of a clinical disorder, his stoicism, killing of the dog, and uncontrolled crying in the final scene of the movie are nonetheless indicators of an underlying condition.

Ironically, Fresh's high level of intelligence might put him at a greater risk of developing a clinical disorder. According to the results of a cross-sectional survey of 349 youth ages 9 to 15, all of whom resided in low-income public housing communities,

Witnessing violence was related to youth reports of intrusive thoughts and feelings, difficulties with concentration, and vigilant or avoidant behavior. Violence victimization was correlated with feelings of despondency about having either a happy or long life, as well as feelings of being unloved, uncared for, and afraid. Younger youth, boys, and active problem solvers were more likely to report intrusive thoughts. Problematic family communication was related to intrusive thoughts, distraction, feeling a lack of belonging, and expressions of emotional numbing. (Howard, Feigelman, Xiaoming, Cross & Rachuba, 2002)

That Fresh is an active problem-solver is evidenced in the frequent games of chess in the park with his father -- an alcoholic street bum -- and later in his manipulation of the drug dealers, turning one against the other. Fear and related avoidant behavior is evidenced in his reluctance to tell the police who killed his friends Rosie and Chucky, in addition to his silent response to his aunt's decision to send him a group home (Fresh, 1994). All things considered, Fresh is an ideal candidate for psychiatric and sociological evaluation, specifically regarding the emotional effects of witnessing violent crimes and chronic drug abuse.

Primary Goals/Objectives

The primary goal of all work regarding Fresh is his rehabilitation from any currently existing disorders, and the prevention of the development of additional disorders. Specifically, treatment objectives consist of the following:

Identify and accurately diagnose currently existing disorders.

Develop an appropriate rehabilitation treatment plan.

Evaluate rehabilitation progression on a regular basis.

Change or make alterations to the treatment plan as indicated as necessary according to evaluations.

Take preventative measure as indicated as necessary according to evaluations.

Reconstruct the child's ability to emotionally deal with past, present, and future circumstances.

Address any and all concerns -- either physical, emotional cognitive or otherwise -- as emerge during the course of treatment, particularly any specific concerns the child himself expresses.

Intervention Strategies and Plan

The first step to Fresh's rehabilitation is a sociological one. In order for him to recover from the violence he has witnessed, he must be removed the environment in which the violence occurred. Specifically, he must be removed from the inner city projects to a place of security, both actual and perceived. As Fresh requests that his sister be removed from the projects also, she should be placed in a drug rehabilitation program that allows frequent contact with Fresh. Meanwhile, Fresh himself should be placed in the care of foster parents with previous experience caring for troubled youths, particularly youths who have either witnessed or been involved in violent crimes.

Once Fresh and his sister are physically removed from the environment of violence, Fresh should be paired with a therapist and undergo a complete psychological assessment. While it is not imperative that the therapist be African-American, it can be difficult for a white therapist to develop a rapport with a patient of color. According to Baker and Bell,

The difficulty in establishing rapport in interethnic and intercultural situations (41) may be confounded by patients' reactions to antipsychiatry literature that has been targeted to the African-American community (42). Clinicians must be prepared to explore antipsychiatry feeling with African-American patients to counteract the negative effects antipsychiatry propaganda they may have heard. (Baker & Bell, 1999).

Meanwhile, African-American therapists -- particularly those who share a similar background with African-American patients -- must be…