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Increasing engagement rates and help-seeking behaviors among African American women
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Increasing engagement rates and help-seeking behaviors among African American women
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Increasing Engagement and Help-Seeking Behaviors Among African American Women in Mental Health by Sharmane Delgado-Payne Rossier School of Education University of Southern California A dissertation submitted to the faculty in partial fulfillment of the requirements for the degree of Doctor of Education December 2022 © Copyright by Sharmane Delgado-Payne 2022 All Rights Reserved The Committee for Sharmane Delgado-Payne certifies the approval of this Dissertation Helena Seli Monique Datta Jennifer L. Phillips, Committee Chair Rossier School of Education University of Southern California 2022 iv Abstract African American women within the United States, gripped by the historic vestiges of slavery, Jim Crow laws, and modern-day systemic racism, experience the highest rates of chronic and untreated mental and physical health conditions as compared to their White counterparts. The purpose of this inductive study was to address the low engagement rates of African American women in mental health and substance abuse services while increasing understanding of the perceived and/or realized implicit bias in the mental health field. Research scholarship to examine other barriers to engagement pertaining to knowledge, motivation, and organizational considerations is scarce. Due to the paucity of research on socio-cultural stigmas, this study examined specific socio-cultural barriers to help-seeking behaviors among the African American female community in Miami-Dade County, Florida. This qualitative study was based on 10 structured interviews with African American women ages 18-80 years old who met the criteria of being an African American woman with residency in Miami-Dade County, Florida. Discussion: Critical Race theory, specifically Interest Convergence and Permeance of Racism was utilized as the framework to explore socio-economic barriers impacting African American women. In the study, participants’ perceptions related to mental health and substance abuse support were influenced by racial norms (stigma), access to mental health care, and support from family, friends, and the Black Church. Findings from the literature review and data from the current study support the implementation of an Afrocentric approach, and Anti-oppressive practice, that leverages community participatory collaboration with stakeholders and faith-based organizations as critical insertion points to engaging the marginalized African American female community. v Dedication To Wilbert, Jordan, and Giselle, thank you for being my biggest fans and supporters throughout this process. I could not have achieved this without your sacrifices and enduring love. Your encouragement motivated me and made the difference to push for Team Payne. Thank you. I love you. I would be remiss if I did not acknowledge my ancestors. To my mothers: Cleopatra I and Cleopatra II, thank you. I understand you. It is the trail that my foremothers blazed for me so that obtaining a doctoral degree is even possible. It is on their backs I stand as I push forward. I am their wildest dream and beyond grateful. Thank you. Ashae, and so it is! vi Acknowledgements I can never go a day without giving thanks and honor to God. It is through God that all things are possible. May this body of work be utilized to heal and restore the areas that have been neglected far too long. Thank you to the faculty members who saw the vision more clearly than I did initially and who assisted me in honoring the countless African American women who feel invisible and do not have a voice. To my Chair, Dr. Jennifer Philips, your ride-or-die commitment, and belief in me I will always cherish. You held me accountable and encouraged me at pivotal moments. Thank you, Committee Members, Dr. Monique Datta and Dr. Helena Seli; your time, insights, and academic rigor made me better and this dissertation possible. Last but certainly not least, my village of The Purple Church Sorors; thank you for the love and the encouragement. I have learned so much from your examples of grace, service, and enduring love. The living expectation of excellence underpins my motivation to be part of the solution and uplift my community. I am humbled that the Creator placed all of you beautiful humans in my life. You have taught me to bring my folding chair to the table and make room for others. I will always honor this sacred tenet. Thank you, Village!! vii Table of Contents Abstract .......................................................................................................................................... iv Dedication ........................................................................................................................................v Acknowledgements ........................................................................................................................ vi List of Tables ...................................................................................................................................x List of Figures ................................................................................................................................ xi Chapter One: Overview of the Study ...............................................................................................1 Field Context and Mission ...................................................................................................2 Global Goal ..........................................................................................................................3 History Relived Related Literature ......................................................................................5 Description of Stakeholder Groups ......................................................................................6 Stakeholder Group for the Study .........................................................................................7 Purpose of the Project and Questions ..................................................................................8 Importance of the Evaluation ...............................................................................................8 Conceptual and Methodological Framework .......................................................................9 Definitions............................................................................................................................9 Organization of the Project ................................................................................................10 Chapter Two: Review of the Literature .........................................................................................11 History of Oppression in the United States of America ....................................................11 Archetypes of African American Women and Media Perceptions ....................................14 Institutional Racism ...........................................................................................................15 Mental Health Disparities Impacting African American Women .....................................18 Cultural Biases that Prevent African American Women From Seeking Help ...................19 viii Critical Race Theory ..........................................................................................................22 Summary ............................................................................................................................25 Chapter Three: Methodology .........................................................................................................26 Participating Stakeholders .................................................................................................26 Data Analysis .....................................................................................................................30 Ethics..................................................................................................................................31 Summary ............................................................................................................................32 Chapter Four: Findings ..................................................................................................................33 Participant Demographics ..................................................................................................33 Qualitative Analysis ...........................................................................................................34 Findings for Research Question 1 ......................................................................................38 Findings for Research Question 2 ......................................................................................47 Summary ............................................................................................................................55 Chapter Five: Discussion and Recommendations..........................................................................58 Discussion of Findings .......................................................................................................58 Recommendations for Practice ..........................................................................................69 Limitations and Delimitations............................................................................................78 Recommendations for Future Research .............................................................................80 Conclusion .........................................................................................................................81 References ......................................................................................................................................84 Appendix A: Information Sheet for Exempt Research ................................................................121 Appendix B: Invitation to Participate in Study ............................................................................123 Appendix C: Recruitment Questionnaire .....................................................................................124 ix Appendix D: Interview Protocol ..................................................................................................125 x List of Tables Table 1 Global Goal and Stakeholder Goal 7 Table 2 Participants’ Demographics 34 Table 3 Interview Questions 35 Table 4 Code Descriptions 37 Table 5 Selected Quotes on Participant’s Perceptions of Seeking Help 41 Table 6 Perceptions of Access and Insurance 44 Table 7 Participant Perceptions of Cultural Stigmas 47 Table 8 Participant Perceptions on Shifting Norms 49 Table 9 Summative Findings by Research Question 56 Table D1 Interview Protocol 126 Table D2 Demographic Categories 127 xi List of Figures Figure 1: Coding Categories 36 1 Chapter One: Overview of the Study This study addressed barriers in community mental health settings that impede African American women’s consistent and active engagement with mental health services to treat their psychological disorders and/or trauma disruptions. The U.S. Public Health Service (2001) purported that disproportionally higher exposure to trauma, interpersonal violence, and socioeconomic malaise among the African American community is a precursor to severe mental health disturbances. African American women account for and have the highest rates of untreated chronic physical and mental health compared to their counterparts (U.S. Department of Health & Human Services [US DHHS], 2001). African American women in the United States have suffered more severely from chronic and mental health diagnoses than other races and ethnicities (Chin, 2015). African American women most experience a lack of insurance and chronic depression, contributing to economic barriers, as more than 52% of these women work in low-paying jobs (Copeland 2011, Copeland & Snyder 2005). African American women with many different intersections experience a multitude of cultural barriers and social stigmas surrounding mental health and positive help-seeking behaviors, perpetuating poor engagement rates in mental health and substance abuse services (Brenick et al., 2017). History validates the chronic racial discrimination experienced by African American women since enslavement. Chattel slavery provided the vehicle for medical exploration on Black bodies due to the designation of being non-human according to the United States Constitution before the ratification of the 14th Amendment that outlined citizenship and legislated protections for the newly freed individuals (Jacobs et al., 2006). African American descendants of slaves in modern times have observed and experienced the far-reaching remnants of Jim Crow laws that are environmental and evidenced by the social and healthcare care disparities overrepresented by 2 communities of color. Researchers have posited that prolonged exposure to social stressors triggers an adverse physiological erosion, as evidenced by high rates of chronic illness among African American women (Chinn et al., 2021). Failure to seek mental health services for comorbid diagnoses and traumatic conditions based on mistrust of non-minority practitioners results in poor engagement and lack of medical guideline adherence (Jacobs et al., 2006). According to Jacobs et al. (2006), the inverse occurs when trust is present, motivating patients to seek medical care. Guy et al. (2020) noted the importance of African American representation in research on evidence-based practices for communities of color. Increased diversity among medical personnel will lend to the trust-building and help-seeking behaviors of Persons of Color in medical settings. Williams and Mohammed, (2008) posited that not addressing social and communal stigmas will result in further degradation of African American communities will adversely impact society. Field Context and Mission The lack of practitioners of color in the mental health field is concerning and problematic when ascertaining institutions’ cultural competency and the need for more inclusive frames for African American women and all of their intersections. The American Psychological Association (2016) reported that the diversity makeup of African American mental health providers in the United States is less than 2% for psychiatrists, 2% for psychologists, and 4% for licensed clinical social workers. In the medical realm, stereotypes are useful in triaging patients; however, these methods facilitate negative stereotypes about a group, causing bias in medical care (Moskowitz et al., 2012). This phenomenon is known as implicit bias. In this study, implicit bias refers to service providers’ unconscious beliefs or constructs about a group of people that can manifest in discriminatory behavior (Heberlien et al., 2019). However, implicit bias can operate as a factor 3 for the medical provider as well as the patient. For this study, African American women are the focus and stakeholder group. Holroyd and Sweetman (2016) explored the implication of implicit bias in the medical profession and its impacts on marginalized communities. While extensive research examined the impact of implicit bias in the mental health profession on the African American male community, research on barriers to engagement among African American women is lacking, particularly in terms of their seeking professional mental health support. Research on implicit bias has consistently found that stereotypes and judgements inform practitioners’ behaviors towards patients (Holroyd & Sweetman, 2016). Evidencing historical oppression, states that relied heavily on slavery show higher rates of anti-African American implicit bias towards descendants of African American slaves (Payne et al., 2019). Southern Florida is home to the country’s highest concentration of urbanites with untreated severe mental illness, approximately 9.1% of its population (Eleventh Judicial Circuit of Florida, 2019). Lack of help-seeking behaviors is especially problematic for African American women as they are at a higher risk of developing mental illness. Social risk factors such as lower income, poor health, multiple role strain, and the double minority status of race and gender are predictors of increased psychiatric disruptions (Neufeld et al., 2008). Global Goal The global goal for the mental health field that this study explored is increasing engagement rates among African American women utilizing clinical mental health and substance abuse support services. Specifically, this study was bounded with a geographic focus on African American women living in an area within Southern Florida. The Richmond Heights area is of particular concern due to its concentration of African American female-led households. The area 4 was known as Naval Air Station Richmond during World War II. This station housed blimps that searched for German U boats in the Caribbean area of responsibility for the U.S. Navy. Later, a hurricane and fire destroyed the base (Benowitz, 2021). According to the Richmond Heights Community Development Corporation (RHCDC; 2019), Captain Frank C. Martin, a White man who served with African American servicemen, purchased the land, creating parks, schools, and housing for African American veterans who could not live in Miami or the surrounding areas during the Jim Crow era. Richmond Heights was established as an affluent community in Southern Florida. Captain Martin also donated the land where the area’s first African Methodist Church operates. Martin Memorial AME is commonly known as The Purple Church (Benowitz, 2021). This entity will be discussed further in Chapter Three, as its community outreach arm served as the source of recruitment for this study’s participants. According to the latest U.S. Census Bureau’s (2019a) income and poverty report, the rate of households headed by Black women living below the poverty line is 31.7%, compared to 8.9% of their White counterparts. Female-led African American households comprise more than 43% of single-headed households in the United States (U.S. Census Bureau, 2019). Specific to this study, Florida Department of Health (2018) data demonstrates the prevalence of mental health disorders among the state’s residents. The state is 49th in mental health spending for its residents, with an average of $37.28 per resident (NAMI Greater Orlando, 2020). To that end, outreach efforts are necessary to reach the high population of African American women in the Southern Florida area who need mental health services. Further, the recommendations arising from this study’s findings can inform future community outreach work to connect African American women with professional mental health services 5 History Relived Related Literature The circumspection exercised by African Americans and their tenuous relationship with the medical community come from 400-plus years of oppression, racism, and lack of confidence in the care provided (Hammond, 2010). Specific to this study, the long-term effects of racism may prevent access to care through recurring themes. Barbee (2002) purported that the first theme of racism is power, or the disproportionately distributed capacity to make and enforce decisions. The researcher provided that the second theme deals with unequitable resources or unequal access to resources like money, education, and information. Thirdly, there are predetermined standards for appropriate behavior, which are ethnocentric and reflect and privilege the dominant race/society’s norms and values. The fourth racism problem involved defining reality by naming the problem incorrectly and thus misplacing it (Barbee, 2002). In practice, these themes are barriers to quality mental health care for African American females. Race and racism factor prominently in the psychiatric diagnosis differential, which resulted in African Americans reporting higher and more severe misdiagnoses. According to studies over several decades, African American women receive schizophrenia diagnoses at a rate three to four times higher than White Americans (Adebimpe, 1981; Jones & Gray, 1986; Neighbors, Trierweiler, S. J., Ford, B. C., & Muroff, J. R. 2003). Succinctly, research has found that race, and racism by extension, is a strong factor in hospital admissions and the type of psychiatric treatment that African American patients receive (Flaskerud & Hu, 1992; Lawson et al., 1994), perpetuating the mental health care disparities communities of color endure. Systemic and cultural barriers also influence when African American women seek mental health and substance abuse services. Typically, they do so at a crisis or breaking point, with a negatively perceived biopsychosocial presentation that further enforces misdiagnosis 6 (Carrington, 2006; Davis & Ancis, 2012; Neighbors et al., 2007). Researchers have found that disengagement rates increase early into treatment due to unmet cultural, social, and gender needs, resulting in a higher prevalence of untreated mental illness (Blazer & Hybels, Simonsick & Hanlon, 2000; Brown & Palenchar, 2004; Davis & Ancis, 2012; Miranda & Cooper, 2004; Neighbors et al., 2007; Snowden, 2003; Strakowski et al., 1995; Vega & Rumbaut, 1991). Institutional frameworks that do not address the factors of intersections of African American women in the early stage may increase client dropout (Neighbors et al., 2007). The research indicates that providers should acknowledge implicit bias and ensure cultural competency among mental health providers to understand the intersectionality of racism, gender, and socioeconomic oppression for African American women (Saldaña, 2001). African American women will continue to be underrepresented in mental health and substance abuse self-seeking services if the essential components of racism, gender, and class are not explored when designing culturally specific frames for clinical practice (Ehrmin, 2005; Smedley et al., 2003; USHHS, 2001). The lack of culturally specific frames is due to traditional and institutional norms established for clinical frameworks. The study explores the experiences of African America women in order to inform programming designed to reduce barriers to seeking professional mental and substance abuse support. Description of Stakeholder Groups Two stakeholders are involved in achieving the global goal: African American women and clinical providers in mental health. Clinical providers are licensed clinical social workers and/or licensed professional counselors who provide mental health services and case management in the mental health setting. Stakeholders for this evaluation study were African American women between 18 and 80 years of age who live in Miami, Florida. Participants may 7 have been diagnosed with mental illness, untreated diagnosis, and/or substance abuse issues. However, a diagnosis was not a requirement for participation in the study, and questions related to diagnosis were not asked as part of this study. Clinical providers are licensed clinical social workers and/or licensed professional counselors who provide mental health services and case management in the mental health setting. Stakeholder Group for the Study The joint efforts of both stakeholder groups will contribute to achieving the overall global goal of increasing engagement among African Americans in clinical practice. It is important to first understand common nuances among African American women regarding their attitudes, help-seeking behaviors, and social barriers to mental health. The stakeholder’s goal is to increase help-seeking behaviors and engagement rates in clinical mental health and substance abuse support services in crisis. Table 1 reflects the global goal and the stakeholder goal. Table 1 Global Goal and Stakeholder Goal Global goal To increase engagement rates among African American women utilizing clinical mental health and substance abuse support services. Stakeholder goal African American women increase help-seeking behaviors and engagement rates in clinical mental health and substance abuse support services in crisis. 8 Purpose of the Project and Questions The purpose of this study was to explore African American women’s perceptions and experiences in engaging in professional mental health and substance abuse support and the impact of community institutions on their help-seeking. The overall intent was to examine barriers to their help-seeking and identify culturally competent protocols in treatment to address clients’ multiple intersections as a holistic mental health treatment. Two research questions guided this study: 1. What are African American women’s perceptions and experiences with engagement with mental health and substance abuse support? 2. How do community institutions impact African American women’s engagement with mental health and substance abuse support? Importance of the Evaluation It is essential to evaluate the mental health field’s performance in relation to the performance goal of increasing African American women’s engagement in mental health and substance abuse services. According to the National Alliance on Mental Illness (NAMI; 2015), about 30% of African American adults with mental health illness receive treatment versus the national average of 43%. African American women are three times more likely to report psychological distress than their Caucasian counterparts (Barnes & Bates, 2017). African American women who perceive maltreatment, disrespect, and bias during a medical interaction may avoid hospitals and physicians and not comply with treatment protocols (Smedley et al., 2003). As a result of mistrust, African American women sometimes develop misconceptions about the genuine need for mental health and health care help-seeking behaviors (Rutledge, 2003). Non-help-seeking behavior has far-reaching consequences on mental health needs that 9 research has shown to increase rates of incarceration, poverty, and economic malaise, resulting in a 40% higher propensity for being the victim of violence (USHHS Office of Minority Health, 2019). Conceptual and Methodological Framework The conceptual framework for this study is race theory (CRT). CRT informed the explorations of the potential influences impacting African American women’s engagement with mental health services by guiding the research focus. This study employed an inductive approach; as such, no assumed influences were introduced, and findings were identified thematically based on interviews with the participants. This project employed a qualitative method of data gathering and analysis. Current perceptions regarding influences impacting their engagement with mental health services were assessed through interviews with 10 African American women in Southern Florida using the Anvil network and public domain social media platforms as the starting points for recruitment. Research-based solutions were recommended and evaluated comprehensively. Definitions • African American refers to an American having African, especially Black African, ancestors (Merriam-Webster, 2022a). • Racism is “a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race” (Merriam- Webster, 2022b, para. 1). • Slavery is “the state of a person who is a chattel of another, the state of a person who is held in forces servitude, a situation or practice in which people are entrapped (as by debt) and exploited” (Merriam-Webster, 2022c, para. 1). 10 • Serious Mental Illness (SMI), per the National Institute of Mental Health (n.d.-b), is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI (para. 4). Organization of the Project Five chapters are used to organize this study. This chapter provided the key concepts and terminology commonly found in discussions on African American women’s lack of engagement and help-seeking behaviors. Additionally, the global mission and goals, stakeholders, and the framework for the project have been introduced in the previous paragraphs. Chapter Two provides a review of the current literature surrounding the scope of the study. Topics are the history and impacts of racism, racism’s impact on the Black psyche of women, and acknowledgement of African American women’s intersectionality of race, gender, socioeconomic status, and religion. All of these topics are addressed regarding culturally competent clinical practice. Chapter Three details the methodology of participants, data collection, and analysis. Chapter Four presents the data analysis results. Chapter Five provides solutions, based on data and literature, for closing engagement gaps and recommendations for implementation and evaluation plan for the solutions. 11 Chapter Two: Review of the Literature Chapter Two provides a historical overview of oppression in the United States concerning the current condition of the African American woman. Institutional racism was explored through the lens of understanding constitutional and institutional bias. Mental health disparities and their impact on the African American community were dissected to understand the transgenerational consequences of lack of access to treatment. A deeper look into microaggressions in clinical practice has helped to understand barriers to African American women seeking help. The final section discusses the theoretical framework that informs this study: Critical race theory. This framework was used as a lens to explore the influences on African American women to meet the goal of increasing their engagement with mental health and substance abuse services in their communities. History of Oppression in the United States of America African Americans, those individuals having African ancestry, were involuntarily captured and imported into the United States of America. The Atlantic Slave trade was officially recognized in 1601 by the dominant power structure, subsequently legitimizing the institution of slavery, with far-reaching impacts resulting in the socioeconomic disenfranchisement of African Americans to the present day (Berlin, 1996). Slavery as an institution had an adverse transgenerational effect on the African American community, socioeconomically and culturally. Specifically, African American women have been viewed as less valuable, targeted, and oppressed since their arrival to North America due to their race, cultural background, gender, and socioeconomic status (Aspy & Sandhu, 1999). The history of slavery and the systematic destabilization of the African American family has resulted in African American women taking on several roles in the absence of African 12 American men. As such, females have been indoctrinated with the myth of the “strong Black woman” to encourage those who have to compensate to support the family unit and serve in roles that counter their self-esteem (Harris-Lacewell, 2001). This self-help encouragement, officially known as the Sojourner Syndrome, is a protective factor women pass on to their female children (Lekan, 2009). The researcher provided insight into the multiple intersections of transgenerational oppression propagated upon the African American female via the connections of slavery, sexual assault, forced childbearing for institutional profit, and scientific experiments. Historical trauma of African American women offers clues as to the development of resilience and the coping skills needed for adaptive survival with maladaptive consequences that have indirectly created low or no provider trust with the dominant culture. Survival coping mechanisms have allowed Black women’s dysfunction to continue and exacerbated mental health conditions at rates higher than their counterparts (Schulz et al., 2000). Clark et al. (1999) operationally described racism as the belief that an individual is impacted by unfair or inequitable treatment based on one’s racial group membership. This social construct impacts all facets of daily life. To this end, African American women post-slavery have been systemically silenced by the nation's laws and the judicial system that dehumanizes and devalues the African American woman's experiences (Hooks, 1998). As slavery increased in the southern states, gaining freedom appeared to be out of reach for enslaved individuals. The marginalization of slaves in North America, specifically the Southern Region, during this period of history still have psychological and socioeconomic impacts on the offspring of the enslaved (Wilkins et. al, 2012). For Black women, oppression due to the intersections of racism, social class, and gender will continue to be a factor (Alfred & Chlup, 2009). 13 Of particular note, in Southern Florida, the migration of free Caribbean and run-away, now free, African slaves challenged the dominant power structure and ideology around the areas of slavery and racism as a biological construct. W.E.B Dubois, a sociologist in the 1800s, offered that the racism he observed was not biological but a social construct; therefore, the thought of inferiority of African Americans is untrue (Gooding-Williams, 2018). Spanish-controlled Florida welcomed all slaves and allowed those running from the institution of slavery to dwell as free people among the Native Americans if they converted to Catholicism and fought in the war against the United States (Lauber, 1913). Descendants of those from the confederate states, Haiti, and the Caribbean in the Southern Florida area thrived initially as they fled from the Jim Crow south to a place where they could marry, own property, and create communities (Allman, 2013). The utopian society that the Spanish Crown created countered the balance of power in the days when sugar and cotton drove the economic engines of the U.S. economy. The confederate states (farmers) moved to seize power from the Spanish in Florida to end the ideology of anti-slavery and destruction of the workforce that would continue production (Landers,1984). The return to slavery via the United States made Florida the third state ceded to the confederate under the Adams-Onis Treaty of 1819 (Florida Memory State Library, 2021). Racism as a social construct is greatly debated. Due to oppression and socioeconomic barriers, there is a historical and cultural distrust of the White power structure among African Americans (Campbell & Long, 2014). The enslaved initiated a protective factor to address distrust for survival and passed the knowledge on to their kin to preserve the family (Campbell & Long, 2014). Gibbs & Fuery, (1994) asserted that the distrust of science is a strong cultural norm and has become a barrier to engagement with perceived agents of the power structure who provide health care. 14 Archetypes of African American Women and Media Perceptions Archetypes for African American women perpetuate oppression. Negative images and roles have been ascribed to African American women resulting in a dehumanizing and devaluing sense of worth personally and interpersonally (Jordan- Zachery, 2009). During slavery, the roles of the African American slave woman were dictated by the slave master. Typical roles would include those of domestics, caregiving, and childbearing. These roles were created to support the slave master’s family structure while sending a clear message that the enslaved woman’s family was secondary (Smith, 1996). Historical and ongoing portrayals of African American women in this stereotype created and created the misconception of the value of the African American woman as nothing more than a role she had to take on for survival (Parham & Payne, 2014). West (2018) provided the academic community with provocative views on the roles of the African American slaves and the unspoken cost they paid to the institution of slavery via sanctioned rape to subjugate them. This sense of helplessness and forced conformity further supports the need for protective factors for the psyche of Black women to survive their circumstances (Cole & Zucker, 2007). To that end, Sojourner Syndrome and the strong Black woman trope were developed for psychological survival. Protective factors utilized for survival are now viewed with a lack of empathy by modern-day media’s portrayal of negative stereotypes of the African American female, creating an irreversible damaging self-view (Hudson, 1998). Television and media are predominantly owned by the power structure that controls the images and dictates the oppressive lens through which African American females are viewed, creating this is called “White Gaze” (Cammarota, 2011). Dissection of the stereotypes and ascribed roles of the African American woman help to unpack the shame and burden of being an African American woman. In the context of slavery, 15 the role of the “Mammy” caregiver is widely seen in the media. This character is often seen as an overweight, wily, calculating, and unattractive dark-skinned Black woman. This characterization supports the media’s narrative of the standard of beauty for African American women. Characters like Jezebel and Sapphire represent the African American woman’s behavior as indiscriminately hypersexual, ungodly, hateful, and troublemaking (Ladson & Billings, 2004). The media’s presence and covert messaging of prescribed attitudes of African American women are a catalyst for mistrust of the power structure present in the United States among African American women. Institutional Racism Racism is a social construct in which the power structure relegates persons perceived as inferior to demeaning and disempowering social structures (Williams & Mohammed, 2013). As such, racism provides the foundation for institutions to reinforce social hierarchy and oppression of people (Williams, Lawrence, & Davis, 2019). Based on the social construct of racism, institutional racism is normalized, established, and accepted behavior within social and political institutions that discriminate against marginalized persons (Solomos,1999; Merriam-Webster, 2022b). The absence of a personal agenda best categorizes the differences between individual racism and institutional racism. Institutional racism is executed through a system’s procedures and regulations (Carmichael & Hamilton, 2008). Ratified racism is the underpinning for common-day bias experienced by African American women (Broussard, 2013). The U.S. Constitution was the first legislative document giving a non-human status, that of property, to African American slaves by implicitly referencing categories of person and the last designation in Article 1, as the three-fifths clause for taxation purposes (Alvis, 1987). The ambiguity of this 16 declaration in the Constitution clearly defined the social order of African American women in society, and remnants of this designation persist. Institutional Racism Impacts on Mental Health The American Psychological Association (2016) reported that 75% of the patients who utilize mental health psychological services see benefits in their cognition and overall daily life. Williams (2012) reported that African Americans have poorer health and higher morbidity rates than their counterparts due to institutional racism. Field research reflected medical personnel spent less time with patients of color during service interactions, contributing to lower efficacy of diagnosis and quality of care (Campbell & Long, 2014). Medical providers’ training orientation reinforces provider distrust among people of color. In examining medical provider training, Personnel receive medical training on responding to stressful situations and rely on stereotypes that support learned implicit bias to diagnose and treat patients. Thus, underrepresented populations experience higher rates of severe psychiatric diagnosis at a 2.5% higher rate than ethnic majority patients. Bogart et al., (2001) found that White physicians are more vocally dominant and have negative bedside manners with patients of color during appointments than with White patients. Similarly, prescribing physicians’ expectations of treatment adherence are lower for racial minorities based on race (Van Ryn et al., 2006). As a result, marginalized patients who received adverse medical care convert those experiences into medical distrust that decreases the likelihood of consistent medical care and widens the health care disparity gap in at-risk communities (Knibb-Lamounche, 2013). 17 Institutional Bias: Implicit and Explicit During the discussion of implicit and explicit bias, it is important to distinguish their differences in relation to disenfranchised persons. Banaji and Greenwald (1995) coined the terms “implicit bias” and “explicit bias” to explore social behavior. Implicit bias occurs when negative associations about an individual are applied subconsciously during an interaction, as may occur in the healthcare setting (Fitzgerald & Hurst, 2017). Implicit bias research supports that these biases are problematic to patients of color receiving the appropriate standard of care as providers are a reflection of their personal environments (Antony, 2016). Institutional and social implicit harm African American communities. Banaji and Greenwald (1995) described explicit bias as acting upon conscious negative thoughts. Examples are screaming racial slurs at an individual or dismissing a patient’s symptoms because it is thought their race impacts their pain tolerance (Project Implicit, 2021). Experiences of bias created a condition that perpetuates the marginalization of the African American communities (Fitzgerald & Hurst, 2017). Rooth (2010) examined callbacks for employment for non-European names on resumes. Findings were consistent with Bertrand & Mullainathan’s (2004) study of African American-sounding names on resumes versus non-ethnic names. The callbacks were higher for non-ethnic names (Bertraud & Mullainathan, 2004); therefore, Bertraud and colleagues concluded that bias was at play in why the recruiter did not call back applicants with Black-sounding names. Marginalized endured people biases, resulting in multiple factors such as depressed economics, healthcare disparities, low employment, gender discrimination, racism, and sexuality. Holroyd & Sweetman, (2016) posited that individuals must look further into implicit and explicit bias and note that implicit prejudice targets attributes of an individual’s membership (i.e., race, 18 age, gender). An implicit stereotype is the categorizing of negative qualities of one’s attributes based on a false description (bossy, violent, promiscuous) that influences our non-verbal and social behavior. Implicit bias research supports the premise that providers must be aware of such thinking errors to improve health care service with persons of color (Nosek & Riskind, 2012; Nosek et al., 2007). Mental Health Disparities Impacting African American Women Uehara et al. (1996) noted that the United States has a historical account of disenfranchising people of color due to long standing structural, sanctioned institutional, and social bias. One of the most beleaguered groups is African American women, who are members of a double second-class group (Carastathishis, 2016). African American women are victims of the social double standard. This status is reflected in their high rates of cardiovascular disease, hypertension, mental illness diagnosis, diabetes, and obesity (Chinn, Martin, & Redmond 2021). African American women experience more severe medical problems than their Caucasian counterparts. For example, stressors like exclusion, invisibility, isolation, and under-employment are notable antecedent chronic conditions (Gibbs & Fuery, 1994). The Substance Abuse Mental Health Services Administration (SAMHSA; 2018) reported that 4.8 million African Americans suffer from mental health illness, accounting for roughly 16 % of the adult population. Of that 16%, 1.1 million experience seriously mentally illness (SMI; SAMHSA, 2018). African American women have 20% higher mental distress and are diagnosed with psychotic disorders like schizophrenia more often than their White counterparts (USHHS, 2019). They are hospitalized and prescribed heavy psychotropic medication at higher rates (Constantine, 2007). Treatment providers use attention deficit disorder, post-traumatic disorder, and major depressive disorder as common catch-all mental health diagnoses for this population (NAMI, 19 2015). In 2018, 11.5% of Black Americans were uninsured even after the Affordable Care Act (NAMI, 2020). These statistics are based on the known cases of African American women. Of all ethnic minority female groups, irrespective of age, African American women are least likely to seek treatment (Ward & Heidrich, 2009). Lack of healthcare insurance has been cited as a barrier to African American women receiving health care. According to the Kaiser Family Foundation (2017), individuals who are 18 years old and live below the poverty line are at risk of not having adequate or any insurance. In 2017, eight out of 10 families of color lived 400% below the poverty line and did not have health insurance (Kaiser Family Foundation, 2017). African American communities are the most impacted and have significantly higher uninsured rates than their White counterparts. The mayor of Miami–Dade commissioned a mental health task force in 2007 to assess the quality of services offered to the nation’s highest severely mentally ill population (ACLU, 2014). The final report for Miami-Dade noted that African American women are not connected to services at the same rates as their White counterparts due to institutional racism and bias (Miami- Dade County Mayor’s Mental Health Task Force, 2007). Miami-Dade County’s untreated mental health and substance abuse among the African American community reflects the larger health crisis. Cultural Biases that Prevent African American Women From Seeking Help Myers and Anderson (2013) found that cultural barriers and family pressures prevent African American women from demonstrating help-seeking behaviors, resulting in a mental health and substance abuse crisis. In a study to determine attitudes about mental illness among African Americans, Ward (2013) reported that 63% of respondents felt that mental illness was a sign of personal weakness. This ideology was aligned with the thought in African American 20 culture that therapy is seen as weak-minded” and an opulent endeavor, not a necessity (Gaston et al., 2016). This thinking further reinforces the stereotype of not seeking help for problems impacting one’s psyche. Per Woods-Giscombe (2010), narratives concerning African American women’s strength are coupled with extreme superhuman qualities that include not feeling pain or weakness irrespective of circumstances and familial expectations. Woods-Giscombe (2010) discussed the five recurring themes of the Superwoman Schema. The first is the obligation to manifest strength. There is a familial expectation that the public face is on, and there is nothing but the steeled character to face the world. This expectation often forces women to maintain stoicism and unbreakable strengths, irrespective of the circumstance. This expectation causes conflict and stigma, reinforcing the need for mental health as a weakness. The second theme is the need to suppress emotions. Women felt isolated and that only God could understand the true feelings they experienced (Payne, 2008). Woods-Giscombe (2010) described the third theme as an aversion to becoming vulnerable by asking for help. Participants felt this opened their personal life up to being taken advantage of, which was to be avoided at all costs. Fourth is the need to succeed in the face of impossible circumstances. This success is a point of celebration for women making it against all odds. The women in the study expected perseverance even when detrimental to mental health. The fifth is the universal expectation to help others and serve. This tenet was a fundamental principle and expectation. According to Woods-Giscombe, women serve but need help. Dismantling the five problematic characterizations is a starting point for discussion among African American females. Educating the community about spirituality, language, and cultural norms that support non-help-seeking behaviors and discussing the model of an African 21 American woman accepted by the community could be the catalyst for identifying mental health needs and resources outside of the church environment (Dunn & Dawes, 1999). Addressing Institutional Racism and Microaggressions in Mental Health Practice African American women have a bias against the institutional systems from which they receive service and expect maltreatment based on misinformation and historical encounters they have faced (Myers & Anderson, 2013). Research suggests that making concerted efforts to be culturally competent and identify microaggressions can increase African American women’s engagement in clinical practice. Intentional rapport building and creating understanding with clients will potentially increase engagement and self-disclosure among African American women (Matthew & Peterman 1998). Building rapport requires understanding oppression and its intersectionality in an African American woman’s life (Collins, 2000). In the treatment of African American women, affirming and responsible competent cultural frames will increase engagement and prevent poor outcomes (Lewis & Neville, 2015). Collins (2000) posited that utilizing Black feminist theory and history as concepts explored during treatment demonstrated positive results in creating cultures of trust between African American female clients and White providers. In this framework of Black feminist thought, a woman can view herself through the lens of a Black woman and understand the intersectionality of her life experience while bringing valuable insight (Jones, 2015). Therapy that puts African American women at the center provides a perspective to examine resiliency and the impact of society in a meaningful way (Crenshaw, 1989). The understanding of being an African American woman in the United States and the tertiary impacts of feeling invisible are frames that institutions can address to combat the lack of help-seeking behaviors demonstrated by this underserved population (Robinson-Brown & Keith, 2003). 22 Sue and Sue (2008) examined microaggressions against Black Americans and posited that individuals’ microaggression falls into one of six categories: intellectual inferiority, criminality, second-class citizenship, assumption of inferiority, assumed superiority of White culture and values, and assumed universality of the Black experience. Best practice indicates that the only way to decrease implicit bias during the clinical process is to ensure providers are culturally competent and aware of their personal worldviews (Sue et al., 2008). Cross et al. (1989) noted that there must be a willingness to acknowledge one’s level of cultural competence, and in his framework, there are five levels an individual moves through to reach cultural competency. The first is cultural destructiveness. This is whether there is intolerance and attitudes towards diversity. The second is cultural incapacity, where there is stereotyping fear- based behavior towards a group in policy. The third is cultural blindness, meaning ethnocentrism, sameness individuals do not have a knowledge base of others. The fourth is cultural pre-competence, which takes place when self-assessment and active learning occur. The fifth is cultural competence and proficiency, meaning continual learning, allyship, active challenging of institutional bias, and intentionally seeking diversity (Cross et al., 1989). Clinical providers who are committed to practicing at the proficiency level of cultural humility will ensure an unbiased therapeutic process (Chavez, 2018). Critical Race Theory Critical race theory was this study's guiding frame. Given the historical and transgenerational impacts that African American women have experienced in the United States, it is important to understand the foundational concepts that influence and inform the response to the social construct of the dominant culture by this marginalized population. In the following 23 discussion of critical race theory, its tenets demystify the historical and very real present-day connection to institutional racism and Black women's experience in America. Critical race theory (CRT) is a frame through which to examine the relationship of race, racism, and power and their connection to the oppression of marginalized persons via society’s racial stratification (Delgado & Stefanic 2017). At the core of the CRT frame is that all social systems, such as medical, legal, and educational, are set up by the dominant culture to oppress citizens of color (Crenshaw, 1991). The foundational aspect of CRT is an eclectic blend of critical legal theory (CLT) and radical feminist theory. Critical legal theory is the thought the law can be applied using indeterminacy, meaning that depending on the line of authority, a case can be decided differently irrespective of circumstances, supporting instances of inequality for persons of color under the law. Works by writers and advocates like Sojourner Truth, W.E.B Dubois, and Cesar Chavez undergirded Radical Feminism under the Civil Rights and Chicano Movements of the 1960s. Radical feminism insights led to an examination of the female relationship with social roles and power within society (Delgado & Stefancic, 2017). There are seven domains to CRT. The first tenet is the permanence of racism, meaning that people of color experience racism daily, and it is ingrained into the economic, political, and social arenas of their lives (Delgado & Stefancic, 2017). There is a general acceptance that racism exists to maintain the status quo. Secondly, the experiential/counter storytelling is the legitimization of racism experienced by people of color told in their own words (Solórzano et al., 2000). Storytelling is important as this is how people of color orally pass history down generationally. Third, interest conversion is where those in power benefits from acts of racial equality (Floden, 2004). In the Handbook of Critical Race Theory, writers Brown and Jackson, posited that interest convergence can only take place if its agenda aligns and or furthers the 24 power of white males (Lynn & Dixson, 2013). Legal scholar Kimberle` Williams Crenshaw (1989) coined the term “intersectionality.” Under CRT, intersectionality explores gender, race, and racism as all areas of oppression. Understanding intersectionality is critical to seeing invisible aspects of African American women and bringing clarity to their experiences. In the fifth tenet of CRT, Whiteness as property must be understood as privilege and unfair advantage to all that is sacred and is given to the dominant group while suppressing the marginalized group (Mckoy & Rodricks, 2015). White privilege serves as active social stratification and reinforces the hierarchy of society as a deterrent to persons of color to move beyond a prescribed socio- economic status (Verdugo, 2014). The sixth principle, critique of liberalism, is the idea that colorblindness is equality and that racism can be ignored (Decuir & Dixson, 2004). This notion of colorblindness is racist as it negates an individual’s identity and allows the focus on social inequality to be lost. Lastly, Delgado and Stefancic (2017) proposed that a lifelong commitment to social justice to eradicate social inequity by advocating for social justice is critical to addressing all areas of oppression for people of color. African American women face racism, gender, social, economic, and political intersections on a daily basis. This study used CRT to explore the influences on African American women’s engagement with mental health and substance abuse services and provide insight into related themes that contribute to their perceived barriers to engagement. Exploring the experience of African America women in relation to the goal of increasing their engagement with mental health and substance abuse services ensures that their voice guides the development of recommendations to meet their needs. 25 Summary The effects of chattel slavery, coupled with its historical trauma on African Americans, are critical to understanding the transgenerational effects borne in Black women’s experience in America. African Americans were forced to migrate and operate in the social system of the dominant society. Remnants of institutional racism following the reconstruction period of 1867 shaped the response of African Americans in North America. The lack of institutional cultural competence, as evidenced by continued struggles with a candid and in-depth examination of African American experiences and the impact of historical trauma, connection to family ties, spirituality, and community collectiveness, persists as a national health care crisis for this population (McPhatter, & Ganaway 2004). In order to facilitate change, McPhatter and Ganaway (2004), posited that institutions must address social justice, acknowledgement, and advocacy to start African Americans’ holistic healing. Specifically, mental health must be based on inclusion, resiliency, and strength-based practices (Martin & Martin 2002). Practitioners must be aware of the biases and privilege they bring to the treatment of marginalized populations while educating themselves on unconscious bias during the therapeutic process (Bradby, 2010). The paucity of cultural competency among ethnic-majority practitioners, who make up more than 90% of the psychiatric profession, has contributed to low engagement rates and mental health care disparities, posing the widest barrier to receiving treatment. Understanding the historical trauma and oppression experienced by African American clients with the commitment to advocate for equity will ensure motivation to engage. 26 Chapter Three: Methodology The purpose of this study was to explore African American women’s perceptions and experiences in engaging in professional mental health and substance abuse support and the impact of community institutions on their help-seeking. Through phenomenological interviews, participants were asked to discuss their individual experiences, perceptions of institutional barriers to care, and racial or cultural considerations impacting their help-seeking behaviors. This evaluation employed CRT as a primary lens to explore influences that support or hinder the mental health field from reaching African American women from the perspective of African American women. Two research questions guided this study: 1. What are African American women’s perceptions and experiences with engagement with mental health and substance abuse support? 2. How do community institutions impact African American women’s engagement with mental health and substance abuse support? Participating Stakeholders The participating stakeholders were African American women from Southern Florida aged 18 to over 70. I recruited participants via email. Mental health experience or hospitalization were not criteria for participation. The Anvil Community Outreach Corporation served as the network through which to recruit the participants. This organization readily provided access to this group for recruitment via email and snowballing sampling. The Anvil Community Outreach Corporation of Richmond Heights, Florida, is The Purple Church’s 501c3 outreach arm. Under this umbrella, the agency serves the population of Southern Florida through food and clothing programs, tutoring, literacy programming for seniors, STEM lab, youth/young adult street mentorship programming, dance ministry, mental 27 health support, Narcotic Anonymous and Alcoholics Anonymous substance abuse groups, and political awareness information via a voting center (The Purple Church, 2021). According to the corporation’s mission statement, the agency’s goal is to connect diverse populations through quality services that encompass health, housing, and education. Richmond Heights is of particular concern due to its concentration of African American female-led households. Interview Methodology and Design This study’s research design utilized CRT through what Creswell and Creswell (2017) described as an inductive, qualitative approach. The qualitative study took place in the natural environment and is unique due to the non-replicable data explored, such as the lived experience shared by the study’s subjects. According to research, the natural setting is best suited and has been used in similar studies to capture non-quantifiable data (Fleiss et al., 2003). Personal interviews and subjective information that may have a relationship with or affect the research problem must be evaluated to understand the problem under examination holistically and correctly. This study focused on African American women’s perception and experience in engaging with professional mental health and substance abuse support, as well as the impact of the community institutions on their help-seeking. While I could not interview all African American women, the sample represents a cross-section of socioeconomic and age categories in this population. The aggregate data reported are an inference of the population in general. In Miami- Dade County, there are 419,139 African Americans, of which 234, 082, is female, representing 51% of the population (Miami-Dade Matters, 2019). I conducted recruitment via email through Anvil’s network and internal listserv platform. Due to the limitations of COVID-19 and my location, I conducted all interviews virtually via the Zoom platform. I considered surveys as part 28 of the initial research design, but given the stigma surrounding mental health services among African American women, I determined in-depth interviews would be most appropriate and comfortable for the participants. Participants Ten African American females ranging in age from 18 to over 70 took part in the interviews. This widespread age range helped reveal generational differences in perceptions of social stigma and bias these women experienced. According to the U.S. Census Bureau (2014), Miami-Dade is the nation’s seventh-largest low-income county. Southern Florida is home to 52% of African American women (16% of the population), where one-half live below the federal poverty line (Miami Matter, 2020). All participants are residents of various communities in Miami-Dade County and would be considered working-class individuals from upper, middle, and lower socioeconomic backgrounds. Participants answered demographic questions during interviews in which I also asked about their ethnicity, education, gender, age, and income. This study included 10 interviews. I selected the participants by requesting volunteers based on the demographic (African American women living in Miami-Dade county) and age (18-80) criteria. Participants are a cross-section of the African American female population residing in the Miami-Dade area. This selection yielded varied results to inform the answers to the research questions (Creswell, 2014). Given the time and scope of this study, I selected only 10 participants. Instrumentation I conducted interviews in a semi-structured question-and-answer format (Appendix A). I monitored the structure and flow of the questions during the interview to ensure the participants answered the questions and that the insights they provided contributed to the focus of the study. 29 Adherence to the data collection process, aligned with an assurance of neutrality, according to Corbin and Strauss (2008), supports study efficacy. The literature review noted the scarcity of research evaluating African American women’s engagement with mental health. There is a paucity of research about this population due to historical and cultural considerations. Understanding the data allowed me to maintain trustworthiness and demonstrate reliability throughout the study. During the interviews, participants’ personal experiences, feelings, and subjective answers aided in drawing conclusions to answer this study’s research questions. Data Collection Procedures These participants were recruited via email on the Anvil list serve, which has an active membership of 30,000 recipients. I solicited Confirmation of willingness to participate in the interview via the information sheet for exempt research (Appendix B) each respondent received. Only the participant and I were present during each interview. There were no follow-up interviews for this study. Appendix A contains the interview protocol. I asked the respondents the same open-ended questions (Patton, 2002). A researcher should ensure the environment limits distractions with only the researcher and participants present (Creswell, 2014). All interviews were The Zoom software recorded and transcribed the interviews. I took handwritten notes to ensure the interview’s salient points could be annotated and memorialized. I reiterated to the participants that they could decline the recording of the interview at any time during the session. All 10 participants agreed to have the interview recorded. 30 Data Analysis In the third phase of this study, coding/data analysis occurred over two months. The review period and data analysis explored the recurrent themes. All interviews were digitally recorded to ensure data reliability and consistency by maintaining the integrity of the interview contents. Identifiers from aggregate data were removed, and data were encrypted. Contents from interviews were kept on a personal computer. Interview data analysis commenced when the interviews were collected. All data from interviews were analyzed and coded utilizing the NVivo program. Transcribed manuscripts were coded for recurrent themes across all interviews. I addressed the study questions in alignment with the conceptual framework. I removed identifiers from aggregate data, and data were encrypted. Per Creswell (2014), a researcher should ensure the environment limits distractions, and only the researcher and participant should be present. I digitally recorded all interviews to ensure data reliability and consistency by maintaining the integrity of the interviews’ content, which I kept on a personal computer. Credibility and Trustworthiness In research, credibility and trustworthiness are foundational elements of the design. Merriam and Tisdell (2016) discussed credibility and closing the gap between what is real and observed in qualitative research. Maintaining credibility will increase a study’s trustworthiness, mitigating questions and strengthening the data. The benefits of this research method were that participants could verbalize an authentic interpretation of their viewpoint in their own words. I was simply the recorder of the information. Utilizing Anvil’s listserv and email as the platform for recruitment ensured the interview invitations went to a diverse cross-section of target population. According to Glesne (2011), anonymous demographic criteria and interview protocol ensure respondents’ reliability. In this study, the participants were not personally known to me. 31 The themes from the coding analysis measured participants’ perceptions about mental health, help-seeking, and cultural stigmas. A researcher establishes trustworthiness by sensitizing the content of the questions utilized in the study (Corbin & Strauss, 2008). This method gave me a starting point of reference to examine barriers to engagement in the mental health system. The literature review informed the development of the protocol questions. This approach, coupled with a review of the protocol questions by doctoral students, peers, and the dissertation committee, helped to mitigate researcher bias. I ensured that all questions used in the study were generic and not specific to any person. Ethics According to the University of Southern California Institutional Review Board, all researchers studying human subjects must obtain the CITI certificate as standard protocol. Study participants received background information on the study through the information sheet for exempt research, which includes information on how their data would be kept anonymous and confidential. I reiterated that participation was voluntary during all phases. I answered all participants’ questions and concerns, and they had the option of ending their participation at any point. I conducted all data interpretation confidentially. Due to my location outside of Southern Florida, there was no personal relationship with the respondents. This factor addresses all assumptions and biases regarding familiarity that may impact the study. I acknowledge researcher bias and limitations that may directly impact the study. As a researcher, I am self-aware of intersections. I am a clinically licensed African American educated female who has experienced bias in the mental health profession as both practitioner and recipient. Subjects in the study may have perceived this relationship as one of power or 32 alignment. The participants’ responses may have skewed toward their personal interviews, impacting the level of disclosure. I disclosed in the information form that I am a licensed clinical social worker and a mandated reporter of child abuse and harm to self and others. Summary This chapter reviewed this study’s methodology, research design, and interview protocol. I discussed my ethical responsibility and the study’s credibility to validate the execution of this study. Findings from the research and emerging themes will follow in Chapter Four. 33 Chapter Four: Findings Chapter Four presents this study’s findings. Specifically, this research explored the lived experiences of 10 African American women in greater Miami Dade County, identifying the barriers and motivations for using mental health services. This chapter first presents the participants’ demographic information, followed by a summary of the qualitative analysis process. The study’s findings are organized by research question, and the chapter concludes with a summary of the findings. During the study, the domains of race, access to care, religion, and culture were entry points to address the multi-faceted barriers to care. Chapter Three presented a full explanation of the study’s methodology and criteria for participant selection. To further examine participants’ experiences, the following research questions guided this study. 1. What are African American women’s perceptions of and experiences with engagement with mental health and substance abuse support? 2. How do community institutions impact African American women’s engagement with mental health and substance abuse support? Participant Demographics The interviewees’ education levels varied, as some were in college and others had earned graduate or advanced professional degrees. Those who provided their income range reported income levels from below $15,000 to more than $100,000. Almost all (70%) of the participants held at least a college degree at the time of this research. Table 2 presents the participants’ demographic information. Participants were given numerical identifiers rather than pseudonyms to protect their identity. 34 Table 2 Participants’ Demographics Participant Age group Highest education Income Occupation 1 40–49 Master’s $15–30k Pastor/advocate 2 70 + Master’s $70k–80k Retired/sociologist 3 18–29 Bachelor’s $50–60k Teacher 4 60–69 Master’s $100k + Retired/teacher 5 18–29 High school less than $15k College student 6 40–49 Professional $70–80k Teacher 7 30–39 Graduate $70–80k Agency employee 8 40–49 High school $70–80k Business owner 9 40–49 High school $40–50k Retail/store 10 18–29 High school less than $15k College student Qualitative Analysis I interviewed the participants to explore their perceptions of mental health. I analyzed their responses to answer the study’s two research questions. Table 3 presents the core interview questions used to collect and their alignment to the research questions. 35 Table 3 Interview Questions Race: Mental health and environmental context (RQ1) In what ways, if any, have you been unfairly treated by medical or mental health personnel? Can you describe a time, if ever, you have been forced to make drastic decisions such as filing lawsuits because of attitudes against your person? In what ways, if any, have you been unfairly treated by your employers, bosses, or supervisors? In what ways, if any, have you been the recipient of stereotypes? If so, can you describe the situation or situations? What are your general attitudes about mental health? Culture: Mental health and environmental (RQ1) Would you report mental health issues to your family or friends? Why? or why Not? Can you describe a time, if ever, you have observed unfair treatment from family or friends towards someone with mental illness? Has any of your family and friends suffered unfair treatment because of mental health? What are your thoughts about mental health crises and showing weakness? Tell me about a time, if ever, you have you experienced feeling invisible at home or work? Spirituality: Environmental Context (RQ1) In what ways does your church acknowledge mental health? Do you feel God will be angry at people who seek mental health? Why or why not? Would you recommend prayer instead of seeking mental health treatment? Why? Why not? Access: Knowledge and motivation (RQ2) Where would you go in a mental health crisis? What services, if any, are you aware of for mental health services in your community? What mental health services, if any, does your insurance cover? What services are available in your area? What transportation, if any, is available in your area to access mental health? How would you make an appointment at your local mental health agency? How confident are you in identifying mental health issues and the type of support needed? Under what circumstance, if any, would you refer a friend or family member to mental health services? 36 Coding The average interview took approximately 60 minutes, and the longest interview lasted 63 minutes. The interview audio was transcribed and cleaned to remove identifying information that could compromise participant confidentiality. I uploaded the transcripts into NVivo software for further analysis. Excerpts from the responses were coded and recoded to find general common concepts. I reviewed interview responses and coded them into four primary categories: access, culture, race, and spirituality. I coded common interview responses that did not naturally fit the four primary categories with an appropriate identifier and then placed them in a fifth category: general. In the general category, four major sub-categories emerged: barriers, perceptions, suicide, and trauma. In some cases, I further grouped sub-categories into common topics. Figure 1 shows the primary coding categories and sub-categories used to address the research questions. Figure 1 Coding Categories Access Mental Health Location Insurance Services Transportation Culture Referrals Norms • Mental Health Privacy Mental Health Issues Invisible Weakness Race Stereotypes Workplace Racism Unfair Mental Health Treatment Mental Health Personnel Spirituality Prayer & Professional Supportive Church Mental Health Causes God Not Angry General Barriers •Stigmas •Financial Resources •Unaware Suicide Trauma Perceptions 37 The code descriptions for access, culture, race, spirituality, and general and their sub- categories aligned with the two research questions. Table 4 presents the four primary categories and the general category’s major sub-categories, descriptions, and alignment with the research questions. Appendix C presents the full list of all categories and sub-categories. Table 4 Code Descriptions Coded category Description Aligned research questions Access Responses to past and current experience with access to mental health care and associated services to facilitate obtaining mental health care support RQ1 Culture Responses on cultural differences associated with mental health or mental illness, including norms and perceptions in the African American community. RQ2 Race Responses related to race and/or mental health, including negative attitudes due to perceived racism RQ1 Spirituality Responses referring to spiritual connections with mental health, including church attitudes, prayer, and perceptions of God’s position RQ1/RQ2 General Responses that did not directly align with access, cultural, race, or spiritual yet referred to common topics about mental health Barriers Responses describing the barriers that prevent African American women from seeking mental health support RQ2/RQ1 Perceptions Descriptions of personal perceptions of mental health RQ1 Suicide Responses referring to suicide, such as recognizing suicide as a mental health issue RQ1 Trauma Descriptions of a traumatic event in the interviewee’s life or that of a close family member RQ1 38 The following sections present each research question, aligned codes, and outcomes. The outcomes for each research question on the number of participants who commented on the topic. Findings for Research Question 1 In the context of the first research question, the following themes emerged: access, race, and spirituality along with two general sub-categories: suicide and trauma. Based on the interview data analysis, two key themes arose. The following subsections discuss the two themes: • Theme 1: The participants’ knowledge that influenced their increasing engagement with mental health and substance abuse support was largely based on past traumatic personal experiences and suicide awareness. • Theme 2: The participants’ perceptions related to increasing engagement with mental health and substance abuse support were influenced by racial norms (stigma), access to mental health care, and support from family, friends, and the church. Theme 1: Past Experience with Trauma and Suicide Awareness Influences Participant Engagement With Mental Health and Substance Abuse Support Participants’ current knowledge of mental health centered on their experiences with mental health and suicide awareness. Eight participants relayed personal experiences with seeking mental health services due to trauma or other major life events. Participant 1 shared, I believe a lot of us have traumas that we just don't have dissected because we have not been able to get enough information on how the Black bodies are able to live through this and what can help our Black bodies. This interviewee echoed the sentiment that trauma is a part of the African American experience and is normal and unaddressed. Participant 8 stated, 39 When I just feel like enough is enough, and I can't do it on my own, it depends on, you know, what I may be experiencing. When I lost my sister, I didn't know how to handle grief. And, so, it was very hard for me to deal with that emotion. … So, when I went to see my doctor, my doctor was like, “You just experienced a very traumatizing experience. I can prescribe you medication, but I don't think you need it. You need to seek help.” And it still took a long time before I decided maybe. Even my sister passed in 2018 December. Participant 9 expanded on how she adapted to the loss of her parents at a young age but did not seek help: I didn't see a counselor until 2020. …Yeah, because I lost my parents. I lost my mom when I was, you know, as soon as I got out of high school. So, I had a lot of responsibilities. I didn't have the help that I needed. So, it was a lot for me. Schulz et al.’s (2000) study demonstrated the dysfunctional adaptation of African American women waiting to seek help for mental health until they are at a crisis point. Irrespective of the trauma endured, the unrealistic expectation to function while hurting crippled this population, according to the participants’ insights. Nine interviewees believed that they were knowledgeable about mental health support and thus were actively engaged in obtaining services when needed. Participant 8 stated, Pastor was one of the women who taught me that [wanting] or seeking help is a sign of strength, not a sign of weakness. I was a grown woman before I realized that it's not a weakness; it's a sign of strength. Study participants expressed willingness to seek help with the revelation of strength. Participant 2 recounted her professional experience as informing her knowledge: “I would 40 because of my professional experience. I retired as the county government executive assistant director of the county's department of community and human services.” According to Participant 7, “ In a mental health crisis, I would call my therapist first. If she's not available, look, I know it is probably the best answer [to] call on Jesus.” Interview data analysis revealed that all 10 participants were familiar with primary and secondary community resources. However, the participants were unsure about how to fully access these services. Nine interviewees named the emergency room as a place of last resort if a crisis occurred. All 10 participants were also confident in their ability to recognize certain mental health issues in others based on their past experiences. For example, all mentioned that suicidal behavior was a definite reason to refer someone to professional mental health services. Participant 2 shared a recent example of a family member she recognized as in need of assistance: I can share that we, just one of our members, one for the families. His son committed suicide about 4 weeks ago. He was 35. So, I'm sharing with you that here's a family that needs tons of mental health intervention already because of some other situation. But the matter of acknowledging that we need it and we need to do this. … Look, and now it's been aggravated because we had a suicide. Participant 3 discussed her perspective, which relied on going to the emergency room: “I just know that, you know, if I had suicidal thoughts that I could go to the ER, but that's about it.” During the study, all10 participants spoke about the need to address suicide and suicidal ideation among the Black community. Due to the social and religious stigma, the taboo topic has both primary and tertiary impacts on community members. Table 5 presents specific comments illustrating the participants’ perceptions of mental health and help-seeking. 41 Table 5 Selected Quotes on Participant’s Perceptions of Seeking Help Participant Seeking help perceptions Participant 1 Understanding it [suicide] and understanding what it takes. We are able to help hurt people from not hurting themselves or hurting anybody else by seeking services. Participant 5 Like, if they're really depressed or attempting suicide, or thinking about suicide, I will refer them to mental health. Participant 6 If they've gotten to the point where they just, like, talking to the family and friends is not working. If they're talking about the harm. If they're not doing what I would say is not normal. If they're outside of the normal characteristics that they're exhibiting behaviors that are harmful to themselves or others, … I would refer them to mental health services. Participant 7 I would refer them if they’re struggling with an issue or any information that I perceive from them that may be life- threatening. I would push, encourage, them to seek therapy in anything. If I notice that they’re off or they’re not their usual selves. And it’s continuous. It’s not like it’s a one-time thing. But if it’s continuous, like every time I talk to you, there’s some something off. I would recommend them to seek therapy. Participant 8 I think it depends on if a person is contemplating suicide or just feels like giving up. So, that is when I would suggest seeking counseling. Participant 10 If they become harmful to themselves or anyone else, or if they’re not acting normally. If something seems off or wrong, I would suggest them to go seek mental health help. Theme 2: Access, Stigma, and Support From Community Influence Self-Reported Likelihood of Engagement With Mental Health and Substance Abuse Support The subsequent paragraphs discuss three emerging subthemes. Sub-themes extrapolated from the data address access, cultural stigmas, and the influence of community support on participants’ self-reported likelihood of engaging with mental health and substance abuse 42 resources. Exploration of the themes developed as indicating factors that lead to low or no engagement with mental health and substance abuse services. Access to Mental Health and Substance Abuse Support Participants suggested their actions to seek mental health support may depend on knowing how to access insurance and having access to both insurance and facilities for mental healthcare. Eight participants confirmed they had medical insurance, and six of these eight were aware that their insurance covered mental health services. However, these six participants did not know specifically what their coverage for mental health entailed. Participant 10 stated, “I'm not sure, but I do know I do have insurance, and it just covers my health and dental. To be honest, I didn't even know insurance can cover my mental health.” Participant 5 said, “That is a great question. I have no idea about my policy.” When asked, eight respondents could not articulate policy limits specifically for mental health or substance abuse treatment coverage but understood they had some coverage. The lack of knowledge about policy limits and coverage perpetuates non-help-seeking behavior due to the inability to pay for mental health services. Inefficient policy coverage may not support evidenced-based course of treatment timelines due to limitations of coverage, resulting in poor mental health outcomes and increased dropout rates (Brown et al., 2000). When asked if they knew where to go for professional mental health support, eight participants replied affirmatively. However, two of these eight participants only named the hospital emergency room as the location, and three remarked that they were unaware of local or community-level services targeted at mental health. Additionally, all participants commented that the likelihood of African Americans seeking services was due to issues with access to mental health services. The eight participants who could name places to get mental health care 43 named locations outside their community that required transportation to access. Interviewees indicated that they do not know of local transportation available in the Southern Florida community, but all participants were aware of the shuttles for senior citizens, which some of their family members utilized. All 10 participants indicated that they were not aware of local transportation. Additionally, they believed they must seek help in places that are not near their community. The perception that services are neither available nor accessible to individuals without local transportation is noted as a barrier to care. Table 6 presents participants’ perceptions of access and insurance. 44 Table 6 Perceptions of Access and Insurance Participant Access and insurance perceptions Access barrier Insurance barrier Participant 1 I guess because I haven’t accessed or used it, so I’m really not sure what I’ve got because I’ve not dived into it as far as for my insurance is concerned. X X Participant 2 There's room for counselling. You can go to get to a therapist if you needed the services I have. And now that I'm in retired, I have made the Medicare choice. X Participant 3 I believe it covers counseling, or I should say therapy. Mine yeah, I believe that’s about it. I am on antidepressants. X X Participant 4 I know what my what my insurance does, I have a friends that is a therapist she is close to my family ... She knows my family and she keeps me you know, she keeps me in the center. X Participant 5 If you don't have a car, I would say they have Ubers, but everything that I can think of, you have to pay for it. Like it's nothing that's accessible to you for free unless you probably live on [school] campus and you can walk over. But if you stay off campus, then everything you have to pay for. X X Participant 6 [Insurance] covers receive health care services with monthly weekly services with therapists. They also have extended care with that or they're putting it with health care. So, like physical health or mental health, they're offering services like that. They're offering discounts, programs for that. X Participant 7 I don't believe that there is a clinic in the community where they would have to travel to, and they offer transportation. I’m sure if they're willing to go through the full process if they've been enabled. X Participant 8 I don't know of any [transport] just besides public transportation X Participant 9 Where would I go to seek help? Well, normally, our case, it’s pretty much kind of based on if you have insurance. And I don’t even think that we really know where to go if we needed the help, because as long as I can remember, I’ve always had to have insurance to even get help to even speak with someone. X Participant 10 If they have a car, then their car. But I could say public transportation, but transportation just for like strictly like mental- health-wise, I'm not sure of. X X 45 Racial Norms That Deter Persist: Community Supports Engagement With Services Participants described racial norms as a deterrent for the African American community in seeking mental healthcare, but the women indicated that those norms had not dissuaded them from obtaining mental health support. For example, eight participants mentioned that, in the African American community, mental health issues were considered private and not to be discussed or shared outside of the family. Participants noted that the pervasive practice of ignoring one’s mental health is crippling to the person experiencing a breakdown until it manifests publicly and reaches proportions that must be managed. Participant 7 shared her thoughts concerning this phenomenon in the African American community: I know in our community, a lot of times, mental health is overlooked. So, even in the community that I passed through in, I believe that a lot of drug abuse issues that are in the community stemmed from mental health. A lot of times, mental health considered as taboo in our community, or you are crazy or, you know, family is shunned upon most of the times. It's not something that's usually part of our culture in our family. All participants shared revelations regarding their family’s response to a mental health diagnosis of one of its members; collectively, members reported reactionary behaviors that are shame- based and shrouded in secrecy. Participant 8 noted her family’s experience: Just looking back at how [my sister’s] life was, we just felt like she was the black sheep of the family. So, she was kind of counted out because of acting out. And then she began to do drugs. When she was younger, they told my mom that she was bipolar, schizophrenic, and she needs to seek help. The belief that mental health will disappear perpetuates the unspoken but binding social dysfunction implied by culture. 46 Five participants acknowledged that they had pursued and/or received professional mental health support. Participant 8 reiterated that “it's not talked about enough in our community, and I think it's not good. It's not good. Everyone sees it as like such a bad thing.” All 10 participants also noted that motivation to seek mental health increased when family or friends were supportive. They noted that their help-seeking attitudes were predicated on their support system. Individual participants noted that they did not come from environments where support was readily available. There was an acknowledgment by nine participants that system mistrust has been reasons stated within the family as to reasons why people do not seek care. However, the interviewees articulated that life experiences, trauma, and supportive environments shaped how they currently see help-seeking. The participants’ consensus of the study's participants supports the idea that the absence of stigma from family and friends is a powerful predictor of help-seeking behaviors. From a spiritual perspective, half of the participants remarked that their churches supported and, in some cases, encouraged professional mental health services. Their churches, too, were considered a source of motivation to seek and engage in mental health services. Table 7 presents participants’ perceptions of cultural stigmas. 47 Table 7 Participant Perceptions of Cultural Stigmas Participant Cultural and stigma perceptions Participant 1 I believe that my stigma was there as far as against mental health, and let me say this, my Blackness. Growing up Black. So, mental health treatment was not big for the community where I was and not in a bad way. We always, you know, we would say, “Oh, that’s what White people do.” I believe we said that because we didn’t have anybody to see of color. Participant 4 You know, in our culture, you just don’t do it. You just keep on doing the same thing and expecting different results. Participant 7 So, it's overlooked to say that you even need to take care of your mental health because it's not always when you know in our community. It’s when you are on the side of the street talking out of your mind or walking barefoot, something that's unusual, before someone thinks that you need help. Overall, participants reported being knowledgeable and motivated as African American women to actively engage with mental health and substance abuse support. Their engagement with mental health services stemmed from self-awareness, accessibility, and external support from those in their immediate community. According to the participants, racial stigma persists, but the support from their immediate community buffered its influence on their self-reported help-seeking behaviors. Recommendations presented in Chapter Five support these findings and the importance of community outreach and normalization of help-seeking behavior. Findings for Research Question 2 The category of culture and the general category’s sub-category of perceptions address the second research question: How do community institutions impact African American 48 women’s engagement with mental health and substance abuse support? Two themes emerged from the data analysis: • Theme 1: Participants perceive the African American community’s cultural norms regarding mental health may be shifting from private and avoiding to more open and accepting, which they expressed may increase engagement with mental health and substance abuse support. Table 8 presents direct quotes on perceptions related to these themes before turning to an analysis of each theme. 49 Table 8 Participant Perceptions on Shifting Norms Participant Key quotes Theme 1: Shifting norms perception Participant 4 I used to allow people to hold me hostage. Do you understand? And they are so judgmental. Oh, your parents are Mr. and Mrs. This and That. I reject everything that ever held me hostage. Participant 7 I think it was Farrakhan or Malcolm X who said [it]. Black women are the most disrespected, overlooked being in this world, and sometimes because we’ve been [overlooked] and because we’ve been able to manage it all, people think that it’s what [we’re] supposed to do. Because we’ve been able to wear the multiple hats and make it look so, well, keep up culture, keep up all of these things, people believe that this is what we’re supposed to do. Participant 10 No, I don't see it [mental health] as a weakness. I just see [people] as like they can't help themselves, because they came to you for help. So I just see it as them being vulnerable, and they're just trying to take it one step at a time. Theme 2: Perceptions of the strong Black women stereotype Participant 1 I believe that we all need to show when we're weak. … OK to say when you don't have the strength and when you don't have the capacity, when you're lacking the capacity. And, so, for women of color, I know that has been one of our weaknesses is the superwoman syndrome because of history, of carrying, you know, having to carry so much [is]a part of me. Participant 2 I think I may have seen my grandmother cry two times. You know you’re so strong. You show that. Participant 3 I would say it’s OK to not always come off as strong or like, but you can handle it. Me personally, I’m super open about, you know, what I go through and stuff like that. Theme 1: African American Women’s Perception Toward Help-Seeking Behavior Shifting From Private and Avoiding to a More Normalized Cultural Acceptance Eight participants traced cultural and religious stigmas to explain why African American women may have mental health distress. Two participants struggled with categorizing specific 50 answers as to why African American women experience mental health distress disproportionally. Across all 10 interviews, there was a prevailing sentiment associated with the timing of when African American women sought and accessed mental health services. According to them, access to care was often too late for the women experiencing distress. Study participants verbalized factors, such as social pressure and internal cultural conflict, as common occurrences for African American women that impact their help-seeking. Participant 9 discussed her experience: I just had, like, a mental breakdown a few weeks ago because I was so overwhelmed, and I really didn't have nobody to talk to. So, I had that breakdown. And then it's like when I had that breakdown, that's when people's eyes opened like, you know what I'm saying? And it shouldn't have been. I shouldn't have had to break down like that in order for a person to recognize that I'm dealing with a lot. The experience shared by Participant 9, and echoed by other participants, demonstrated the learned dysfunctional adaptation to function while in a mental health crisis, as identified by Schulz et al. (2000). The Black girl magic, or superwoman trope of staying strong and performing the impossible, is the manifestation of the learned dysfunction and social expectation placed on African American women. All 10 participants expressed the need to communicate their feelings irrespective of their environment and social barriers within their circle while modeling help-seeking motivation to obtain mental health services. Participant 4 shared a turning point in her perception of help- seeking via an exchange with a mental health provider: “I'll never forget [my therapist], and she told me it's going to be OK. Everything's going to be OK, and everybody is not going to think the 51 way you think.” Participant 4 described the internal personal struggle of social stigma in the community but expressed a feeling of relief when seeking mental health care. All participants described the restrictiveness of the cultural stigma of seeking mental health care and how not wanting the public (non-family members) to know the family’s business impacted their life. Additionally, all 10 participants expressed an awareness of the need to seek services for mental health breaking the constraints of social stigma. Participant 8 shared her personal experience and need to seek services: When I made the decision to go and seek counseling, that was the best decision that I made for me. It helped me tremendously, and I didn't know where to go, and I'm grateful that it was my job that offered it. Study participants unanimously agreed that shifting one’s focus to self-awareness, normalizing therapy, and utilizing resources in the community have been instrumental in addressing their mental health needs. All 10 participants indicated that spirituality is central to their cultural identity, and they see it as a protective factor. From a spiritual standpoint, nine participants mentioned prayer and mental health treatment as a prescription instead of relying solely on prayer. Participant 3's receptiveness reflects a positive therapeutic experience and the awareness of help-seeking behavior with support: I would say when dealing with a mental illness as a Christian, it's important to have that relationship with God and go to therapy, and it helps if your therapist is also a believer. But if they're good, whether they're a Christian or not, they can still lead you in the right path, you know? 52 Study participants alluded to the duplicity of the two schools of thoughts in the Black Church. Believers were judged by those in the community concerning their faithfulness in their belief or trust in physicians to address their needs. Internally, believers struggle with wanting to prove to those in the community that they are faithful and believe while suffering in silence. Participant 4’s insight represents the opposing common view in religious spaces: I would recommend both. Like prayer, prayer works, but I would also recommend seeing somebody who can help you. And in our churches, you know, pray and trust. But this is a nation and people. There are folks with the wherewithal to help us work through, but we have to culturally understand that there's nothing wrong with seeking help. Five participants reported that they regularly hear messages “across the pulpit” to seek mental health help, especially since the pandemic, as a means to socialize positive help-seeking behaviors among the congregation. Two respondents did not regularly attend church, but they noticed increased messaging to support seeking mental health assistance since the COVID-19 pandemic. Participant 9 stated, “Before the pandemic, they didn't really much discuss mental health issues like that. We don't have like no program or anything in our church where people can come in, you know, get the help that they need or even, like, talk about it.” Three participants reported they did not hear supportive messages about mental health in their places of worship. In exploring the connection between help-seeking and incurring God’s anger, none of the participants thought God would be angry if they sought mental health care. Participant 7 echoed the shared sentiment: 53 No, I don't believe that God will be angry if they will seek the help because I don't think that is a problem of their faith or anything. I believe seeking the help is allowing your faith to be worked out. The insight provided by Participant 7 reflects a common idea the participants expressed of spiritual struggle and how one’s faith walk would be perceived socially if they sought assistance. All 10 participants echoed their personal beliefs on this matter of God’s judgment of seeking mental health support, which was best demonstrated by Participant 5: I don't think God's ever really angry at us. Like, God is a forgiving guy. He’s not going to be angry at you for anything you do. Especially not doing something to better you at the end of the day. Participants referenced the idea that “getting better” could upset the status quo in their social systems because of the enlightenment therapy provides. It was the interviewees’ opinion that both methods, prayer and therapy, are essential to supporting good mental health among the African American community. Theme 2: Participants’ Perceptions of the Strong Black Woman Schema All 10 respondents spoke to the reality of cultural stigma and shame associated with mental health issues and seeking treatment within the African American community. When asked why stigma and shame are persistent and powerful deterrents to seeking mental health, participants expressed that these perceptions are passed down to female members of this group. Participant 2 alluded to generational trauma: There are some generational issues that I've observed in families. For this generation and when they sit and talk about it, but they become so xenophobic, and they're so territorial 54 and parochial how they do things. [They] give this façade [of it] was such a great close family. Participant 2’s comments shed light on the pressure of families to appear perfect, but Participant 4’s perspective provided insight into the family social system: So, now I look at it as a generational curse. How [elders] were treated. You're not going to treat me the same way. Just not. And I'm not going to think you are better than me. Yeah, you get where I'm coming with this. You're not better than me. The enlightenment of the 10 participants regarding the intergenerational transmission of shame and stigma was the impetus for their new behavior. All participants concurred that African American women should not see mental illness or mental health support as a weakness but should seek treatment and address mental health issues without fear or shame. According to Participant 4, the community needs to move past seeing help-seeking as a weakness that they need to “overcome:” We look at it [as] a form of weakness. We criticize people when they have mental illness. You don't know. That's why I'm trying to tell you. My dad taught me about the blue-eyed devil, but it's the devil within. It's the devil within. We look at people when they go to therapists like some wrong with them. Don't you know, it's something right about them? That's the sick part. Ok, we're sick. The theme of the strong Black woman appeared multiple times during the interviews. Eight respondents could extensively describe the weight of familial and community expectations that perpetuate the persona of the strong Black woman. Participant 4 described this state of being as necessary to traverse daily life: 55 What I'm saying is you have to be a strong Black woman. For me, in my life. It helped me every day I would go and punch that clock where people used to demean me, not say it was worthy, but you know, my mother taught me. Even the prostitute wants the best for their children. So, I had to be strong no matter what I feel. Participant 8 provided another perspective of the strong Black woman trope: So, I felt like I was singled out because I was a Black woman, the only black woman that had a leadership position. And I felt targeted. I felt like my character was in question, my integrity. This is why we must be strong Black women. Respondents also reported the external struggle to function perfectly, better known as Black girl magic. Participants noted that the social pressure and praise to arise despite adversity has a paradoxical relationship with community acceptance and self-preservation. The celebration of dysfunction is understood as the social reward of the strong Black woman trope (Lekan, 2009). Participant 9 offered a keen cultural observation as to the outward manifestation of the social expectations that emerge in the African American community: I guess in the Black community, we're so prideful. Like, we don't feel like we really need to talk to someone. So, I think that if [mental health] becomes available, I don't even think that the people would really come because I think they're too prideful. Participant interviews provided a deeper understanding of the counterproductive non-help- seeking behavior that has affected African American women generationally. Summary Based on the interview results, Table 9 presents the summative findings pertaining to the two research questions. 56 Table 9 Summative Findings by Research Question Research question Key Findings What are African American women’s perceptions and experiences with engagement with mental health and substance abuse support? Knowledge: Informed by traumatic personal experiences, suicide awareness Motivation: Support from family, friends, and church motivated engagement with mental health and substance abuse support How do community institutions impact African American women’s engagement with mental health and substance abuse support? In summary, 10 African American females aged 18 to over 70 from Miami-Dade County represented a percentage of African American women who experienced engagement with mental health services due to their personal situations and access. This study revealed the need to proactively socialize the idea of positive help-seeking behaviors within the community and family to combat the low or no engagement with community-based mental health care and substance abuse. This study’s subjects provided insight into the barriers and motivations that either encourage or prevent African American women from acknowledging or receiving help for mental health issues. Access to services and cultural stigmas were among the major concerns expressed by participants, while race and religion were less so, though still present. Participants further acknowledged that despite the barriers they noted in their community, each was open and receptive to seeking mental health support for herself. This openness reflects the shifting perceptions the participants described among African American women to be more accepting in mental health spaces. However, the participants also acknowledged that the narrative of the strong Black woman and the celebration of dysfunction creates a new barrier that, at minimum, 57 causes African American women to hesitate in seeking mental health services when needed. According to the participants, the implied social and personal behaviors trans- generationally transmitted to female children strengthen the disconnect between self-preservation and expectation. This reality clouds one’s ability to identify and respond when help is needed. Chapter Four presented the study’s findings, highlighting the participants’ demographics, qualitative analysis process, and outcomes in response to the research questions. Chapter Five will discuss these outcomes in more detail, present the findings’ implications, and provide conclusions derived from the research. Additionally, Chapter Five presents recommendations for practice and the discipline. 58 Chapter Five: Discussion and Recommendations The purpose of this study was to explore African American women’s perceptions and experiences in engaging in professional mental health and substance abuse support and the impact of community institutions on their help-seeking. Specifically, this research explored the lived experiences of 10 African American women in Miami-Dade county, Florida to identify the barriers and motivations for using mental health services. Data analysis sought to provide a deeper understanding of the cultural stigmas, access to care, mimicked transgenerational behaviors, and the shifting perceptions of mental health care that support or hinder help-seeking practices among African Americans. Two research questions guided this study: 1. What are African American women’s perceptions of and experiences with engagement with mental health and substance abuse support? 2. How do community institutions impact African American women’s engagement with mental health and substance abuse support? Discussion of Findings The data analysis revealed several critical findings. All participants alluded to the conditional acceptance of the African American community and its importance individually, which they reported as based on perceptions of one’s mental health. This finding supported an exploration of the stronghold that group acceptance has on the socialization and normalizing of seeking care. Alang’s (2019) study paralleled findings from this study. According to Alang’s study, persons 64 years and older do not tend to report stigma as a reason why they do not seek mental healthcare compared to their younger counterparts. Adults 18-50 years of age tend to more frequently report social stigma as a barrier to care. Alang went on to describe findings in the study that reinforced stigma related resistance was most likely to come from a college 59 educated degreed person versus those with less than high school or diploma holders (2019). Women in this dissertation's study all possessed a high school diploma or post-secondary education. This study demonstrated a possible trend similar to the correlation found Alang’s study in regard to higher education and the minimization of mental health prevalence due to social stigma. All participants in this study did speak to their experiences of social pressures and perceptions impacting who they reveal their confidences to when in crisis. The greater finding in Alang’s (2019) study alluded that African American women are more likely than African American men to think that they can overcome problems without seeking help. This finding speaks to the Superwoman Syndrome and the socialization that African American women experience, which is problematic in attempts to increase engagement rates and completion of treatment for this population. Pascoe and Richman’s (2009) study suggested that the difference in the reporting of African American men was the perceived deviance and association to violence vice the accepted social stereotype of the African American female. There is growing research about this phenomenon from other parts of the diaspora, but extraordinarily little information exists specifically on women of African American descent due to the trauma of the early experimental American healthcare system endured by this group (Savitt, 1982). This study sought to add insight to the mental health field to encourage the demonstration of help-seeking and engagement with professional mental health services among this population. Findings will be reviewed in the following sub-sections through the CRT framework to provide context to the data points provided by the interviews of the participants. The transferability of the data research during this study can be utilized to inform outreach efforts, organizational support, and the education of African American women in Miami-Dade County, Florida. For the 60 following discussion, the research provides insight into the study’s two research questions by examining the themes from the coding process aligned to each research question. Discussion of Research Question 1 Findings The interviewees perceived and experienced engagement with mental health and substance abuse support as an issue of past and present knowledge, and they expressed motivation for seeking help as tied to the endorsement from their immediate community. All 10 participants conceded that both knowledge and motivation were barriers, at times, to seeking mental health and substance abuse support. However, they also considered both aspects instrumental in changing their perceptions to be more accepting of mental health services, such as individual counseling, group therapy, or support groups. Participants candidly shared their experiences internally battling perceptions of their public personas and public opinion while needing to seek help during moments of disruptions. Transgenerational oppression and not discussing personal information can be traced back to slavery, which necessitated the need to survive and assimilate within the majority’s hostile social system (Powell, 2018). The African American culture often views mental health as a weakness that casts a negative familial reflection (Corrigan et al., 2006). Corrigan et al. (2006) posited that the root of family stigma is being linked to the person experiencing a mental health or substance abuse disruption, reinforcing the social pressure for families and individuals to avoid public embarrassment. Therefore, the adage “what happens at home stays at home” is very much alive and a determinant factor in engaging with services. Myers and Anderson (2013) explored African Americans’ negative expectations of institutions based on the historical trauma perpetrated against this group. The authors solidified the impact of historical trauma as cultural and a driving force informing an individual’s coping 61 response and belief in the efficacy of treatment. Data from this study support the need for understanding historical trauma to inform treatment intervention and empower the client to address their presenting issue irrespective of perceived public opinion. The African American Church serves as the epicenter of social support and inclusion within the Black community (Chatters et al., 2011). From its origin to contemporary times, religion and spirituality are central to the identity and cultural schema of people of African descent in America and the Diaspora (Billingsley, 1999). Within the Black Church, a framework that builds community and gives psychological support while acting as a protective factor exists for congregants (Bashi, 2007). Studies show that African Americans have higher church commitment and involvement than their White and Latinx counterparts (Chatter et al., 2009). Participation in daily activities that consist of prayer, worship, devotion, and non-organized gatherings provide psychosocial support, fortifying the protective factor needed for survival (Chatters et al., 2009). Krause (2006) posited that social inclusion and support within the church lead to improved mental and physical outcomes. The religious commitment theory by Stark et al. (1983) expanded on the earlier work of Durkheim, which identifies religion was a prophylactic against suicide. Single belief was not a factor in decreasing suicide, but commitment within the church was a determinant of suicides executed by parishioners (Stark et al., 1983). All participants in this study referenced Christianity and their spirituality regarding the thought of committing suicide as an unforgivable sin. All participants also had direct knowledge of the direct and indirect impacts of suicide or ideation in their social circles. Suicide was a commonality among this cohort as a critical indicator for mental health intervention. Participants all reported heightened awareness and execution of help- seeking when suicide as a risk factor was present. 62 The National Healthcare Survey from 2006–2013 reported that African Americans are the largest U.S. minority group with the lowest healthcare utilization compared to their Caucasian counterparts (Travers et al., 2017). African American women in Miami-Dade County have the lowest rates of service connectiveness to healthcare in Florida (ACLU, 2018). Over 50% of African American children are raised by single mothers and fall below the poverty line in the United States (Hofferth, 2002). Suggesting the outcomes of socioeconomic status, Leaf et al. (1987) confirmed that marginalized communities experience more barriers to health care treatment due to lower socioeconomic status. Persons who live below the poverty line report struggling with factors like access to care, lower education, lack of disposable income, and financial challenges, thus skewing the importance of help-seeking to survive. The participants in this study, whose intersections are as African American women and a marginalized group, communicated that their understanding or not knowing policy limitations and navigating the healthcare system are additional burdens to seeking care. Critical Race Theory: The Influence of Racism on Engagement Critical race theory was the primary conceptual framework through which the findings were analyzed. The participants indicated that many of the barriers and lived experiences connect to foundational systemic oppression due to gender, race, and class. According to Rogers et al. (2014), the perception of how others in the environment and society view the individual determines the concept of self. Self-concept is constructed and internalized based on positive or negative information received. For members of minority groups, internalized racism is a challenge that harms their psychological well-being (Sullivan & Cross, 2016). Crenshaw (1991) introduced the framework of intersectionality to understand the connection and implications that 63 racial stress has on members of BIPOC communities. African American women bear many intersections with impacts that are often not seen or understood. The perceived value of African American women has been characterized by the construct of the White gaze (Cammarota, 2011). Ill-informed perceptions, behavioral characterizations, and distortions, known as stereotypes, resulted in a distortion of Black women’s perceived self- worth becoming the internalized negative self-concept (Cammarota, 2011; Hudson, 1998). All participants indicated their internal struggle and feelings of invisibility in society through their experiences as Black women, leading to a general belief of low or no positive expectations during interactions with Latinx and White counterparts. As discussed in Chapter 4, Participant 5 shared a professional experience: “Oh, stereotypes. Like, I've been followed around. And just the way people look at you or be like, oh, you're this, I didn't expect you to be there [The profession] because you're black or stuff like that.” Participant 10 discussed her viewpoint: “When you act out at a school, when you act out of the store, and then you be that typical Black woman, that angry Black woman. Participant 6 explained the expected and perceived treatment: “I live in Miami.” Participants voiced the common thread of acceptance of ratified racism and negative interface in society on a daily basis. Their perspectives supported the idea distilling through the negative self-image and messages received daily is a constant struggle for African American women, and that the CRT tenet of the “permanence of racism” is a part of their lived experience in Miami-Dade County. The weaponization of structural racism is the convergence of institutional, ideology, and systemic laws that maintain the oppression of the marginalized group with codified practices that lead to discriminatory and racist actions toward the oppressed person (Jones, 2002: Williams et al., 2013). Jones (2002) posited that the systemic oppression that disenfranchised persons endure 64 is the impetus for racial disparities in education, healthcare, and socio-economic growth. The nation’s economics, politics, and culture landscape of the United States was birthed from the ideology of White supremacy, therefore, conflicting with minority viewpoints and interests outside of that value system (Hardeman et al., 2016). Critical race theory evaluates the relationship the oppression perpetrated against marginalized groups of color has caused (Delgado & Stefancic, 2017). Delgado and Stefancic (2017) explored the major domains of CRT: (a) the permanence of racism, and its everyday occurrence, (b) the general acceptance of racism and is functional to maintain the societal status quo, (c) interest convergence of those in power that benefit from the codified practices structural oppression, (d) the concept of Whiteness as property, the privilege, advantage to being White, (e) the importance of storytelling of people of color from their own narrative, and (f) the critique of liberalism, specifically the colorblind doctrine that equates to equality. Nine of 10 participants in the study acknowledged mistrust of the system as a reason, culturally, family members do not seek care. Mistrust of the health care system in America is based on the systematic experimental misuse throughout history against African Americans, especially the non-valued African American female (Kennedy et al., 2007). Several systemic barriers have impacted the African American group as a whole, including the segregation from the public health system that drove marginalized members to seek alternative healthcare management (Fahie, 1988). The development of mistrust that has resulted as a form of self-help is prevalent and responsible for poor engagement and the response to the broken healthcare system that is the only option for African Americans (Shippee et al., 2013). Addressing institutional bias, as indicated by the data review from this study, highlighted the necessity of 65 trust being present in the health care relationship between African Americans and mental health providers (LaVeist et al., 2000). Interest Convergence All participants acknowledged that the African American community needs more access to mental health resources and comprehensive care. Participants recounted personal or familial instances where poor mental health and substance abuse was the manifestation of institutional bias, lack of education, and low socio-economic status (SES). Broussard (2013) discussed ratified or legal institutional racism as a barrier to populations of color, retaining the power structure’s control of resources. Birzer and Ellis (2006) demonstrated the correlation between the discrimination experienced by African Americans and the absence of housing, education, and employment opportunities as creating separate and unequal Black and Brown communities in society, in which the majority benefits and maintains power (Birzer & Ellis, 2006). United States history has witnessed seminal moments in which African Americans were perceived as the recipients of legislation to correct institutional discrimination. The ruling in Plessy v. Ferguson in 1896 marked a turn in American history, where the separate but equal doctrine was born (Bell, 1980). Interest convergence, for the United States, perpetuated segregation in schools and communities. Bell (1980) described the Supreme Court’s ruling as allowing segregation to continue, thereby maintaining the status quo for the majority’s socio- economic oppression of African Americans. The propaganda regarding the United States’ image as the world’s example of true democracy and equity for all people during the Cold War is a testament to interest convergence via the Plessy v. Ferguson decision (Kauper, 1954; Ladson- Billings, 2004). The Brown V. Board of Education decision 4 decades later highlighted the generational impacts of separate but equal as separate is unequal. Therefore, integration was 66 necessary to level the educational landscape by providing opportunities and resources for African Americans (Ladson- Billings, G., & Tate, 1995). Morris and Morris (2005) found that Black Americans believed their White counterparts viewed them as subordinate intellectually and felt their presence was the catalyst for the social decay in the Black communities. In the discourse concerning interest convergence, post-racialism, in the New Jim Crow era; disparities persist in the areas of health care (mental/substance) utilization, education, housing, and social justice aspects increased incarceration rates and police brutality within the African American community (Alexander, 2019). Given what is now understood as interest convergence, socio- economic issues that plague the African American community, specifically by legislation, can be perceived as the explicit expression of structural racism that subjugates the Black community by design (Birzer & Ellis, 2006). Discussion of Research Question 2 Findings During this study, participants collectively cited many disparities between community institutions in Miami-Dade County and the intentional engagement of African American residents with mental health and substance abuse disruptions. All interviewees passed indictments on the perceived failure of community institutions to address the collective issues that exacerbate mental health and substance abuse prevalence that directly impact their Black community. All participants identified the gaps in health care in their community based on their perceptions and lived experiences. Emerging themes cited the need for local agencies to earmark resources, including targeted outreach, transportation, accessibility, financial and educational support, and patient-centric care that represents all communities of color. To address the negative stigma of mental health and substance abuse, Patrons of the study communicated that trust 67 building between the community organizations and the Black community is paramount to members engaging in care and treatment adherence. The interviewees voiced their perceptions of the lack of accessibility in their communities. They had mixed knowledge regarding local mental health services and how to access them, as none could communicate a known process with certainty. Their consensus on the appropriate action to take in a mental health crisis was to call the police or go to the emergency room. Due to lack of education and access in the African American community, Participant two alluded to the service gap concerning Black families not knowing whom to call or how to access support in an emergency mental health crisis. Families default to the reactionary response of calling 911, which has led to increased incarnation rates, forced hospitalizations, and death (Waters, 2021). According to a study that measured the life risk of marginalized populations and police violence, African American women are five times more likely to receive discriminatory treatment during a police officer encounter due to intersectional socio-economic membership (Smith, 2016). Edwards et al. (2019) found that African American women are at the highest risk for death and violence at the hands of police compared to their Caucasian counterparts. In the following discourse regarding the emerging themes pertaining to the second research question, there is overlap in the findings from the preceding sections on CRT and its implications. Organizations must recognize the foundational ideology of racism and discrimination within institutions to become inclusive of African American women. The current presidential administration identified financial resources and support as a public health priority. The USHHS (n.d), through SAMHSA, dedicated more than $35 million to address the growing mental health and substance needs of children and young adults post- 68 pandemic (SAMSHA, 2020). Participants reported that they are not the recipients of mental health and substance federal funding at the level of identified need in their communities. When I asked interviewees if their health insurance covered mental health and substance abuse, those with insurance spoke about coverage and finances being barriers to care. Participant 9 shared, Well, in our case, it's pretty much kind of based on if you have insurance. And I don't even think that we really know where to go if we needed the help, because as long as I can remember, I've always had to have insurance to get help to even speak with someone. Participant 2 commented on financial means to access care: Knowing where [services] are and getting them but recognizing that there's a deficit in the resources available, particularly, I mean, across the board. Unless you have a ton of money, you can get some things done for your family because you've got some resources, some good insurance, and maybe you can pay to get them in a private facility, but that can often be difficult to access”. Participant 10 expressed her viewpoint and it is reflective of many of the comments:” I'm not sure, but I do know I do have insurance, and it just covers my health, my health and dental. But to be honest, I didn't even know like insurance can cover mental health.” African American women experience the most severe mental health and psychotic disruptions compared to their White counterparts (USHHS, 2015). At the introduction of President Barrack Obama’s Affordable Care Act, African American women were in the margins, uninsured at 11% (NAMI, n.d.-a). The distinction of being at a 20% higher risk rate for mental distress describes the need for community institutions to create financial safety nets for African American women who have limited coverage, uninsured individuals, and those who are ineligible for public Medicaid or 69 Medicare. Community institutions’ examination of policies that are structural barriers to care can increase engagement. The interviewees noted the topic of transportation to access mental health and substance abuse services as a potential insertion point for community agencies to augment or create. When asked if they were aware of community transportation for mental health and substance abuse, participants only identified the transport for senior citizens and vaguely acknowledged public transportation. Additionally, 10 participants in the study listed transportation options that require financial support. Hines-Martin et al. (2003) posited that the availability of disposable funds is a determinant in decision-making when categorizing the priority of treatment engagement in the African American community. Copeland and Snyder (2011) discussed the importance of individuals understanding the utility value of learned procedural knowledge. In this case, procedural knowledge (Krathwohl, 2002) about mental health and substance abuse services offered by community organizations, how to make an appointment, and understand and access transportation is missing among the participants. The socio-economic strain felt by the Black community underscores institutional practices to perpetuate the inequality of the healthcare system in meeting this population’s mental health needs (Beal et al., 2003). Implementing Community based strategic outreach efforts by community institutions and faith-based organizations that target the underserved African American female population can improve healthcare outcomes and increase mental healthcare utilization by removing barriers to care. Recommendations for Practice The study’s findings have generated four recommendations to address the study’s essential findings. The first is community-based participatory research. This method of 70 engagement with several community stakeholders has been noted as a significant factor in understanding the community needs and enacting social change (Barnett, 2013, 2019). The second recommendation is to educate community participants concerning mental health coverage and policy limits. The third recommendation involves creating spaces to explore Afrocentric frames and discuss adverse transgenerational familial behavior on mental health topics. Lastly, the fourth recommendation addresses the engagement of faith-based institutions that guide spirituality to support mental health wellness among this population. Recommendation 1: Conduct Community-Based Participatory Research All participants in this study reported that they and other African American community members would benefit from global access to mental health treatment and interventions that support their culture- and gender-specific needs. African American clients' preferences for a Black provider are predicated on the elevated cultural distrust of medicine, low expectations of care, and lack of Afrocentric perspectives (Hollingsworth & Phillips, 2017). Borum (2007) theorized that African Americans may perceive medical personnel of a different race as agents of institutional bias; therefore, the protective response of cautiousness is activated. Collectively the participants noted that representation is central to building rapport for understanding. Having a Black therapist is familiar and appeals to the cultural communal construct of African American women's psyche (Asante, 1988). The interviewees expressed that access to care and inclusion in mental health care institutions was not evident, given their experiences with mental health services. Participants surmised that the lack of culturally competent and inclusive frames in mental healthcare was due to a lack of representation in the foundational aspects of institutional care. The recommendation to address 71 these findings is to implement community-based participatory research (CBPR) processes at mental health and substance abuse institutions in collaboration with community stakeholders. This CBPR approach is based on the model of action research, which evolved from the work of researcher Kurt Lewin in the 1940s. Community-based participatory research validated the need for the community to be an active driver of the identification of the social problem and part-owner of the architecture of the solution with community stakeholders (Barnett, 2019, Wallerstein et al. (2019). This ideology challenged the action research model in which the researcher formulates the community’s needs versus empowering the community to communicate its needs to the researcher. Wallerstein, et al. (2019), described CBPR as the mechanism that facilitates blending various expertise, perspectives, and capabilities to address one commonly identified community need for social action. Sohng (1996) outlined the CPBR process in four steps. The first step is to foster and create collaboration with present community relationships. Once Step 1 is completed, the next step is creating settings in which to exchange diverse opinions and knowledge among stakeholders. This is critical to facilitating and bridging the knowledge and value of the information among the partakers, which is Step 3. The final step is taking action steps to build capacity and increase self-sustainment long-term Themes derived from the data suggest that active collaboration between African American women and community stakeholders may support increasing help-seeking behaviors and access to care issues while building the capacity of resources at mental healthcare institutions. Israel (2000) posited that communities are collectives with shared values and interests. All participants in this study noted that the degradation of mental health care was linked to their local community breakdown. The process of CBPR would naturally align with the 72 African American cultural value of communal connectedness (Asante, 1988). Asante (1988) introduced the term “Afrocentrality” to highlight African consciousness, values, mores, and interests as central focal points of reference versus Eurocentric points of view. The researcher posited that, in African culture, all things are connected spiritually, meaning there is no individualism. The Afrocentric belief system derived from ancestors of central and west Africa, where the Trans-Atlantic slave trade originated. According to Schiele (1996, 1997), African Americans see the link between the spiritual and the physical worlds as the same; therefore, sameness is valued. In this study, the participants' understanding suggests that implementing a CBPR model would lead to efficacious outcomes commensurate with the community’s shared belief system. Recommendation 2: Understanding Your Policy Limits All study respondents reported that they have health insurance but did not know their plans' policy limits and coverage details. Recommendation 2 is collaboration with community- based organizations to implement mini-30-minute workshops in strategic locations and online for community members to learn how to read health insurance policies, including death coverage. Accessible online content and personal interactions during the mini groups will support members in understanding their coverage’s limitations. The study’s participants suggested that healthcare systems and insurance policy illiteracy resulted in low or non-utilization of healthcare, foreshadowing the inability to access healthcare, and creating a barrier to receiving and seeking mental health care. Participants acknowledged their personal coverage but could not describe policy limits for mental health care or if their policy covered mental health at all. They assumed that mental health care was automatically covered. In the Alang study (2019), participants who were covered by private or public insurance policies minimized health care issues at a higher rate 73 vice their counterparts that were uninsured. All 10 participants indicated that the emergency room is a treatment option if they or their family needed mental health crisis care. The interviewees all had a high school or post-graduate education. Their education was not an apparent factor in determining their knowledge of their policy coverage. Nine participants relayed instances of family members or themselves being unable to afford mental healthcare at some point. The U.S. Census Bureau (2016) reported that Miami- Dade County’s population consists of 23.10% uninsured persons, which is significantly higher than the U.S. average of 11.7 %. While the sample in this study was small, the theme of uninsurance and lack of knowledge regarding policy limits and coverage reflects the trend identified within the larger African American community. Collaboration with stakeholders in the CBPR process is a recommendation to address the need for knowledge about how to read and understand healthcare policy declarations. Establishing support and community is central to the African American cultural schema. According to Yalom and Leszec (2005), women working in groups have a bilateral experience in which members can hear, see, and learn from other individuals. The researchers posited that workshops provide a safe space free from stigma due to the composition of its members. In these groups, opposing views and external concepts can be reflected on while trust building, mutual aid, and support are demonstrated (Yalom & Leszec, 2005). Krathwohl (2002) described four types of knowledge: factual, procedural, conceptual, and metacognitive. Denler et al. (2014) posited that participants must connect new knowledge concepts to old information to attain successful knowledge transfer. According to social cognitive theory, the learning process is social, and observation is a critical factor in retaining knowledge (Denler et al., 2014). The authors further theorized that learning can occur without 74 immediate change and is activated by individual motivation (Denler et al., 2014). Community- based organizations that understand the premise of social learning theory and information transfer would support workshop attendees in increasing their baseline knowledge, thus increasing healthcare literacy. Recommendation 3 capitalizes on the connection to faith-based organizations in the African American community and the commonality of the study participants’ connection to the Black Church in their communities. Recommendation 3: Mental Health Practitioners Should Explore Afrocentric Frames to Overcome Aversion to Mental Health All ten participants indicated that social stigmas predicted their understanding of mental health and execution of help-seeking behaviors. During this study, there was a recurrent theme of representation preferred by participants to access care and partake in therapy. Participant 6 stated, “There needs to be more resources that's right here. Just like in the community, I think that's one of the struggles [no representation] as well. You may not see a therapist that looks like you.” Participant 6 alluded to the sentiment that therapy with someone who represents their cultural identity and understands African American women’s experience is highly desired and regarded as non-judgmental. Participant 9 said, “I would just like to find a Black doctor,” underscoring the lack of representation and spaces in the mental health field to address the participants’ cultural needs. Expanding the number of African American providers is an ideal solution, and such a solution takes time to implement at a macro level. In the absence of African American providers, non-minority mental health providers can achieve cultural humility by executing intentional self-awareness, education, and allyship during the therapeutic process (Cross et al., 1989). 75 The third recommendation is to create spaces within the community, church and helping institutions to explore Afrocentrism and investigate the nexus to adverse transgenerational familial behavior toward mental health topics. Afrocentrism is the act of placing African values schema at the center of thought while contextualizing African Americans' experiences (Stewart, 2004). Stewart (2004) posited that Afrocentrism does not eliminate Eurocentric framing but seeks to explore other points of view concerning the African experience. In this study, eight participants indicated that representation matters when seeking a therapist for treatment. Myers and Speight (2010) made a compelling argument concerning the critical need in the field of psychology to culturally acknowledge the experiences of African descendants within therapeutic treatment. The acknowledgment of race and culture in the therapeutic process is central to problem solving and client trust building (Williams, 1994). Williams (1994) posited that homogenous groups who share common concerns and cultural traditions recreate mutual aid, and develop the informal formation of social networks, which benefits therapeutic intervention. Persons of African descent are not monolithic (Schiele, 1996). Therefore, the adoption of an Afrocentric point of view within the clinical practice is simply acknowledgement of culture, traditions, and shared commonalities of those participating. The NTU (“In To U”) therapeutic framework is a Bantu people of Central Africa Afrocentric concept that supports well-being utilizing the seven principles of Nguzo Saba, formed out of the African tradition, with a focus on creating balance, interconnectedness, authenticity, and cultural awareness in all aspects of life (Phillips, 1990). NTU intervention acknowledges the role of spirituality in the physical human existence as a symbiotic relationship. Philips (1990) contrasted the differences of NTU where the client is at the center of the approach, moving the therapist to the position of a guide, which is a departure from the 76 Eurocentric-based framework taught in human service education to classically trained clinicians. The NTU therapeutic framework reiterates the interdependence and linkage of mind, body, and soul balance with its environment (Myers & Speight, 2010). Woods-Giscombe and Black (2010) discuss the intervention of NTU as an Afrocentric frame that would connect the socio-historical trauma experienced by African American women while affirming forgotten history and the impact of structural racism resulting in high prevalence rates of health care disparities endured by African American women. Elkins (1963) discussed the blood tie, the slave family’s belief that its survival depends on its members’ contributions (Chatter et., al,1994; Surdarsaka, 1997). This value system was broken during the slavery experience, contributing to the destabilization of the Black family, erasure of blood ties, and the need to establish community. The principles of Umoja (unity) and UJima (collective work) were drawn on the African perspective that members shared the responsibility for the tribe/family’s success (Collins, 2000). Collins (2000) posited that African Americans’ cultural practice of shared and extended parenting was not dysfunctional if viewed through the Afrocentric lens. Instead, it is purposeful in maintaining the family members and the African-based family value system. Understanding the significance of blood tie rites of passage in program intervention aligns with the African construct of community (Stewart, 2004). Programming that incorporates family and community has been successful among African Americans (Harvey and Raush, 1997). Research by Sue and Sue (2016) highlighted the impact of institutional bias within healthcare that has led to provider mischaracterization, misdiagnosis, and poor outcomes for African American patients due to socio-political and/or norms that are propagated by society. Therefore, there is a need to ensure providers are aware of their biases when interacting with 77 patients. Copper-Patrick et al. (1999) suggested that medical personnel needed additional cultural humility training for person-centered care, as their encounters with African Americans were less positive compared with their White counterparts, affecting healthcare perception and engagement. Ekman et al. (2011) reiterated the necessity of implementing person-centered care that considers personal factors, such as preference, social context, co-decision making, and personalized intervention. Interventions like patient centered care mirror that of Afrocentric treatment. Implementing this level of care would result in increased engagement of marginalized populations in medical treatment. African Americans that perceive Afrocentrism’s person- centered approach is present within the mental health practice will see the intervention as positive. Miller and Mangan’s (1983) research on family members’ informational needs found that individuals either seek or avoid information according to their coping styles. Miller and Mangan determined that the most effective intervention must factor in the preferred coping style. Afrocentric interventions support African Americans women’s need to connect while allowing their perspective to become the narrative of the therapeutic process. Recommendation 4:The (Black) Church: An Ally Institution In The African American Community The fourth recommendation is collaboration in the CBPR process, introduced with Recommendation One, with the Black Church to reach African American communities. In these communities, faith-based organizations traditionally serve as conduits that provide approval, access to information, and linkage to members. Therefore, its platform is ideal for interventions in the Black community (Lincoln & Mamiya, 1990). African American women historically represent the largest group of members in the Black church and are seen in their familial role as 78 the guardians and decision makers for families’ health and wellness (Darnel et al., 2006; Feltwell & Rees, 2004). Henderson and Lee (1995) indicated that a pastor’s influence or approval as a Black leader is crucial to members trusting the message and the intervention. Henderson and Lee addressed socio-cultural factors to consider when implementing faith-based collaborations and recommended appointing a church-based layperson of the same race as a health care advocate who speaks the participants’ language (Swanson & Ward, 1995). The messaging from the pulpit is the catalyst for buy-in. According to Ford et al. (2003), linking health and prosperity messages to biblical scripture was effective in faith-based health initiatives giving participants more of a connection to the content (Ford et al., 2003). Further, a location on church grounds, access to transportation, and alternative meeting time outside of work or church hours predicted and drove attendance to workshops (Henderson & Lee, 1995) Swanson and Ward (1995) discussed the need to have representation and create trust with African Americans due to prior federally funded studies that exploited this community’s members. Delivering healthcare utility content in a social manner through workshops and online platforms would address this study’s finding regarding participants’ low or lacking knowledge of the healthcare system and insurance policy limitations. Faith-based organizations and churches, as primary stakeholders in CBPR, represent a holistic approach to accessing congregants who may not interface with the healthcare system. Limitations and Delimitations The objective of this qualitative inductive study was to determine African American women’s social and cultural barriers to seeking mental health or substance abuse services. While there are many theories as to why this population has low engagement with these services, this study sought to specifically explore Miami-Dade county residents’ experiences. The first 79 limitation was that the invitation email yielded a sparse number of responses from qualified respondents. The invitational email was sent out on the Anvil listserv and forwarded by recipients to African American women who did not meet the study criteria. Also, I anticipated a large dropout rate as a limitation of this study. The initial type form indicated 72 responses to the criteria questions, but 60 persons did not pursue the second part of the invitation form that instructed them to indicate they were willing to participate in the study. Ten participants were interviewed individually of the 12 respondents who agreed due to schedule conflicts. Another limitation was the sample’s size and this study’s geographic location. While 10 interviewees do not speak for all African American women in Southern Florida and the United States, they did provide diverse insight into factors that impede mental health service connections for the African American community. The respondents’ educational level was post- high school. This level may be a limitation, as the study’s data does not reflect responses from participants who have not completed high school. Due to education, there is a baseline assumption that respondents were exposed to formal educational resources, unlike individuals without their education or access. A final limitation of this study is the researcher’s bias. Schindler and Burkeholder (2016), discussed that the researcher’s perception could impact data analysis. As this study’s only investigator, my intersection as an African American woman with an independent clinical social work license could be perceived as a source of bias. While I do not reside in Southern Florida, I have lived and worked in the Miami-Dade county community. I disclosed my positionality in the consent for the interview that I gave all participants. Looking at the availability of research on African American females and mental health specifically, there are gaps. Scarcity of research 80 material that does not include the African American male is less prevalent. This study’s references are exhaustive, reflecting the information gap concerning the topic of focus. On the heels of COVID-19, a delimitation out of my control was the participants' drop- out rate. The pandemic necessitated a shift to execute all interviews online. COVID-19 produced concerns about surveys and online interviews as well as Zoom platform fatigue among participants. Participants initially voiced that 45-minute interviews were burdensome; however, each interview ran longer, with the longest lasting 63 minutes. Doctoral program protocol called for data collection to occur over three months after approval from the institutional review board. The timeline, resources, and program requirements are delimitations of this study. These factors contributed to the low number of respondents. Recommendations for Future Research The previous section on limitations discussed the sample’s size. Future research should consider increasing the sample size, study criteria, and geographical location. This study’s transferability could be utilized to assess barriers germane to African American women in various U.S. regions. The study’s criteria can be expanded to African American women’s various intersections. Broadening the selection criteria would inform future Afrocentric interventions to support communities in normalizing help-seeking and mental health awareness. This inductive study introduced informative themes. As a starting point for future practitioners, implementing CBPR will address the lack of community stakeholders’ representation and empowerment to solve, from their view, issues most critical for future praxis. This study illuminates the need to explore more institutional interventions to increase trust between African American women and medical providers. Institutional interventions have direct implications for future social workers, psychologists, mental health care providers, and 81 physicians. Due to the paucity of research on African American women in the mental health field, the execution of targeted studies specifically about women descended from the Trans- Atlantic Slave Trade in the Americas would add value to the field. Lastly, intentional advocacy, education, and the retooling of Eurocentric frames of engagement in the social work and mental health fields would support healthcare policy to address service gaps endured by African American females. Conclusion African American women are double second-class citizens in the United States (Carasthis, 2016). As such, this marginalized population’s resiliency has endured institutional discrimination and racism since the arrival of the first West African Slaves in the Virginia Colony in 1609. The field of social science has a plethora of studies on African Americans’ health care utilization, yet there is a dearth of published research that gives an amplified voice to the Black woman’s perspective of systemic and non-institutional barriers to mental health care and the experience of being Black a woman in America (Snowden, 2003, Buston 2002, Littell, Alexander & Reynolds, 2001). This inductive study sought to provide insight into the African American family's closed social and familial circle to free women through their narratives, validating their lived experiences while providing support to other women who suffer in silence. This study illuminated the adverse adaptation of the celebration of dysfunction as a highly sought-after reward that adds perceived value to an individual in the Black community. This adaptation, as evidenced by the study’s data, is fundamental to understanding the duality of Black women’s experience and why they grapple with their self-concept to assimilate and achieve mental health stability and wellness. The study participants described an adaptation to the externally and internally dictated societal norms. The data highlighted emerging themes on 82 the dichotomy of familial and societal expectations and their far-reaching consequences for the African American female, causing breakdowns with family members and others. Based on the findings, there is a need for transparent dialogue within social circles and community institutions to foster inclusive frames that propagate Afrocentrism while providing quality, patient-centric, collaborative therapeutic relationships with healthcare providers. Evidence from this study’s data and field research supports the suggestion that access to healthcare is an inherent right of all people. This study’s results indicated that SES is a factor in access, quality, and motivation to seek mental health and substance abuse treatment. Themes from data concerning health care literacy and system navigation shaped how the study’s participants interfaced with healthcare. Thus, I presented recommendations regarding educational recommendations to improve how African American women receive care. The tenets of CRT revealed in this study can inform a systematic review of institutionalized racism and bias that predicated the low utilization of mental and substance abuse health care in this ostracized community. In the study, the participants all spoke to discrimination and public stigma that impact their daily life via the permeance of racism. The deconstruction of structural racism must take place in the majority power structure. The negotiation for structural change relies on interest convergence. Understanding privilege, or Whiteness as property, and its impact on African American women is critical to bridging medical mistrust and equity of access to the U.S. healthcare system. Emerging themes during the study support intentional evidenced-based interventions to improve our national health care system, address cultural and societal stigma, and increase the understanding of spirituality and Afrocentrism while advocating for efficacious protocols to better serve the African American female community and demolish institutional and structural 83 racism. This study suggests the Black Church is the focal point for the African American community, serving as the access and informational touchpoint to reaching the African American community. Advocacy and research show that establishing community collectives with institutions, informal and formal stakeholders, and the Black church would decrease the mistrust of medical care and initiatives from outside the Black community. Further, the collaboration of all community stakeholders is critical to identifying and solving societal issues that erode the fabric of the Black community. 84 References Adebimpe, V. (1981). 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You are invited to participate in a research study. Your participation is voluntary. This document explains information about this study. You should ask questions about anything that is unclear to you. PURPOSE The purpose of this study is to increase help seeking behaviors of African American Women within mental health; by addressing barriers to care and stigmas within the community. I hope to learn what the barriers social stigmas are to the field of mental health and why engagement is so low amongst African American women. You are invited as a possible participant because you are an African American woman, between the age of 18-80 years old living in Southern Florida area. PARTICIPANT INVOLVEMENT If you volunteer to participate in this study, you will complete an online interview via zoom that will take no longer than 45 minutes. Potential risk in taking part in this interview is that participation may take time away from completing another task. Secondarily, there may be interview questions that may induce stress. You are free to stop interview participation at any time. Zoom Interviews will be recorded and transcribed. Participants in the interview portion of this study may at any time decline to be recorded to stop or continue your participation in the interview portion of this study. A full transcript of the interview can be provided upon request. Potential benefits to stakeholders in this study and the field of mental health, will come from the insight you contribute to inform the research and recommendations of how to identify and address the engagement and stigma within the field of mental health regarding African American Women help seeking behaviors. 122 If you decide to take part, you will be asked to complete the online demographic link that you will receive in your email address as part of the in the interview confirmation email. CONFIDENTIALITY The members of the research team, and the University of Southern California Institutional Review Board (IRB) may access the data. The IRB reviews and monitors research studies to protect the rights and welfare of research subjects. When the results of the research are published or discussed in conferences, no identifiable information will be used. The data from this study will only be reported in aggregate form so that individual responses will be kept confidential. Data from this study to include all video, audio and survey recordings will be kept indefinitely with principal researcher in secure electronic catalogue. INVESTIGATOR CONTACT INFORMATION If you have any questions about this study, please contact Sharmane Delgado- Payne at: sharmanp@usc.edu. IRB CONTACT INFORMATION If you have any questions about your rights as a research participant, please contact the University of Southern California Institutional Review Board at (323) 442-0114 or email irb@usc.edu. 123 Appendix B: Invitation to Participate in Study I am a doctoral candidate at the University of Southern California, Rossier School of Education looking for participants to participate in a personal interview for my dissertation study focusing on Increasing the Engagement Rates of African American women in Mental Health. The online personal interviews will last 45 minutes. If you are interested or know someone who may be interested in participating in this study, please complete the survey link and or email directly for interviews at: sharmanp@usc.edu: I am excited to work towards finding solutions that explore barriers preventing African American females within the community from assessing mental health care and support. Your feedback on the survey and or participation in the interview, would greatly assist this study in moving forward to meeting this goal. You qualify for this study if you: 1) Live in the Southern Florida area 2) Identify as an African American woman between 18-80 years of age If you meet these two criteria and are interested in participating an interview with me, please follow this link to provide your information so that I can contact you. 124 Appendix C: Recruitment Questionnaire 1. Do you identify as African American? Yes/No 2. Are you a woman? Yes/No 3. What is your age? {Free Text} Name: Phone Number: Email: 125 Appendix D: Interview Protocol Researcher Interview Script Welcome and thank you so much for taking part in this interview. 1. (Establish Rapport) My name is Sharmane Payne, and I will be facilitating this interview today. Please note that I am a licensed clinical social worker. Any disclosure about harm to self or others, I have a duty to report. 2. (Purpose) I would like to ask you some questions about your background, your education, some experiences you have had. This is a safe space. 3. (Motivation) I hope to use this information to support this study in exploring the low engagements rates in mental health and barriers within the African American female community. 4. (Time Line) The interview should take about 45 minutes or less. 5. Please feel free to ask any clarifying questions. 6. You may stop the interview at any point. 7. Please note that I may take note during the interview and there may be a pause. This is solely to ensure I am accurately recording any notes or follow up questions. ASK: Do I have your permission to proceed with this interview to be recorded via Zoom? Are you ready to start the interview? ASK: May I record this interview? Record respondent’s confirmatory response (Yes/No) on the information sheet Administer Information Sheet ASK: Please ask respondent if they have reviewed the information sheet provided with the demographic sheet prior and if they have any questions. Transition: Thank you for completing the demographic and information sheet. We will now move to the first set of interview questions. 126 Table D1 Interview Protocol Crosswalk of interview questions to categories Information and access Where would you go in a mental health crisis? What services, if any, are you aware of for mental health services in your community? What mental health services does your insurance cover, if any? Under what circumstances, if any, would you refer a friend or family member to mental health services? What transportation, if any, is available in your area to access mental health services? If you needed to access mental health services, how would you make an appointment at your local agency? If you were experiencing a mental health crisis, where would you seek support? What, if anything, would help to encourage you in seeking professional mental health services? How confident are you in identifying mental health issues and the type of needed support? Racism: Mental health and environmental context What is your general attitude about mental health? In what ways, if any, have you been unfairly treated by medical or mental health personnel? Can you describe what factors are considered when it comes to choosing a provider for mental health care? Can you describe a time, if ever, when you were forced to make drastic decisions, such as filing lawsuits, leaving treatment, changing providers because of attitudes against your person? In what ways, if any, have you been unfairly treated by your employers, bosses, or supervisors? In what ways, if any, have you been the recipient of stereotypes? If so, can you describe the situation or situations? Cultural: Mental health and environmental context Would you report mental health issues to your family or friends? Why or why not? Can you describe a time, if ever, you have observed unfair treatment from family or friends towards someone with mental illness? Can you remember a time, if any, when you, your family, or friends suffered unfair treatment because of mental health? What are your thoughts about mental health crisis and showing weakness? Tell me about a time, if ever, you have experienced feeling invisible at home or work? What barriers to engaging in mental health services you have observed in your community? Spiritual: Environmental context In what ways, if any, does your church acknowledge mental health? Do you believe God will be angry at people who seek mental health? Why or why not? Would you recommend prayer instead of seeking mental health treatment? Why or why not? At this Time the demographic questions will be introduced to interview participants. 127 Table D2 Demographic Categories Category Age Education <Highschool Highschool College Graduate School Professional School INCOME < $15,000 $15,000-$30,000 $30,000-$40,000 $40,000- $50,000 $50,000 -$60,000 $70,000 + Wrap-up of interview ASK: Is there anything that you would like to add to this interview? Is there anyone you would refer to interview for this study? Thank you for your participation in the study.
Abstract (if available)
Abstract
African American women within the United States, gripped by the historical vestiges of slavery, Jim Crow laws, and modern-day systemic racism, experience the highest rates of chronic and untreated mental and physical health conditions as compared to their White counterparts. The purpose of this inductive study was to address the low engagement rates of African American women in mental health and substance abuse services while increasing understanding of the perceived and/or realized implicit bias in the mental health field. Research scholarship to examine other barriers to engagement pertaining to knowledge, motivation, and organizational considerations is scarce. Due to the paucity of research on socio-cultural stigmas, this study examined specific socio-cultural barriers to help-seeking behaviors among the African American female community in Miami-Dade County, Florida. This qualitative study was based on 10 structured interviews with African American women ages 18-80 years old who met the criteria of being an African American woman with residency in Miami-Dade County, Florida. Discussion: Critical Race Theory, specifically Interest Convergence and Permeance of Racism, was utilized as the framework to explore socio-economic barriers impacting African American women. In the study, participants' perceptions related to mental health and substance abuse support were influenced by racial norms (stigma), access to mental health care, and help from family, friends, and the Black Church. Findings from the literature review and data from the current study support the implementation of an Afrocentric approach and Anti-oppressive practice that leverages community participatory collaboration with stakeholders and faith-based organizations as critical insertion points to engaging the marginalized African American female community.
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Delgado-Payne, Sharmane Monique
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Core Title
Increasing engagement rates and help-seeking behaviors among African American women
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Educational Leadership (On Line)
Publication Date
11/21/2022
Defense Date
11/18/2022
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Philips, Jennifer L. (
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payne628@outlook.com,sharmanp@usc.edu
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