Improving Mental Health of African and Black Americans
Culturally responsive Service with African American Clients
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
CEUs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/42/c/
– Explore the culture, values and traditions of African Americans
– Identify issues and barriers which need to be considered to provide culturally responsive treatment
– Learn about how to provide culturally responsive group psychoeducation
– African Americans or Blacks are people whose origins are “in any of the black racial groups of Africa”
– The term includes
– Descendants of African slaves brought to this country against their will
– More recent immigrants from Africa, the Caribbean, and South or Central America
– many individuals from these latter regions, if they come from Spanish-speaking cultural groups, identify primarily as Latino
– In most African American communities, significant alcohol or drug use may be socially unacceptable or seen as a sign of weakness even in communities where the sale of such substances may be more acceptable.
– Overall, African Americans are more likely to believe that drinking and drug use are activities for which one is personally responsible; thus, they may have difficulty accepting alcohol abuse/dependence as a disease
– African Americans are less likely than White Americans to receive treatment for anxiety and mood disorders, but they are more likely to receive treatment for drug use disorders
– In one study evaluating posttraumatic stress disorder (PTSD) among African Americans in an outpatient mental health clinic, only 11 percent of clients had documentation referring to PTSD, even though 43 percent of the clients showed symptoms of PTSD
– African Americans are more likely to be diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than White Americans, even though multiple studies have found that rates of both disorders among these populations are comparable
– African Americans are about twice as likely to be diagnosed with a psychotic disorder as White Americans and more than three times as likely to be hospitalized for such disorders.
– For an overview of mental health across populations, refer to Mental Health United States, 2010 (SAMHSA 2012a).
– Blacks were much more likely to receive mental health services from general practitioners than from mental health specialists
– Were significantly more likely than White Americans to have an undetected co-occurring mental disorder, and, if detected, they were significantly less likely than White Americans or Latinos to receive treatment for that disorder
– 74% of African Americans who had a past-year major depressive episode were identified as also having both alcohol and marijuana use disorders
– African Americans are overrepresented among people who are incarcerated in prisons and jails
– A substantial number of those who are incarcerated (64.1 percent of jail inmates in 2002) have mental health problems
– African Americans are more likely to be referred to treatment from criminal justice settings rather than self-referred or referred by other sources
– Lack of familiarity with the value and use of specialized behavioral health services may limit service use.
– An essential step in decreasing disparity in behavioral health services among African Americans involves using culturally sensitive instruments and evaluation tools
– African Americans were, next to Asian Americans, the least likely of all major ethnic and racial groups to state a need for specialized treatment
– African Americans were more likely than members of other major ethnic/racial groups to state that they lacked transportation to the program or that their insurance did not cover the cost of such treatment
– Longstanding suspicions regarding established healthcare institutions can also affect African Americans' participation in, attitudes toward, and outcomes after treatment
– Attitudes toward psychological services appear to become more negative as psychological distress increases
– In many African American communities, there is a persistent belief that social and treatment services try to impose White American values
– African Americans, even when receiving the same amount of services as White Americans, are less likely to be satisfied with those services
– Once engaged, African American clients are at least as likely to continue participation as members of other ethnic/racial groups
– Providers also need to craft culturally responsive health-related messages for African Americans to improve treatment engagement and effectiveness
– African American clients generally respond better to an egalitarian and authentic relationship with counselors
– Request personal information gradually rather than attempting to gain information as quickly as possible
– Avoid information-gathering methods that clients could perceive as an interrogation
– Be willing to address the issue of race and to validate African American clients' experiences of racism and its reality in their lives, even if it differs from their own experiences
– Racism and discrimination can lead to feelings of anger, anxiety, or depression.
– These feelings are pervasive
– Counselors should explore with clients the psychological effects of racism and develop approaches to challenge internal negative messages that have been received or generated
6 Core Principles
– Discussion of clients' substance use should be framed in a context that recognizes the totality of life experiences faced by clients as African Americans.
– Equality is sought in the therapeutic counselor–client relationship, and counselors are less distant and more disclosing.
– Emphasis is placed on the importance of changing one's environment—not only for the good of clients themselves, but also for the greater good of their communities.
– Focus is placed on coping strategies and solutions that underscore personal rituals, cultural traditions, and spiritual well-being.
– Recovery is a process that involves gaining power in the forms of knowledge, spiritual insight, and community health.
– Recovery is framed within a broader context of how recovery contributes to the overall healing and advancement of the African American community.
– Interventions should make use of the core African American value of communalism by addressing the ways in which the individual's substance abuse affects his or her whole community.
– African American music, artwork, and food can help programs create a welcoming and familiar atmosphere,
– One intervention that appears to work better for African American (and Latino) clients than for White American clients node-link mapping (visual representation using information diagrams, fill-in-the-blank graphic tools, and client-generated diagrams or visual maps).
– Cognitive–behavioral therapy (CBT) has certain distinct advantages
– it fosters a collaborative relationship
– recognizes that clients are experts on their own problems
– When comparing CBT and 12-Step facilitation for a group of mostly African American (80 percent) men who were homeless and found that CBT achieved significantly better abstinence outcomes
– The Living in the Balance intervention, which uses psychoeducation and CBT techniques, has also been shown to improve treatment retention and reduce substance use
– A review of cultural adaptations of evidence-based practices is given by Bernal and Domenech Rodriguez (2012)
Strengths of African American Family Life
– Strong bonds and extensive kinship.
– Adaptability of family roles.
– A strong family hierarchy.
– A strong work orientation.
– A high achievement orientation.
– A strong religious orientation.
– African American clients appear more likely to stay connected with their families throughout the course of their illness.
– African American families are embedded in a complex kinship network of biologically related and unrelated persons. Hence, counselors should be willing to expand the definition of family to a more extended kinship system
– Clients need to be asked how they define family, whom they would identify as family or “like family,” who resides with them in their homes, and whom they rely on for help.
– To build a support network for African American clients, counselors should start by asking clients to identify people (whether biological kin or not) who would be willing and able to support their recovery and then ask clients for permission to contact those people and include them in the treatment process.
– Engaging Moms is family-oriented program and intervention developed specifically for African American mothers that has been shown to significantly improve treatment engagement
– Multisystem family therapy approach, which incorporates an extended network of relationships that play a part in clients' lives.
– Using this model, social service and other community agencies can be considered a significant part of the family system. Network therapy, which involves clients' extended social networks, has also been found to improve outcomes for African American clients when added to standard treatment
– The family team conference model can be a useful approach, given that it also engages both families and communities in the helping process by attempting to stimulate extensive mobilization of activity in the formal and informal relationships in and around clients' families
– Because of the communal, cooperative values held by many African Americans, group therapy can be a particularly valuable component of the treatment process
– Speaking in groups is generally acceptable to African American clients.
– note that Black Caribbean Americans can be less comfortable with the group process, particularly the requirement that they self-disclose personal problems to people who are relative strangers.
– African Americans seem less likely to self-disclose about the past in group settings that include non-Hispanic Whites
– Homogenous African American groups can be good venues for clients to deal with systemic problems, such as racism and lack of economic opportunities in the African American community
Mutual Help/Support Groups
– The Black community has changed the mutual-help model for substance use and mental health to make it more empowering and relevant to African American participants.
– For additional information on the 12 Steps for African Americans, visit Alcoholics Anonymous World Services (AAWS), AA for the Black and African American Alcoholic, available online (http://www.aa.org/pdf/products/p-51_CanAAHelpMeToo.pdf).
Values and Attitudes
– African American culture and history is steeped in healing traditions passed down through generations, including herbal remedies, root medicines, and so forth
– Acceptance of traditional practices by African American clients and their families does not necessarily indicate that they oppose or reject the use of modern therapeutic approaches or other alternative approaches.
– They can accept and use all forms of treatment selectively, depending on the perceived nature of their health problems.
– Psychological and substance abuse problems can be seen as having spiritual causes that need to be addressed by traditional healers or religious practices
Values and Attitudes
– African Americans are much more likely to use religion or spirituality as a response to physical or psychological problems
– African American cultural and religious institutions play an important role in treatment and recovery, education, politics, recreation, and social welfare in African American communities.
– A growing number of African Americans are converts to Islam, and many recent immigrants from Africa to the United States are also Muslims
– It is not uncommon for African Americans to approach clergy first with mental health or substance abuse problems, but many clergy members believe they are not well-prepared to address those problems
– Opportunity for outreach and education and to facilitate referrals
– Consider involving African American clergy in treatment programs to improve better engage clients and their families.
– Other means of engagement within the church can lead to recovery.
– Participation in religious services
– Use of peer mentors
– African American clients to underestimate the difficulties they will face after treatment
– they report a greater need for resources and greater exposure to high risk situations, but they still have a greater belief in their ability to maintain recovery
– Although an individual's belief in coping can have a positive effect on initially managing high-risk situations, it also can lead to
– A failure to recognize the level of risk in a given situation,
– Anticipate the consequences
– Secure resources and appropriate support when needed
– Engage in coping behaviors conducive to maintaining recovery.
– Counselors can help clients practice coping skills by role-playing, even if clients are confident that they can manage difficult or high-risk situations.
Culturally Responsive Group Education
– A common misconception about culturally responsive instruction is that facilitators must teach the “Asian way” or the “black way.”
– People often get intimidated by the words culturally responsive because of the incredible number of cultures and mixes of cultures in today's treatment groups.
– Too often, clinicians subscribe to the misguided idea that clients of different races need to be taught differently, and they waste an enormous amount of effort in the process.
– For example, incorporate hip hop music into sessions because many of the participants relate to this style of music
– You don't have to be African American, Latino, or from any particular cultural background to listen to a specific type of music
Culturally Responsive Group Education
– When you teach complicated concepts, make analogies or use metaphors about cars, animals, sports, or other topics that will pique student interest.
– Teach the entire concept in a way that all of your participants can relate to and understand, using aspects of their cultures with which you are comfortable.
– Vulnerability Prevention
– Teach to their collective culture
– Knowing the Learner: Group facilitators need to know as much as possible about their participants to teach them well, including learning styles and pace, multiple intelligences, personal qualities such as personality, temperament and motivation, personal interests, potential disabilities, health, family circumstances, and language preference.
– Traits of a Quality Facilitator: Believes all participants can learn, has the desire and capacity to differentiate curriculum and instruction, understands diversity and thinks about participants developmentally
– Quality Curriculum: Curriculum needs to be interesting to participants and relevant to their lives, appropriately challenging and complex, thought provoking, focused on concepts and principles and not just facts; focused on quality, not quantity; stress depth of learning, not just coverage.
– Flexible Teaching and Learning Time Resources: Includes team facilitation, block scheduling, homework, auditory, visual, kinesthetic resources presented for the active and reflective learner.
– Instructional Delivery and Best Practices: Includes flexible grouping, cooperative learning, learning stations and centers, individual treatment plans, literature/learning circles.
– Assessment, Evaluation: Includes observations, skills checklists, demonstrations, semistructured interviews and standardized tests
– Communication of High Expectations – There are consistent messages, from both the facilitator and the whole school, that participants will succeed, based upon genuine respect for participants and belief in student capability.
– Active Teaching Methods – Instruction is designed to promote student engagement by requiring that participants play an active role in crafting curriculum and developing learning activities.
– Leader as Facilitator – Within an active learning environment, the facilitator's role is one of guide, mediator, and knowledgeable consultant, as well as instructor.
– Positive Perspectives on Families of Culturally Diverse participants – There is an ongoing participation in dialogue with participants and community members on issues important to them, along with the inclusion of these individuals and issues in group/program curriculum and activities.
– Lobby is filled with reading materials about families and children from different walks of life.
– Therapist/facilitator maintains frequent communication with family members.
– Facilitator attempts to relate all stories to the personal lives of the participants.
– Concepts are linked to learning about families, backgrounds, and cultures.
– Cultural Sensitivity – To maximize learning opportunities, facilitators gain knowledge of the cultures represented in their classrooms and translate this knowledge into instructional practice.
– Reshaping the Curriculum – A reshaped curriculum is culturally responsive to the background of participants. Utilizes a variety of learning strategies, such as cooperative learning, whole language, and diverse learning styles
– Culturally Mediated Instruction – Instruction is characterized by the use of culturally mediated cognition, culturally appropriate social situations for learning, and culturally valued
– Student-Controlled Classroom Discourse – participants are given the opportunity to control some portion of the lesson, providing facilitators with insight into the ways that speech and negotiation are used in the home and community.
– Small Group Instruction and Academically-Related Discourse Instruction is organized around low-pressure, student-controlled learning groups that can assist in the development of academic language.
Culturally Responsive Outreach and Psychoed
– Gamification: Most games employ a lot of the cultural tools you’d find in oral traditions – repetition, solving a puzzle, making connections between things that don’t seem to be related.
– Token economy based on points earned by individuals or the class
– Create a game
Culturally Responsive Outreach and Psychoed
– Make it Social Organizing learning so that participants rely on each other will build on diverse participants’ communal orientation.
– This communal orientation can be summed up in the African proverb, “I am because we are.”
– Even making learning slightly competitive in a good-natured way increases participants’ level of attention and engagement.
– “How can we work together to solve this problem or prevent it in our children-”
Culturally Responsive Outreach and Psychoed
– Storify it The brain is wired to remember stories and to use the story structure to make sense of the world.
– Diverse participants learn content more effectively if they can create a coherent narrative about the topic or process presented. That’s the brain’s way of weaving it all together.
– Have them create skits or role plays
– In outreach break them into similar groups (i.e. parents, pastors)
– Have them relate it to something they already know (i.e. the bible, Quoran, a piece of literature or a current event)
– Explored the culture, values and traditions of African Americans to include communalism and the importance of spirituality for many clients
– Identify issues and barriers which need to be considered to provide culturally responsive treatment including ineffective assessment tools, lack of insurance or transportation and lack of awareness of the types and benefits of counseling services
– Learn about how to provide culturally responsive group psychoeducation including how to teach to the collective culture in a multicultural group and how to be an effective group facilitator.
– Learned about a variety of evidence based practices demonstrated to be effective with African Americans.