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How do societal perceptions and stereotypes surrounding black women, particularly the expectation of strength and resilience, impact the development of maladaptive coping mechanisms in response to anxiety and fear?

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1. Black Women tend to prioritize others at the expense of their own mental & emotional health.

2. It discusses the fact that black women overwork, overextend themselves, and nurture others. This is an issue, the article indicates a broader societal awareness.

3. Reflection, evidence, and external sources were used as a method of inquiry. The author reflected on her own experiences and observations of a black woman's behavior.

4. Focusing on "Black Woman Syndrome" provided insight into maladaptive behaviors. This sheds light on the factors contributing to maladaptive behaviors. Societal expectations play significant roles in shaping black women's behavior, they neglect of personal needs and sacrifice. Understanding this could further inform the underlying causes of maladaptive behaviors in Black women.

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1. Exploring how mental health challenges are faced by Black Women and the barriers that they encounter when trying to access mental health care.

2. Personal experiences and observations as a Black woman and psychologist. Societal and systematic factors contribute to mental health challenges among black women (workplace dynamics, neighborhood environments, racial violence, and economics).

3. Qualitative research methods, personal reflection, and evidence is an approach taken to explore mental health challenges. Also, personal experiences, insights, and societal analysis are used.

4. It emphasizes the systematic factors (workplace dynamics, neighborhood environments, racial violence, and economic inconsistencies) with societal expectations. These factors contribute to maladaptive behaviors in Black women.

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1. Exploring the emotional lives of black women and the cultural/societal expectation of being a "strong Black woman". The consequences of experiences suppressing pain and trauma and as a result mental, physical, and emotional health problems occur.

2. Personal experiences, anecdotes, societal and cultural factors, the impact of maintaining a certain image, and strategies for Black women to address their pain are analyzed in this work.

3. The method of inquiry involves qualitative research methods, personal reflections, and anecdotal evidence. The method of inquiry is characterized by personal experience, insights, and societal analysis to explore the emotional lives and challenges of Black women.

4. This provides insights into the underlying factors that contribute to maladaptive behaviors in Black women. Discussing the impact of maintaining an image of mental health outcomes such as anxiety, depression, and chronic diseases.

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1. How the strong black women schema is rooted in oppression and societal norms. It affects the physical and mental health of black women & girls. The author looked into the origin of the strong black women schema. The article advocates for systematic changes for the well being of black women and girls.

2. Anecdotal experiences, academic research, scholarly articles, and historical context is incorporated in the analysis that examines the complexities of the SBW schema.

3. There is a combination of literature review and qualitative analysis, and synthesis of previous research. Anecdotal experiences, academic research studies, and scholarly articles, and historical context to explore the strong black women schema and its impact on black women.

4. This sheds light on the societal and cultural factors that contribute to maladaptive behaviors. The Strong Black Women schema imposes an unrealistic expectations of strength,resilience, and self-sacrifice on Black women.

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1. The main question in this article is how Black women can break free from the harmful societal expectations of embodying the Strong Black Woman persona and prioritize their self-care. Some may think it's a myth, but the author challenges the myth which says how Black women always have to be strong and sacrifice.

2. Personal narratives, cultural analysis, and empirical data were combined to draw an analysis of the impact of the Strong Black Women and advocate for prioritizing self-care.

3. The method of inquiry is qualitative and interpretive, the author draws on personal experiences, cultural analysis, and anecdotal evidence to explore the concept of the Strong Black Women and Black women's well-being.

4. This highlights the societal expectations and cultural narratives that contribute to behaviors among Black women. The author draws on personal anecdotes and cultural analysis. Understanding societal and cultural factors that contribute to maladaptive behaviors will help emphasize the need for systematic changes.

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Coping With Perceived Racism: A Significant Factor in the Development of Obesity in African American Women?

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Coping With Perceived Racism: A Significant Factor in the Development of Obesity in African American Women?

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1. African American women have the highest obesity rates in the US, why?

2. This study looked at how dealing with racism emotionally and behaviorally affects their weight.

3. 110 African American women were studied and measured by their height, weight, and feelings of racism and stress.

4. The relationship between how they coped behaviorally with racism was linked to their weight, their emotional responses and overall stress levels were not.

5. Obese women tended to use more behavioral coping strategies for racism than those with normal or overweight.

6. All of this is possibly through stress-related processes.

7. Figuring out which coping strategies are linked to weight gain could help create better interventions for them.

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This picture depicts a woman who is struggling to pull herself out of bed on a Monday morning.

Emphasizes her success and the importance of working towards your goals diligently, despite the circumstances.

Depicting the lives of African Americans, not only the struggles but our humility, unity, and strength.

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A popular and timeless open edition work of art by the late master artist Annie Lee that depicts an African American woman rising on a Monday morning tired but ready to keep on keepin' on.This work of art ships framed and ready to hang in a black 2 inch frame.

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Survey &/or Interview

Interview someone who knowingly or unknowingly suffers from anxiety or stress and copes unhealthily.

Put out a survey for women to answer.

QUESTIONS:

Do you suffer from anxiety or stress?

If so, do you cope?

If so, how do you cope?

Would you consider this unhealthy?

Meaning does this affect how you function or the choices you make

EXAMPLE:

Joanne Doe has work to do before she goes out but she gets anxious that she may not finish in time. So she goes to the kitchen and grabs some snacks (cookies, ice-cream, and chocolate). All while she is lactose & tolerant, chocolate makes her break out. Overall eating sweets adds pounds onto her so she will start to feel bad about herself causing more anxiety or bad thoughts. Now Joanne is going to be late to her function because shes going to be stuck on the toilet.

Joanne Doe 2 is depressed and has locked herself in her room and doesn't come out unless shes refilling her cup of ice. This is doing more harm than good because she is anemic and consuming large amounts of ice doesn't help her.

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Eating To Cope: Advancing Our Understanding Of The Effects Of Exposure To Racial Discrimination On Maladaptive Eating Behaviors

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Eating To Cope: Advancing Our Understanding Of The Effects Of Exposure To Racial Discrimination On Maladaptive Eating Behaviors

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1. This study looked at how racial discrimination affects the eating habits of young Black women.

2. 27 Black women were studied as overweight or obese over 14 days.

3. Focused on their experiences of discrimination and eating behaviors.

4. 81.5% of the women reported facing racial discrimination.

5. The women who experienced discrimination were more likely to overeat or eat uncontrollably.

6. The study found that how these women felt about their racial identity influenced how discrimination affected their eating habits.

7. Feeling positive about their race helped lessen the impact of discrimination on eating habits, feeling negative made it worse.

8. Racism can lead to unhealthy eating habits for Black women, we need to address its impact on their health.

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The Relationship of Early Maladaptive Schemas & Anticipated Risky Behaviors in College Students

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The Relationship of Early Maladaptive Schemas & Anticipated Risky Behaviors in College Students

# data[].attributes.body
1. The transition from adolescence to adulthood is a time of personal growth.

2. Risky behaviors can hinder positive development.

3. This study looked at how certain patterns of thinking (early maladaptive schemas) relate to risky behaviors in college men and women.

4. For women, thinking patterns were linked to risky academic/work and illegal & aggressive behaviors.

5. Different types of risky behaviors were linked to different thinking patterns for each gender. we know it is different for men & women

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Abstract

The developmental transition from adolescence to adulthood, a period of time known as emerging adulthood, is marked by great personal growth and interpersonal maturation (Arnett, Emerging adulthood: The winding road from the late teens through the twenties, Oxford University Press, New York, 2004). Risk-taking behaviors are seen as a significant impediment to positive development during emerging adulthood. However, few researchers have examined how underlying cognitive processes contribute to the development and exacerbation of risk-taking behaviors at this time. In the current study, we examined the multivariate associations between early maladaptive schemas (disconnection and rejection, impaired autonomy, impaired limits, other-directedness, overvigilance, and inhibition) and expected involvement in five indices of risky behaviors for college women ( n = 341) and college men ( n  = 143). Gender-specific patterns emerged in the prediction of different risk-behavior indices. Early maladaptive schemas accounted for 24% of the variance in men's anticipated engagement in risky sexual behavior (vs. 9% of women's). Early maladaptive schemas accounted for 20% of the variance in women's anticipated engagement in both academic/work and illegal/aggressive risky behaviors (vs. 11 and 9% of men's). In addition, unique schema domains differentially predicted variance in risky sexual, illicit drug use, heavy drinking, and aggressive/illegal risk behavior for each gender. Gender-sensitive and schema-specific prevention efforts for different types of risky behaviors, often present during emerging adulthood, may be warranted.

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References

Centers for Disease Control and Prevention. (2009). Family health. Retrieved from Centers for Disease Control and Prevention http://www.cdc.gov/family/college.

Paulhus, D. L., Robins, R. W., Trzesniewski, K. H., & Tracy, J. L. (2004). Two replicable suppressor situations in personality research. Multivariate Behavioral Research, 39(2), 303-328. https://doi.org/10.1207/s15327906mbr3902_7.

Stumblingbear, G. P., Klibert, J. J., & Winterowd, C. (2007). Negative self-schemas and emotional distress in college students. In Poster presented at association of behavioral and cognitive therapies 2007 conference, Philadelphia.

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Author information

Authors and Affiliations

1. Northwestern State University, Natchitoches, USA

Stacy M. Marengo

2. Georgia Southern University, 2670 Southern Dr., Statesboro, GA, 30460, USA

Jeffrey Klibert & K. Bryant Smalley

3. University of South Alabama, Mobile, USA

Jennifer Langhinrichsen-Rohling

4. Mercer University School of Medicine, Macon, USA

Jacob Warren

Corresponding author

Correspondence to Jeffrey Klibert.

About this article

Cite this article

Marengo, S.M., Klibert, J., Langhinrichsen-Rohling, J. et al. The Relationship of Early Maladaptive Schemas and Anticipated Risky Behaviors in College Students. J Adult Dev 26, 190-200 (2019). https://doi.org/10.1007/s10804-018-9313-1
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Keywords

# data[].attributes.attachment_link.title
The Relationship of Early Maladaptive Schemas and Anticipated Risky Behaviors in College Students - Journal of Adult Development

# data[].attributes.attachment_link.description
The developmental transition from adolescence to adulthood, a period of time known as emerging adulthood, is marked by great personal growth and interpersonal maturation (Arnett, Emerging adulthood: The winding road from the late teens through the twenties, Oxford University Press, New York, 2004). Risk-taking behaviors are seen as a significant impediment to positive development during emerging adulthood.

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When Others Don't Believe in Mental Illness

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When Others Don't Believe in Mental Illness

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When Loved Ones Don't Believe in Mental Illness: What to Do

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Some loved ones don't believe in mental illness and this can really hurt suffering people. How to you educate someone who doesn't believe in mental illness?

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Mediators of a Culturally-Sensitive Intervention for Suicidal African American Women

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Mediators of a Culturally-Sensitive Intervention for Suicidal African American Women

# data[].attributes.body
1. Do spiritual well-being and coping skills play a role in mental health & headspace?

2. Data from 89 women were analyzed.

3. The study showed that women in the program reported fewer suicidal thoughts and less depression, along with feeling better about their lives and have better coping skills compared to those not in the program.

4. In this study, feeling better about life played a big role in reducing suicidal thoughts and depression.

5. Other factors like religious feelings and coping skills didn't have the same effect.

6. Programs that focus on improving how people feel about their lives, can be very helpful for black women.

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Abstract

This study explored intervention outcomes and mechanisms that could help explain why low-income, African American women with a history of intimate partner abuse and suicide attempt improve in response to a culturally-informed intervention, the Grady Nia Project. Specifically, the investigation examined whether or not the intervention had effects on the women and whether or not spiritual well-being and coping mediated the effects of the intervention on suicidal ideation and depressive symptoms. In this randomized controlled clinical trial, data from 89 women who completed both pre- and post-intervention assessments were analyzed. During the post-intervention follow-up, women in the active intervention group reported lower levels of suicidal ideation and depressive symptoms and higher levels of existential well-being and adaptive coping skills than those women randomized to the treatment as usual group. However, only existential well-being was found to mediate treatment effects on suicidal ideation and depressive symptoms. Religious well-being, as well as adaptive and maladaptive coping, did not serve a mediational function. These findings highlight the importance of designing and implementing culturally-sensitive and evidence-based strategies that enhance existential well-being in this population.

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References

Claessens, M. (2009). Mindfulness and existential therapy. Existential Analysis, 20, 109-119.

Google Scholar

Ellison, C. W. (1983). Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology, 11, 330-340.

Google Scholar

Flay, B. R., & Petraitis, J. (1994). The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. Advances in Medical Sociology, 4, 19-44.

Google Scholar

U.S. Census Bureau. (2005). Poverty thresholds 2005.

Utsey, S. O., Bolden, M. A., Williams, O., III., Lee, A., Lanier, Y., & Newsome, C. (2007). Spiritual well-being as a mediator of the relation between culture-specific coping and quality of life in a community sample of African Americans. Journal of Cross- Cultural Psychology, 38, 123-136.

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Acknowledgments

This research was supported by grants from the Centers for Disease Control and Prevention National Center for Injury Prevention and Control (R49 CCR421767-01, Group interventions with suicidal African American women) and the National Institute of Mental Health (1R01MH078002-01A2, Group interviews for abused, suicidal Black women) awarded to the last author (Kaslow).

Conflict of interest

Huaiyu Zhang, Tomina J. Schwenke, Miesha N. Rhodes, and Nadine J. Kaslow, Emory University; Kiranmayi Neelarambam, Georgia State University; Delishia M. Pittman, Lewis & Clark College. None of the authors have any conflicts of interest to report.

Author information

Authors and Affiliations

1. Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Grady Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA

Huaiyu Zhang, Tomina J. Schwenke, Miesha N. Rhodes & Nadine J. Kaslow

2. Georgia State University, Atlanta, GA, USA

Kiranmayi Neelarambam

3. Lewis & Clark College, Portland, OR, USA

Delishia M. Pittman

Corresponding author

Correspondence to Nadine J. Kaslow.

About this article

Cite this article

Zhang, H., Neelarambam, K., Schwenke, T.J. et al. Mediators of a Culturally-Sensitive Intervention for Suicidal African American Women. J Clin Psychol Med Settings 20, 401-414 (2013). https://doi.org/10.1007/s10880-013-9373-0
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Keywords

# data[].attributes.attachment_link.title
Mediators of a Culturally-Sensitive Intervention for Suicidal African American Women - Journal of Clinical Psychology in Medical Settings

# data[].attributes.attachment_link.description
This study explored intervention outcomes and mechanisms that could help explain why low-income, African American women with a history of intimate partner abuse and suicide attempt improve in response to a culturally-informed intervention, the Grady Nia Project.

# data[].attributes.attachment_link.readable_text
Some people just don't believe mental illness exists. There are reasons for this. Not good reasons, but reasons.

I recently saw a meme that blamed mental illness on capitalism. There was no mental illness per se, only the toxic effects of a culture that compels us to put up with overwork and underpay, exploitation and inescapable drudgery. The stress of dealing with these conditions is what causes us - an increasing number of people who struggle - to experience depression and anxiety.

There may be something to this, sort of. Environmental conditions that lead to stress and anxiety can certainly make mental illness worse, particularly those like bipolar disorder and other mood disorders. And, while capitalism may or may not be the cause, the majority of us are working harder with less to show for it than ever before. But the majority of us are not mentally ill.

My mother may have bought into this philosophy. She knew I had mental struggles, but she thought if I only got a better job, I would be all better. Admittedly, finding a better-paying job that was less stressful would improve anyone's mood, but it can do little or nothing for a clinical mood disorder.

Then there are people who seem to "believe" in mental illness, but really don't. These are the people who acknowledge it exists, but think it is a "choice" - that any person can choose happiness, health or sanity merely by an effort of will. Those of us who can't "pull ourselves up by our bootstraps" are simply not trying hard enough.

The "choose happiness" people don't seem to get that for most of us, our only choice is whether or not to get help from someone else - a doctor who prescribes a psychotropic, a therapist or counselor who listens or advises or even a friend who reaches out.

And, of course, there are people who acknowledge mental illness, but think it is a good thing, the fount of creative brilliance. They point to Vincent van Gogh and his amazing art. They forget about the suffering, the self-harm and the suicide. But, romanticizing mental illness and even revering it does nothing to help people who actually have psychiatric conditions.

It's true that some people with mental disorders - Sylvia Plath and Dale Chihuly to name two in addition to van Gogh - have created works of great art, beauty and significance. But it's certainly valid to wonder what they would have produced if they had not been through the trials of mental illness. Would their work have been less inspired or more? It's impossible to say. Personally, I believe that mental illness interferes with creativity more often than it enables it.

But I believe the most common reason people don't recognize the existence of mental illness is that it has never touched their lives, it isn't a part of their perceptions. A relative of mine once watched a talk show where women recounted dire experiences of having hysterectomies. "Those women are such liars," my relative said. "I had a hysterectomy and it was nothing like that." Her perception of reality - her personal experience - was extended to the whole world.

Similarly, when someone has no direct experience of mental illness, either by having a disorder themselves or by knowing someone close to them with the disorder, the reality of mental illness itself comes into doubt. "No one I know has it, so no one does."

Sometimes people who believe such things are capable of changing their minds, though. If a woman goes through a profound, long-lasting depression after the death of her husband, she may have more sympathy and understanding for people who have profound, long-lasting depression, or major depressive disorder (MDD) as it's more commonly known. Or a dear friend's struggles to help a son with schizophrenia may awaken her to what mental illness truly can be. Once it touches her life in some way, mental illness becomes real.

And since according to statistics, one in four or five Americans will experience some type of mental or emotional disturbance in their lifetimes, the odds increase that people's personal experience with mental illness will also increase accordingly.

In the meantime, those of us in the mental health community can help spread the word that mental illness does exist, that it affects the lives of millions of people and that even people who are not directly affected need to understand how easily it can happen to someone they know.

Blaming mental illness on capitalism, overwork or an unstable world may be easy and may make us feel better by comparison, but it will do nothing to address the actual problem.

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Why Some People Don't Believe in Mental Illness (and Why They Need To)

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A woman goes through the reasons why some people don't "believe" in mental illnesses and why we all need to be educated about them.

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Abstract

Enfant terrible of psychiatry and widely known as one of its most indefatigable as well as iconoclastic critics, Thomas Szasz (1961-2012) had a prolific writing career that extended some 51 years beyond the publication of his first book, The Myth of Mental Illness, in 1961. This editorial identifies and critically discusses three major themes in Szasz's writings: his contention that there is no such thing as mental illness, his contention that individual responsibility is never compromised in those suffering from what is generally considered as mental illness, and his perennial interest in calling attention to the political nature of psychiatric diagnosis.

The non-existence of mental illness

Arguing in The Myth of Mental Illness: Foundations of a Theory of Personal Conduct that they are merely 'indirect forms of communication',1 Thomas Szasz posited that so-called mental illnesses cannot legitimately be categorised as diseases. This launched an argument that Szasz would elaborate over the course of a prolific writing career that spanned more than 50 years. Szasz repudiated psychiatry's misappropriation of concepts such as 'illness', which he took to be relevant to medicine and its 'physicalist framework'2 but not to matters of mind and human conduct. In The Myth of Mental Illness,1 after arguing that virtually any entity can have a counterfeit version, Szasz articulated his views with characteristic iconoclasm, contending that only physical illnesses are real and that mental diseases are 'counterfeit and metaphorical illnesses' (p. 34). Illnesses are understood, according to Szasz,3 with respect to deviation from a norm, and in the case of physical illness the norm refers to the structural or functional integrity of the body or some aspect of it. But the norm - deviation from which results in so-called mental illness - is altogether more problematic for Szasz; this norm is a 'psychosocial and ethical one'.3 With this as the case, first, the search for a medical remedy seems poorly justified, and second, the points where diagnostic lines are drawn are bound, according to Szasz, to be somewhat arbitrary.

Szasz did not deny that humans have difficulties but he preferred to conceptualise them not as mental illnesses or as diseases, but as 'problems in living'.1 Nor did he deny psychiatrists a role in assisting individuals with problems. Psychiatrists could have a legitimate role to play but the ideal relationship between psychiatrist and patient, for Szasz, should be based on consensual contract rather than coercion. Second, the psychiatrist cannot justifiably claim that only he has the expertise to help people experiencing problems in living, since help from 'family members, friends, clergymen, mental health professionals, physicians, drugs, religion, faith healing, marriage, divorce, and so on'4 could be legitimately solicited by or on behalf of those experiencing problems in living, according to Szasz.

As Kendell5 pointed out in his rebuttal of Szasz's claim that mental illnesses fail to conform to the definition of disease, Szasz's notion of disease, influenced by Virchow, was overly narrow, for it placed excessive importance on the criterion of 'cellular pathology'.5 Kendell also claimed that Szasz's argument understated the extent to which 'suffering and incapacity are fundamental attributes of disease'.5 He brought attention to the fact that in medicine generally there is no universally agreed upon definition of disease - and if Szasz's criterion were to be widely adopted, several diseases widely recognised in medicine, such as migraine and torticollis (neither of which are associated with lesions or cellular pathology) would fail to qualify.

Beginning in the 1990s, psychiatry saw an unprecedented shift in its culture, with an explosion of interest in biological and neuroscientific research. Shorter,6 on the basis of the claim that 'the discipline today acknowledges a neurological basis for much psychiatric illness' (p. 183), argued that contemporary neurobiological research findings in fact provide support to counter Szasz's argument. This view that Shorter attributed to 'the discipline' is arguably overstated, since there is by no means unanimity among psychiatrists in attributing biological aetiologies to mental illnesses. For example, several authors writing as recently as early 2000s have contested the very claim that schizophrenia is a brain disease.7,8

Pathologisation of everyday life

A further area examined by Szasz concerns the proliferation of new psychiatric disorders. Szasz decried 'fictitious mental diseases'9 such as body dysmorphic disorder, multiple personality disorder and frotteurism. What he appeared to be objecting to here is the encroachment of psychiatric discourse upon ever-increasing domains of human life. Szasz adopted a mocking tone, for example, when discussing 'the behavior we call shoplifting - but psychiatrists call kleptomania',9 arguing that the construal of such behaviours as pathological entities for one thing perpetuates an assumption that the individual's actions are devoid of motivation and that they occur outside the orbit of their control. Medicalisation hands responsibility for such behaviours away from the individual concerned to physicians, specifically to psychiatrists.

In this respect, Szasz was cognizant of the interplay between diagnosis and political and social power; medicalisation gives a pre-eminent role to doctors, it privileges the role of medication as a therapeutic intervention and so the pharmaceutical industry stands to profit much by stretching the boundaries of the concept of mental disorder. Several authors in addition to Szasz have brought critical attention to this ever-widening reach of psychiatric diagnosis, and to the pharmaceutical industry's complicity in this phenomenon,10-14 not only by supporting 'new' categories of psychiatric disorder (such as adult attention deficit disorder), but by endorsing the lowering of diagnostic thresholds for a host of established psychiatric disorders, such as bipolar disorder.

Mental illness and personal responsibility

Ever interested in the interface between psychiatry and the law, another recurring theme in Szasz's writing concerns the issue of individual agency and personal responsibility. Law, Liberty, and Psychiatry 3 is his first book-length attempt to grapple with these important issues. In it, Szasz articulated a critical position with respect to legal and jurisprudential orthodoxy which assumes that individuals with mental illness, in some cases, are not responsible for their actions (especially with reference to criminal acts). Distinguishing between explanation and responsibility, Szasz argued that regardless of a diagnosis of mental illness, individuals are 'always responsible for their conduct'.3

In discussing the hypothetical example of a deluded individual with schizophrenia who shoots several visitors outside the White House acting under the belief that he was pre-emptively shooting communist assassins, Szasz argued that the endorsement of a range of 'explanations' does not imply that the person committing the crime did not have responsibility for the act. Critical of what he dubbed the 'progressive psychiatrization of the law',3 Szasz challenged the sorts of assumptions about personal responsibility in mentally disordered individuals that are reflected in such jurisprudential principles as the M'Naghten and Durham rules. There are other, more wide-reaching, implications of this assumption for Szasz - widespread in his view among psychiatrists and in jurisprudence - about the impairment of personal responsibility in the 'so-called mentally ill'.3 These he articulated in works such as The Therapeutic State 15 and The Manufacture of Madness,16 arguing that it is on the basis of the false assumption that the so-called mentally ill person 'is presumed to be incompetent'15 to make decisions about treatment that such paternalistic interventions as involuntary hospitalisation and coercive treatments are justified. These concerns gave rise to such pragmatic developments as his concept of the psychiatric will15 in which it was proposed that an individual, when well, could document an objection to receiving coercive treatments in the event of falling sick.

Discussion

Szasz consistently debunked the existence of mental illness on the basis of his assumption of the relevance to mental illness of the criteria of physiological abnormality, or the so-called 'medical-pathological definition of disease'.17 But this line of argument is problematic, with Kendell pointing out that this criterion is of dubious merit in physical disorder, let alone mental disorder. The scope of Szasz's erudition was broad but it did not encompass non-Western conceptualisations of mental disorder. Had it done so, the somewhat idiosyncratic nature of his argument would perhaps have become apparent to Szasz himself, for the criterion of physiological abnormality as a means of validating the existence of mental disorder is anathema to non-Western conceptualisations of mental illness.18-22 As such, Szasz could appeal neither to history nor to insights from cultural psychiatry or anthropology as a way of giving credibility to his argument.

Szasz's concerns about the medicalisation of emotional, behavioural and interpersonal problems remain relevant and psychiatrists' engagement with them would be warranted. Vigorous effort continues to be expended in shoehorning a range of human problems into the medical model and resulting over-diagnosis furthers the professional interests of psychiatrists and the pharmaceutical industry. Many contemporary writers10,12,13 share a concern for the societal impact of ever-greater number of psychiatric diagnoses and lowering of diagnostic thresholds for existing ones. However, there is a reality and suffering attached to mental illness, to psychological dysfunction, that Szasz's writings simply fail to acknowledge. In this respect, I fully agree with Lieberman: 'I think Szasz trivializes devastating malfunction - serious mental illness - by dismissing such patients as attention seekers, imposters, and so forth'.23 Admittedly, the language of histopathological lesions, of cellular pathology and infectious organisms has very little or no relevance to most psychiatric conditions, but to insist that problems with thought, emotions, drive, impulse control, cognition, perception, behaviour and so forth should be exempted from the rubric of illness, and the assertion that there is no such thing at all as psychopathology, seem entirely unjustified. Szasz might have attracted less opprobrium from psychiatrists and others had he acknowledged the reality of psychopathology and of mental illness while conceding that it does indeed have characteristics that set it apart from many - although not all - physical illnesses. These characteristics include phenomenological overlap with spiritual experience,24,25 diagnostic boundaries that are often much less well defined than in physical illness,12 boundaries that are subject to the influence of such factors as social context, and so forth. Such characteristics behove clinicians to conceptualise mental illness in different ways from physical illness, not to discard altogether the very concept.

Effort needs to be poured into formulating a conceptual definition of mental disorder12 that does justice to serious mental illness so that such bona fide psychiatric illnesses as schizophrenia and major depression and mere problems in living are not conflated with each other. This would be a far more humane path along which to proceed than following the highly flawed Szaszian strategy of jettisoning the concept of mental illness.

Psychiatric labels have undoubtedly been deployed in the service of a range of political agendas and Szasz was justified in bringing attention to such historical constructs as 'drapetomania' and 'sluggish schizophrenia',17 but his contention that contemporary psychiatric diagnoses represent nothing more than the labelling of those who are deviating from 'psychosocial, ethical, or legal norms'17 was overstated. This is not a description that resonates with me as a clinical psychiatrist and I doubt that I am alone in this regard. Psychiatrists, contrary to what Szasz appeared to suggest, do not make judgements about pathology on the basis of arbitrary, socially constructed notions of normalcy, conformity and deviance. This is not to say though that there is no concept of a normative reference point. There is, but it usually is assumed as being an approximation to the patient's previous (so-called premorbid) state of health or level of functioning, deviation from which has resulted in distress and/or concern from the patient or their significant others. This is quite a different scenario from the one conceived by Szasz which would appear to portray psychiatrists as playing some sort of role, as agents of social control or as 'social engineers'.3

On the issue of Szasz's views on personal responsibility and on his wholesale dismissal of the claim that individuals diagnosed with mental disorder could ever lack competence to make treatment decisions, I agree with Lieberman23 that while the default assumption on the part of physicians should be that patients retain competence, in some circumstances this assumption is proven to be false. In cases when a mentally disordered individual lacks decision-making competency psychiatric intervention may prevent them from harming themselves or others.

The specific question of Szasz's legacy became all the more salient following his death in 2012. Williams & Caplan,26 writing in The Lancet, credited Szasz with the increasing preoccupation among psychiatrists - especially in the latter part of the 20th century - with disease nosology and with the quest to elucidate biological substrates for mental illness. The justifiability of such attribution of credit in this respect and to this extent to Szasz is debatable since the pursuit of a putative biological basis for mental illness is likely to be explained, as Walter27 points out, by several converging streams of influence, recent as well as remote. They include the localationist imperatives that were advanced by Wernicke and Meynert at the end of the 19th century, the psycho-pharmacological breakthroughs of the mid-20th century, and the genetic studies of schizophrenia that soon followed. Williams & Caplan's argument, then, fails to convince. The more persuasive claim regarding his legacy is that which credits Szasz with engendering greater awareness around issues of psychiatric power.28 Today, there is growing disquiet about the fact that 'psychiatric talk' has come to be a sort of go-to discourse for an ever-widening range of human concerns.10,12,13 Undergirding that disquiet is cognizance of the fact that psychiatric power, as Breeding suggests,28 need not be overt to be pervasive. As a body of writings that can sensitise us to these important issues, I can think of none more compelling than Szasz's.

Footnotes

Declaration of interest None.

References

14. Whitaker R. Anatomy of An Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Broadway Books, 2010. [[ PubMed] Google Scholar]

22. Teuton J, Bentall R, Dowrick C. Conceptualizing psychosis in Uganda: the perspective of indigenous and religious healers. Transcult Psychiatry 2007; 44: 79-114. [[ PubMed] Google Scholar]

26. Williams AR, Caplan AL. Thomas Szasz: rebel with a questionable cause. Lancet 2012; 380: 1378-9. [[ PubMed] Google Scholar]

Articles from BJPsych Bulletin are provided here courtesy of Royal College of Psychiatrists

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No such thing as mental illness? Critical reflections on the major ideas and legacy of Thomas Szasz

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Enfant terrible of psychiatry and widely known as one of its most indefatigable as well as iconoclastic critics, Thomas Szasz (1961-2012) had a prolific writing career that extended some 51 years beyond the publication of his first book, The Myth ...

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Behavioral Outcomes in the Strong Black Woman

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Behavioral Outcomes in the Strong Black Woman

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Normalized Chaos: Black Feminism, Womanism, and the (Re) Definition of Trauma and Healing

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Normalized Chaos: Black Feminism, Womanism, and the (Re) Definition of Trauma and Healing

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1. Black women neglect self-care and self-love, especially concerning mental health.

2. Many Black women live chaotic lives but normalize their struggles as a way to cope.

3. The idea of "normalized chaos" is a way Black women downplay their pain and trauma.

4. Normalized chaos leads to harmful behaviors, making chaos seem normal.

5. Defense mechanisms are fueled by the belief in the Strong Black Woman/Superwoman, stigma around mental health in the Black community, and a limited understanding of trauma.

6. Black women are often diagnosed with dysthymia rather than major depressive disorder.  Dysthymia is a milder, but long-lasting form of depression.

7. Reporting depression symptoms can be difficult for some African American women due to the pressure of the Strong Black Woman persona.

8.  Black women normalize experiences that haven't been recognized as traumatic.

9. Despite experiencing traumatic events Black women do not recognize them as such.

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Normalized Chaos: Black Feminism, Womanism, and the (Re)definition of Trauma and Healing on JSTOR

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Shawn Arango Ricks, Normalized Chaos: Black Feminism, Womanism, and the (Re)definition of Trauma and Healing, Meridians, Vol. 16, No. 2, Speaking for Ourselves: Reclaiming, Redesigning, and Reimagining Research on Black Women's Health (2018), pp. 343-350

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Coping Behaviors & Barriers Seeking Mental Health Services

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Coping Behaviors & Barriers Seeking Mental Health Services

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Qual Health Res. Author manuscript; available in PMC 2010 Apr 14.

Published in final edited form as:

Abstract

Little is known about African American women's beliefs about mental illness. In this qualitative study we employed the Common Sense Model (CSM) to examine African American women's beliefs about mental illness, coping behaviors, barriers to treatment seeking, and variations in beliefs, coping, and barriers associated with aging. Fifteen community-dwelling African American women participated in individual interviews. Dimensional analysis, guided by the CSM, showed that participants believed general, culturally specific, and age-related factors can cause mental illness. They believed mental illness is chronic, with negative health outcomes. Participants endorsed the use of prayer and counseling as coping strategies, but were ambivalent about the use of medications. Treatment-seeking barriers included poor access to care, stigma, and lack of awareness of mental illness. Few age differences were found in beliefs, coping behaviors, and barriers. Practice and research implications are discussed.

Keywords: African Americans, coping and adaptation, dimensional analysis, mental health and illness, stigma, women's health

In 2000 there were 34.7 million African Americans in the United States, making up approximately 13% of the population ( U.S. Census Bureau, 2002). Unfortunately, almost 25%-or 7.5 million-African Americans have been diagnosed with a mental illness ( Davis, 2005). African American women might be overrepresented in this population as they are at a higher risk for developing mental illness. Risk factors include lower income, poor health, multiple role strain, and the "double minority status" of race and gender ( Neufeld, Harrison, Steward, & Hughes, 2008; Schneider, Hitlan, & Radhakrishnan, 2000). Older African American women might be at an additional risk because of the high prevalence of chronic disease in this population, and the demonstrated correlations between chronic disease and mental health issues such as depression ( Artinian, Washington, Flack, Hockman, & Jen, 2006; Centers for Disease Control and Prevention, 2004).

A national study conducted by the California Black Women's Health Project (2003) revealed that 60% of African American women experience symptoms of depression. Even so, the use of outpatient mental health services is lower for African American women compared to White women and African American men ( Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005; Mays, Caldwell, & Jackson, 1996; U.S. Department of Health and Human Services [DHHS], 2001). Another study examined treatment seeking among adult African American women with panic disorders, and found that only 13% sought treatment ( Neal-Barnett & Crowther, 2000). Low rates of service use also hold true for older African American women. Matthews and Hughes (2001) found African American women over age 50 were less likely to participate in therapy than those under age 50.

To date, little research has examined how individual beliefs and attitudes influence coping behaviors and treatment seeking specific to African American women ( Mays et al., 1996). Qualitative studies based on a comprehensive theoretical framework are virtually nonexistent and critically needed ( Moodley, 2000). To address this gap, we employed the Common Sense Model (CSM) to guide us as we queried African American women's beliefs about mental illness, their coping behaviors in response to mental illness, and the barriers to their seeking mental health services. We also examined whether beliefs and coping behaviors varied by age.

Literature Review

Attitudes and Beliefs About Mental Illness

Events like the Tuskegee Experiments ( Rusert, 2009) are hypothesized as contributing to many African Americans' negative attitudes about seeking health care services. For African Americans, sociopolitical history might play a large role in fostering cultural mistrust toward the United States health care system ( Whaley, 2001). Cultural mistrust is defined as "paranoia, in the form of mistrust, of whites due to past and present experiences with racism and oppression" ( Terrell & Terrell, 1981). High levels of cultural mistrust have been associated with mental illness stigma in the African American community. Stigmas are cues that elicit stereotypes about a particular social group ( Corrigan, 2000). These stereotypes are manifested in people's attitudinal responses to individuals with mental illness. A study conducted in the early 1980s found that African Americans held more negative attitudes toward individuals with mental illness compared to other racial and ethnic groups ( Silva de Crane & Spielberger, 1981). Research by Diala and colleagues (2000) found that attitudes have not changed: African Americans are still more likely than Whites to have shameful attitudes about friends who have sought help for a mental health problem. Furthermore, the shame about having a mental illness can result in treatment avoidance ( Alvidrez, 1999; Sirey et al., 2001).

Despite the growing body of literature on stigma and mental illness, little has addressed adult or older adult African American women's experiences. Most research tends to be gender neutral, meaning that specific information about each gender is not provided. In addition, current research has failed to examine the influence of stigma on attitudes about mental illness and treatment-seeking behaviors specific to African American women. Examination of stigma, mental illness, and treatment-seeking behaviors among older African American women is virtually nonexistent. These gaps in current research limit opportunities to develop culture-, gender-, and age-specific interventions to reduce stigma and increase treatment-seeking behaviors among young, middle-aged, and older African American women.

Coping With Mental Illness

Lazarus and Folkman (1984) defined coping as "the constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as stressful or exceeding the individual's resources." These efforts range from seeking professional help to ignoring the problem. The treatment-seeking literature suggests that African Americans tend to cope with mental health problems by using informal resources such as the church, family, friends, neighbors, and coworkers ( Matthews & Hughes, 2001). Jackson, Neighbors, and Gurin (1986) noted that African Americans sought services as a result of referrals by family members, and tended to seek treatment from ministers and physicians as opposed to mental health professionals. In a study conducted by Yick (2008), culturally diverse women who survived domestic violence used religion and spirituality to cope with the effects of abuse.

Use of informal coping mechanisms (family, friends, and church) is frequent among African American women ( Abrams, Dornig, & Curran, 2009). Alvidrez (1999) found that African American women, compared to White women, held stronger beliefs that family problems should not be discussed outside of the family. Neighbors, Musick, and Williams (1998) found that African American women were more likely to seek help from ministers; if a minister was contacted first, the likelihood of seeking help from other sources was decreased. Cultural beliefs appear to affect coping behaviors, as well. In particular, the stress and anxiety of maintaining an image reinforced by the cultural community can have deleterious effects on coping behaviors and health ( Neal-Barnett & Crowther, 2000), such as in the case of the cultural stereotype of the strong Black woman. Maintaining the image of the self-reliant Black woman might delay or hinder treatment seeking among African American women ( Matthews, Nelesen, & Dimsdale, 2005; Mays et al., 1996).

Although the research described above has provided insight into coping strategies used by African American women, and might explain why African American women evidence low mental health service use, most of these studies were conducted in the 1980s and 1990s, and thus the findings are dated. In addition, the samples in those studies did not include older African American women (65 years and older), thus providing no information about how older African American women cope with mental illness.

Barriers to Seeking Treatment for Mental Illness

Recent studies highlight many barriers that impede treatment seeking among African Americans. Cristancho and colleagues created a vulnerability model that outlined the interaction of two types of barriers: (a) system-level barriers-those that are created by systems designed to provide mental health service, and (b) individual-level barriers-how individuals view and experience their encounters with the system (interpersonal and intrapersonal; Cristancho, Garces, Peters, & Mueller, 2008; see also Neufeld et al., 2008). Among the barriers, stigma has been identified as the most significant ( DHHS, 2001) because it is both a system- and individual-level barrier. Other system-level barriers include access issues (inaccessible location, transportation problems, and lack of health insurance), availability of services (few opportunities for group counseling and in-home services), social issues (lack of child care), poor quality of care (limited access to culturally competent clinicians and case management), and cultural matching (few opportunities to work with racial and ethnic minority clinicians; Cristancho et al., 2008; Miranda et al., 2003; Tidwell, 2004).

Although the growing body of literature on systemic-level barriers makes a significant contribution, it fails to provide insight into whether other beliefs (individual level)-such as internalized stigma of mental illness, shame and embarrassment about mental illness, lack of knowledge of mental illness and cultural norms-might serve as barriers for African American women. Also, little research has assessed the individual-level barriers experienced by older African American women. For example, it is possible that the interaction between negative stereotypes of aging and the stigma of mental illness might exacerbate barriers for older African American women.

In sum, African Americans hold negative attitudes toward seeking mental health care. Stigma associated with mental illness and treatment seeking is prevalent among African Americans; they tend to cope with mental illness through informal support networks (family, friends, church leaders), and experience numerous barriers when seeking treatment. It is also important to note that most of the research in these areas is dated and does not address the specific issues of African American women in general, and older African American women in particular. To address these research gaps, a qualitative study using the Common Sense Model (CSM) seemed most appropriate. The CSM, which focuses on beliefs that are intrapersonal in nature, provides a theoretical framework to examine beliefs and coping behaviors from the perspective of African American women, thus giving value to their voices.

Theoretical Framework

Common Sense Model

The Common Sense Model (CSM) postulates that individuals use common sense beliefs to construct lay theories, called representations of health threats or illnesses. These representations are based on ideas, attitudes, and beliefs formed by experience, cultural traditions, formal education, and stories from family and friends ( Diefenbach & Leventhal, 1996; Donovan et al., 2007; Ward, 1993). Representations, or beliefs, guide the manner in which individuals cope with health threats and illnesses ( Petrie, Jago, & Devcich, 2007). The CSM has been used in studies involving chronic fatigue syndrome, myocardial infarction, diabetes mellitus, HIV/AIDS, and rheumatoid arthritis to examine perceptions of illness and how people cope ( Hagger & Orbell, 2003). More recently, use of the CSM has been extended to include mental illnesses such as schizophrenia, depression, and eating disorders ( Fortune, Smith, & Garvey, 2005; Holliday, Wall, Treasure, & Weinman, 2005; Lobban & Barrowclough, 2005). These studies have supported the relationships between illness representations and symptom reporting, treatment seeking, behavior change, and adherence to treatment ( MacInnes, 2005; Petrie et al., 2007).

The CSM incorporates seven key dimensions of illness representations: identity, cause, timeline, consequences, cure or controllability, illness coherence, and emotional representation. Identity focuses on beliefs about symptoms of an illness. Cause refers to beliefs about factors that cause the illness or are associated with illness onset. Timeline relates to beliefs about whether an illness is acute, chronic, or cyclic. Consequence refers to beliefs about the short- and long-term outcomes of the illness. Cure or controllability includes beliefs about the curability or controllability of the illness, and illness coherence involves the meaning of the illness to the individual. Finally, emotional representation refers to the emotional impact of and response to the illness.

Because of the manner in which representations are formed, illness representations might differ based on cultural background and age cohort. Furthermore, depending on the information source, the representations might or might not be medically accurate. Representations can influence how individuals cope with health threats; as a result, coping strategies are often employed in a manner consistent with the individual's representations of the illness. For example, it is possible that an African American woman who believes that living with psychological pain is commensurate with her role as a strong Black woman might not perceive her pain as a health threat or seek treatment. Also, among older African Americans, it is possible that depression might be dismissed as a normal part of aging because of negative stereotypes about aging.

To date, the CSM has not been used to study beliefs about mental illness in an African American population; however, its use with racial and ethnic minorities has been recommended ( Diefenbach & Leventhal, 1996). Moodley (2000), in particular, states that "research which investigates the representations/beliefs of subjective psychological distress from black and ethnic minority groups will not only provide conceptual and theoretical knowledge, but offer therapeutic strategies to support present practice and future research" (p. 2). Building on the literature reporting low rates of mental health service use and high prevalence of stigma in the African American community, the CSM can provide information about beliefs, attitudes, and coping behaviors, thus guiding the development of interventions tailored to this group. To this end, we examined the following research questions: (a) What are African American women's representations/beliefs about mental illness? (b) What are African American women's coping behaviors in response to mental illness? (c) What are the individual-level barriers (interpersonal and intrapersonal) to seeking mental health care among African American women? and (d) Are there age differences in representations, coping, and barriers among African American women?

Method

Study Design and Sample

Because this study is the first, to our knowledge, to use the CSM with an African American population, an exploratory descriptive qualitative design seemed most appropriate. Inclusion criteria for this study were intentionally broad to maximize recruitment. Recognizing that little research has focused on older African American women, and hypothesizing that beliefs, coping behaviors, and barriers might vary by age, we sought a sample of young, middle-aged, and older African American women. Thus, African American women aged 25 years and over were eligible for the study. In addition, these women were eligible regardless of history of mental illness, as we were interested in their beliefs rather than their lived experience with mental illness. Exclusion criteria included males and White, Latino, and Asian women.

Purposeful sampling procedures were used to recruit 15 African American women from three age groups (young, 25 to 45 years, n = 5; middle-aged, 46 to 65 years, n = 5; and older, 66 to 85 years, n = 5). Purposeful sampling allowed for inclusion of subgroups of women and comparisons among subgroups ( Creswell, 2007). The median level of education was two years of college or technical school. Annual income ranged from $0 to $50,000, with a median of $20,000 to $30,000. More than half of the participants described their socioeconomic status as middle class (55%). Only 14 participants reported marital status: 4 were married or living with a partner, 5 had never married, 3 were widowed, and 2 were divorced. The mean number of children was three. More than 50% of the sample reported that they had been diagnosed with a mental illness (young, n = 4; middle-aged, n = 2, and older, n = 2). The most commonly reported mental illness diagnosis was depression ( n = 8).

Procedures

African Americans historically have a low rate of participation in health research; thus several recruitment strategies were employed: (a) flyers were posted at community agencies including local African American churches, senior housing facilities, and community centers; (b) advertisements were published in a local African American magazine; (c) flyers were strategically posted around the local neighborhood and in businesses; and (d) meetings with pastors/leaders of local churches and directors of community agencies were set up to build community partnerships and promote the study. We also used a snowballing technique in which participants were encouraged to inform other women about the study.

The study was approved by the institutional review board (IRB) of a large university in the Midwestern United States. Written informed consent was waived; however, participants were given an information letter containing all of the elements of informed consent (i.e., purpose of the study, benefits, risks, confidentiality, the principal investigator's contact information, and IRB representative contact information). Participants gave only verbal consent, which reduced the possibility of linking participants to their data, thus further protecting confidentiality. To enhance comfort level and trust, participants were allowed to choose their interview location; some participants were interviewed in their home and others in the researcher's office. At the end of the interview, participants completed a brief demographic questionnaire, which took about 5 minutes. The demographic questionnaire queried participants' ages, marital status, level of education, socioeconomic status, and income. In addition, two questions asked participants if they ever had a mental illness and, if so, what they did about it. To aid responses, a list of the more prevalent mental illnesses and coping mechanisms were provided in a checklist format. After completion of the interview and demographic questionnaire participants were invited to participate in a debriefing session, which was designed to give them an opportunity to process any emotional reactions to the interview, concerns about their participation, and referrals for mental health counseling, if needed. Only 1 woman participated in the debriefing session.

Interviews

All women participated in a 60- to 75-minute, semistructured, face-to-face interview designed to elicit candid beliefs, attitudes, and opinions about the issues of inquiry. The interview questions (see Table 1 ) were based on the CSM and focused on the seven dimensions: identity/symptoms, cause, timeline, consequences, cure/controllability, illness coherence, and emotional representation. All interviews were recorded and transcribed by a trained transcriptionist.

Table 1

Question

Dimension of the Common Sense Model

What does "mental illness" mean to you?

Illness coherence

What do you think causes mental illness?

Cause

What do you think are some signs that suggest a person is experiencing a mental illness?

Identity/symptoms

What do you think happens to people with mental illness?

Consequences

How do you feel when you see someone with a mental illness?

Emotional representation

Do you think people with mental illness can get better?

Cure/control & timeline

What do you think can help people with mental illness?

Cure/control

If you had a friend or family member with a mental illness, what would you tell them to do about it?

Cure/control

The interviews were conducted by the principal investigator (the first author), an experienced researcher and licensed psychologist. The use of a single interviewer was employed to ensure adherence to the study protocol and to reduce bias attributable to interviewer variability. The interviewer was a Black female with 9 years of active involvement in the community in which the data were collected; these factors, which we believe facilitated entry into the participants' worlds, provided a deeper understanding of their perspectives ( Ward, 2005) and enhanced rapport and participant trust-all important issues when high levels of cultural mistrust might be present ( Hamilton et al., 2006).

Data Analysis

Using the CSM, the data were analyzed with the goal of identifying the seven conceptual dimensions consistent with the CSM. Dimensional analysis was employed, involving constant comparative analysis, with the goal of integrating the data to better understand "what all is involved here?" ( Schatzman, 1991, p. 310). The following analytic strategies were employed: line-by-line analysis of transcripts to facilitate open coding, memo writing, constant comparative analysis, saturation of emerging dimensions, and integration of the emerging dimensions ( Charmaz, 2000; Kools, McCarthy, Durham, & Robrecht, 1996; Schatzman, 1991).

Data analysis was conducted by a research team consisting of the first author, the second author (an advanced doctoral student in counseling psychology), and a doctoral student in nursing. Each team member was Black, female, and actively involved in the African American community for at least 5 years prior to working on this study. Each team member independently conducted open coding, then met as a team to address discrepancies in coding. Differences were resolved by consensus. Thereafter, the team met weekly to review memos, conduct constant comparative analysis, and integrate the data. Below is a description of the data analysis procedures.

Phase one was open coding, which involved identifying salient emerging dimensions, properties, and conditions. Salience was determined by language expression such as phrasing, repetition, and description of meaningful actions and events. Dimensions were based on the CSM (e.g., identity, cause, consequences, and so forth). Properties were descriptors of the dimensions (e.g., trauma, stress, or biology, as related to the cause dimension). Conditions influenced an action (e.g., barriers are a condition). Open coding was conducted by uploading the transcripts into NVivo, a qualitative computer software program that facilitates data coding, rapid retrieval and comparison of codes, and data management ( Richards, 2006).

Phase two was memo writing, which involved recording stages of the analysis. Memos were used to decipher and expand dimensions to identify properties and conditions, and also to identify interrelations among dimensions, properties, and conditions ( Charmaz, 2000; Glaser & Strauss, 1967). For example, one memo focused on the cause dimension and identified three properties/descriptors that participants believed caused mental illness: general, culturally specific, and age-related.

Phase three was constant comparative analysis. Dimensions identified in phases one and two were compared across individual participants to better understand the individual dimensions, as well as the similarities, differences, and interrelations among dimensions ( Bowers, 1989; Glaser & Strauss, 1967). In phase four, analysis continued until saturation, or the "point in which the researcher cannot discover new dimensions in the data being collected," was achieved ( Bowers, 1989, p.48). In phase five, the data were integrated by combining the dimensions, properties, and conditions into a whole in an effort to understand "what all is involved here" ( Schatzman, 1991, p. 310).

At analysis completion, the results section of the manuscript was given to two participants to conduct member checking ( Lincoln & Guba, 1985). These women were selected because they explicitly expressed an interest in maintaining a research-related relationship with the principal investigator, and offered to participate in future research opportunities; one was a middle-aged woman with some college education, and the second was a retired high school teacher. The two women were instructed to review the results, and both indicated that their experiences were accurately captured.

Results

The three subgroups of participants differed in education level, income, and mental health diagnoses. Participants in the young age group (25 to 45 years) were less educated, reported lower incomes, and had the highest average number of children. They were also more likely to report a history of a mental health diagnosis, the most prevalent being depression. Results are presented specific to each research question. The first question examined African American women's representations/beliefs about mental illness.

Identity

Three categories of symptoms (identity) were identified in the data: behavioral, emotional, and cognitive. Behavioral symptoms included irrational, bizarre, violent, and suicidal behaviors; sleep problems; and difficulty keeping a job. Emotional symptoms included excessive crying, extreme reactions to events and situations, emotional instability, and signs of depression and posttraumatic stress disorder. Cognitive problems were described as distorting reality, mental disturbance, and difficulty solving problems and making decisions. Below are three quotes illustrating participants' beliefs about symptoms of mental illness:

A lot of people get into real binds. I think their physical health suffers, I think their relationships with other people suffers. I think sometimes you find that those are the people who can't keep jobs, or have difficulty in jobs, or have problems with relationships. (Older woman)

And now, me being [age] and faced with depression for like three years now, it's totally different to me, because I'm doing irrational things, things that I can't control myself. Like, constantly crying, and I don't know why I'm crying, and waking up in the morning, just crying for no reason. (Young woman)

[One] who acts out either subconsciously, unconsciously, unintentionally ... actions and thoughts that are different from what the expected norm is. (Older woman)

Cause

Causes of mental illness were categorized as 3 types: general, culturally specific, and age related. Table 2 presents descriptors (properties) of general causal factors, which included trauma, stress, biology or genetics, alcohol and other drug abuse, social relationships, individual personality issues, environment, and triggers. The following quote illustrates participants' beliefs about general causal factors:

Table 2

General Causal Factors

Descriptors of the Causal Factors

Trauma

Childhood abuse, neglect, sexual abuse, loss of parent from death, divorce or separation

Stress

Work-related stress, financial stressors, general stress, and stress because of life events and situations

Biology

Genetics, heredity, and predisposition

Drugs

Use and abuse of alcohol and other drugs

Social relationships

Absent father, family problems, and peer pressure

Individual issues

Personality issues and low self-esteem

Environment

Neighborhood and home environment

Triggers

Past trauma, self-blaming, discrimination, and internalized racism

It's a wide range of causal issues. I think that some of it might be the simple stress of living, all the way to the extreme of perhaps some genetic defect, or some familial proclivity toward mental illness. Things like substance abuse, and even poor nutrition, I think, could cause mental illness. So I think there's a whole range of issues that can cause mental illness. (Middle-aged woman)

Culturally specific causes included social issues and psychological problems. Social issues included racism, discrimination, dual discrimination (race and gender), oppression, injustice, and daily stress and hassles related to being Black. Psychological problems were perceived as low self-esteem resulting from racism, dual discrimination, and historical oppression. The women's beliefs about culturally specific causes are captured in the following quotes:

I think probably for African Americans in general, it's the stress of living in a racist society. (Middle-aged woman)

But um, I think sometimes it [mental illness] happens with Black people who have been in um totally Black situations and then have to cope with a White situation. (Middle-aged woman)

It [mental illness] could also be from some of the issues that's in society, stereotypes, uh racial stereotypes and things like that. (Young woman)

There is a difference, I am quite sure. You have people in different communities, that's not African American that have, you know, centers where they can get help, those kind of services you know! And they are aware of them; they know where to go and how, you know, how to go about getting those services. (Young woman)

Women over 65 described two age-related causes of mental illness, illustrated in the following comment:

I've been busy and you're supposed to keep your mind busy, as well as your body, too. I'm sure there's a lot of retired people who don't do [anything]. They just stop working, they stop thinking, they stop learning, they stop everything. Then you have plenty of idle time to go into depression. (Older woman)

Timeline and Consequences

Participants believed mental illness is a chronic health problem with symptoms of a cyclical nature, and that it can result in negative consequences including behavioral problems, institutionalization (including inpatient care or incarceration), homelessness, cognitive problems, physical health problems, and stigmatization by society and the mental health system. Below are two quotes illustrating beliefs about chronicity and negative consequences:

From what I've seen, I think it can get better, but in the long term, I think they might not die from mental illness but they will still have it. They will still have those problems when they die. But I have not seen it that far, [but I] think that they can never overcome it. It will always be a struggle for them. (Middle-aged woman)

Coming from where I came from, that's what I saw: African American females as well as males being institutionalized, because when you don't know what's wrong with them, the simple thing to do with them is to lock them up. You just have a mental problem, let's treat them [but instead they] lock them up sometimes in jail. I believe there's a lot of people in prisons that need mental help! (Young woman)

Cure/Control

Participants believed mental illness can be controlled with treatment, specifically individual and group counseling. They were, however, ambivalent and apprehensive about the use of medication to control mental illness. In particular, the women believed that use of medication could result in negative health outcomes including over-medication, side effects, and addiction. The women's support of counseling and concerns about medication are captured in the following participant comments:

This doc [doctor], he don't understand, he just wanted to give them medication for this, he just want to give them medication for that.... When she really probably just needs support. When she probably needs a therapist, she probably needs a women's support group. (Young woman)

I've seen what medication for mental illness does to a person, and I don't think it makes them themselves, it appears to make them like zombies. It's like brain-washing, or that's what it seems like to me. That's why I don't care for it. (Middle-aged woman)

Illness Coherence and Emotional Representation

The women's understanding of mental illness (illness coherence) appeared to be influenced by their culture. They reported that Blacks are supposed to be strong. However, being strong was accomplished by denying mental illness and, at times, viewing mental illness as a normal part of life. The participants reported that they were able to recognize when someone else has a mental illness, and were emotionally affected when seeing other people with mental illness. They reported experiencing a range of emotions on seeing someone with visible signs of mental illness, including empathy, sadness, compassion, and a desire to help. Participants also reported experiencing conflicting emotions such as empathy and hope for the individual, while at the same time blaming the affected individual. Below are three quotes that highlight these issues:

Being African American, stubborn, "I don't need that. Those things don't happen to our people. We don't have any mental issues." That's just a given thing. I guess because we have to be so strong in everything else, they figure that we're not inclined to have nervous breakdowns, and things like that, which we do. I mean, it's a lot of people sitting at home having nervous breakdowns and don't even know what they had. (Young woman)

I never realized until I was in my late 20s that I did have mental problems. Because I always thought it was normal. Because I was raised around a bunch of what I thought were seemingly normal women. And I look at them now and they weren't so normal. (Young woman)

I just really feel sorry for them. I feel sorry for them, and then there's something in my heart that says, "Is there something I could do for this person?" I just really feel sorry for them. (Middle-aged woman)

In summary, these women held beliefs about symptoms (identity), causes, duration (timeline), consequences, and controllability of mental illness. In addition, their understanding (illness coherence) of mental illness appeared to be influenced by culture. They were also emotionally affected by mental illness (emotional representation).

Coping Responses to Mental Illness

Our second question examined African American women's coping behaviors in response to mental illness. The participants endorsed a range of coping responses such as seeking professional help; informal support from people in their support network or going to a community-oriented support group; religious coping, which involved talking to a pastor, praying, and reading their Bible; self-help such as reading, journaling, or having a positive attitude; and denial or avoidance of the problem. Women 65 years and older endorsed staying busy as a coping strategy, which involved regular exercise, volunteering, and staying physically and emotionally active. Following are quotes highlighting some of these coping responses:

I was never able to get professional help, so I had to fight my way through. It can be a good thing in a way, but for most people, it's not good because everybody needs help. If they don't get some type of help, anything could happen. They could hurt themselves in a lot of ways, like committing suicide, and that's what professional help is out there for-to prevent that from happening. So I advise anybody, if they have a problem that can elevate, get help right away. Don't wait until something bad happens, or something tragic happens. (Professional help; older woman)

For me, it has always been having women around to give me some perspective. Talking to them, and listening to them, even though I might not initially agree with them, but I need to have people around me that provide me that kind of input. (Informal support network; middle-aged woman)

I had gone through something that I thought that I would never be able to handle. And my coping mechanism was prayer. (Religious coping; older woman)

I do a journal and I look for three things at the end of my day: what is one thing I learned, if I helped somebody, and if something or somebody made me laugh. Those are the three important things for me. Also, a close family is important. It would be very important for my family to be there to help me through whatever the storm is. Yeah, family's important, and friends too. (Self-help; older woman)

Sometimes I just don't do anything about it, I just let it pass. Yeah it does pass, and you expect it to. It might take a couple of days, but it passes. (Denial or avoidance; middle-aged woman)

Yeah, I will call her an' say I'm coming over to work, you know. She's got blinds; I clean blinds you know; I vacuum down the drapes and stuff, you know.... So that's my therapy, you know. Basically, that's my psychiatrist. (Staying busy; older woman)

Barriers

The third question examined individual-level barriers (interpersonal and intrapersonal) to seeking mental health care among African American women. Both systemic- and individual-level barriers were identified in the data; however, individual-level barriers were more prevalent. The one systemic barrier identified was access, which included agency issues and socioeconomic issues. Individual barriers included lack of knowledge of where to seek mental health services, embarrassment about mental illness, negative cultural perception, discriminative actions toward people with mental illness, and lack of awareness-which included lack of education about mental illness and lack of knowledge of signs/symptoms of mental illness (see Table 3 ). The two quotes below capture participants' beliefs about systemic (access) and individual barriers (lack of education):

Table 3

Barriers

Descriptors

Systemic barriers

Agency

Agencies not located in the African American community

Access issues within the agency; "have to fight to get an appointment"

Poor quality of care and culturally incompetent clinicians, which increases the risk of misdiagnosis

Government unwilling to make genuine commitment to mental illness

Socioeconomic status

Cannot afford cost of services/no health insurance

Poverty

Low education

Housing issues

Unemployment

Individual barriers

Knowledge of services

Don't know where to go

Perception that the right kind of help (culturally sensitive) is not available

Embarrassment

Embarrassment about mental illness, seeking professional help, and taking medication for a mental illness

Cultural perception

Mental illness does not happen to African Americans

You can "handle it" on your own

"Strong woman syndrome"

Silence and family secrets; "what happens in the family, stays in the family"

Discrimination

Feeling singled out and isolated

You know when someone has a mental illness by the "the look"

Stigmatizing attitude and discrimination

Lack of awareness about mental illness

Lack of education about mental illness

Do not know signs, symptoms, and what type of treatment to seek

A lot depends on if you're able to have access to treatment and if you're able to have access to early treatment; so, again, it gets back to the whole poverty issue. A lot of the systems that are set up in poor neighborhoods are overstretched; they don't have adequate resources. And so people can't go to get support. And, even for a lot of working people, their insurance covers "x" number of visits and if you have to go beyond that, you pay out of pocket. A lot of people simply don't have that ability to pay. (Older woman)

The answer is education. A person may be aware that they have diabetes; a person may be aware they have heart disease. We spend a lot more time talking about heart disease and diabetes and cancer and this kind of thing. In our society we don't spend a lot of time talking about mental illness. (Middle-aged woman)

Age Variations

The fourth question explored age differences in representations, coping, and barriers among African American women. First, we examined age differences in representations. Of the seven dimensions of the CSM, cause was the only dimension in which age differences were observed. Compared to young and middle-aged women, women over 65 years of age believed that inactivity during retirement could lead to mental illness (see the quote immediately preceding "Timeline and Consequences", p. 7).

Second, we examined age differences in coping. Women in the over-65 age group were the only participants to endorse exercise, physical activity, volunteering, and ongoing activity as important to coping. Below is a quote describing the older women's belief about exercise as a coping strategy:

So exercise is good for mentally ill people. They hurt and hurt and hurt, even with medication they still hurt. 'Cause that's the way I do mine; it works for me. There are different things for different people, I know that you know. But exercise would be good. (Older woman)

Thus, older women believed staying active and engaged were protective. No age differences were found pertaining to barriers.

Discussion

To our knowledge, this study is the first to use qualitative methodology combined with the Common Sense Model (CSM) theoretical framework to comprehensively examine African American women's beliefs about mental illness, coping behaviors in response to mental illness, and barriers to seeking treatment. Use of the CSM helped to illuminate underlying beliefs of participants. The findings from the present study provide a framework to better understand this group's conceptualization of mental illness, their coping mechanisms, and how stigma and other barriers affect treatment-seeking behaviors.

Beliefs About Mental Illness

The women believed that culturally specific factors (racism, discrimination, and oppression) can lead to depression. This supports an earlier study conducted by Ward and Heidrich (in press). Ward and Heidrich used an exploratory descriptive study to examine beliefs about mental illness among 185 African American women. Study results indicated that participants believed racism and discrimination cause depression. Several other investigators have supported these findings, as well ( Cain & Kington, 2003; Williams & Williams-Morris, 2000).

The participants accurately identified consequences of mental illness; however, all consequences were negative and quite severe. Of particular concern is the belief that African Americans with mental illness are often hospitalized or sent to jail. Recent statistics from Wisconsin, the site of this study, supported these women's belief. In particular, recent research indicates significant disparities between African Americans and Whites in rates of hospitalization for mental illness. For instance, African American women receive inpatient care for bipolar disorder at a rate of 122 per 100,000 persons, compared to 44 per 100,000 for White women ( Wisconsin Minority Health Program, 2004). Rates of incarceration among African Americans and Whites in Wisconsin are also disparate. Although African Americans make up only 6% of the population, they account for 48% of the prisoners in Wisconsin ( Wilayto, 2000).

The women's beliefs about the identity or symptoms associated with mental illness and the course of the illness (timeline) were accurate and consistent with the Diagnostic and Statistical Manual of Mental Disorders ( American Psychiatric Association, 2001). However, some women reported a lack of awareness and, at times, denial of the existence of mental illness in the African American community, possibly influenced by cultural beliefs that Blacks are supposed to be strong or that mental illness is normal in the African American community. These beliefs could be related to the mental illness stigma in the African American community.

The women believed that mental illness can be treated with counseling (individual or group), yet, mainly because of side effects, they expressed ambivalence toward medication use. Their concern is supported by a recent study in which it was found that African Americans were more likely to be prescribed older, less tolerable, and less safe tricyclic antidepressants than Whites, who were significantly more likely to receive newer, safer, and more tolerable serotonin reuptake inhibitors (SSRIs) for depression ( Melfi, Croghan, Hanna, & Robinson, 2000). Whether because of fear of side effects, insurance status, or mistrust in the health care organization, African Americans are less likely to fill prescriptions for antidepressant medications. A study by Ray, Hall, and Meador (2007) found that only 29% of African Americans fill a prescription, compared to 51% of Whites.

Coping Responses

The women endorsed a range of coping behaviors, including seeking professional help, using informal support networks, prayer, and avoidance. It is possible that the sole use of informal support networks or religious coping can result in adverse consequences, as they tend to delay treatment seeking. Consistent with previous research, the women preferred counseling to medication ( Dwight-Johnson, Sherbourne, Liao, & Wells, 2001).

Barriers

Our finding of the perceived systemic barrier to treatment (access) is consistent with current research ( DHHS, 2001). In particular, issues of access such as lack of health insurance, availability of services, and quality of care were underscored in the former Surgeon General's report addressing disparities in access to mental health care and the poor quality of care received by racial and ethnic minorities ( DHHS, 2001). Using the CSM, most of the barriers identified appeared to be individual-level issues such as a lack of knowledge of where to seek mental health services, embarrassment about mental illness, normalizing mental illness, and discriminative actions toward people with mental illness. Further research on the individual-level barriers identified in this study is needed, with the goal of developing appropriate educational interventions.

Age Variation

Few age variations were found. Compared to young and middle-aged women, older women believed that inactivity during retirement could lead to mental illness, and that staying busy through regular exercise, physical activity, and volunteer work was an important coping strategy. A growing body of research suggests a positive link between physical activity and mental health among older individuals; those who are physically active show significant improvements in reasoning, working memory, reaction time ( Clarkson-Smith & Hartley, 1989), postural control, reduced incidence of falls ( Day et al., 2002), cognitive resilience ( Hogan, 2005), and quality of life ( Fontane, 1996).

Limitations and Implications for Future Research and Practice

The subsample within each group was small ( n = 5), which might have reduced the possibility of identifying more age variations. Future research could expand the sample among young, middle-aged, and older participants to further examine age variations in beliefs, coping, and barriers to treatment seeking. The theoretical framework, the Common Sense Model, guided our interview questions and data analysis, and helped to illuminate underlying beliefs. Future research could combine the CSM with more general questions querying additional beliefs about mental illness and individual-level barriers. Based on our findings, research is needed to develop and evaluate effectiveness of interventions designed to increase awareness and treatment seeking while reducing stigma. Examples of such interventions are outreach programs/interventions using a psychoeducation format designed to educate individuals about mental illness, treatment options, and community resources that also address the misconceptions and stigma associated with mental illness and seeking treatment for mental illness. Such interventions and clinical intervention research could make a significant contribution to increasing treatment-seeking behaviors while reducing disparities in mental health and mental health care for this group.

Conclusion

As noted previously, we believe this study is the first to use qualitative methodology combined with the Common Sense Model theoretical framework to comprehensively examine African American women's beliefs about mental illness, coping behaviors in response to mental illness, and barriers to seeking treatment. Use of the CSM helped to illuminate participants' underlying beliefs. The findings provide a framework to better understand this group's conceptualization of mental illness, their coping mechanisms, and how stigma and other barriers affect treatment-seeking behaviors. Furthermore, these findings can serve to inform future research and the development of interventions designed to increase awareness of mental illness while reducing stigma, increase treatment-seeking behaviors, and increase the use of appropriate coping behaviors. These findings can also inform research and development of interventions for older African Americans women, with a focus on physical activity and mental health.

Acknowledgments

We are grateful to the participants of this study and the community elders who endorsed the study. A special thanks to Linda Baier, Doriane Besson, Jorna Cychosz, Tola Ewers, and Ernise Williams for their constructive feedback on the manuscript.

Funding: The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This research was funded in part by an NIH Roadmap Grant, K12HD049077, and the UW Center for Women's Health Research.

Biographies

Earlise C. Ward, PhD, LP, is an assistant professor at the University of Wisconsin-Madison School of Nursing in Madison, Wisconsin, USA.

Le Ondra Clark, MS, is a doctoral candidate in the University of Wisconsin-Madison Department of Counseling Psychology in Madison, Wisconsin, USA.

Susan Heidrich, PhD, RN, is the Helen Denne Schulte Professor of Nursing at the University of Wisconsin-Madison School of Nursing in Madison, Wisconsin, USA.

References

California Black Women's Health Project. Healing for the mind, body & soul. News notes from California Black women's health project. 2003. Retrieved May 15, 2005, from http://oldsite.cabwhp.org/pdf/oct2003.pdf.

Centers for Disease Control and Prevention. The burden of chronic diseases and their risk factors: National and state. 2004. Retrieved August 25, 2006, from http://www.cdc.gov/nccdphp/burdenbook2004/pdf/burden_book2004.pdf.

Davis K. Decreasing discrimination and stigma associated with mental illness in the African American community. 2005. Retrieved May 15, 2005, from http://promoteacceptance.samhsa.gov/update/archive/march2005.aspx.

U.S. Census Bureau. Census 2000 profile. 2002. Retrieved April 27, 2009, from http://www.census.gov/prod/2002pubs/c2kprof00-us.pdf.

Ward EC, Heidrich SM. African American women: Beliefs about mental illness, perceived stigma, and coping behaviors. Research in Nursing and Health in press. [[PMC free article] [PubMed] Google Scholar]

Wilayto P. Wisconsin's exploding prison population: The Bradley connection. Money, Education and Prisons. 2000. Retrieved November 13, 2007, from http://www.mediatransparency.org/story.php?storyID=50.

Wisconsin Minority Health Program. Minority health report: The health of racial and ethnic populations in Wisconsin: 1996-2000. 2004. Retrieved November 12, 2007, from http://dhs.wisconsin.gov/Health/MinorityHealth/Report.htm.

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African American Women's Beliefs, Coping Behaviors, and Barriers to Seeking Mental Health Services

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Little is known about African American women's beliefs about mental illness. In this qualitative study we employed the Common Sense Model (CSM) to examine African American women's beliefs about mental illness, coping behaviors, barriers to treatment seeking, ...

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Understanding Psychological Distress Among Black Women

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Understanding Psychological Distress Among Black Women

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Ethn Health. Author manuscript; available in PMC 2022 Nov 1.

Published in final edited form as:

Joi-Sheree' Knighton, Ph.D., Licensed Psychologist, ¹ Jardin Dogan, M.Ed., Ed.S., Doctoral Candidate, ² Candice Crowell, Ph.D., Assistant Professor, ² and Danelle Stevens-Watkins, Ph.D., Associate Professor ²

Abstract

Objective:

Current racial mental health disparities among African American women have been attributed to chronic experiences of race-related stressors. Increased exposure to racism in predominately White spaces may increase reliance on culturally normative coping mechanisms. The objective of this study was to investigate the relationship between psychological distress, perceived racial microaggressions, and an obligation to show strength/suppress emotions among educated, middle-class African American women.

Design:

A sample of 243 African American women aged 19-72 years ( M = 39.49 years) participated in an online study. Participants completed self-report measures of psychological distress (PHQ-8 and GAD-7), racial microaggressions (IMABI), and modified items from the Stereotypical Roles for Black Women (SRBWS) to assess an obligation to display strength/suppress emotions. Factor analyses were conducted to assess the reliability of the obligation to show strength/suppress emotions subscale in our sample. Descriptive statistics, multiple linear regression, and mediation analyses were also conducted to examine variable associations.

Results:

Statistical analyses revealed educated, middle-class African American women who endorse an obligation to show strength/suppress emotions with perceived racial microaggressions experienced increased psychological distress.

Conclusion:

Obligation to show strength/suppress emotion may increase risk for psychological distress among African American women who perceive racial microaggressions. Future research and clinical implications are discussed.

Keywords: African American women, middle-class, Superwoman Schema, racial microaggressions, psychological distress

1.0. Introduction

Recent research provides mixed findings regarding the prevalence and rates of mental health symptoms among African American women. For example, scholars suggest African American women have lower odds of every mental health disorder except posttraumatic stress disorder (PTSD) compared to White women ( Erving, Thomas, & Frazier, 2019). On the contrary, other scholars suggest African American women experience poorer psychological outcomes than their White counterparts ( Allen et al., 2019). For example, population-based statistics indicate African American women disproportionately report psychological distress such as sadness (5.3% vs. 3.3%), hopelessness (7.1% vs. 5.5%), and worthlessness (4.6% vs. 4.7%) when compared to women of other racial/ethnic groups ( CDC, 2019). These conflicting numbers have been attributed to underreporting among African American women due to stigma of appearing weak ( Woods-Giscombé et al., 2016).

In addition to race and gender, socioeconomic class can influence African American women's reports of mental health problems. Higher percentages of mental health concerns are present among women with postsecondary degrees ( SAMHSA, 2018). Educational and financial resources do not always absolve mental health concerns among African American women as they encounter societal, career, and cultural pressures to achieve success, which can lead to psychological distress ( Woods-Giscombé, 2010). Scholars purport one of the reasons African American women report higher psychological distress is their increased exposure to racism in predominantly White spaces ( Ashley, 2014; Walton & Boone, 2019; Woods-Giscombé & Lobel, 2008). Yet, middle-class African American women who frequently encounter race-related stressors, such as racial microaggressions, stereotype threat, and tokenism are overlooked in existing research ( Allen et al., 2019; Walton & Boone, 2019).

Among middle-class African American women, their intersectional identities of race, gender, and class influences their lived experiences. The Superwoman Schema has been presented as a cultural norm for mitigating stressors associated with their multiple marginalized identities ( Abrams, Maxwell, Pope, & Belgrave, 2014; Liao, Wei, & Yin, 2019; Watson-Singleton, 2017; Woods-Giscombé, 2010). However, a recent study suggests endorsement of the Superwoman Schema can produce negative psychological outcomes ( Liao, Wei, & Yin, 2019). Limited research has examined the influence of Superwoman Schema on the mental health of African American women when responding to chronic racial microaggressions. Using a culturally specific framework, the purpose of this study is to examine the relationship between perceived racial microaggressions, an obligation to show strength/suppress emotion, and symptoms of psychological distress among a sample of middle-class African American women. Findings from this study will inform recommendations for clinical interventions with this understudied group.

1.1. Racial microaggressions and African American women

Racism continues to plague African Americans despite proclamations of a post-racial society ( Bonilla-Silva, 2015). An ideology of presumed superiority of the White race is often perpetuated through individual and institutional-level practices ( Golash-Boza, 2016). Microaggressions are examples of individual-level racism and are broadly defined as unintentional, yet derogatory slights directed towards African Americans ( Sue, 2010). Racial microaggressions are based upon underlying stereotypes about African Americans such as differences in cultural norms, intelligence, work ethic, and criminality ( Lewis, Mendenhall, Harwood, & Huntt, 2016). Gender differences influence how African Americans experience and contend with racial microaggressions. The added burden of racism produces consequences for African American women such that they report disproportionate rates of psychological distress compared to African American men ( Donovan, Galban, Grace, Bennett, & Felicie, 2013).

Existing research indicates African American women with higher levels of education and incomes may be particularly at risk for encountering racial microaggressions ( Holder, Jackson, & Ponterotto, 2015). African American women are the racial minority in predominantly White professional spaces due to social stratification based on education and SES ( West, 2019). Further, given African American women's continued quest to earn higher education ( U.S. Department of Education, 2019) and achieve workplace mobility ( Bureau of Labor Statistics, 2017), it is likely many will continue to encounter predominantly White and racially invalidating spaces. Frequent encounters of racial microaggressions exhaust cognitive resources ( Sue, 2010) and often result in psychological distress ( Nadal, Griffin, Wong, Hamit, & Rasmus, 2014). However, the unique ways in which middle-class African American women cope with the psychological impact of racial microaggressions may be overshadowed in studies sampling their lower-SES counterparts.

1.2. Racial microaggressions and mental health among African American women

African American women encounter biased racial and gender stereotypes, and subsequent unfair treatment as a function of their intersecting race and gender identities ( Thomas, Witherspoon, & Speight, 2004). Internalization of such stereotypes can be harmful to one's mental health ( Waldron, 2019). Hence, exposure to racial microaggressions fueled by racism has been positively associated with psychological distress among African American women ( Donovan, Galban, Grace, Bennett, & Felicie, 2013; Williams, Kanter & Ching, 2018; Williams & Lewis, 2019). For example, a study examining stressors among African American women found experiencing racial micro- and macroaggressions significantly predicted their depressive and anxiety symptoms ( Donovan et al., 2013). Although depression and anxiety tend to be parsed for appropriate diagnosis and treatment planning, they are often indicators of psychological distress that together have a major impact on one's health ( Assari, Dejman, & Neighbors, 2016).

To understand how middle-class African American women combat the effects of racial microaggressions, extant literature has explored coping and resilience strategies among this population ( Holder, Jackson, & Ponterotto, 2015; Williams & Lewis, 2019). For example, a sample of educated African American women qualitatively described being "superwoman" as a self-protective strategy against racial microaggressions (Lewis, Mendenhall, Harwood, & Huntt, 2013). Further, African American women who worked in corporate settings noted a need to develop an "armor" of protection to deal with racial microaggressions ( Holder, Jackson, & Ponterotto, 2015). Since racism elicits strong emotional reactions, this self-protective shield likely entailed portraying strength and suppressing emotions in response to microaggressions in the workplace. Displaying strength and suppressing emotions are common responses among African American women because they are culturally learned ways to organize, understand, and react to racism in a predominantly White society ( Beauboeuf-Lafontant, 2003).

1.3. Superwoman Schema: Cultural framework for coping with racial microaggressions

The conceptualization of African American women's behavioral and affective responses to perceived racial microaggressions warrants exploration of Beauboeuf-LaFontant's (2003) research on the culturally defined construct of strength. Historically, the concept of strength was derived in part due to the fortitude exhibited by African American women to withstand the emotional, psychological, and physical atrocities committed against them during slavery ( Beauboeuf-Lafontant, 2003). During the post-slavery era, African American women were praised for their strength and ability to assume multiple roles, be the backbone of their respective communities, breadwinner in the household, provide for their families, and ensure family survival ( Beauboeuf-Lafontant, 2003).

The construct of strength is interwoven into a culturally valued norm, known as the Superwoman schema ( Woods-Giscombé, 2010). The Superwoman schema is operationally defined as an African American woman who constantly suppresses emotion in response to personal stressors to attend to the emotional needs of others and effectively manage multiple roles ( Woods-Giscombé, 2010). Natural emotional responses such as sadness and worry are perceived as 'weaknesses' and threats to individual strength ( Collins, 2005). Subsequently, African American women may be more likely to exude strength even during times of extraordinary stress. Incidents of racial microaggressions may be endured with significant poise and pride in an effort to conceal distressing emotions and/or perceived weaknesses.

The ability to show strength and suppress emotions are two commonly endorsed ways African American women manage daily race-related stressors. For instance, Woods-Giscombé (2010) engaged a community-based sample of 48 African American women to assess attitudes about stress, coping strategies, and the concept of strength. The women revealed displaying strength and suppression of emotion were culturally valued ways of concealing strong emotions or signs of 'weakness.' Despite these attempts, however, many of the participants endorsed symptoms of depression and anxiety, including: "nervous breakdowns," feeling overwhelmed, racing thoughts, difficulty concentrating, and hopelessness ( Woods-Giscombé, 2010; p. 15). These findings suggest obligations to show strength and suppress emotion may overlap in many ways and may not represent separate constructs. Instead, both constructs are likely to capture an intertwined culturally valued norm associated with ways in which African American women manage multiple roles while simultaneously managing race-related stressors.

The findings from the study also revealed even as a widely endorsed coping strategy, an obligation to show strength/suppress emotions may be psychologically maladaptive for African American women. Scholars have separately examined the deleterious impact of racial microaggressions on the mental health of African American women ( Moody & Lewis, 2019; Williams & Lewis, 2019) and poor mental health outcomes resulting from endorsing Superwoman Schema among African American women ( Liao, Wei, & Yin, 2019). Our study seeks to bridge this discussion by investigating an obligation to show strength/suppress emotions as a potential mediator between racial microaggressions and psychological distress among highly educated African American women. Although Allen and colleagues (2019) posit displaying strength and suppressing emotions in response to racial discrimination is generally protective for African American women's physical health, encounters with race-related stressors, particularly in the workplace, have a stronger impact on one's mental health ( Erving, Satcher, & Chen, 2020). We argue endorsing Superwoman Schema while facing pervasive racial microaggressions may explain the high prevalence of psychological distress among this population. Addressing this norm as a mediating variable can provide implications for coping with microaggressions that occur in predominantly White spaces of work, school, and social settings.

2.0. Methods

2.1. Study sample

The sample in the current study consisted of 243 African American women who volunteered to participate in an online study examining health-related outcomes from March to May 2013. Study recruitment procedures included posting advertisements to professional email listings, social media websites, email solicitations to Historically Black Colleges and Universities (HBCUs), and dissemination of fliers on colleges and universities in a southern state. A snowball sampling procedure was also used to encourage participants to refer friends and relatives to participate in the study. Interested participants were asked to complete a 15-minute survey via QuestionPro.com. Eligible participants were at least 18 years of age and self-identified as Black or African American. The study was approved by the Institutional Review Board and participants were offered an opportunity to enter a drawing to receive one of three $50 Amazon gift cards. Overall, the African American women reported an average age of 39.49 years, a mean of 17.16 years of education (12 years equals a high school diploma or equivalent), no current partner (57%), full-time employment (75%), and a median annual income of approximately $63,000. The women in the sample were considered highly educated because on average, participants had acquired post-baccalaureate/graduate level training or its equivalent. Descriptive statistics of the sample are presented in Table 5 .

2.2. Measures

Control Variables.

The control variables in this study were age, years of education, partner status, and employment status (see Table 5 ). Participants were asked "How old are you?" to assess age. Years of education were calculated using the following question: "How many years of education have you completed?" The participants were asked, "What is your marital status?" to determine partner status. Partner status was re-coded from 1 = single/never married, 2 = married/cohabitating, and 3 = divorced/separated/widowed to 1 = current partner or 0 = no current partner. The women were prompted to "check one (or more) that apply to you?" and select from the following options: 1 = employed full-time, 2 = employed part-time, or 3 = unemployed/don't work. Employment was dummy coded whereas full-time employment was the reference category comparing it to part-time and unemployment. Independent variables were perceived racial microaggressions and an obligation to show strength/suppress emotions.

Psychological Distress.

Symptoms of psychological distress were analyzed using items from the Patient Health Questionnaire 8-item (PHQ-8; Kroenke, Spitzer, & Williams, 2001; see Table 1 ) and the Generalized Anxiety Disorder-7 item (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006; see Table 2 ). Depressive symptoms were measured with the research version of the PHQ-8 ( Kroenke et al., 2001). The questions are based on criteria for major depressive disorder derived from the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR; APA, 2000). Participants were asked how often in the last two weeks they were bothered by depressive symptoms. Responses are rated on a 4-point Likert scale ranging from 0 = not at all to 3 = nearly every day. Anxiety symptoms were measured with the GAD-7 ( Spitzer et al. 2006). The items are derived from criteria outlined in the DSM-IV-TR ( APA, 2000) and used to screen or assess generalized anxiety. Participants were asked how often in the last two weeks they were bothered by anxiety symptoms. Responses are rated on a 4-point Likert scale ranging from 0 = not at all to 3 = nearly every day.

Table 1.

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Little interest in doing things.

2. Feeling down, depressed, or hopeless.

3. Trouble falling asleep, staying sleep, or sleeping too much.

4. Feeling tired or having little energy.

5. Poor appetite or overeating.

6. Feeling bad about yourself-or that you're failure or have let yourself or your family down.

7. Trouble concentrating on things, such as reading the newspaper or watching television.

8. Moving or speaking so slowly that other people have noticed. Or the opposite- being so fidgety or restless you have been moving around a lot more than usual.

Table 2.

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge.

2. Not being able to sleep or control worrying.

3. Worrying too much about different things.

4. Trouble relaxing.

5. Being so restless it is hard to sit still.

6. Becoming easily annoyed or irritable.

7. Feeling afraid as if something awful might happen.

Items on the PHQ-8 and GAD-7 were moderately positively skewed and transformed to the square root for data analyses ( Tabachnick & Fidell, 2007). The results also revealed depressive and anxiety symptoms were correlated ( r = .753, p < .001). Thus, depression and anxiety symptoms were combined to create the psychological distress scale. Higher scores of psychological distress suggests comorbid symptoms and impairment associated with major depression and generalized anxiety. The total score ranges from 0 to 9.27 ( M = 3.98; SD = 2.10) (see Table 5 ). The Cronbach's alpha for the psychological distress scale was 0.86.

Racial Microaggressions.

The Inventory of Microaggressions against Black Individuals (IMABI; Mercer, Zeiger-Hill, Wallace, & Hayes, 2011; see Table 3 ) consisted of a 14-item instrument to measure the independent variable of experiences of racial microaggressions. Participants were asked in the last year, how often they experienced incidents of racial microaggressions and how much they were upset by the experiences. Sample items include: "I was made to feel that my achievements were primarily due to preferential treatment based on my racial/ethnic background", "Someone reacted negatively to the way I dress because of my racial/ethnic background", and "When successful, I felt like people were surprised that someone of my racial/ethnic background could succeed." Responses are rated on a 5-point Likert scale ranging from 0 = this has never happened to me to 4 = this event happened to me and I was extremely upset. The Cronbach's alpha was 0.89, and summed item responses ranged from 0.00 to 49.00 ( M = 15.48, SD = 11.33). Higher scores are indicative of greater distress related to perceived racial microaggressions (see Table 5 ). The IMABI has been validated through exploratory and confirmatory factor analyses and item response theory analysis in previous research ( Mercer, Zeiger-Hill, Wallace, & Hayes, 2011).

Table 3.

1. I was made to feel that my achievements were primarily due to preferential treatment based on my racial/ethnic background.

2. I was treated like I was of inferior status because of my racial/ethnic background.

3. I was treated as if I was a potential criminal because of my racial/ethnic background.

4. I was made to feel as if the cultural values of another race/ethnic group were better than my own.

5. Someone told me that I am not like other people of my racial/ethnic background.

6. Someone made a statement to me that they are not racist or prejudiced because they have friends from different racial/ethnic backgrounds.

7. I was made to feel like I was talking too much about my racial/ethnic background.

8. When successful, I felt like people were surprised that someone of my racial/ethnic background could succeed.

9. Someone assumed I was a service worker or laborer because of my race/ethnicity.

10. I was followed in a store due to my race/ethnicity.

11. Someone reacted negatively to the way I dress because of my racial/ethnic background.

12. Someone asked my opinion as a representative of my race/ethnicity.

13. Someone told me that they are not racist or prejudiced even though their behavior suggests that they might be.

14. Someone told me that everyone can get ahead if they work hard when I described a difficulty related to my racial/ethnic background.

Obligation to Show Strength/Suppress Emotions.

Participants were administered items from the Stereotypic Roles for Black Women Scale (SRBWS; Thomas, Witherspoon, & Speight, 2004) that were modified based on the Superwoman Schema conceptual framework ( Woods-Giscombé, 2010). For example, an item from the SRBWS, "I tell others that I am fine when I am depressed or down" was modified to "I tell others that I am fine when I am depressed or anxious" (see Table 4 ). A principal component analysis (PCA) and varimax rotation (DeVellis, 2012) were conducted to determine latent variables associated with Superwoman schema and identify clusters of items consistent with the hypothesized construct, obligation to show strength and suppress emotions.

Table 4.

Factor Loadings

1. I find it difficult to ask others for help.

.633

2. It is difficult for me to tell other people my problems.

.607

3. I do not want others to know if I experience a problem.

.564

4. I do not expect nurturing from others.

.601

5. I feel that I need to push my emotions down.

.586

6. I tell others that I am fine when I am depressed or anxious.

.593

7. It is difficult for me to share problems with others.

.608

8. I cannot let others see me cry.

.640

9. It is difficult for me to turn to others when I need help.

.706

10. When I have limited resources (ex. Money, friends, food), I am willing to ask others for help.*

.648

A recent study examining the psychometrics of the SWS revealed the questionnaire contained five subscales. Obligation to show strength (α=.70) and suppress emotions (α=.85) loaded onto separate constructs ( Woods-Giscombé et al., 2019). In the current study, a factor analyses revealed 10 items theoretically consistent with obligation to show strength and suppress emotions overlap among our sample of higher educated African American women ( Table 4 ). A subscale hereinafter referenced as obligation to show strength/suppress emotions was created. Participants were asked to rate agreement with attitudes African American women hold about themselves and their environment. Other sample items include: "I find it difficult to ask others for help," "I feel that I need to push my emotions down", and "I cannot let others see me cry." Responses are rated on a 4-point Likert scale ranging from 1 = strongly agree to 4 = s trongly disagree. Internal consistency of the items was assessed using reliability analysis. The Cronbach's alpha was 0.88, and summed item responses ranged 10.00 to 40.00 ( M = 26.67, SD = 5.74). Negatively worded items were reverse scored. Higher scores indicate greater identification with an obligation to show strength/suppress emotions.

Pearson correlation coefficients were calculated to examine the associations between continuous variables. Point-biserial correlation coefficients were calculated to examine associations between dichotomous and continuous variables. The control and independent variables significantly correlated with the dependent variables at the bivariate level were retained for further analyses. Linear regression analyses were conducted to examine the proportion of variance racial microaggressions and obligation to show strength/suppress emotions accounted for while measuring psychological distress. Control variables significant at the bivariate level were entered first, perceived racial microaggressions were entered second, and obligation to show strength/suppress emotions were entered third. Variables significant at the p level of ≤ .05 were displayed at each step and interpreted in the final model. Tolerance and variance inflation statistics did not indicate multicollinearity among the study variables. List-wise deletion was used to account for missing data, resulting in a final sample of 227 participants.

To analyze potential mediation effects, the bootstrap method ( Preacher & Hayes, 2004) was utilized to estimate indirect effects of an obligation to show strength/suppress emotions as a mediator between racial microaggressions and psychological distress. The bootstrapping method has been deemed more powerful than the three-step multiple regression approach ( Baron & Kenny, 1986) and Sobel test ( Sobel, 1982). Mediation analyses with bootstrap estimates based on the recommended 5,000 resamples were performed using PROCESS macro v3.3 ( Hayes & Scharkow, 2013) in SPSS 26.0.

3.0. Results

The principal component and varimax rotation analyses revealed 10 modified items from the SRBWS loaded onto a single construct. The items theoretically represent obligation to show strength and suppress emotions as qualitatively discussed in prior research (e.g. Woods-Giscombé, 2010). The subscale descriptives ( M = 2.66, range: 2.52 - 2.86). Initial bivariate correlations (see Table 6 ) revealed the hypothesized independent variables of racial microaggressions and an obligation to show strength/suppress emotions were positively and significantly correlated with psychological distress. Age was negatively and significantly associated with psychological distress. Neither years of education, partner status, nor employment status were significantly associated with psychological distress. Subsequently, these variables were not included in further analyses.

Table 6.

Variables

1

2

3

4

5

6

7

4) Partner Status a

−.12

−.25**

.03

-

The multivariate analyses examining the relationship between demographic factors, independent variables, and psychological distress are displayed in Table 7 . The final model was significant, F (3, 227) = 33.09, p < .001, and accounted for 30.7% of the total variance in symptoms of psychological distress. Age was a significant negative correlate of psychological distress in the first model ( β = −0.24, p = .000). Older women in the sample endorsed fewer symptoms of psychological distress. In the second model, age remained a significant negative correlate and perceived racial microaggressions ( β = 0.24, p = .000) emerged as a significant positive correlate of psychological distress. Participants who perceived more racial microaggressions endorsed greater symptoms of psychological distress. In the third model, age remained a significant negative correlate ( p < .01) and perceived racial microaggressions remained a significant positive correlate ( p < .05). Obligation to show strength/suppress emotion ( β = 0.45, p = .000) was a significant positive correlate of psychological distress and accounted for 17% of the total variance. African American women who endorsed a greater obligation to show strength/suppress emotion endorsed more psychological distress (see Table 7 ).

Table 7.

Model 1

Model 2

Model 3

B (SE)

β

B (SE)

β

B (SE)

β

Age

− 0.04 (0.01)***

−.24

− 0.03(.01)***

− 0.22

−0.02 (.01)**

− 0.16

Racial Microaggressions

0.04 (.01)***

0.24

0.02 (.00)*

0.13

Obligation to show Strength and Suppress Emotions

0.16 (.02)***

0.45

R2

.05***

.11***

.29***

ΔR ²

.12***

.30***

In the mediation model (see Figure 1 ), age was treated as a covariate to control for its influence on the estimates of the direct and indirect effects. First, there was a positive association between racial microaggressions and psychological distress ( B = .02, SE = .01, 95% CI [.0013, .0470]). Second, there was a positive association between an obligation to show strength/suppress emotions and racial microaggressions ( B = .13, SE = .03, 95% CI [.0641, .1919]). Third, there was a positive significant association between an obligation to show strength/suppress emotions and psychological distress ( B = .16, SE = .02, 95% CI [.1138, .1978]). Last, an obligation to show strength/suppress emotions emerged as a significant mediator between racial microaggressions and psychological distress. The demonstrated bootstrap confidence interval for the indirect effect did not contain zero (c' = .02, SE = .0053, 95% CI [.0103, .0309], see Figure 1 ).

4.0. Discussion

The current study examined how an obligation to show strength/suppress emotion, a norm associated with the Superwoman Schema, contributes to negative mental health outcomes among middle-class African American women who experience racial microaggressions. This group of women remain an underrepresented and understudied population in existing literature because research has focused primarily on less educated and lower income African American women ( Woods-Giscombé, Robinson, Carthon, Devane-Johnson, & Corbie-Smith, 2016). The results demonstrated racial microaggressions and an obligation to show strength/suppress emotions were positively significant correlates of psychological distress. Age was a negatively significant correlate of psychological distress. Mediation analyses further indicated middle-class African American women who endorse an obligation to show strength/suppress emotions when encountering racial microaggressions experience more psychological distress. This finding extends prior scholarship by positing a culturally-endorsed coping strategy of showing strength/suppressing emotion may be an initial protective asset that becomes a psychological liability when overused ( Watson & Hunter, 2016).

Our findings revealed older African American women in our sample reported less psychological distress. Further, older women reported less endorsement of an obligation to show strength/suppress emotions. Older middle-class African American women may be less likely to be involved in the workforce due to retirement, thereby buffering them from a significant source of racial microaggressions ( Holder, Jackson, & Ponterotto, 2015). However, younger African American women often encounter racial microaggressions in addition to experiencing daily intimidation and sexual harassment in the workplace ( Holder, Jackson, & Ponterotto, 2015). Those who experience racial microaggressions and endorse the Superwoman schema are at an especially high risk for mental health problems ( Nuru-Jeter et al., 2018). Psychological distress is consequently associated with poor work productivity, physical health problems, and decreased lifespan ( Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015).

The results of this study align with previous research which argued endorsement of the Superwoman schema results in high rates of psychological distress ( Abrams, Hill, & Maxwell, 2019; Watson & Hunter, 2016). Abrams and colleagues (2019) suggest self-silencing behaviors such as presenting an image of strength and emotional suppression are associated with depressive symptoms among African American women. African American women may engage in these behaviors to fulfill expectations of taking care of others and managing multiple responsibilities simultaneously. Interestingly, many African American women take pride in showing strength and suppressing distressful emotions. This tendency can be temporarily adaptive and is often culturally rewarded ( Abrams, Maxwell, Pope, & Belgrave, 2014).

Long-standing cultural norms of strength and emotional suppression may be an impediment towards help-seeking among African American women ( Watson & Hunter, 2016). Research suggests African American women who feel an obligation to show strength/suppress emotions are more likely to report less perceived emotional support from others ( Watson-Singleton, 2017). Further, an obligation to help others and deprioritize one's own health is another cultural script for African American women who endorse Superwoman Schema ( Woods-Giscombé et al., 2019). Untreated mental health concerns further widen health disparities and increases the likelihood of suicidal ideation among African Americans due to feeling burdensome ( Hollingsworth et al., 2017). The number of suicides among younger African Americans has increased significantly in the past decade ( Price & Khubchandani, 2019), which raises concern for African American women who suppress emotions and avoid seeking support when experiencing distress ( Oh, Waldman, Koyanagi, Anderson, & DeVylder, 2020).

Of interest, the association between perceived racial microaggressions and psychological distress was mediated by an obligation to show strength/suppress emotions. In other words, the absence of active coping strategies, through an obligation to show strength/suppress emotions, results in psychological distress ( Williams, Kanter, & Ching, 2018). Recent literature suggests disengagement coping increases depressive symptoms among African American women who report gendered racial microaggressions ( Williams & Lewis, 2019). Our study confirms this finding and demonstrates showing strength/suppressing emotions may be a way in which middle-class African American women experience race-related psychological distress. Active coping strategies including social support, assertiveness, physical activity, and seeking professional counseling may be beneficial in managing chronic and often unavoidable experiences of racial microaggressions ( Holder, Jackson, & Ponterotto, 2015). The development of active coping strategies may alter the deleterious impact of racial microaggressions and reduce psychological distress among middle-class African American women.

4.1. Implications

Given their increased socioeconomic mobility ( Department of Education, 2019), it is vital to discuss implications specific to middle-class African American women who encounter racial microaggressions and subsequently experience psychological distress. African American women who endorse an obligation to show strength/suppress emotions may be less likely to seek help from others, due to belief it would undermine perceptions of strength, survival, and self-esteem ( Woods-Giscombé et al., 2016). This population may not seek professional help until their mental health concerns have reached a crisis such as an emotional breakdown or manifestation of physical health problems. Therefore, informal resources that have been shown to mitigate psychological distress such as faith-based services and sister circles can assist African American women in practicing vulnerability and receiving emotional support in the face of race-related stressors ( Abrams, Hill, & Maxwell, 2019).

Some African American women with greater education and high incomes may also be less likely to seek professional help despite increased access to mental health care services and resources ( Alang, 2019). There is concern about the availability of culturally competent mental health practitioners ( Woods-Giscombé et al., 2016) as many African American women encounter racial microaggressions within therapy ( Owen, Tao, Imel, Wampold, & Rodolfa, 2014). To reduce the occurrence of racial microaggressions perpetuated in clinical practice, developing trainings tailored for addressing racial microaggressions within the therapeutic context with African American women is imperative. Our findings can inform culturally tailored clinical interventions with this group ( Woods-Giscombé et al., 2016).

An important feature of culturally-competent mental health care is to validate the experiences of racially marginalized populations, who face obstacles of invisibility and ostracization ( Ahmed, Wilson, Henriksen Jr., & Jones, 2011). An obligation to show strength/suppress emotions may manifest in therapy as African American women embody caregiver and fixer roles ( Watson-Singleton, 2017). Thus, it is important to acknowledge when African American women show strength/suppress emotions as a function of Superwoman Schema in treatment. Utilizing terminology that appropriately labels and normalizes one's experience has the potential to decrease psychological distress ( Nadal et al., 2014). Further, acknowledging the experiences of African American women can cultivate space to express emotions such as anger, hurt, and sadness without reinforcing stereotypes such as the Angry Black Woman ( Ashley, 2014). Additionally, fostering self-esteem and self-efficacy through empowerment can be protective of the mental health consequences of racism ( Erving, Satcher, & Chen, 2020). Mental health practitioners working with this population have a unique opportunity to discuss how cultural norms such as the Superwoman Schema is one, but not the only, coping strategy African American women can utilize when responding to racial microaggressions.

5.0. Limitations

The current study has limitations. First, data was collected via an online survey, which may hinder the generalizability of our results to all African American women. Second, given the timing of data collection in 2013, the IMABI was available to measure perceived racial microaggressions. In 2015, the Gendered Racial Microaggressions Scale (GRMS) was developed and validated to assess gendered racial microaggressions among African American women. This measure should be utilized in future research with this population to better capture their gendered-racial experiences. Third, geographic location is an important consideration in examining SES. However, participants were not asked about their geographic locations. Future studies may benefit from inquiring about geographic location when studying demographic correlates of mental health among middle-class African American women.

Employment status was assessed using a forced choice item and may have posed limited options for students and self-employed women. Additionally, partner status was calculated using a single item. As operationalized, the question may not adequately capture a range of partner statuses (e.g. unmarried but dating). Identification with the Superwoman ideology is associated with caretaking roles ( Woods-Giscombé, 2010). However, neither parental status nor responsibilities were assessed in the current study. Despite these limitations, our findings suggest middle-class African American women rely on culturally specific coping strategies to respond to racial microaggressions but often at the expense of their mental health. To avoid presenting all middle-class African American women as monolithic, exploring within-group differences of mental health symptoms among this group based on education level, income, and occupation can also inform future research.

6.0. Conclusion

In summary, the current investigation provides insight into the mechanisms through which middle-class African American women experience psychological distress when encountering racial microaggressions in predominately White settings. The culturally relevant coping strategy of displaying strength/suppressing emotions produces only temporary benefits that eventually leads to adverse effects on mental health. Prevention and intervention efforts such as increasing access to culturally competent mental health care and encouraging use of active coping strategies can buffer the effects of racial microaggressions. Despite the pervasiveness of racism, middle-class African American women can benefit from utilizing a variety of tools to manage and reduce their race-related psychological distress.

References

Ahmed S, Wilson KB, Henrikson RC Jr, & Jones JW (2011). What does it mean to be a culturally-competent counselor?. [Journal for Social Action in Counseling & Psychology, 3(1), 17-28. Retrieved fromhttps://openjournals.bsu.edu/jsacp/article/view/329 Google Scholar]

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4[th ed.). Washington, DC: Author. Google Scholar]

Bureau of Labor Statistics. (2017). Labor Force Characteristics by Race and Ethnicity, 2017. Retrieved from https://www.bls.gov/opub/reports/race-and-ethnicity/2017/home.htm

Centers for Disease Control and Prevention (2019). Summary Health Statistics: National Health Interview Survey: 2018. Tables A-7 and A-8. Retrieved from https://www.cdc.gov/nchs/nhis/shs/tables.htm

Collins PH (2005). Black Sexual Politics: African Americans, gender, and the new racism. New York, NY: Routledge. [Google Scholar]

Erving CL, Satcher LA, & Chen Y (2020). Psychologically resilient, but physically vulnerable? Exploring the psychosocial determinants of African American women's mental and physical health. Sociology of Race and Ethnicity, 2332649219900284. doi: 10.1177/2332649219900284 [[CrossRef] Google Scholar]

Liao KYH, Wei M, & Yin M (2019). The misunderstood schema of the strong Black woman: Exploring its mental health consequences and coping responses among African American women. Psychology of Women Quarterly, 0361684319883198. doi: 10.1177/0361684319883198 [[CrossRef] Google Scholar]

Nuru-Jeter AM, Michaels EK, Thomas MD, Reeves AN, Thorpe RJ Jr, & LaVeist TA (2018). Relative roles of race versus socioeconomic position in studies of health inequalities: A matter of interpretation. Annual Review of Public Health, 39, 169-188. doi: 10.1146/annurev-publhealth-040617-014230 [[PubMed] [CrossRef] PMC free article] [Google Scholar]

Oh H, Waldman K, Koyanagi A, Anderson R, & DeVylder J (2020). Major discriminatory events and suicidal thoughts and behaviors amongst Black Americans: Findings from the National Survey of American Life. Journal of Affective Disorders, 263, 47-53. doi: 10.1016/j.jad.2019.11.128 [[PubMed] [CrossRef] PMC free article] [Google Scholar]

Sobel ME (1982). Asymptotic confidence intervals for indirect effects in structural models. In Leinhardt S (Ed.), Sociological methodology (pp. 290-312). San Francisco: Jossey-Bass. [Google Scholar]

Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from [https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm Google Scholar]

Sue DW (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. Hoboken, NJ: Wiley. [Google Scholar]

Tabachnick BG, Fidell LS, & Ullman JB (2007). Using multivariate statistics (Vol. 5). Boston, MA: Pearson. [Google Scholar]

U.S. Department of Education. (2019). The Condition of Education 2019. Washington, DC: National Center for Education Statistics. Retrieved from [https://files.eric.ed.gov/fulltext/ED594978.pdf Google Scholar]

Waldron IRG (2019) Archetypes of Black womanhood: Implications for mental health, coping, and help-seeking. In Zangeneh M, Al-Krenawi A (Eds.) Culture, Diversity and Mental Health - Enhancing Clinical Practice. Advances in Mental Health and Addiction. Springer, Cham. doi: 10.1007/978-3-030-26437-6_2 [[CrossRef] Google Scholar]

Woods-Giscombé C, Robinson MN, Cathon D, Devane-Johnson S, & Corbie-Smith G (2016). Superwoman schema, stigma, spirituality, and culturally sensitive providers: Factors influencing African American women's use of mental health services. Journal of Best Practices in Health Professions Diversity: Education, Research, & Policy, 9(1), 1124-1144. Retrieved from [[https://www.jstor.org/stable/26554242 PubMed] PMC free article] [Google Scholar]

# data[].attributes.attachment_link.title
Superwoman Schema: A Context for Understanding Psychological Distress among Middle-Class African American Women who Perceive Racial Microaggressions

# data[].attributes.attachment_link.description
Current racial mental health disparities among African American women have been attributed to chronic experiences of race-related stressors. Increased exposure to racism in predominately White spaces may increase reliance on culturally normative coping ...

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Researchers explore where it came from, why it's so destructive, and how to dismantle it.

The angry Black woman stereotype exists in many parts of American culture - including the workplace. Studies show people in organizations believe Black women are more likely to have belligerent, contentious, and angry personalities, an assumption not as readily assigned to other men and women. Recent studies suggest this negative perception is a unique phenomenon for Black women, and the researchers suggest that when Black women outwardly express anger at work, her leadership and potential are called into question.

The angry Black woman stereotype has penetrated many parts of American culture, including the workplace. This pervasive stereotype not only characterizes Black women as more hostile, aggressive, overbearing, illogical, ill-tempered and bitter, but it may also be holding them back from realizing their full potential in the workplace - and shaping their work experiences overall.

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Daphna Motro is an assistant professor of management and entrepreneurship at Hofstra University's Frank G. Zarb School of Business.

Jonathan B. Evans is an assistant professor of the Organizational Behaviour and Human Resources Division at the University of British Columbia's Sauder School of Business.

Aleksander P.J. Ellis is the management and organizations department head at the University of Arizona's Eller College of Management

Lehman Benson III is an associate professor of management and organizations at the University of Arizona's Eller College of Management.

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# data[].attributes.attachment_link.title
The "Angry Black Woman" Stereotype at Work

# data[].attributes.attachment_link.description
The angry Black woman stereotype exists in many parts of American culture - including the workplace. Studies show people in organizations believe Black women are more likely to have belligerent, contentious, and angry personalities, an assumption not as readily assigned to other men and women.

# data[].attributes.headline
Showalter, E. (2009). The Development of Black Women’s Fiction: From Slavery to the Harlem Renaissance. The Journal of Blacks in Higher Education, 64, 70–79. http://www.jstor.org/stable/40407495

# data[].attributes.subject
Showalter, E. (2009). The Development of Black Women’s Fiction: From Slavery to the Harlem Renaissance. The Journal of Blacks in Higher Education, 64, 70–79. http://www.jstor.org/stable/40407495

# data[].attributes.attachment_link.title
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# data[].attributes.attachment_link.description
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Alio, A. P., Lewis, C. A., Elder, H., Norwood, W., Mufhandu, K., & Keefer, M. C. (2020). Self-Reported Experiences of Racial Discrimination Among African Americans in Upstate New York. Journal of Black Studies, 51(5), 481–500. https://www.jstor.org/stable/26985201

# data[].attributes.subject
Alio, A. P., Lewis, C. A., Elder, H., Norwood, W., Mufhandu, K., & Keefer, M. C. (2020). Self-Reported Experiences of Racial Discrimination Among African Americans in Upstate New York. Journal of Black Studies, 51(5), 481–500. https://www.jstor.org/stable/26985201

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Hall, J. C. (2018). It is Tough Being a Black Woman: Intergenerational Stress and Coping. Journal of Black Studies, 49(5), 481–501. https://www.jstor.org/stable/26574573

# data[].attributes.subject
Hall, J. C. (2018). It is Tough Being a Black Woman: Intergenerational Stress and Coping. Journal of Black Studies, 49(5), 481–501. https://www.jstor.org/stable/26574573

# data[].attributes.headline
Sutherland, M. E. (2013). Overweight and Obesity Among African American Women: An Examination of Predictive and Risk Factors and Weight-Reduction Recommendations. Journal of Black Studies, 44(8), 846–869. http://www.jstor.org/stable/24572895

# data[].attributes.subject
Sutherland, M. E. (2013). Overweight and Obesity Among African American Women: An Examination of Predictive and Risk Factors and Weight-Reduction Recommendations. Journal of Black Studies, 44(8), 846–869. http://www.jstor.org/stable/24572895