9.3: Treatment for Black Americans

According to the 2010 U.S. Census definition, African Americans or Blacks are people whose origins are “in any of the black racial groups of Africa” (Humes et al. 2011, p. 3). The term includes descendants of African slaves brought to this country against their will and more recent immigrants from Africa, the Caribbean, and South or Central America (many individuals from these latter regions, if they come from Spanish-speaking cultural groups, identify or are identified primarily as Latino). The term “Black” is often used interchangeably with African American, although sometimes the term “African American” is used specifically to describe people whose families have been in this country since at least the 19th century and thus have developed distinct African American cultural groups. “Black” can be a more inclusive term describing African Americans as well as more recent immigrants with distinct cultural backgrounds.

Beliefs About and Traditions Involving Substance Use

In most African American communities, significant alcohol or drug use may be socially unacceptable or seen as a sign of weakness (Wright 2001), even in communities with limited resources, where the sale of such substances may be more acceptable. Overall, African Americans are more likely to believe that drinking and drug use are activities for which one is personally responsible; thus, they may have difficulty accepting alcohol abuse/dependence as a disease (Durant 2005).

Mental and Co-Occurring Disorders

A number of studies have found biases that result in African Americans being over diagnosed for some disorders and underdiagnosed for others. African Americans are less likely than White Americans to receive treatment for anxiety and mood disorders, but they are more likely to receive treatment for drug use disorders (Hatzenbuehler et al. 2008). In one study evaluating post-traumatic stress disorder (PTSD) among African Americans in an outpatient mental health clinic, only 11 percent of offenders had documentation referring to PTSD, even though 43 percent of the offenders showed symptoms of PTSD (Schwartz et al. 2005). Black immigrants are less likely to be diagnosed with mental disorders than are Blacks born in the United States (Burgess et al. 2008; Miranda et al. 2005b).

African Americans are more likely to be diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than White Americans, even though multiple studies have found that rates of both disorders among these populations are comparable (Baker and Bell 1999; Bresnahan et al. 2000; Griffith and Baker 1993; Stockdale et al. 2008; Strakowski et al. 2003). African Americans are about twice as likely to be diagnosed with a psychotic disorder as White Americans and more than three times as likely to be hospitalized for such disorders. These differences in diagnosis are likely the result of clinician bias in evaluating symptoms (Bao et al. 2008; Trierweiler et al. 2000; Trierweiler et al. 2006). Clinicians should be aware of bias in assessment with African Americans and with other racial/ethnic groups and should consider ways to increase diagnostic accuracy by reducing biases. For an overview of mental health across populations, refer to Mental Health United States, 2010 (SAMHSA 2012a).

In some African American communities, incidence and prevalence of trauma exposure and PTSD are high, and substance use appears to increase trauma exposure even further (Alim et al. 2006; Breslau et al. 1995; Curtis- Boles and Jenkins-Monroe 2000; Rich and Grey 2005). Black women who abuse sub- stances report high rates of sexual abuse (Ross-Durow and Boyd 2000). Trauma histories can also have a greater effect on relapse for African American offenders than for offenders from other ethnic/racial groups (Farley et al. 2004). There are few integrated approaches to trauma and substance abuse that have been evaluated with African American offenders, and although some have been found effective at reducing trauma symptoms and substance use, the extent of that effectiveness is not necessarily as great as it is for White Americans (Amaro et al. 2007; Hien et al. 2004; SAMHSA 2006).

Treatment Patterns

African Americans may be less likely to receive mental health services than White Americans. In the Baltimore Epidemiologic Catchment Services Area study conducted during the 1980s, African Americans were less likely than White Americans to receive mental health services. However, at follow-up in the early 1990s, African American respondents were as likely as White Americans to receive such services, but they were much more likely to receive those services from general practitioners than from mental health specialists (Cooper-Patrick et al. 1999). Stockdale et al. (2008) analyzed 10 years of data from the National Ambulatory Medical Care Survey; they found significant improvements in diagnosis and care for mental disorders among African Americans in psychiatric settings between 1995 and 2005, but they also found that disparities persisted in the diagnosis and treatment of mental disorders in primary care settings. Fortuna et al. (2010) suggest that persistent problems exist in the delivery of behavioral health services, as evidenced by lower retention rates for treating depression.

Even among people who enter substance abuse treatment, African Americans are less likely to receive services for CODs. A study of administrative records from substance abuse and mental health treatment providers in New Jersey found that African Americans were significantly more likely than White Americans to have an undetected co-occurring mental disorder, and, if detected, they were significantly less likely than White Americans or Latinos to receive treatment for that disorder (Hu et al. 2006). Among persons with substance use disorders and co-occurring mood or anxiety disorders, African Americans are significantly less likely than White Americans to receive services (Hatzenbuehler et al. 2008). African Americans who do receive services for CODs are more likely to obtain them through substance abuse treatment programs than mental health programs (Alvidrez and Havassy 2005).

African Americans are over represented among people who are incarcerated in prisons and jails (for review, see Fellner 2009), and a substantial number of those who are incarcerated (64.1 percent of jail inmates in 2002) have substance use disorders (Karberg and James 2005) and mental health problems (SAMHSA 2012a). However, according to Karberg and James 2005), African Americans with substance dependence disorders who were in jail in 2002 were less likely than White Americans or Latinos to participate in substance abuse treatment while under correctional supervision (32 percent of African Americans participated compared with 37 percent of Latinos and 45 percent of White Americans). In the 2010 TEDS survey, African Americans entering treatment were also less likely than Asian Americans, White Americans, Latinos, Native Hawaiians/Pacific Islanders, or American Indians in the same situation to be referred to treatment through the criminal justice system (SAMHSA, CBHSQ 2012). Notwithstanding, African Americans are more likely to be referred to treatment from criminal justice settings rather than self-referred or referred by other sources (Delphin-Rittmon et al. 2012)

Beliefs and Attitudes About Treatment

According to 2011 NSDUH data, African Americans were, next to Asian Americans, the least likely of all major ethnic and racial groups to state a need for specialized substance abuse treatment (SAMHSA, CBHSQ 2013a). Still, logistical barriers may pose a greater challenge for African Americans than for members of other major racial and ethnic groups. For example, 2010 NSDUH data regarding individuals who expressed a need for substance abuse treatment but did not receive it in the prior year indicate that African Americans were more likely than members of other major ethnic/racial groups to state that they lacked transportation to the program or that their insurance did not cover the cost of such treatment (SAMHSA 2011a). African Americans experience several challenges in accessing behavioral health treatment, including fears about the therapist or therapeutic process and concerns about discrimination and costs (Holden et al. 2012; Holden and Xanthos 2009; Williams et al. 2012).

Longstanding suspicions regarding established healthcare institutions can also affect African Americans’ participation in, attitudes toward, and outcomes after treatment (for review, see Pieterse et al. 2012). Historically, the mental health system has shown bias against African Americans, having been used in times past to control and punish them (Boyd-Franklin and Karger 2012; Jackson 2003). After controlling for socioeconomic factors, African Americans are significantly more likely to perceive the healthcare system as poor or fair and significantly more likely to believe that they have been discriminated against in healthcare settings (Blendon et al. 2007). Attitudes toward psychological services appear to become more negative as psychological distress increases (Obasi and Leong 2009). In many African American communities, there is a persistent belief that social and treatment services try to impose White American values, adding to their distrust of the treatment system (Larkin 2003; Solomon 1990).

Treatment Issues and Considerations

African American offenders generally respond better to an egalitarian and authentic relationship with counselors and other correctional professionals (Sue 2001). Paniagua (1998) suggests that in the initial sessions with African American offenders, correctional professionals should develop a collaborative offender–counselor relationship. Correctional professionals should request personal information gradually rather than attempting to gain information as quickly as possible, avoid information-gathering methods that offenders could perceive as an interrogation, pace the session, and not force a data-gathering agenda (Paniagua 1998; Wright 2001). Correctional professionals must also establish credibility with offenders (Boyd-Franklin 2003).

Next, correctional professionals should establish trust. Self- disclosure can be very difficult for some offenders because of their histories of experiencing racism and discrimination. These issues can be exacerbated in African American men whose experience of racism has been more severe or who have had fewer positive relationships with White Americans (Reid 2000; Sue 2001). Correctional professionals, therefore, need to be willing to address the issue of race and to validate African American offenders’ experiences of racism and its reality in their lives, even if it differs from their own experiences (Boyd-Franklin 2003; Kelly and Parsons 2008). Moreover, racism and discrimination can lead to feelings of anger, anxiety, or depression. Often, these feelings are not specific to any given event; rather, they are pervasive (Boyd-Franklin et al. 2008). Correctional professionals should explore with offenders the psychological effects of racism and develop approaches to challenge internal negative messages that have been received or generated through discrimination and prejudice (Gooding 2002).

Family therapy

African American offenders appear more likely to stay connected with their families through- out the course of their addiction. For instance, Bourgois et al. (2006) reported that in comparing African American and White American individuals who injected heroin, African Americans appeared to be more likely to maintain contact with their extended families. Some research also suggests that African Americans with substance use disorders are more likely to have family members with histories of substance abuse, suggesting an even greater need to address substance abuse within the family (Brower and Carey 2003).

Strong family bonds are important in African American cultural groups. African American families are embedded in a complex kinship network of biologically related and unrelated persons. Hence, correctional professionals should be willing to expand the definition of family to a more extended kinship system (Boyd-Franklin 2003; Hines and Boyd-Franklin 2005). Offenders need to be asked how they define family, whom they would identify as family or “like family,” who resides with them in their homes, and whom they rely on for help. Hines and Boyd-Franklin (2005) discuss the importance of both blood and nonblood kinship networks for African American families. To build a support network for African American offenders, correctional professionals should start by asking offenders to identify people (whether biological kin or not) who would be willing and able to support their recovery and then ask offenders for permission to contact those people and include them in the treatment process.

Group therapy

Because of the communal, cooperative values held by many African Americans, group therapy can be a particularly valuable component of the treatment process (Sue and Sue 2013b). A strong oral tradition is one of many forms of continuity with African tradition maintained in the African American experience; therefore, speaking in groups is generally acceptable to African American offenders. How- ever, Bibb and Casimer (2000) note that Black Caribbean Americans can be less comfortable with the group process, particularly the requirement that they self-disclose personal problems to people who are relative strangers. African Americans seem less likely to self- disclose about the past in group settings that include non-Hispanic Whites (Johnson et al. 2011; Richardson and Williams 1990). Consequently, groups composed only of African Americans can be more beneficial. Homogenous African American groups can also be good venues for offenders to deal with systemic problems, such as racism and lack of economic opportunities in the African American com- munity (Jones et al. 2000).

Mutual-help groups

A variety of mutual-help groups are available for African Americans entering recovery from substance use and mental disorders. However, most of the literature focuses on 12-Step groups, including Alcoholics Anonymous (AA) and Narcotics Anonymous. Some find that the 12-Step approach warrants careful consideration with African Americans, who can find the concept of powerlessness over substances of abuse to be too similar to experiences of powerlessness via discrimination. Additionally, the disease concept of addiction presented in 12-Step meetings can be difficult for many African Americans (Durant 2005). In some instances, the Black community has changed the mutual-help model for substance use and mental health to make it more empowering and relevant to African American participants. For additional information on the 12 Steps for African Americans, visit Alcoholics Anonymous World Services (AAWS), AA for the Black and African American Alcoholic, available online (www.aa.org/ pdf/products/p-51_CanAAHelpMeToo.pdf).

Relapse prevention and recovery

African Americans appear to be responsive to continuing care participation and recovery activities associated with substance use and mental disorders, yet research is very limited. According to NESARC data (Dawson et al. 2005), African Americans in recovery from alcohol dependence were more than twice as likely as White Americans to maintain abstinence rather than just limiting alcohol consumption or changing drinking patterns. In another study analyzing the use of continuing care following residential treatment in the U.S. Department of Veterans Affairs care system, African American men were significantly more likely than White Americans to participate in continuing care (Harris et al. 2006). Other research evaluating continuing care for African American men who had been mandated to outpatient treatment by a parole or probation office found that participants assigned to a continuing care intervention were almost three times as likely to be abstinent and five times less likely to be using any drugs on a weekly basis during the 6-month follow-up period compared with those who did not receive continuing care (Brown et al. 2004).

In evaluating appropriate relapse prevention strategies for African American offenders, Walton et al. (2001) found that African American offenders leaving substance abuse treatment reported fewer cravings, greater use of coping strategies, and a greater belief in their self-efficacy. However, they also expected to be involved in fewer sober leisure activities, to be exposed to greater amounts of substance use, and to have a greater need for continuing care services (e.g., housing, medical care, assistance with employment). Walton notes that these findings could reflect a tendency of African American offenders to underestimate the difficulties they will face after treatment; they report a greater need for resources and greater exposure to substance use, but they still have a greater belief in their ability to remain free of substances. Although an individual’s belief in coping can have a positive effect on initially managing high-risk situations, it also can lead to a failure to recognize the level of risk in a given situation, anticipate the consequences, secure resources and appropriate support when needed, or engage in coping behaviors conducive to maintaining recovery. Correctional professionals can help offenders practice coping skills by role-playing, even if offenders are confident that they can manage difficult or high-risk situations.