A Qualitative Study of Black Women’s Experiences in Drug Abuse and Mental Health Services

Abstract

Little is known about black women’s perceptions of service barriers in mental health and substance treatment. This article reports the findings of a qualitative study that explored the perceptions of 29 black women who received treatment in a small urban Northeastern city. Findings of the focus group data revealed participants’ experiences of services as discussed through the themes of bias and stigma; incompatible perspectives of wellness versus illness between consumer and provider; consumer mistrust; and holistic wellness. Participants endorsed counseling as a treatment strategy but were adverse to the use of medication. Practice and research implications are discussed.

Keywords

mental health race and ethnicity social work practice substance abuse

Black women experience complex and substantial individual, interpersonal, and socioeconomic stressors. Compared to women of other racial groups, they are more likely to be single parents, have lower educational attainment, fewer financial resources, fewer job skills, limited employment opportunities, live in impoverished communities, and have experienced intimate partner and community violence (Amaro et al., 2005; DeNavas-Walt, Proctor, & Smith, 2008; McKinnon, 2003). Moreover, they experience substantial barriers to and discriminatory treatment in mental health and substance abuse services (Borum, 2012; Davis & Ancis, 2012; Ehrmin, 2005; Miller & Neaigus, 2002; Smedley, Stith, Nelson, & Institute of Medicine, 2003).

Although a number of studies have been conducted to examine mental health and substance abuse barriers to treatment among black women, few have explored their experiences and perceptions of barriers faced when seeking services. Research indicates that racial, gender, class, and sexual identity differences are important factors to consider in the design of mental health and substance abuse services (Ehrmin, 2005; Smedley et al., 2003; U.S. Department of Health and Human Services [USDHHS], 2001; Wallen, 1992; Weiss, Kung, & Pearson, 2003). Yet, little attention has been paid to cultural variations that may have important implications for strengthening service provision for black women. An understanding of specific barriers to mental health and drug abuse service utilization, in addition to culturally endorsed coping strategies, will aid researchers and clinicians in developing culturally relevant interventions as well as treatment engagement and retention strategies to meet the needs of this growing population.

Data collection and dissemination regarding racial and gender experiences in mental health and substance abuse services have been recommended by the Substance Abuse and Mental Health Services Admiration (SAMHSA, 2012). The purpose of this qualitative exploratory research was to gain firsthand data on black women’s experiences in mental health and substance abuse treatment services and to inform future intervention development.

Literature Review

Professional Help Seeking

Black women with mental health or substance abuse problems are less likely than white women to have ever sought specialty mental health or substance abuse services and to be currently in treatment (Anderson et al., 2006; Borum, 2012; Brown & Palenchar, 2004; Conner et al., 2010; Davis & Ancis, 2012; Mays, Caldwell, & Jackson, 1996; Neal-Barnett & Crowther, 2000; Substance Abuse and Mental Health Services Administration [SAMHSA], 2012; USDHHS, 2001). Rather, when black women with psychosocial difficulties do seek help, it has been through family, friends, clergy, and other informal sources (Glass, 2012; Nadeem, Lange, & Miranda, 2009). Despite the growing body of literature focused on the role of culture-specific issues in mental health and substance abuse treatment, the needs of black women remain marginalized (Constantine, 2006; McAdoo, 2002; Miranda & Cooper, 2004; Roberts, Jackson, & Carlton-LaNey, 2000; Wright, 2001). Studies have shown that only one third of black women with mental disorders use professional services (Fiscella, Franks, Doescher, & Saver, 2002; Jackson et al., 2007), and those with co-occurring mental health and substance use disorders are even less likely to use any professional services (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008; Wells, Klap, Koike, & Sherbourne, 2001; Woodward et al., 2008). The underutilization of professional mental health and substance abuse services by black Americans for psychological or addiction problems has been well documented. In fact, the President’s New Freedom Commission on Mental Health (2003) described in detail the gender, racial, and cultural problems associated with service access and utilization in mental health and drug abuse services, concluding that higher burden of disability among racial minorities may be attributed to treatment barriers.

Research has identified a number of barriers to treatment engagement for black women with mental health and substance abuse problems. These barriers include shame and stigma, cultural and language differences, fear and distrust of the treatment system, lack of information, and lack of insurance and transportation (Bowie & Dopwell, 2013; Choi & Gonzales, 2005; Nadeem et al., 2009; Snowden, 2001). The development of research-based recommendations to improve access and utilization has been hampered by the lack of racial and ethnic minority representation in treatment and intervention studies (Neighbors et al., 2007; SAMHSA, 2012). Thus, any bearing that race and culture may have on the manifestation, perception, recognition, and salience of psychosocial symptoms and substance abuse risk factors continues to be overlooked in service utilization research (Davis & Galvan, 2012; Good & Good, 1986; Ono, 2013).

When black women do seek professional mental health and substance abuse services they are more likely than others to have reached a crisis point and are more likely to be misdiagnosed (Carrington, 2006; Davis & Ancis, 2012; Neighbors et al., 2007). Additionally, they may withdraw from treatment early because their ethnic, cultural, and/or gender needs go unrecognized or mistreated (Blazer & Hybels, 2000; Brown & Palenchar, 2004; Davis & Ancis, 2012; Miranda & Cooper, 2004; Neighbors et al., 2007; Snowden, 1999; Strakowski et al., 1995; Vega & Rumbaut, 1991). One consistently highlighted shortcoming is that treatment interventions lack cultural relevance and are inadequate to meet the specific needs of black women (Comas-Díaz & Greene, 1994; Jones & Warner, 2011; Smedley et al., 2003; Snowden, 2001; USDHHS, 2001).

The fields of mental health and substance abuse have progressively given attention to the needs of diverse populations through culturally sensitive practice methods that adapt existing practice models. These methods equip practitioners with knowledge about racial groups to increase cultural literacy and improve the level of understanding that mental health practitioners bring to their work (Husband, 2000). However, many of these approaches are based on an unexamined assumption that they will be effective for all women (Brown & Palenchar, 2004; Carrington, 2006; Comas-Díaz & Greene, 1994; Wallen, 1992; Williams, 1999). Although this attention is a step in the right direction, it overlooks the importance of developing and utilizing practice interventions that reflect the lived experiences of black women. Inquiry into black women’s perceptions of service needs and attitudes would contribute to improvements in the expanding area of culturally responsive interventions.

Qualitative Inquiry With Black Women

Culturally responsive research uses qualitative research methods such as focus groups to illuminate the experiences of consumers. It emphasizes the socially constructed nature of one’s reality, within one’s own context, seeking to answer questions of how social and psychological experience is created and given meaning (Denzin & Lincoln, 1994). Consequently, qualitative methods capture the social, political, economic, and psychological factors that comprise the holistic experience of black women. Qualitative narratives offer what Tillman (2002, p. 5) refers to as “culturally responsive research approaches” with racially and ethnically diverse persons. Tillman describes these approaches as “interpretive paradigms that offer greater possibilities for the use of alternative frameworks, co-constructions of multiple realities and experiences, and knowledge that can lead to improved outcomes for African Americans.” Culturally sensitive qualitative research inquiry was used in this study to provide a richer understanding of mental health and substance abuse experiences and the multiple factors that serve to facilitate or impede service utilization for this population.

Method

Design

This study employs grounded theory methods to explore the experience of black women who have received substance abuse treatment, mental health services, or both. Grounded theory is appropriate for this study because it provides a framework for reconceptualizing problems related to mental health and substance abuse treatment and examining assumptions about black women receiving services.

Sample

Black women who received mental health and/or substance abuse services in a small city in the northeastern region of the United States were recruited for study participation through mailings and flyers sent to substance abuse programs, housed in larger community-based organizations that offer health, substance abuse, mental health, and HIV services. The flyer invited women of African descent (defined as African American [including biracial], Caribbean [West Indian], African, and African Latino) and who had received substance abuse and/or mental health services to participate in the study. Prospective participants indicated their interest in participating by notifying their service provider or by calling the number on the flyer. Those interested were provided with detailed information regarding the nature of the study. The first 10 women in each of the three sites who confirmed their interest in participating and met the eligibility criteria were selected.

A focus group consisting of 8–10 women was conducted at each of the three study sites, and a total of 29 women participated. The average age of participants was 37. Most women had at least one child (86.2%) and, based on a set of closed-ended socioeconomic class options, self-identified as being in a lower or middle socioeconomic status (85.2%).

Procedures

A grounded theory approach (Corbin & Strauss, 1990; Glaser & Strauss, 1967) was used to explore participants’ thoughts, feelings, and beliefs regarding substance abuse and mental health treatment services with the purpose of informing a conceptual model of factors that contribute to successful treatment outcomes as well as factors that were barriers to service provision. Across sites, women were asked questions about both mental health and substance abuse services, given their common experiences with both systems of care. Four primary opened-ended questions motivated each focus group discussion:

Tell us your thoughts about and/or experiences in mental health treatment services.

Tell us your thoughts about and experiences in substance abuse treatment services.

What are some of the challenges or barriers faced in successfully completing mental health and substance abuse treatment?

If anything, what changes would you suggest in the delivery of mental health and substance abuse services in your community?

Each focus group was cofacilitated by two senior researchers and a graduate research assistant. All participants provided informed consent prior to participating. Focus group members were compensated US$10.00 for their participation in a 60- to 90-min focus group that was audiorecorded and transcribed. Participants were assured that the research team would maintain their confidentiality and were told that the taped conversations would be transcribed with no identifying information for data analysis. Focus group members were also asked to protect the confidentiality of fellow group members.

Prior to the sessions, participants completed questionnaires that asked for information about their age, race, ethnicity, education, socioeconomic status, social support, and psychosocial history, such as substance use, types of substance abuse and mental health services received, and length of time in treatment. All interviews took place in a designated private space at an accessible location. A subcontractor transcribed the audio-taped interviews. The audio files were checked by the interviewers to ensure fidelity with the transcriptions. Human subjects research approval was obtained from the Institutional Review Board at the senior researcher’s university.

Data Analysis

The analysis team, consisting of four senior investigators and a graduate research assistant, read the transcripts and identified codes and categories from the data. The research team read the interviews using an open-coding approach, and each member of the team independently developed codes representing a category or theme found in the data and attached the codes to corresponding segments of text. The research team reviewed the open coding and discussed any coding differences until they reached consensus. The lead senior researcher checked all coded interviews throughout the coding process. This cross-checking of interpretations is one approach used to increase confidence that different researchers would generate similar findings from the data and that the analysis correctly represents the views of participants (Franklin & Ballan, 2001).

Using an axial coding approach, the research team discussed how themes were interrelated and whether or not the codes adequately represented the data across sites. This constant comparative method continued until no new categories were generated from the codes; that is, until saturation was reached. In the final stage of axial coding, the research team identified the core categories of data and relationships among categories (stigma, race, barriers, support, family, and recovery). Relationships among themes and their subthemes served as the basis for drawing conclusions about the experiences of the women in this study and how those experiences shaped their service utilization.

Upon completion of the coding process, the principal investigator met with service providers in the participating agencies to review the themes. This process of peer debriefing was used to validate the research team’s interpretation of the data. The service providers reviewed the themes and reported that they resonated with their experiences of working with black women.

Findings

Participants across the three groups reported many similar experiences when discussing and describing factors central to the experience of black women in mental health and substance abuse services. During each of the focus group sessions, members were attentive as they shared their experiences of dejection, pain, and disappointment; many offered acknowledgments of support through nods of heads and encouraging words. For some members, their affirmation by silence indicated that they all knew that it was a story they had told and heard many times before.

The following four themes emerged from the analysis: (1) Bias and stigma are powerful impediments to treatment, (2) incompatible perspectives of illness and wellness between consumer and provider, (3) consumer mistrust of both service providers and methods of treatment, and (4) wanting to be “well within my soul.” In discussing both mental health and substance abuse services, participants described experiences they felt were unique to being black women in treatment.

Theme 1: Bias and stigma are powerful impediments to treatment

The women in this study articulated the effects of stigma that influenced both mental health and substance use experiences. Participants wanted those that they know to “stop putting labels on individuals” with mental health and/or substance abuse disorders, and, similarly, individuals with mental health and substance abuse disorders should stop accepting the categories in which others may place them. The categorization occurs when service providers assume all black people are the same, and when black women judge each other based on a label or diagnosis.

I think [doctors] have a tendency to generalize the black population. They just put us all in one lump, regardless to what the problem may be. You could be having a stroke, that one’s having a heart attack but they going to give you the same medication. You know what I mean?

[Service providers] look at the black people thinking we’re all addicts, or think that we’re mentally ill … you know when you come in all broken down, looking bad and the reception at the desk give you the look and turn her head on you just coming off the street and you’re looking for help, you know. But they don’t want to touch you or come near you.

The women suggested that people in their communities should be more compassionate and reach out to those struggling with mental health and addiction challenges because they may be dealing with many additional issues, such as general health concerns, poverty, and unemployment.

We got two things going on and after the, the mental thing, and the addiction, here comes your health, you know. So, it, it, it would help more to reach out to those and have a little compassion about it. Don’t put labels on them, you know. Everybody’s got a label. ‘Oh, that’s a crack-head. Oh that’s an addict. Oh, she got HIV or she got syphilis.’ You know what I’m saying? Or ‘she’s on welfare. You know,’ Or ‘she ain’t never going to be nobody.’ We got to stop that. Stop labeling people and people got to stop accepting labels.

Even though participants recognized that mental health stigma derives from ignorance, they were able to identify the feeling of embarrassment related to the diagnosis and experience of mental illness. The women did not want to be stereotyped as women with mental illness and were afraid of letting their peers know they were receiving services from a mental health service provider.

When they told me I had to go the psych, I was so embarrassed to, I was extremely embarrassed when they told me. I was scared. I was embarrassed to tell people outside of here and my peers in here that I had to go to the psychiatrist, I was extremely embarrassed.

Another participant discussed the difficulty of gaining employment as a black woman and as an addict after completing substance abuse treatment. She believed that due to stigma, it would not be beneficial for her to disclose that she was in treatment for the last 10 years. One participant said:

Being a black woman and an addict, being alienated and shamed not only because of my addiction, but based on my race and gender. Showing them my resume and having such a big hole in my work experience you know, and trying to figure out what lie I’m going to tell when they asked me what was you doing for ten years? What was you doing for ten years? So what’s my lie? I was raising my son. And what’s their view of me? Black uneducated, lazy, just making babies. It’s enough to put you back on the streets.

Theme 2: Incompatible perspectives of illness and wellness between consumer and provider

A central theme was the disconnect between the women’s perceptions about their own service needs and access to appropriate and effective treatment. Participants discussed feeling their mental health concerns were not being taken seriously by providers and that they were not offered the professional help they needed even though their symptoms were extreme. One woman said, “I get real depressed and I get angry or I want to get violent, I don’t know if I’m bipolar, schizophrenic or whatever but I feel like sometimes I’m just ready to snap and hurt somebody you know so I don’t even, I wasn’t even offered to talk to anyone.”

Several participants described feeling that their mental health needs were serious, but they were not receiving the help they needed through mental health treatment. In fact, some women in the focus groups said they had to be deceptive in order to receive professional help. One participant talked about an experience when she felt like she was “going out of my mind” and her subsequent visit to a local hospital emergency room. She suggested that the hospital did not help her until she said she would harm herself. She said:

I was just going crazy. You know, they wouldn’t do nothing for me they didn’t think my issues were important enough. And that’s when I said I’m going kill myself. I wasn’t going to kill myself, I just wanted to know what the hell is going on with me.

Participants emphasized the need to discuss their feelings and problems with practitioners and support networks. There was a general consensus among participants that talking about their stressful issues with others, including those in support group meetings, is helpful.

Participants indicated that medications are prescribed by providers who do not take the time to discuss presenting problems in depth. Many felt that medications were prescribed unnecessarily and without a clear understanding of the problem. One woman described her frustration with her psychiatrist:

I would try to talk to him about what’s wrong and the first thing he would do was pick up the pen and let’s go Abilify, oh Zoloft, oh dededadaa. At one point I was on like six medications, all based on the recommendation of my so-called psychologist, and what bothers me is that I go to the appointment to try to talk to him about what’s wrong with me and all he can say is ‘Let me see the psychiatrist about writing you a prescription.’ That’s all they do, they don’t even listen to what I have to say deep down inside.

The women voiced tremendous frustration that practitioners were not genuinely interested in hearing about their concerns but prescribed medication in lieu of supportive counseling.

One participant connected this practice to a lack of cultural sensitivity, in that service providers offered medication to avoid discussing issues related to race and gender.

Yes, I think that when you go looking for mental health help, um, basically you go with an idea of what is the kind of help you want to get, so you expect a person that is interviewing you or gets your case, gives you different approach, one you can relate to as a woman, as an African American not necessarily medication but like you know, holistic approach or stress relief program, or different depend on the case, but most therapist can’t relate to you either because culturally they don’t know or they cannot understand what you went through or where you’re coming from, so, they don’t get into details, they basically don’t know what you can, they could offer much, but, I feel, is basically give you prescriptions and think all your problems will go away.

Some of the incompatibility between women and providers may be explained by the cultural myth of the strong black woman. Women alluded to this expectation to be strong as a significant barrier to acknowledging mental health problems and seeking care. As one participant described:

I think Black women are stronger when it comes to mental health. I think they’ll fight it faster I think a White person would sink in and believe it. Like a Black woman would be like ‘nah, this can’t be, nah’.

In order to fulfill the role of the strong black woman, many participants discussed their symptoms as being “just the blues” and downplayed the providers’ diagnosis and the severity of their symptoms.

For one participant, the barrier to treatment that results from a disconnect between treatment preferences and the offered service was diminished by receipt of supportive counseling: “I thought that being prescribed medication meant that I was crazy, which caused me to be in denial about my mental illness.” She added that “after seeing a therapist I realized that I was not ‘crazy’ and that I simply needed help to deal with some of the things I was going through.”

Theme 3: Consumer mistrust of both service providers and methods of treatment

Specific barriers identified by participants regarding white (European) clinicians included lack of trust and understanding. Many women agreed with the following statements made by participants in different groups: “Sometimes I don’t think White people understand where we’re coming from”; “You could have 20 things on the list and you’re like ‘ok, I’m talk to you about these 5’ but the other 15 you can’t even get with me because you can’t identify with me and there is no trust.” The following quote suggests that providers’ acknowledgment of the relevance of race in treatment might help address the perception of being misunderstood, but one participant indicated the norm is for nonblack counselors to ignore issues of race:

People don’t want to talk about race and substance abuse, people don’t want to talk about that in treatment. Not Blacks, we can talk about it all day amongst each other, but when we mix up in groups with White people—counselors too, no one wants to talk about that.

The lack of cultural competence appears to be a particular barrier to engaging in long-term therapeutic relationships. For ongoing counseling, participants emphasized the preference for a clinician of the same gender and race.

I mean, and, it’s something that would make me more comfortable if I was speaking with another African American woman.

There’s a bond between Black women, you know what I’m saying.… Just knowing that you’re Black, to me, is like a sense of comfort sometimes especially in a place like this [substance abuse treatment program].

However, the preference for a clinician of the same race and gender appears to vary with the type of need. For example, one woman explained that in a crisis situation, the provider must be able to provide effective support.

When … I’m going through the mood swings, I don’t care what color you are. Because if I don’t get it out then I’m gonna get destructive and I’m going to hurt myself or somebody else and I don’t care if you look purple with pink polka dots, you need to listen to me.

The previous theme (i.e., perceived incompatibility between provider perspectives and those of black women in treatment) is related to the women’s aversion to psychotropic medication. Problematic aspects of medication were described, including unpleasant side effects, and beliefs that medications are either ineffective or make things worse. Participants stated that medications have a number of side effects, which make them slow, drowsy, and prevent them from normal functioning. Some equated medication with substance use: “it’s the same thing as taking illegal drugs, just substituting one drug for another.” They stated a desire for providers to use alternative approaches, such as talk therapy and physical exercise, to treat their mental health conditions.

You can’t just medicate some and not let them get out their feelings. I think the best medication to have, I mean, a conversation. The pill is not going to set you free … you are a slave to that pill.

Participants said that when they were taking medication, they could not “feel” or “deal” with their problems. It was noted that some individuals may want to receive medication to numb their pain but others want to “feel” and experience life and receive the tools to be able to manage their health. A participant described her experience with the prescribing of medication in treatment as an hindrance to her recovery “It shut me down, I didn’t participant in my treatment the way I was supposed to, I was always sleeping. I really think they (provider) gave it to me on purpose, they didn’t want me here in the first place.”

In addition, medication was perceived as unhelpful because participants felt that they needed to be able to deal with their problems instead of medicating them to the point where they felt “other” than themselves.

I’ve been dealing with mental illness for a long time and I thought that I needed that medication in order for me to maintain but I found that every time I was on that medication it made me feel other than myself. I was no longer a strong black woman, I was a weak black woman and that ain’t cool. I couldn’t function, I couldn’t concentrate, and so like going to therapy and talking to the, um, my social worker he helped me worked through that. I don’t have to be dependent on medication, I don’t have to just, it’s not going to make me feel better or make me another person that I could do it through expressing how I feel, talking about where I’m at, it ain’t the medication.

Theme 4: In search of holistic wellness

All participants reported the desire to be well emotionally, physically, and spiritually and wanting to overcome their difficulties whether due to substance abuse or mental health problems. Some women discussed health concerns as a key motivation for recovery. For example, one woman described her diagnosis of HIV/AIDS as her primary reason for seeking treatment.

I, I took a bad fall when I found I was HIV positive, can I say that? Ok. I, I was in denial about it, I wouldn’t take my medication and um …. I was constantly in the hospital and practically knocking on death’s door, so I knew that if I didn’t take my treatments, didn’t take my medications, and didn’t stay clean that I was basically dead. So that’s really what turned my life around and I really got serious about my recovery. I now even help other HIV-infected women get into recovery and tell them how to get medical care.

Other women presented their children as reasons for abstaining from drug use or seeking treatment. They reported that they wanted to be a positive influence on their children and physically and emotionally available to them.

I want to live today, I want to do something with my life, you know, I want a career, I want to have something to show my grandkids, I want to be a good role model to see you know, and for my daughters you know, and family you know, they always supported me, they always been there for me, you know.

Women also said that their children asked them directly to stop using substances.

My daughter sat down next to me one day and said Mommy, why are you doing this, why are you making yourself look bad, don’t do that no more, don’t do this, don’t do that. So my daughter picked up like, the battery in my back, she was only 9 years old and she said Mommy I don’t want you to do this no more, we need nice things. So I just automatically stopped, I didn’t have to go to no program or nothing like that, I just stopped on my own.

Some participants described challenges to their recovery goals, including daily stressors related to poverty and direct challenges of remaining clean while recovering from substance abuse. For example, participants spoke to the challenges of being in relationships where their partner was still using. One woman quoted her partner, “You doing pretty good. Maybe we can get this bag of weed. Or, you know, maybe I can go get some of this to smoke. Just let me do this one bag of dope.” Additionally, the wide availability of drugs was a challenge to sobriety.

If you go through [street names] there are going to be folks sitting on the corner. They’re going to be sitting on the [street name] and that’s because that’s where a lot of people do what they got to do over there. And like see, when I have to pass through because I live down the block, I’m tempted.

Most of the women in the study equated being in recovery with freedom. When asked what being in recovery would mean to them, they stated, “… being free. That’s the big phrase. That’s the word. I feel freedom.”

It means freedom and it means … your feelings come back. You, all of something, all of sudden, you’re out of that cloud.

Discussion and Conclusion

The focus groups revealed themes consistent with other research, including the central issues of bias and stigma as impediments to treatment among black women (Alvidrez, Snowden, Rao, & Boccellari, 2009; Glass, 2012). The shame and stigma associated with treatment in black communities may dissuade black women from seeking mental health or substance abuse services (SAMHSA, 2012; USDHHS, 2001). Providers’ lack of cultural awareness has been noted as another persistent barrier for black Americans (Briggs, Briggs, Miller, & Paulson, 2011). As mentioned earlier, when black women do seek treatment, they are less likely to receive culturally competent services (Blazer & Hybels, 2000). Consequently, mental health and/or substance abuse practices are implemented without attending to issues of race and culture. The women who participated in this study also discussed these issues and suggested that pairing them with black female counselors would address some of their concerns about the cultural competence of service providers.

The women who participated in this study argued that social supports are essential for remaining in recovery. Yet, they revealed many challenges to staying in recovery because their existing social networks are likely to favor substance use. For example, women who engage in substance use are likely to be in relationships with other substance abusers, and histories of abuse and neglect that lead to substance use also compromise their ability to access social supports within their own families (Durr, Small, & Dunlap, 2010).

Some themes that emerged from the present study have yet to be fully explored in the current literature. One of these themes relates to racial identity and its influence on black women’s desire to receive more counseling and be less reliant on medication (Schnittker, 2003). Studies of black Americans have shown they have negative attitudes about psychiatric drugs (Kranke, Guada, Kranke, & Floersch, 2012; Schnittker, 2003) and less favorable attitudes about them than whites (Dos Reis et al., 2003; Wagner et al., 2005). Our study participants discussed how service providers are reluctant to engage in discussion about race as an important context for substance abuse and mental health treatment outcomes. Race may also contribute to the feelings of mistrust that these women often feel toward service providers.

Given the mistrust of service providers and medication-based treatment approaches that emerged in the discussion, effective treatment for the women in this study may need to be grounded in supportive counseling before medication is prescribed. In some cases, supportive counseling may need to be offered in place of medication. In all cases, the need for providers to bridge the divide between their own belief systems and those of patients was striking.

Limitations

The purpose of the present study was to provide rich descriptions of the experience of the women who participated in the focus groups. The findings cannot be generalized to represent the experiences of black women or women receiving substance abuse and mental health services. The findings should also be interpreted with caution since the research team was not able to review and validate findings with the participants (member checking). Gathering the participants for member checking proved to be infeasible because most of the women were no longer in programs at the agencies when data analysis was completed. Instead, the research team debriefed with service providers at each of the agencies to validate the findings.

Other limitations of this study should be considered. The lack of generalizability resulting from the qualitative research design limits the larger potential implications of the study. In view of the diversity that exists among black women, additional studies with black women of different ethnicities, age, socioeconomic status, and geographic region are needed. Second, given that the participants volunteered, the results may be influenced by selection bias. However, participants were not asked specifically about the services received at the locations where the focus groups occurred, and they were assured that their responses would not be shared with the agency. Third, across the focus groups, the women emphasized experiences with psychiatrists or at emergency rooms may have limited the depth of discussion of other service-related experiences.

Practice and Research Implications

Despite these limitations, the findings underscore the importance of recognizing how issues of race and stigma influence access to behavioral health services and shape black women’s experience of the treatment they receive. Improving the efficacy of treatment services for the women represented in this study will require acknowledging the strengths inherent in their focus on improving their own and their family’s well-being. Participants’ emphasis on the need to be perceived as strong black women should be considered in future studies of black women receiving mental health and substance abuse treatment. Identifying ways to use such strength to engage women in treatment will be critical for future services provision (Beauboeuf-LaFontant, 2007; Glass, 2012; Miranda & Cooper, 2004; Woods-Giscombé, 2010). Just as noteworthy is the resilience evident in the women’s ability to cope with numerous stressors in their current lives and histories. Future research will need to examine the extent to which issues of stigma and cultural competence shape the experience of substance abuse and mental health services for a larger community of black women.

Future practice decisions about mental health and substance abuse services for black women will be largely influenced by the demonstration of effective services. Although previous researchers have affirmed the need for mental health and substance abuse programs that assist black women in recovery, there remains a paucity of research on effective service components and approaches (Boyd-Franklin, 1991; Francis-Spence, 1994; Wallen, 1992). The impact of culture on recovery continues to be a necessary future direction for practice (Comas-Díaz & Greene, 1994; Greene, 1997; Jones & Warner, 2011; Williams, 1999; Woods-Giscombé, 2010). To avoid repeating the failures of past reforms, consumers and allies must develop new strategies to make the mental health and substance abuse system more responsive to the concerns expressed by the women themselves.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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