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The Strong Black Woman:

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Telsie Davis

on 2 October 2015

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Transcript of The Strong Black Woman:

Caretaking
anticipating and meeting the needs of other people, often at the sacrifice of one's own needs


Trauma-Focused Treatment Strategies
Do you Know the
Strong Black Woman
Acknowledgments
Patients

Partner in Life:

Family & Ancestors:


Mentors:

Colleagues
Problems Faced & Promise Seen in

Recovery from Trauma

Pre-treatment sessions
State personal agenda
Willingness to be uncomfortable
Instill hope that can get better
Reframe frustration
The Strong Black Woman:
Donald L. Davis, MBA
Chloe, Carter, Charlee, Papa George, Mom, Dad & Loved Ones
Drs. Hill, Gunter, Beaton, Kaslow, & Bradley
“It is not that Black women have not been and are not strong; it is simply that this is only a part of our story, a dimension, just as the suffering is another dimension – one that has been most unnoticed and unattended to.”
bell hooks,
Talking Back (1989)
Participants

8:30-10:00am How culture counts when treating the SBW


10:15-12:00pm Cultural characteristics of the SBW


1:30-2:30pm Implications for TX of SBW with PTSD

2:30-3:15pm Use of E-B TXs for PTSD with the SBW


3:15 - 4:00pm Use of E-B TXs for PTSD with the SBW

Symposium Schedule
10:00-10:15am Break
12:00-1:30pm Lunch
3:15-3:30pm Break
4:00-4:30pm Closing
Strong Black Woman
historical root
the promise
the challenge
Therapists as Experts
black therapist for black clients
ethnic matching:

related to greater length of treatment, higher rates of participation in therapy, and better therapeutic outcomes (S. Sue, 1991)
cognitive match:
found to be the mediating factor in ethnic matching and successful treatment outcomes (S. Sue, 1998)
Culture Counts:
the patient has to come, stay and become engaged
the patient has to give a complete and accurate psychological history
therapist has to make the correct diagnosis
collaboratively develop the best treatment plan for the patient

Lack of cultural competency influences therapy underutilization and premature termination (USDHHS, 2001)
When ethnic minorities receive tx it is often of less quality (USDHHS, 2001)


AfA clients held more responsible for the solution to the problems they experience (Burkard & Knox, 2004)
EA students AfA and AA students attended significantly less sessions and reported significantly more distress at termination than EA students (Kearney, Draper, & Baron, 2005)
All minority groups were less likely to seek treatment for PTSD than Whites (Roberts et al., 2011)
Multicultural Counseling Competencies Tripartite Model:
1. become culturally self-aware

2. gain specific cultural knowledge about client groups with which we work

3. learn culturally relevant clinical skills appropriate to those groups

Sue, Arrendondo, McDavis, 1992
Therapist Self-Awareness
Male Privilege
White Privilege
Heterosexual Privilege
Christian Privilege
Middle Class Privilege
Educational Privilege
The Mind of the
Strong Black Woman
break
The
Strong Black Woman
1. Affect regulation (I Got This!)

2. Self-reliance (I Got Me!)

3. Caretaking of others (I Got You Too!)

High self-esteem based on strength in 3 areas:
Affect Regulation
to mask or suppress negative emotions
Stay focused on the positive
Projection of unflappability and well-being
Resilient to emotional injury, stress and devaluation
Positives:
Challenges
1. Denial/Passive coping (Abel et al., 2014)
2. Decreased perception of stress (Hamin, 2008; Pierce
et al., 1996)
3. Belief system that Distress = Weakness
4. Emotional numbness
5. Anger management problems
6. Use of negative affect regulation strategies (binge
eating, substance abuse, hyper-sexual behavior,
frivolous spending, etc.)

Therapist Considerations
validate risk of sharing feelings
unrealized fear of emotion
belief that emotions are chaotic and make things worse
seeking power
societal normalization of lying
modeling truth-telling
emotional distress doesn't have to mean suffering

Self-Reliance
“Reliance on one's own efforts and abilities”


Positives
"work-til-you-drop" mentality
Faking = stress
Emotional breakdown
Ego = help-rejecting
backlash from others to restore equilibrium
Self-care is linked to self-worth and self-love
core belief of incapability
avoidance
education about stress and prosocial behavior (Feldman, 2012, Andari et al., 2010)
"Sisterella Complex" (Jones & Shorter-Gooden, 2003)
"Fabulousity" (Moody & Williams, April 2014)
Suicidality

Positives
locus of control is external
relationship with others valued over self
"Mammyism" - suffering in silence in public
higher levels of perceived stress (Hamin, 2008)
absence of self-care
resentfulness
holding on to all relationships
Building social bonds
Feeling useful
Being needed

LUNCH
Challenges
Therapist
Considerations
Challenges
Therapist
Considerations
Asking makes you vulnerable
Knowing when to ask for help or quit is linked to knowing one’s value
"Exchange constructive reads on one another's lives." bell hooks, 2005, p.43
Self-reliance body posture can foster confidence (Ann Cuddy)
strong
independent
capable
in control
unique
"Until the lion has its own historian, the tale of the hunt will always glorify the hunter."

- African Proverb
intentional and continuous process
of learning about and effectively responding to
the client in the context of their culture
Cultural Competence
(Merriam-Webster Online, 6/2014)
when women genuinely feel they can handle the challenges they face, they identify as:
Self-reliance may be harmful if combined with affect regulation (Hamin, 2008)

The only time some of us take a break is when we break down. “ (Taylor, 2002, 9)
(Green, 2011; Hamin, 2008)
Treatment of the
Strong Black Woman
with PTSD
Culture of
Posttraumatic Stress Disorder
Patterns of onset

Course, Progression, & Outcome

Idioms of distress



1. fear-based/re-experiencing/
anxious individuals
2. anhedonic/dysphoric mood and
negative cognitions
3. arousal and reactive-
externalizing
4. dissociative
5. combinations of 2 or more of the
above
Five Different PTSD Phenotypes:
Traumatic Event occurs:
Exposure to actual or threatened death, serious injury, or sexual violence

Experience of four types of symptoms:

1. Intrusion and Re-experiencing symptoms:
• nightmares.
• flashbacks
• emotional and physiological reactions when reminded of the trauma

2. Avoidance symptoms:
• trying not to talk or think about the trauma
• trying to stay away from external reminders of the

3. Negative changes in thoughts and feelings
• negative thoughts about yourself, other people, and the world
• loss of positive or loving feelings
• persistent negative mood
• inability to remember important parts of the traumatic event

4. Increased hyperarousal and reactivity
• angry outbursts
• reckless behavior
• always alert
• easily startled
• difficulty sleeping and concentrating

PTSD Criteria
A majority* of African American women
identify with the SBW ideology
*
not all
Beauboeuf-Lafontant (2007): being strong consistently emerges as a culturally distinctive aspect of 70.1% of Black women’s experiences

Neal-Barnett et al.'s (2011) study on sister circles as an anxiety intervention noted, “Most participants saw themselves as leaders, balancing multiple roles, and as strong black women.”

Jones & Shorter-Gooden (2003) in Shifting noted that the majority of the women, having to choose a stereotype about Black women that they identified with, “…were most likely to pick strong."

The SBW with PTSD
Increased risk for adverse health conditions (Satcher, 2001)
Racism contributes to PTSD (Loo, 2003)
Lower expectations about the benevolence of the world compared to European American women (Zoellner et al., 1999)
More problematic consequences from their trauma-related cognitions as compared to their European American counterparts (Williams, 2012)
May hold more rigidly to negative emotion-regulation strategies like binge-eating (Harrington et al., 2010)
life stressors interfere with PTSD treatment (Alim et al., 2006; Zoellner et al., 1999)
cultural mistrust, lack of cultural competency among therapists and a lack of empirical studies on culturally relevant adaptations in protocols are thought to be responsible for these disparities
mental health disparities
(Theoretical & Evidence-Based
Treatments)
Lack of empirical data on the relationship between ethnocultural variables and the treatment of PTSD, so theoretical and EBTs are warranted

AfA women who are willing to enter therapy may differ from those who do not on variables that likely affect their response to treatment (Feske, 2001)

Strength is a cultural mandate that provides clear guidelines for behavior and operates as a “tyranny of . . . shoulds” that will influence treatment interactions and experiences (Beauboef_Lafontant, 2007)
Theoretical Strategies
Evidence-Based PTSD Interventions
Working Alliance Development

Identify Index Trauma

Breathing Re-training

Symptom Measurement

Avoidance
African American female, age 55, 1 adult child, married. Regal woman, meticulous appearance, husband drops her off at every session. He cooks, cleans, while she paces during the day and watches the video monitor like a television program at night. Verbalizes shame and low self-esteem. Attempted unsuccessfully to engage in TFT twice before but dropped out of pre-treatment education (i.e., PTSD 101 class) without warning. Labeled as treatment resistant.
Case Vignette
Cognitive Processing Therapy
Break
*there are intersections between these factors
Strength (i.e. SBW) is a cultural mandate that provides Black women with clear guidelines for their behavior and operates as a tyranny of shoulds that will influence their treatment interactions and experiences
(Beauboef_Lafontat, 2007)
without cultural knowledge, good intentions can do grave harm
EXAMPLES
Romero, 2000; Thomas, 2003; Hamin, 2008
(DSM5, APA 2013)
Building trust in therapy
Building trust in therapist
Dealing with client's anger
Coaxing out hidden feelings
Redefine panic symptoms
Fostering ability to ask for help
Addressing anger at God
Addressing anger at therapist
Theoretical Strategies
Resick & Schnicke
targets thoughts that are believed to be 100% accurate but in fact are not, and that by being believed perpetuate distress and maladaptive behaviors that prevents healing
Friend is 45 minutes late to dinner.
• I shouldn't be crying over this.
• Crying shows weakness.
• I can't rely on anyone but myself.
• Nobody cares about me as much I care about them.
• If I tell somebody about my business, they will use it against me.
• I am supposed to be able to handle everything.
• I shouldn't say "no" when family requests something of me.
• It's better to give help than to receive help.
• I'm being punished.
• I have to forgive those who hurt me.
• I have to forgive.

SBW Stuck Points
Prolonged Exposure Therapy (Edna Foa et al.)
Treatment that stops avoidance by:
(1) exposure to the memory
(2) exposure to things in real life avoided because of the trauma
Negative cognitions prevent healing: Pain vs. Suffering
• have realistic understanding of danger for client
before assignment of in vivos
• co-construct together
• use behavioral activation in vivos
• encourage posture of power before doing the exercise

SBW In vivo exposures
sharing emotional/personal material at various degrees with support network (thoughts, behaviors, feelings) to see if the info will be used to hurt them

Case Vignette:
24 yo AfAW is depressed and has PTSD secondary to MST. Is caring for her older sister in chemo often at the expense of her school work, job and home responsibilities. Does not currently participate in any social or recreational activities. Reports loving her sister and all her sisters and family “to death.” Suffers from severe migraines and gastrointestinal problems, takes medications.

Problems:

Promise:

Identify stuck points (CPT)

In Vivo Exposure (PE)


Case Vignette:
24 yo AfAW is depressed and has PTSD secondary to MST. Is caring for her older sister in chemo often at the expense of her school work, job and home responsibilities. Does not currently participate in any social or recreational activities. Reports loving her sister and all her sisters and family “to death.” Suffers from severe migraines and gastrointestinal problems, takes medications.
SBW Problems:
1. care-taking at expense of personal well-being consistently – no break for self-care
2. self-reliance – trying to do it all with no help
3. affect regulation – somatization of feelings is possible.

Promise:
1. connected to family and potential support
2. capable
3. in therapy – so part of her understands and accepts she needs support – and she can practice in therapy what she needs to do in the real-world

Identify stuck points (CPT)
• caretaking: “You can’t say no to family... saying no doesn’t mean you don’t care.”
• self-reliance: “I should be able to handle this, my mom did.” … otherwise I’m weak.”
• affect-regulation: “Crying means your weak.” “When you’re vulnerable, you get hurt.”

In Vivo Exposure (PE)
in vivos – ask for assistance (start at stores, then strangers, then friends, family; directions, opinions about benign things then personal)



Problems:

Promise:

Identify stuck points (CPT)

In Vivo Exposure (PE)
African American female, age 55, 1 adult child, married. Regal woman, meticulous appearance, husband drops her off at every session. He cooks, cleans, while she paces during the day and watches the video monitor like a television program at night. Verbalizes shame and low self-esteem. Attempted unsuccessfully to engage in TFT twice before but dropped out of pre-treatment education (i.e., PTSD 101 class) without warning. Labeled as treatment resistant.
Case Vignette
Problems:
affect regulation – meticulous appearance disguises the chaos on the inside

Promise:
acceptance of support from husband which can be generalized to others

Identify stuck points (CPT):
“I am incapable of keeping myself safe.”

Construct in vivo hierarchy (PE):
sitting watching t.v. for one hour during day and one hour at night without safety behaviors

Conclusions
"When you learn - teach. When you get - give."

Dr. Maya Angelou
Affect
reg.
to mask neg. emotions
Full transcript