Depression has been characterized by symptoms including a “lack of interest and pleasure in daily activities, significant weight loss or gain, insomnia or excessive sleeping, lack of energy, inability to concentrate, feelings of worthlessness or excessive guilt and recurrent thoughts of death or suicide” (APA). Depression is the most widespread mental illness in America, affecting about 20% of the population, with women diagnosed more often than men, as women account for 7 million depression diagnoses per year (Gotlieb & Hammen, 2002; Carrington, 2006). Despite this, African American women are less likely to seek care for their depression than Caucasian women (Jones, 2007). Depression in African Americans has been under-researched and under-diagnosed, yet it has been surmised that despite this, it is probable that the rate of depression in African Americans are much higher than other races (Hunn & Craig, 2009). Depression in African American women often goes untreated due many factors such as: stigmatization, health care avoidance, health care mistrust, and psychosocial beliefs (Nicolaidis et al., 2010, Miranda et al., 2006). When depression is treated, it has been found that there are inaccuracies in assessments and diagnosis due to the differences in the manifestations of depressive symptoms in African American women (Hunn & Craig, 2009). The lack of data on African American women in clinical trials, also contributes to the misdiagnosis and under-treatment (Carrington, 2006). Thus, it is essential to identify a psychotherapy that is appropriate to this type of clientele.
When working with African American women, it is important to recognize the issues that African American women face when attempting depression treatment. Some research has shown that African Americans tend to conceal symptoms of depression and stress (as cited in Hunn & Craig, 2009) and when symptoms are discussed, the manifestation of symptoms are relatively different than the traditional symptoms of sadness, lost interests, and worthless feelings. African American women often present symptoms of anger, irritability, and self hatred; such behaviors can be misconstrued and make it difficult to diagnose and treat this disorder (Kohn et al., 2002; Hunn & Craig, 2009). As depression is a common mental illness, there are many types of psychotherapies that attempt to treat it, but which treatment might be most applicable for African American women?
Freudian psychoanalysis is arguably the first mental images people may see when they think of seeing a psychologist. Psychoanalysis is a psychodynamic theory that encompasses Freudian psychoanalysis, Adlerian psychotherapy and Jungian psychotherapy. Psychodynamic therapy attempts to understand individuals through the unconscious mind through clinical associations, therapeutic listening, therapeutic responding, and therapeutic alliance. There is a focus on childhood memories, sexual development, defense mechanisms and transference (Luborsky, O’Rielly-Landry, & Arlow, 2008; Maniacci & Mosak, 2008). Although psychoanalysis may be affective for a particular clientele, the focus on the unconscious mind may not allow for the direct discovery and treatment of depression. In addition, the transference process may not be possible with an African American client, due to the high probability that the therapist will be of another race and there may be too much of a cultural separation for transference. Thus, psychoanalysis may not be right for this clientele.
Another psychotherapy is client centered therapy, which is a form of humanistic therapy. Client centered therapy aims to focus on the client, and not the ‘problems’. The client in this therapy also guides the therapeutic process. The therapist in this form of therapy is seen as entering a unique relationship with their clients, which is unlike psychodynamic therapy. Therapists follow three core conditions in this relationship: congruence, unconditional positive regard, and empathic understanding. Therapists exhibit these conditions by being aware and accepting of experiences, accepting the client and their thoughts and feelings, and regarding their client with true understanding (Raskin, Rogers & Witty, 2008). This form of therapy may be best for the highly motivated client. As African Americans are less likely to have experienced previous therapy experiences, client centered therapy may prove to be difficult. As a result, this form of therapy might not be helpful for this clientele.
Cognitive Behavioral Therapy (CBT) brings several approaches that are not considered by other psychotherapies. CBT introduces new concepts such as collaborative empiricism, which involves the therapist and patient working together to find evidence to support or discredit the clients thoughts. Guided discovery, involves the therapist ‘guiding’ the maladaptive behaviors of the client in behavioral experiments that allow for new skills to develop (Beck & Weishaar, 2008; Wilson, 2008). The CBT approach allows clients to challenge and correct maladapted and distorted thoughts (Forsyth et al., 2010). CBT can be as effective as pharmacotherapy, which is recommended by the American Psychiatric Association as the first treatment course for depression (Forsyth et al, 2010; Jackson, 2006). However, there is stigma associated with anti-depressant use in the African American culture (Nicolaidis et al., 2010) and thus, CBT may be preferable. Therapists working with CBT may use collaborative empiricism to challenge depressive symptoms in African American women regardless of whether the traditional symptoms are presented or not. Collaborative empiricism can be used to discover if feelings of anger, irritability and self hatred are evidence based and if not, can change such feelings. Guided discovery allows for the therapist and client to work through various issues to ensure the client’s recovery.
Depression may be effectively treated with CBT, as several empirically based articles attest. Forsyth et al., reported clients who participated in a study of CBT presented less symptoms of depression, more positive thinking with a decrease in maladaptive thoughts (Forsyth et al., 2010; Coleman, Cole, & Wuest, 2010). As depression in the African American woman is under-researched, there are a lack of empirically based research articles. However, many empirical articles which focused on depression in African American women identify CBT as the preferred psychotherapy treatment for such clients. This may be due to CBT’s core concepts which enable the client to deal actively with their feelings and maladaptive thoughts. This process can positively affect clients regardless of their symptom manifestations. Miranda et al., (2006) presented a study of African American women clients assigned to different treatments. They hypothesized symptoms of depression would be lowest with the most remission rates with CBT through examination of an one year study of African American women randomly assigned to CBT, medication or community health centers. The results showed that CBT presented continued effectiveness for African American women with depression. CBT proved to have a remission rate equal to medication treatment and resulted in improved social functioning(Miranda et al., 2006). As an African American woman’s experience and culture may affect depressive symptoms, a more specialized treatment of CBT may prove beneficial.
The benefits of an adapted CBT program were presented by Kohn et al., (2002) in which a CBT program specifically tailored for African American women was studied. It was hypothesized that an adapted CBT approach specifically created to address the aspects of the African American culture would result in decreased depressive symptoms when compared to a traditional CBT treatment. Concepts of the CBT program were emphasized with figures, role-models, and anecdotes from African American culture and literature. Therapy modules were made specific to cultural issues and the African American experience. The CBT treatment was presented in group therapy sessions, which appealed to this particular clientele. When tested, it was determined that a specially adapted treatment program resulted in decreased depressive symptoms (Kohn et al., 2002). These results further support evidence that CBT, particularly in a group setting, works for African American women. A study by Jones (2008) determined that evidence based treatment, such as CBT, in a group setting resulted in improvement for clients and the group environment is particularly advantageous for working with this particular population. A group setting allows for a client to experience camaraderie with other group members when there is cultural and gender similarities (Jones, 2008). However, for clients new to therapy or for clients with unique problems, it may be favorable to begin with initial one-on-one sessions.
While depression treatment in African American women will continued to be studied until much more empirical evidence has been obtained, it appears that CBT provides auspicious evidence of having a beneficial affect on such clientele. CBT provides an impressive array of therapeutic tools in which the African American depressed client may advance past cultural and societal barriers to improve their psychological disorder. As CBT can be made adaptable and customizable for clients, it further allows for this clientele to ensure they are getting the most out of their therapeutic experience. Consequently, of the aforementioned psychotherapies, CBT presents the most concepts than can be adapted for applicable treatment with African American women.
References
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