Look to the relationship: a review of African American women substance users' poor treatment retention and working alliance development

"Every time I tell my story I learn something new": Voice and inclusion in research with Black women with histories of substance use and incarceration

While current ethical procedures aim to minimize risks to imprisoned individuals, there is heightened awareness of the need to protect those who participate in research post-incarceration while under community-based supervision. Formerly incarcerated women, in particular, face myriad challenges to community reintegration which also make them vulnerable participants in research. As such, this study explores how 28 formerly incarcerated Black women experience the qualitative research process. Findings revealed that women engaged in research because these contexts were viewed as therapeutic spaces for raising awareness that can help others. Moreover, the interview process allowed women to share their pasts in ways that promote their recovery from addiction. Participants also reported risks of emotional distress and fears regarding researcher stigma. The implications for trauma-informed interviewing practices underscore the need for greater considerations of the role of the researcher, research environment, and how they contribute to one's personal recovery.

Work-in-progress: Focus groups evaluate and inform revisions of a socio-behavioral health intervention

African American men and women are disproportionately impacted by HIV/STI risk. Particularly, African American women are more likely to be infected with HIV from heterosexual sex. Yet, much of the intervention research has focused on men who have sex with men. This article describes the development and feasibility study of a six-session socio-behavioral health intervention that utilized sociodrama to reduce substance use and HIV/STI risk among heterosexual, African American men and women who have multiple sex partners. The intervention was developed based on theories and models of critical consciousness, social scripts, and group work practice. Content and delivery were informed by qualitative data collection with a range of stakeholders including service providers and members of the target population. The resulting intervention was six group sessions, delivered by two licensed social workers, with one of the facilitators trained in sociodrama. The results of the qualitative study explored the feasibility of conducting this six-week intervention and evaluated a trial run of the intervention. The data was obtained through focus group interviews and observations. Findings revealed that the intervention could be delivered with fidelity and was acceptable to participants and indicated that the intervention's innovative components of sociodrama and critical consciousness resonated with the participants and has potential to reduce HIV/STI risk and substance use. Reported barriers and suggested revisions need to be examined further and addressed to develop and implement a sustainable program that can be delivered in community-based settings. A future randomized control trial of the revised intervention will evaluate the intervention's efficacy.

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

INTRODUCTION

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

METHODS

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

RESULTS

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

CONCLUSIONS

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse

BACKGROUND

The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse.

METHODS

In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model.

RESULTS

Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions.

CONCLUSIONS

The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Reducing health disparities among black individuals in the post-treatment environment

An important step in reducing health disparities among racial and ethnic minorities with substance use disorders involves identifying interventions that lead to successful recovery outcomes for this population. The current study evaluated outcomes of a community-based recovery support program for those with substance use disorders. Participants included 632 residents of recovery homes in three states in the US. A multi-item recovery factor was found to increase over time for these residents. However, rates of improvement among Black individuals were higher than for other racial/ethnic groups. Black Americans perhaps place a higher value on communal relationships relative to all other racial/ethnic groups, and by adopting such a communitarian perspective, they might be even more receptive to living in a house that values participation and involvement. The implications of these findings for health disparities research are discussed.

Transforming responses: Exploring the treatment of substance-using African American women

This article explores how intrapersonal and structural oppression may impact treatment and the recovery process of 23 self-identified African American women with histories of incarceration and substance use. Using a critical consciousness (CC) framework and content-based thematic analysis, researchers systematically coded and extracted themes and patterns from focus group data to evaluate how marginalizing processes-such as race-based discrimination-impact treatment, the therapeutic relationship, and service provision. Results indicate that participants' health and treatment were negatively impacted by oppressive factors, specifically the oppressive process of silencing. The authors discuss research and practice implications.

From Sculpting an Intervention to Healing in Action

Blacks/African Americans have the most severe and disproportionate burden of HIV of all racial/ethnic groups in the United States. Oppression (i.e., socio-structural (macro), institutional (exo), community (meso), and interpersonal (micro)), operates as four interrelated prongs that perpetuate the HIV epidemic in Black/ African American communities. Oppressive (i.e., racist and sexist) cultural scripts transferred to individuals through community, family and interpersonal relationships may play a role in HIV/STI risk. However, socio-behavioral health interventions or behavioral risk reduction interventions have traditionally focused solely on individual-level health risk behaviors allowing invisible, inequitable socio-structural factors to continue unchallenged. A new intervention, Black Men and Women: Empowering Self, Relationships and Community, was sculpted from two existing interventions Community Wise and Men of African American Legacy Empowering Self (MAALES) to develop awareness of oppressive cultural scripts operating on interpersonal and intrapersonal levels and to take action against these oppressive messages to reclaim identity, restore relationships, and build community. This paper summarizes the theory and selected sociodramatic components of the intervention that promote healing in action to reduce HIV/STI risk among heterosexually identified, low-income African American men and women with multiple sex partners. Lessons learned in theory, research and practice are also discussed.

Understanding the link between racial trauma and substance use among American Indians

Historians and scholars from various disciplines have documented the pervasive influence of racism on American society and culture, including effects on the health and well-being of American Indian (AI) people. Among the many health problems affected by racial discrimination and oppression, both historical and current, are substance use disorders. Epidemiological studies have documented greater drug and alcohol-related morbidity and mortality among AI/AN Alaska Natives compared to other ethnic groups, and culturally appropriate, effective interventions are sorely needed. We collected, as part of a larger community-based participatory research project to address substance use disparities in rural AI communities, qualitative interview data from 25 AI key informants from a frontier reservation in Montana. Using a semistructured interview guide, we asked participants to discuss their perceptions of the causes of substance use problems and barriers to recovery on the reservation. Although no questions specifically asked about discrimination, key informants identified stress from racism as an important precipitant of substance use and barrier to recovery. As one participant stated: "Oppression is the overarching umbrella for all sickness with drugs and alcohol." Participants also identified historical trauma resulting from colonization as a manifestation of race-based stress that drives behavioral health problems. Findings suggest that interventions for AIs with substance use disorders, and possibly other chronic health problems, may be more effective if they address social determinants of health such as racial discrimination and historical trauma. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A systematic scoping review of research on Black participants in the National Drug Abuse Treatment Clinical Trials Network

Black individuals experience a disproportionate burden of substance-related disabilities and premature death relative to other racial/ethnic groups, highlighting the need for additional research. The National Drug Abuse Treatment Clinical Trials Network (CTN), a research platform for multisite behavioral, pharmacological, and integrated trials designed to evaluate the effectiveness of substance use treatments in community settings with diversified patient populations, provides a wealth of research knowledge on substance use. Although CTN trials have enrolled over 5,000 Black individuals since its inception in 2000, there has been no synthesis of the findings, discussion of the implications, or suggestions for future research for Black individuals. Members of the Minority Interest Group of the CTN conducted a scoping review of published research on Black participants in CTN trials. Studies were included if the sample was more than 75% Black and/or specific findings pertaining to Black participants were reported. The review yielded 50 articles, with studies that mostly focused on baseline characteristics, followed by substance use treatment outcomes, HIV/risky sex behaviors, retention, comorbid conditions and measurement issues. This review highlighted the importance of several issues that are critical to understanding and treating substance misuse among Black people, such as the characteristics of Black people entering treatment, measurement equivalence, and engaging/retaining adolescents and young adults in treatment. There is still a continued need to identify the most effective treatments for Black individuals who use substances. The CTN offers several untapped opportunities to further advance research on Black individuals who use substances (e.g., secondary analyses of publicly available data). (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Posttraumatic Stress Disorder, Health Problems, and Depression Among African American Women in Residential Substance Use Treatment

BACKGROUND

Rates of posttraumatic stress disorder (PTSD) are high among women seeking treatment for substance use disorders (SUDs). Minority women, in particular, experience high rates of trauma and may be less likely to disclose trauma history. This article identifies items from pre-existing screening measures that can be used across settings to sensitively but noninvasively identify women with likely PTSD.

METHOD

For a sample of 104 African American women in residential SUD treatment who provided informed consent as a part of a larger randomized clinical trial, the prevalence of trauma and PTSD, as well as the relationships between trauma, health, depression, and distress, was examined. Measures included Posttraumatic Stress Diagnostic Scale (PDS), Center for Epidemiologic Studies-Depression Scale (CES-D), Pennebaker Inventory of Limbic Languidness (PILL), and Brief Symptom Inventory (BSI). Additional analyses were undertaken to determine if a subset of noninvasive items could serve to identify the presence of a probable PTSD diagnosis.

RESULTS

Most women (94.2%) reported at least one lifetime trauma, with over half (51.0%) meeting DSM-IV criteria for PTSD. Women with greater trauma symptom severity reported more health problems and higher levels of depression and distress. Five BSI items and one CES-D item were significantly associated with a probable PTSD diagnosis with a sensitivity of 88.7%, a specificity of 66.7%, a positive predictive value of 73.4%, a negative predictive value of 85.0%, and an accuracy of 77.9%.

CONCLUSION

Findings affirm that African American women with SUDs present for residential treatment with comorbid psychiatric and emotional conditions that warrant assessment and treatment. Results highlight potential benefits of brief screening with routine measures and coordinated access to ancillary psychiatric and medical services, in conjunction with substance treatment, such as in residential or primary care.

Initial abstinence status and contingency management treatment outcomes: does race matter?

OBJECTIVE

Limited research has evaluated African American substance users' response to evidence-based treatments. This study examined the efficacy of contingency management (CM) in African American and White cocaine users.

METHOD

A secondary analysis evaluated effects of race, treatment condition, and baseline cocaine urine sample results on treatment outcomes of African American (n = 444) and White (n = 403) cocaine abusers participating in one of six randomized clinical trials comparing CM to standard care.

RESULTS

African American and White patients who initiated treatment with a cocaine-negative urine sample remained in treatment for similar durations and submitted a comparable proportion of negative samples during treatment regardless of treatment type; CM was efficacious in both races in terms of engendering longer durations of abstinence in patients who began treatment abstinent. Whites who began treatment with a cocaine positive sample remained in treatment longer and submitted a higher proportion of negative samples when assigned to CM than standard care. African Americans who initiated treatment with a cocaine positive sample, however, did not remain in treatment longer with CM compared with standard care, and gains in terms of drug use outcomes were muted in nature relative to Whites. This interaction effect persisted through the 9-month follow-up period.

CONCLUSIONS

CM is not equally effective in reducing drug use among all subgroups, specifically African American patients who are using cocaine upon treatment entry. Future research on improving treatment outcomes in this population is needed.

Homeless women and hazardous drinking: screening results in a primary health care setting

BACKGROUND AND OBJECTIVES

Screening for alcohol use in primary care is underutilized, especially for women. The current study implemented systematic women's alcohol use screening in a health care for the homeless primary care program.

METHODS

All women (n=541) seeking care over 12 months were screened.

RESULTS

Of the 541 screening forms returned, 80 women refused to answer the alcohol use questions. Of 461 completed screens, over 40% reported no alcohol use, while 43.8% reported hazardous drinking. Hazardous drinking was significantly associated with younger age, African American race, and living on the street or in a shelter.

DISCUSSION AND CONCLUSIONS

High rates of drinking were identified among women in different housing situations and use of systematic screening was beneficial to providers.

SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS

Health care settings are important sites to identify hazardous drinking as well as alcohol disorders among women with unstable housing histories. The growing integration of behavioral health care into primary care, and the medical home concept, both provide opportunities for brief interventions for at-risk drinkers, as well as treatment options for those with alcohol use disorders that may be particularly appealing to women. Findings support further investigation of the relationship of housing stability to drinking, and suggest African American women may need special attention.