THE RISK AND PROTECTIVE FACTORS FOR DEPRESSION AMONG AFRICAN AMERICAN PROFESSIONAL WOMEN: A GROUNDED THEORY STUDY By Heather C. Lofton A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Human Development and Family Studies – Doctor of Philosophy 2018 ABSTRACT THE RISK AND PROTECTIVE FACTORS FOR DEPRESSION AMONG AFRICAN AMERICAN PROFESSIONAL WOMEN: A GROUNDED THEORY STUDY By Heather C. Lofton For African Americans (AA) who experience discriminatory events or interactions, this can lead to psychological and physiological responses, producing adverse changes in mental health. Factoring in race, mental health disorders such as, depression among AAs is more pronounced, accounting for inadequate treatment, comorbid medical and psychiatric illnesses, socio-ecological status, and joining cultural factors. Highlighting the relationship between race, sex and depression, African American women (AAW)—who encounter multiple oppressions such as sexual objectification and gendered racism—are most vulnerable to depressive symptoms and ineffective coping behaviors such as desensitization and internalization. Within the AA female population is a sub group of women navigating their dual minority status, in addition to the identity of a professional. African American Professional Women (AAPW) encounter differential professional experiences when compared to their white female counterparts, experiencing the weight of social inequity and objectification both in and out of the workplace. The experience of mental health concerns such as depression among AAPW, exposes the unique intersections of racism, sexism, oppression, power, and resilience. To further analyze depression among AAPW, resilience theory and stress theory will serve as the primary guiding frameworks, supported by the historical theoretical grounding of black feminist theory and critical race theory. This grounded theory study seeks to build a conceptual framework, exploring and explaining the risk and protective factors for depression among 15 AAPW from a large Midwestern city, withholding high status occupations because of their high achieving academic history. This study conclusively seeks to contribute to research on the experience of mental health constraints among an underrepresented yet growing population. ACKNOWLEDGEMENTS I would like to acknowledge the contributions of those who have prayed, supported and, assisted me during the completion of my doctoral degree. I am overwhelmed with love and gratitude for the people who have guided me through this process. To George and Felecia Lofton, I am eternally thankful God chose you to be my parents. You taught me how to lean into the discomfort and to trust God and the process. You gave me everything I needed to become the black female scholar I am today. I also wish to separately thank all the phenomenal women in life, my mother, godmothers, aunts, sisters and best girlfriends, for enriching the meaning of black female identity and privileging my experience as a black woman. To my dissertation committee, I thank you for mentoring and guiding me through the growing pains of becoming a Doctor of Philosophy. I am honored to have learned from each of your expertise. I would also like to give a special thanks to my chair and co-chair, Dr. Carolan and Dr. Johnson, for not only believing in me but my research interests as well. You have helped me recognize my voice as a researcher and the power of qualitative research. Lastly, I thank my brave research participants for inviting me into their intimate experience as a black female professional. I admire the strength and vulnerability present when discussing the societal stressors and mental health concerns you each have endured while simultaneously excelling in your career. iv TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES CHAPTER ONE: INTRODUCTION Significance of Problem Purpose Rational Definition of Terms and Theoretical Constructs African American Professional Women Depression Intersectionality Strong Black woman persona Racial socialization Ethno-gendered socialization Resilience theory Black feminist theory Stress theory Critical race theory Summary of Methodology Research design overview Qualitative design approach Grounded theory approach Sampling and participants Recruitment procedure Inclusion and exclusion criteria Data collection Data management Data analysis Trustworthiness Credibility Summary of Manuscripts ix x 1 1 3 4 4 4 5 5 6 7 8 10 10 10 11 11 11 12 13 13 14 14 15 15 15 16 17 17 CHAPTER TWO: STUDY ONE: Exploring Resilience and Ethno-Gendered Socialization as Protective Constructs for Coping with Depression among African American Professional Women: A Grounded Theory ABSTRACT Introduction Literature Review The Relationship Between African American Women and Mental Health African American female identity Intersectionality v 18 18 19 20 20 21 21 Results Trustworthiness Black feminist theory Resilience theory Racial socialization Ethno-gendered socialization Open and axial coding Socialized understanding of depression Socialized experience of depression Socialized coping with depression Spirituality Sisterhood Mentorship Physical activity Internalized/Silenced Stress induced Emotional Familial Socio-cultural Individual Participants Data collection Data analysis Methods Findings Guided Theoretical Frameworks Socially constructed images of black women Strong black persona Theoretical Concepts linked to the findings and Grounded Theory Discussion and Implications Conclusion APPENDICES APPENDIX A: Study Consent Form APPENDIX B: Study Recruitment Form APPENDIX C: Patient Health Questionnaire (PHQ-9) APPENDIX D: Interview Protocol REFERENCES CHAPTER THREE: STUDY TWO: Exploring the Risks of Microaggressions, Racial Discrimination, and Sexual Harassment for Depression among African American Professional Women: A Theoretical Perspective ABSTRACT Socialized understanding of depression Socialized experience of depression Socialized coping with depression 22 22 23 23 24 25 25 26 26 27 28 28 31 32 32 33 33 33 34 34 34 34 34 34 35 35 35 35 39 39 39 40 41 43 46 47 48 51 52 53 55 Grounded theory 62 62 vi Findings Risk factors Introduction Literature Review Critical race theory Stress theory Depression Mental health engagement Stigma Desensitization of symptomatology Methods Participants Data collection Data analysis Results Trustworthiness Open and axial coding Stress risk Allostatic load Life events Mental health risk Professional risk Depression spectrum Desensitization Poor Mental Health Care Engagement 63 64 The Relationship between African American professional women and Mental Health 64 64 65 66 66 67 African American Professional Women and Workplace Discrimination 67 67 Guided Theoretical Frameworks 67 68 69 69 70 71 71 74 74 74 75 75 75 75 76 76 76 76 76 76 77 80 80 81 81 82 83 85 87 88 91 92 93 95 Theoretical Concepts linked to Findings and Grounded Theory Workplace oppression Workplace isolation Navigating Racial Tensions Grounded theory Stress risk Mental health risk Professional risk Discussion and Implications Conclusion APPENDICES APPENDIX A: Study Consent Form APPENDIX B: Study Recruitment Form APPENDIX C: Patient Health Questionnaire (PHQ-9) APPENDIX D: Interview Protocol REFERENCES vii Cultural competent care Study strengths CHAPTER FOUR: CONCLUSION Overarching Implications for Practice and Research APPENDICES APPENDIX A: Study Consent Form APPENDIX B: Study Recruitment Form APPENDIX C: Patient Health Questionnaire (PHQ-9) APPENDIX D: Interview Protocol APPENDIX E: IRB Exempt Status REFERENCES 101 102 102 103 105 106 109 110 111 113 116 viii LIST OF TABLES 77 36 TABLE 1.0 STUDY ONE TABLE OF THEORY AND RESEARCH QUESTIONS 30 TABLE 1.1 STUDY ONE EMERGING QUOTES TABLE TABLE 2.0 STUDY TWO TABLE OF THEORY AND RESEARCH QUESTIONS 73 TABLE 2.1 STUDY TWO EMERGING QUOTES TABLE ix LIST OF FIGURES 31 38 73 79 FIGURE 1.0 MAP OF FORMAL THEORY FIGURE 1.1 MAP OF GROUNDED THEORY FIGURE 2.0 MAP OF FORMAL THEORY FIGURE 2.1 MAP OF GROUNDED THEORY x CHAPTER ONE: INTRODUCTION Significance of Problem Depression is a persistent public health concern among women of varying racial/ethnic backgrounds and socioeconomic statuses (Brown, Bromberger, Schott, Crawford, & Matthews, 2014). In fact, the lifetime prevalence rates indicate that 21.3% of women live with this mental health condition (Noble, 2005). The U.S. mental health care system consistently overlooks the experience of mental health disorders among minorities with respect to prevention, treatment methods, and overall research (Hunn & Craig, 2009). African American women (AAW) with depression are among those overlooked populations (Hunn & Craig, 2009). While there is research that approximates the incidence and prevalence of depression among AAW, that research is quite limited by generalizations and inconsistent reported estimates on rates of depression (Hunn & Craig, 2009). When accounting for socioeconomic status, increased rates of depression among low-income AAW have been accurately identified, concluding with the finding that these women are subject to increased levels of stress, advancing the opportunity for depression among other mental health disorders (Nadeem, Lang, & Miranda, 2008). Yet, the components of the overall experience need further exploration as well. While it is evident that low-income AAW are at high risk for mental health concerns such as depression, little is known regarding culturally competent treatment and prevention methods (Nadeem et al., 2008). When factoring in the internal stressors of racism and social context, depression among low-income AAW is understood to be associated with other hazardous behaviors such as drug use and violence, conclusively altering current understanding of depression as an illness and the way it is then treated (Nicolaidis, Timmons, Thomas, Waters, Wahab, Mejia, & Mitchell, 2010). While these results are imperative to research focused on AAW and mental health constraints, such as 1 depression, such results are not representative of additional lived experiences among black women. As a result of these findings, the most prevalent topic of research concerning depression among AAW is the relationship between mental health, racism, sexism, classism and the multiplicity of black female identity and experience. The National Survey of Black Americans gathered data on the relationship between perceived discrimination and health status as well, uncovering that baseline societal racial discrimination is associated with poor mental and physical health, regardless of the severity (Schulz et al., 2006; Brown, Williams, Jackson, Neighbors, Torres, Sellers & Brown, 2000). While the previous findings are generalized to the AA population, discrimination and mental health can disparately impact communities within this population. In a study looking at longitudinal data of AAW living in the city of Detroit, Michigan, researchers examined the relationship between discrimination and depression, tracking the experience of perceived discrimination over time alongside depressive symptomatology (Schulz, Gravlee, Williams, Israel, Mentz & Rowe, 2006). Results from this study showed that consistent encounters with discrimination are causally related to poor mental health outcomes for AAW, specifically targeting the outcome of depression (Schulz et al., 2006). Within the AA population are specific identities that should be explored considering the weight of oppression and its diverse negative effects on mental health. African American professional women (AAPW) are among those isolated communities of AAs. According to Cross (1991) there is a complex nature to the history of AA identity development and the association with mental health. Dating back to the Black Power movement, AAs were beginning to utilize strength within the community, exposing a positive change in self-esteem development, after making advancements and social strides never accomplished before (Cross, 1991). As more 2 social and professional doors opened for black men and women, these changes allowed for a significant expansion of black identity, venturing into higher social status, professionalism and financial stability, each sustained by the transformations of black identity (Cross, 1991). As black identity began to expand, and black people were able to live beyond pre-determined identities dictated by historically constraining factors (e.g. slavery, Jim crow, segregation), the experiences of oppression did not vanish (Cross, 1991). Not only are men, and more specifically women, challenged by the encounters of racism and sexism, but in addition to the hardships of vocational development as well (Richie, Fassinger, Linn, Johnson, Prosser, 1997). Therefore, AA women are triumphantly progressing in society, attaining social and professional status, ultimately advancing black identity and experience, while still being psychologically strained by ever present encounters with interlocking systems of oppression. Purpose This qualitative study has two objectives. First, to investigate the experiences and coping mechanisms for depression among AAPW, highlighting the intersection of race and sex. The first manuscript will focus on depression among AAPW, while exploring resilience theory and ethno-gendered socialization as influential and protective constructs. The research questions guiding this task were: 1. What are the protective factors for AAPW coping with depression? 1a. What are the influences of ethno-gendered socialization? 1b. What are the influences of familial, social support? 1c. What are the influences of spirituality? The second goal of this study explores stress theory and critical race theory to explain the experience and risks of micro-aggressions, racial discrimination and sexual harassment in the 3 workplace for depression among AAPW. Given the increasing population of AAW joining the executive work field, challenges explored with mental health can inform treatment methods. The research questions guiding this goal will be: 2. What are the risk factors for AAPW coping with depression? 2a. What are the intersections of being AA, a woman and a professional? 2b. What are effects of racial discrimination in the workplace? 2c. What are the effects of sexual harassment in the workplace? 2d. What are the effects of microaggressions in the workplace? Rationale There is evidence that for many AAPW, recurrent exposure to discriminative environments, such as the professional workplace can induce psychological distress and the onset of depression (Buchanan & Fitzgerald, 2008; Brown et al., 2000). Given the weight of intersecting systems of oppression, and vulnerabilities concerning ethno-gendered subjugation, the experience of depression among AAPW requires mental health research attention, as it is in addition to the experiences of depression among AA non-working women and AAW working non-white-collar occupations. With the principles of qualitative research methodology and the conceptual framework of grounded theory, this research approach seeks to build a more inclusive representation of the AA female identity in mental health research, by focusing on depression among AA women who occupy high status professional positions. Definition of Terms and Theoretical Constructs African American Professional Women. For this qualitative study the term African American professional women (AAPW), will define individuals who 1.) identify with being a 4 biological female, 2.) identify with being of Black/African American decent and 3.) currently obtaining a white-collar occupation. Depression. According to the National Institute of Mental health, the term depression is relatively common mood-altering experience, which can transition into a consistent mood disorder (NIMH, 2018). The onset of depression can be a result of biological factors or situational factors, encompassing life events and social constraints. While there are varying different forms of depression, the most common form can severely affect an individual’s daily routine and ability to function, impeding general feelings and thoughts (NIMH, 2018). Symptomatology of depression can range, from acute to severe, noticing irritability to the experience of suicidal ideation (NIMH, 2018). Intersectionality. Prior to the concept of intersectionality and the appropriate theoretical foundations for ethno-gendered experiences, AAW were researched based on the standard of Eurocentric ideology and the perception of the majority racial/ethnic background (Howard- Hamilton, 2003). Researchers have just recently begun to examine the reality of intersectionality and the salience of the term, concerning work with racial/ethnic and sex minorities across many disciplines. The term intersectionality defines the experience, meaning and ramifications of intersecting categories of socio-cultural group membership (Cole, 2009). The rubric of intersectionality was developed from the theoretical grounding of feminism and critical race theory (Cole, 2009). Psychologists are among the many researchers increasingly concerned with the effects of the intersecting nature of race/ethnicity, sex, social class, and sexuality (Cole, 2009). Outcomes such as, mental and physical health and well-being, personal and social identities, political views and participation, are among the concerning results under investigation (Cole, 2009). There is little known research focusing on the effects of the relationship between 5 race and sex, in addition to literature isolating the two terms and correlating them with issues such as mental health. While, increased scholarly attention has begun to focus on the multidimensional aspects of people and their experience with mental health, the importance of applying multiple contextual factors in comprehending and treating psychological phenomena has not yet surfaced in mental health practice (Banks & Kohn-Wood, 2002). Extrapolating the dimensions of race and sex, can serve as an aid for analysis of current research focused on sex and race variations in mental health concerns such as, depression (Banks & Kohn-Wood, 2002). Furthermore, securing the other forms of membership, such as occupational positionality can provide a context for mental health research that addresses the intersecting experience of mental health among racial ethnic minorities, specifically AAW. Strong Black woman persona. African American women have had to navigate and combat the complex journey of being black and being a woman, for centuries. Combining the weight of socially constructive images with the narrative of slavery, black feminism and identity development have withstood a great struggle. Amidst these historical restrictions, AAW have grown accustomed to maintaining the structure of the black community. The construct of the strong black woman schema (SBW) is a response to the stigma of the aforementioned images, ultimately portraying a woman who can complete all tasks and withstand all challenges, with seemingly no psychological challenge or maintenance. The foundation of being strong in the AA community has a positive and consistent connotation yet bares a lot of pressure to uphold that archetype, with many disadvantages for the AAW that are challenged by the task of living within those socially constructed parameters (Walker- Barnes, 2009). The concept of strength the in the black female community has transformed over time, encompassing many different meanings, while solidifying the experience of intersectionality (Walker-Barnes, 2009). 6 Displaying unmoving emotional resilience, AAW are assumed to be able to permit the psychological stress of loss, traumatic events, and oppressions without an emotional response (Walker-Barnes, 2009). Proving to be immune to the burdens of navigating multiple roles, a study by Abrams, Maxwell, Pope and Belgrave (2014) reviewed the varying constructs of the SBW schema through thematic analysis. With the research goal of exposing the characteristics of constructs built off the SBW schema are superwoman schema, sojourner truth syndrome, sisterella complex Abrams et al., 2014). The thematic results compiled the reported characteristics of SBW resulting with 1. Embodies, and displays multiple forms of strength 2. Possesses self -ethnic pride, in spite of intersectional oppression 3. Embraces being every woman and 4. Anchored by religion and spiritualty, uncovering the intricacies and expounding on the experiences of 44 diverse AA women, researchers revealed that the mental and physical health outcomes of SBW characteristics are worth substantive examination and exploration of the term (Abrams et al., 2014). Supporting that conclusion, researchers Donovan & West (2015), revealed that AAW are experiencing high levels of identified stress symptoms, yet low expression of distress, resulting with the notion that SBW has a high tolerance for stress. As a result of the SBW persona, AAW have been triumphant in overcoming adversities, yet their coping mechanisms have been in the form of stoicism, silence and selflessness, ultimately an unconscious self-suppression of their symptoms (Donavan & West, 2015; Beauboeuf-Lafontant, 2008). Racial socialization. Literature on racial socialization primarily examines the transference of information and developmental life skills from parents to their children (Hughes, Rodriguez, Smith, Johnson, & Stevenson, 2006). In the development of AAs, racial/ethnic socialization has been linked to ecological predictors, barriers and buffers during childhood 7 (Hughes et al., 2006). Further investigating the salience of racial socialization among AAs, the messages received from parents and/or society have been linked to aiding the coping process with racial/ethnic discrimination and other vulnerable processes such as ethnic identity development, academic achievement and self-esteem (Hughes, et al., 2006). The presence of discrimination, prejudice and racism marginalize racial/ethnic minorities, creating a division of race and socialization of many groups (Brown & Lesane-Brown, 2006). Therefore, the construct of racial socialization emphasizes the importance of in-group authentic attachment, fulfilled by messages and teachings of AA history (Lesane-Brown, Brown, Tanner-Smith, & Bruce. 2010; Brown & Lesane-Brown, 2006). In a study conducted by Caughy, Nettles & Lima (2011), 281 AA parents were profiled via self-report and observation, based on their perceived racial socialization practices. The parents participating were tested into four different racial socialization categories: silence about race, emphasis on cultural socialization, emphasis on cultural socialization and coping strategies and balanced combination (Caughy et al., 2011). The most harmful of the racial socialization categories, was “silence about race” most prevalent among AA parents of male children (Caughy et al., 2011). Whereas, parents of female AA children received most messages centered on cultural socialization (Caughy et al., 2011). Variables such as negative social climate, community involvement and socioeconomic status, influenced how and what messages parents delivered to their children (Caughy et al., 2011). While AA young girls are more likely to be well-socialized regarding culture, cultural socialization alongside coping strategies was most associated with fewer negative childhood behaviors (Caughy et al., 2011). Ethno-gendered socialization. The concept of ethno-gendered socialization refers to the way individuals were exposed to and taught values and perspectives on race and sex combined 8 (Thomas & King, 2007). Ethno - gendered socialization serves as a method of survival for many AAW navigating a society that systematically marginalizes their positionality based on race and additionally sex (Scottham & Smalls, 2009). For AA young women, ethno- gendered socialization is most often first navigated in institutional academic settings (Ogbu, 1981). It is also during this introduction to academic institutions, where parents begin to personalize their socialization competencies based on sex (Ogbu, 1981; Brown, Linver, Evans, & DeGennaro, 2009). Ethno-gendered socialization has been researched alongside academic performance substantially, finding that sex and gender informs and shapes the way AA young women experience academic settings, and respond to the systemic oppressions (Fordham & Ogbu, 1986; Brown et al., 2009). In a study focusing the influences of academic discrimination and racial identity on the outcome of academic achievement among AA adolescent men and women, there are a few moderating effects on the relationship between the experience of academic discrimination and academic success (Chavous, Rivas-Drake, Smalls, Griffin 7 Cogburn, 2008). Socioeconomic status and racial centrality were the more prominent moderators for the effects of academic discrimination and academic outcome for both males and females (Chavous et al., 2008). Racial centrality was found to be a protective factor against peer discrimination, targeting academic sense of self and academic salience among AA female adolescents (Chavous et al., 2008). These results support the idea that through ethno-gendered socialization the importance of in group attachment is presented and later serves as a protective factor, in the form of racial centrality among AA adolescent women, experiencing racial discrimination and its effect on academic outcomes (Chavous et al., 2008; Lesane-Brown, Brown, Tanner-Smith, & Bruce. 2010; Brown & Lesane-Brown, 2006). Conclusively ethno- gendered socialization has been the platform for developmental skills geared towards navigating not only racisms but sexism as well. 9 AAW are most susceptible to the unique challenges of the intersection of racial and gendered identity development, ultimately leaving them vulnerable to the experience of racism and sexism (Thomas & King, 2007). Resilience theory. Resilience as an individual construct uncovers the systemic nature of overcoming adversity, while highlighting personal traits or attributes (Masten, 2014). Analyzing resilience systemically is necessary to recognize disadvantageous conditions, possibly adding to or maintaining stressors, such as the effects of impoverishment, mental or physical illness, and/or the experience of traumatic events (Walsh, 2003). Resilience theory has evolved over the past decade, acknowledging that resilience processes are not monolithic (McCubbin & McCubbin, 2013). The diversity among resilience processes now encompass the nuances of culture, promoting culturally competent resilience research (McCubbin & McCubbin, 2013; Ungar, 2008). Black feminist theory. Black feminist theory was designed to give voice to the experiences of marginalized and unrepresented AA men and women in research (Howard- Hamilton, 2003). According to Collins (1990), black feminist theory is a school of thought that empowers AAW to be the agents of their own lives. For AAW experiencing mental health concerns, such as depression it is important to learn more about the intimate details of those experiences with the intent to inform mental health treatment. Stress theory. The elements of stress have been researched in relationship to the negative effects of socio–environmental demands, in addition to the lack of and present struggle to attain resources (Anehensel 1992, Lazarus & Folkman, 1984). According to Lazarus, psychological stress refers to the relationship between an individual and their environment (2009). That stress relationship is most apparent when the environmental demands tax or exceed the resources 10 available to decrease the severity of the stress relationship. The experience of workplace discrimination will be explored uses stress theory, to highlight the psychological risk for depression among AAPW. Critical race theory. Critical race theory is used to build an understanding around the concepts power and race, addressing hegemonic practices that oppress minority populations (Haskin & Singh, 2015). When applying this theory to the lives of AAPW, the salience of their intersecting identities becomes more apparent (Howard-Hamilton, 2003). Prior to the concept of intersectionality and the appropriate theoretical foundations for ethno-gendered experiences, black women were researched based on the standard of Eurocentric ideology and the perception of the majority racial/ethnic background (Howard-Hamilton, 2003). Summary of Methodology Research design overview. This qualitative study has dual purpose; first to investigate the experiences and coping mechanisms for depression among AAPW, highlighting the intersection of race and sex, alongside the socio-historical relationship between black women and mental health. The first manuscript focuses on depression and the relationship to cultural resilient factors, while exploring ethno-gendered socialization as an influential and protective concept. The second manuscript and goal are to explore the experience of racial discrimination, microaggressions and sexual harassment as mental health risks in the workplace among AAPW, explaining this these risks using stress theory and critical race theory. Given the increasing population of AAW joining the executive work field, challenges explored with mental health can inform treatment methods. This research study has an exploratory qualitative research design, following the tenants of a constructivist grounded theory approach. Qualitative data was collected through in-depth, 11 individual interviews, with 15 AAPW that met the study eligibility requirements. By using qualitative methodology, researchers can begin to explore the nuances of AAPW’s identity and their relationship to depression, providing insight on the presence of depression and the underlying components for its manifestation and maintenance. Data analysis involved the processes of open coding, axial coding and selective coding facilitated by NVIVO software. Throughout this process actions were taken to ensure trustworthiness of the research findings. Qualitative design approach. Qualitative research is a distinct field of inquiry, designed to achieve an in-depth understanding and competence of social processes, as well as the meanings people draft and attribute to their experiences (Merriam, 2009; Serry & Liamputtong, 2013). Following specific methodological approaches, researchers that follow the tenets of qualitative work, immerse themselves into the social context of the population being researched (Fischer, 2009) A constructivist grounded theory qualitative approach guided by the lenses of resilience theory, stress theory, black feminist theory and critical race theory, will be used to lead data collection and data analysis (Charmaz, 2000; Charmaz, 2006). By utilizing a qualitative research approach, a clear and concise understanding of a phenomena can then be closely examined through systemic analysis and presented to accurately report a detailed investigation of a community of people (Serry & Liamputtong, 2013; Creswell, Hanson, Clark Plano, & Morales, 2007) Therefore when using qualitative methodology the researcher upholds a purely subjective position, versus data collection being fueled by the intent to find specific information (Dodgson, 2017). It is imperative to qualitative research that the researcher considers the multiple views of reality and varying perceptions and experiences of people (Serry & Liamputtong, 2013). For example, by following the theoretical foundation of qualitative work, researchers can gather the information straight from the source with the intent 12 to inform other researches of the findings, ultimately encouraging a continuation of more thorough research focusing on the same population (Fischer, 2009). Researching underserved and underrepresented populations such as the AAPW community while being guided by qualitative research methodology, allows for the voices of marginalized communities to be heard; hence the reason why qualitative methods are most capable of researching the intricacies and complexities of social change and the human experience (Snap & Spencer, 2003). Capturing the essence of a community perspective, requires data collection methods that place the participant at the center of the meaning making process, conclusively building a representation of community at large (Snap & Spencer, 2003). Grounded theory approach. Constructive grounded theory will guide the data collection and analysis process. Grounded theory is a methodology used to develop concepts and theory emerging from data that is systemically collected and analyzed using open coding, axial and selective coding (Corbin & Strauss, 2014). Grounded theory methodology explicitly requires producing theory while conducting social research as a simultaneous process (Walker & Myrick, 2006). A constructivist approach to grounded theory allows the researcher to employ a more involved position in the research, in the form of an active research instrument (Miller & Salkind, 2002). According to Miller and Salkind, a constructivist researcher "makes decisions about the categories throughout the process, brings questions to the data, and advances personal values, experiences, and priorities” (2002). With this method the researcher can constantly refer to and compare the analysis and data, ensuring the validity of the theories developed and highlighting the need for further investigation and elaboration. (Glaser, 2002; Corbin & Strauss, 2014). Sampling and participants. For this study, a snowball sampling method was used to recruit participants from a Midwestern metropolitan city, where a large AAPWs community 13 resides. Currently in this location, AAW are upholding executive positions at corporations, tenured faculty positions at nationally ranked universities, becoming partners at major law firms and physicians with many accolades. The inclusion and exclusion criteria were decided based on current research focused on depression among women, using specific cohort criteria (e.g., age, SES, race, etc.) Currently depression research primarily targets four separate age groups of women, scaling from adolescents (13-16), to emerging adults (18-25), to adults (30-55) and late (60 +) life adults. For this study the target age group of AAPW is adults ages 35-55, to ensure substantive labor force involvement to and life experience to support the presence of depressive symptoms. In addition, the use of the Patient Health Questionnaire (PHQ-9), was determined based on the extensive empirical validity and use of the depression assessment tool, furthermore the current research findings suggesting its effective use with minority populations (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006). Recruitment procedure. The recruitment process was executed by the primary investigator (PI), along with social network assistance. Female professional network assistance defines the previously developed relationships with various AAPW and requesting access to their professional female network. By contacting community leaders of elite minority organizations, active professionals in corporations and institutions/universities and explaining the elements of the study, soliciting participants began. A snowball sampling method was used, relying on participants who agreed to be a part of the study to recruit additional participants if needed. Voluntary representatives from varying occupational fields served as recruitment leaders for their designated field. Once the targeted number of desired participants was reached, participants were made aware of the study and interviews were scheduled individually. 14 Inclusion and exclusion criteria. In order to be considered for inclusion in the study, individuals have to meet the following criteria: 1.) racially identify with African American decent, 2.) identify with being a biological female, 3.) be between the ages of 35-55 years old, 4.) have college experience or a college bachelor’s degree, 5.) confirm 2 or more years of active involvement in the white collar labor force, 6.) identify with acute to moderate depression severity, according to the Patient Health Questinnaire-9 (Appendix C) and 7.) provide written consent for participation in the study. Any prospective participants will be excluded if they fail to meet the inclusion criteria or if they identify with the following: 1.) have a serious diagnosed mental health condition, upon verbal confirmation (e.g. Borderline personality disorder) that impedes their ability to participate in the study, 2.) prior treatment and formal diagnosis of depression upon verbal confirmation and 3.) present with a substance abuse problem upon verbal confirmation. After successfully passing the inclusion criteria and verbally consenting via phone, in person or via email, the SI will individually schedule an interview either at the participant’s home, office or private space. Data collection. When conducting qualitative research, the role of the interviewer is critical to the desired interview outcome, a contextual interpersonal relationship is developed and must be secure (Weller, 2017). Based on the sensitive nature of the study examining mental health, it is most appropriate to conduct face-to-face in-depth interviews ensuring there is a healthy and trusted initial rapport (Creswell et al., 2007; Whiting, 2008). Data management. Ensuring proper data management, all interviews were audio recorded and the audio files are stored in password-enabled lab top folder. All paper files were protected in a confidential file cabinet with locked access. Data management was guided by the recommendation of the Michigan State Institutional Review Board. 15 Data analysis. Post transcription of each individual interview, the PI conducted a thorough analysis of the data guided by grounded theory and observed through the lenses of black feminist theory, critical race theory and resilience theory. As reviewed, grounded theory analysis, promoted the production of theory and conceptual frameworks (Strauss & Corbin, 1998). Data was coded using NVIVO software (QSR International, 2016). The innovative NVIVO software is an analysis system that supports qualitative and mixed methods research (QRS International, 2016). NVIVO serves as an organizational aid for analysis of unstructured data ranging from interviews to open ended surveys (QRS International, 2016). With the structured assistance of NVIVO software, data analysis followed the three-part grounded theory analytical approach (open coding, axial coding and selective coding) (Glaser, 2002; Walker & Myrick, 2006). The first step of analysis will begin with an open coding process. This will involve coding the transcripts line-by-line, being mindful of potential themes emerging within the data. In the second phase of coding, open codes will be situated into categories to solidify axial coding. The final stage will consist of selective coding, the concepts and themes will be theorized, and the conceptual framework can be developed. During the selective coding process, the SI connected the concepts and themes in a fluid manner with the goal of explaining the phenomena being researched (Glaser, 2002). To differentiate and organize each step of analysis and emerging concepts, an audit trail will be used with the intent to ensure completion of each analytical component and codify the data clearly. Trustworthiness. The term trustworthiness in qualitative research, demonstrates that the data collected presents with evidence that the results being reported are of substance and validity (Krefting, 1991). Trustworthiness is a construct of qualitative research designed to ensure the credibility, transferability and dependability of research (Lincoln & Guba, 1986; Morrow, 2005; 16 Sinkovics & Alfodi, 2012). Judging the quality of qualitative inquiry, the concepts of credibility, transferability and dependability are components of authenticity criteria (Lincoln & Guba, 1986). There are different elements of authenticity criteria (ontological, educative, catalytic and tactical) each focused on the proper construction of data and that is able to mature and improve (Morrow, 2005; Lincoln 1995). Credibility. According to Morrow (2005) the term credibility in qualitative research, assures that the findings have not been tampered with and have a substantial level of reliability and honesty. Credibility bluntly refers to the researcher’s ability to truthfully interpret the participant’s responses, securing concise representation (Polit & Beck, 2014; Cope, 2014). Due to the SI identifying with the racial and gender demographics necessary for inclusion, there is a level of familiarity that can serve as primary basis for securing the parallels between the human experiences being researched and the reality of those experiences. Summary of Manuscripts Manuscript one explores resilience theory and ethno–gendered socialization as culturally influential and protective constructs to explore the experience and coping mechanisms for depression among AAPW. Manuscript two employs stress theory and critical race theory to explore the risks of Micro-aggressions, Racial discrimination and Sexual harassment in the work place, focusing on AAPW and depression. Both studies were designed to highlight a community of AAW, that currently have limited to no mental health research attention. 17 CHAPTER TWO: STUDY ONE Exploring Resilience and Ethno-Gendered Socialization as Protective Constructs for Coping with Depression among African American Professional Women: A Grounded Theory ABSTRACT The mental health care system in the United States consistently overlooks the experience of minorities with mental health disorders with respect to prevention, treatment methods, and overall research (Hunn & Craig, 2009). African American women (AAW) with depression are among those overlooked populations (Hunn & Craig, 2009). While there is research that approximates the incidence and prevalence of depression among AAW, that research is quite limited by generalizations and inconsistent estimates of depression rates (Hunn & Craig, 2009). In building a conceptual framework for analyzing the experience of depression among a more specific minority population such as African American professional women (AAPW), the constructs and concepts of racism, sexism, power, racial identity, culture, and resilience emerged as components that should be addressed. In this study, qualitative interviews were conducted with 15 AAPW from a large Midwestern city. Using a constructivist grounded theory approach, interviews focused on exploring the diverse experiences of depression and coping mechanisms that the participants developed over time. Results are organized to show the cultural influence of ethno–gendered socialization on resilience theory as protective constructs for AAPW grappling with depression symptoms. Findings from this investigation are relevant to mental health research because they indicate a culturally specific experience of depression and the informative and protective elements of black female identity essential to coping with mental health concerns. 18 Introduction Although depression among African American women (AAW) is not a new phenomenon, there is a lack of research on the multifaceted relationship between African American (AA) female identity and mental health. According to the National Institute of Mental Health, depression is a relatively common mood-altering experience that can transition into a consistent mood disorder, and it affects both men and women of all racial and ethnic backgrounds, socioeconomic statuses, and age groups (NIMH, 2018). The onset of depression can be a result of biological factors or diverse situational factors, encompassing life events and/or social constraints. Little is known about the connections between mental health, the experiences of depression, and AA female identity. Current understanding of the experience of depression among African American professional women (AAPW) is quite limited, compared to the investigations of other AA female cohorts. Yet, the AA female professional community is growing after decades of AAW breaking barriers and enduring the pressures of societal and institutional oppressions (Pearson & Bieschke, 2001). Despite those historical strides, AAPW are still subject to historically binding social circumstances, leaving them at a high risk for developing mental health disorders such as depression (Hunn & Craig, 2009). AA women as a population must regularly navigate dominant and minority cultures, often enduring societal pressure to maintain the persona of “the strong black woman” (Davis, 2014). This image has historical roots and puts societal pressure on AAW to uphold a façade of constant self-efficiency, resilience, and inner strength (Davis, 2014). While the experience of depression can be observed among all black women, AAPW deserve specific mental health research attention because they must navigate their professional identities, along with the potential risks of their professional identities. This study seeks to acknowledge the relationship between AAPW and mental health, 19 parallel to the socio-historical development of black female identity, while exploring resilience theory and ethno-gendered socialization as influential, informative, and protective constructs for AAPW’s experience of depression, along with the actions employed to achieve healthy mental health outcomes. Literature Review The Relationship between African American Women and Mental Health Depression is one of the most prevalent mental disorders in the United States (National Institute of Mental Health, 2016). Depression affects males and females from all age groups and racial/ethnic backgrounds (Carrington, 2002). Women are twice as likely to be diagnosed with a mental health disorder, placing women at a higher risk for initial and ongoing experiences with depression (Noble, Ashby, & Gnilka, 2014; McGrath, Keita, Strickland, & Russo, 2001). AAW are vulnerable to experiencing the mental and physical challenges of depression and are subject to misdiagnosis, underdiagnosis, and overall mistreatment (Carrington, 2002). Prevalence rates reveal that AAs seeking mental health services present more depression symptoms than people in any other racial/ethnic background (Dwight-Johnson, Unutzer, Sherbourne, Tang & Wells, 2001; Carrington, 2002). Social confrontations with racism, sexism, and poverty have resulted in an increased risk of depression and other mental health concerns among AAW (Schulz, Gravlee, Williams, Israel, Mentz, & Rowe, 2006). African American women have had to negotiate multiple identities, such as being black, being women, work-life stress, and in some cases the stress of being a mother or caretaker. Each identity influences social support, mental health, and well-being (Warren, 1997). Historically, many AAPW have journeyed through careers recognizing that, in many ways, race and sex have determined their career paths, creating obstacles and barriers for potential advancement (Bell & 20 Nkomo, 2001). AAW have a long-standing relationship with societal victimization (Buchanan & Ormerod, 2002). In addition to experiencing racism in the workplace, AAPW also experience sexual harassment, which can be viewed as a psychological process affecting mental health status (Buchanan & Ormerod, 2002). While depression among AAW is becoming a topic of social discussion, the multiplicity of black female identity requires further analysis and appropriate representation, to uncover the unique intersections and relationships between race, sex, professionalism, and the experience of depression. African American female identity. Racial identity of AAs has been historically examined, regarding marginalized and stigmatized status, the development of psychological constraints, and the salience of group membership (Sellers, Smith, Shelton, Rowley, & Chavous, 1998). The updated status of research on AAW and racial identity has expanded, beginning to accommodate the growth and diversity of the AA female experience while validating the previous groundwork. One example is the research on racial identity and the experience of highly educated AAW navigating the exclusive and rigorous spaces of education and the advanced workplace (Gosine, 2008; Hall, Everett & Hamilton-Mason, 2012). Intersectionality. Despite the development of concepts such as intersectionality and the use of appropriate theoretical foundations for ethno-gendered experiences, researchers continuously study AAW based on the standard Eurocentric ideology and the perceptions of the majority racial/ethnic background (Howard-Hamilton, 2003). The term intersectionality was developed from feminism and critical race theory and is defined as the experiences, meanings, and ramifications of intersecting categories of socio-cultural group membership (Cole, 2009). Extrapolating the dimensions of race and gender identity can aid the analysis of current research, which examines the intersectionality of sex and race to explain variations in mental 21 health concerns, namely depression, among AA women (Banks & Kohn-Wood, 2002). Furthermore, confirming other forms of membership, such as occupational positionality, can provide context for mental health research addressing the intersecting experiences of mental health among racial ethnic minorities, specifically AAW. Socially constructed images of black women. AAW have historically been labeled and then stereotyped by images like mammy, jezebel, and sapphire. These images have followed AAW around as dark shadows for decades, depleting them of a sense of self and self-esteem, greatly hindering their social advancement (Brown Givens & Monhan, 2005). Over time, images like the jezebel have placed AAW at high risk for sexual harassment and sexual assault (Davis & Tucker-Brown, 2013). This is primarily due to the salience of socially constructed stereotypes defining the womanhood and sexuality of black women based on Eurocentric ideologies of behavior and an incessant socio–historical denial of the long history of sexual abuse against AAW (Gillum, 2002; Davis & Tucker, 2013; Brown Givens & Monahan, 2005). Likewise, the socially constructed image of the sapphire punishes AAW who demand respect and encourages them to be passive (West, 1995). Reclaiming AA female identity is essential to combat harmful portrayals of AAW that influence their well-being in social situations, such as job-seeking, mothering, partnering, and being a consumer (Brown Givens & Monahan, 2005). While many of these images are bygone they each remain relevant in the lives of AAW today. Strong black persona. The construct of the strong black woman (SBW) schema is a response to the stigma of the aforementioned images, ultimately portraying a woman who can complete all tasks and withstand all challenges with seemingly no psychological effort or maintenance. The idea of being strong in the AA community has a positive and consistent connotation, but there is a lot of pressure to uphold that archetype, which creates many 22 disadvantages for AAW living within those socially constructed parameters (Walker- Barnes, 2009). Several recent studies have looked at the SBW schema and have recognized the potential for harm and the high levels of stress associated with this status (Abrams, Maxwell, Pope, & Belgrave, 2014; Donovan & West, 2015). Because of the SBW persona, AAW have been triumphant in overcoming adversities, but their coping mechanisms have been stoicism, silence, and selflessness, often leading to an unconscious self-suppression of symptoms such as depression (Donavan & West, 2015; Beauboeuf-Lafontant, 2008). While there is research that examines the coping strategies for depression among AAW, there is little known about how AAPW overcome the adversities of depression. Vulnerabilities of AAPW are often unseen or hidden to maintain a strong black persona, but this fact does not negate their troubling mental health experiences or the challenge of developing coping mechanisms. Guided Theoretical Frameworks Black feminist theory. Using black feminist theory to address depression among AAPW ensures that this group’s diverse identities are accurately represented. Black feminism encourages a more in-depth understanding of self-identity, family structure, and societal presence and representation (Collins, 1986). When reviewing the relationship between mental health status and racialized and gendered historical oppression, the experiences of AAPW have not received enough attention. Specific attention to the interlocking systems of simultaneous oppressions is at the center of black feminism, serving as an aid to address the potential psychological threat of intersectionality (Collins, 1986). Depression among AAW is both “gendered and racialized (Beauboeuf-Lafontant, 2007). Over-representing and generalizing the experience of depression disempowers and psychologically silences AAW as a population and 23 AAPW as a sub- population, ultimately hindering and possibly enabling the development of self- employed protective behaviors in response to adverse mental health experiences (Beauboeuf- Lafontant, 2007). Resilience theory. Resilience is understood as a multidimensional construct that highlights the bidirectional interactions between individuals and the systems in which they belong (e.g. work, community, and family) (APA, 2008). In addition, resilience theory explores the mechanisms used in response to adverse conditions (Masten, 2014). As AAW began to expand their presence in the professional arena, the negotiations between bicultural roles and identities increased, requiring AAW to have above-average coping-skill management and immediate attention to adaptive behaviors (Denton, 1990). After using the National Survey of Black Americans to document the stressors that AAs face, it appears that resilience mechanisms among AAs are rooted in sociocultural factors (Neighbors, Jackson, Bowman, & Gurin, 1983). Research on AAW who are over the age of 55 and identify with a low socioeconomic status has found that they predominately treat mental health concerns with prayer and related religious practices (Neighbors et al., 1983). Historically, AAW have primarily used non-clinical forms of mental health coping, such as informal treatment from a religious or spiritual community or support from family and/or acquaintances (Mattis, 2002; Snapp, 1992). Mental health engagement is highly stigmatized, and reports of low access rates to mental health care continue to rise; therefore, resilience takes on varying forms among AAW experiencing mental health concerns (Chow, Jaffee, & Snowden, 2003). Observing the experiences of depression among AAPW through the lens of resilience reveals the processes they use to prevent themselves from succumbing to challenging circumstances that could negatively affect their mental health functioning, thereby assuaging 24 symptoms of depression. In a study that observed depression among AAW, explored their resistance to treatment, and focused on resilience revealed that there are cultural aspects to overcoming adversity that need to be researched in order to properly treat minority women with depression (Smith, 2009). While research has exemplified the importance of cultural congregation among AAW, this present study further supports that knowledge post supplementary examination of a more specific community of black women (West, 1995). Overall, culturally informed resilience mechanisms were viewed as protective factors for women with depression, encouraging the development of positive and culturally grounded learned behaviors during vulnerable life events, such as mental and physical illness, or societal constraining factors (e.g. systemic racism, sexism, classism) (Smith, 2009; Jeffries, 2015). Racial socialization. Literature on racial socialization examines the transference of information and developmental life skills, primarily from parents to their children, designed to protect them from discriminatory events (Hughes, Rodriguez, Smith, Johnson, & Stevenson, 2006). In the development of acknowledged AA racial presence and identity, racial/ethnic socialization has been linked to ecological predictors, barriers, and buffers during childhood (Hughes et al., 2006). The presence of discrimination, prejudice, and racism marginalize racial/ethnic minorities, creating a division of race and socialization for many groups (Brown & Lesane-Brown, 2006). Therefore, the construct of racial socialization emphasizes the importance of in-group authentic attachment, which could be fulfilled through messages and teachings of AA history (Lesane-Brown, Brown, Tanner-Smith, & Bruce. 2010; Brown & Lesane-Brown, 2006). Ethno-gendered socialization. The concept of ethno-gendered socialization refers to the combined ways individuals are exposed to and learn about values and perspectives on race and 25 gender (Thomas & King, 2007). Ethno-gendered socialization serves as a method of survival for many AAW navigating a society that systematically positions AAW in the margins, based on race and sex (Scottham & Smalls, 2009). For young AA women, ethno-gendered socialization is most often first navigated in institutional academic settings (Ogbu, 1981). These results support the idea that ethno-gendered socialization is important and that it influences in-group attachment and later serves as a protective factor in the form of race and gender centrality. The concept of ethno-gendered centrality acknowledges the extent to which an individual places salience on group membership (Turner & Brown, 2007). Conclusively, ethno-gendered socialization has been a platform on which AAW can develop skills to navigate racism and sexism. AAW are the most susceptible to the unique, intersectional challenges of race and sex identity development, in addition to their potential professional identities, ultimately leaving them vulnerable to racism, sexism, and mental health constraints in and out of the workplace (Thomas, Witherspoon, & Speights, 2008; Buchanan & Fitzgerald, 2008). Methods Participants Fifteen AAPW working in a large Midwestern city participated in this study. Eligibility for participation required: (1) racial identification with African American decent, (2) identification with being a biological female, (3) being 35-55 years old, (4) college/university experience or a bachelor’s degree, (5) two or more years of active employment in the white– collar labor force, and (6) acute to moderate depression based on the Patient Health Questionnaire (PHQ-9) assessment (Appendix C). The PHQ-9 depression assessment tool was chosen to determine inclusion and exclusion criteria based on the extensive empirical validity of the tool, in addition to current research findings suggesting its effective use with minority 26 populations (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006). Prospective participants were excluded if they verbally confirmed a serious mental health diagnosis or substance abuse issue. Participants ranged from 39 to 53 years of age, with a mean age of 50 years old. All were employed in high status professional positions. Data collection The Institutional Review Board of Michigan State University deemed this study protocol exempt. The recruitment process was executed by the primary investigator (PI) with the help of female professional network assistance. Professional network assistance defines the previously developed relationships between the PI and various AAPW allowing the PI access to their professional female network. The goal was to solicit participants by contacting community leaders of elite minority organizations and active professionals from corporations and institutions/universities and then explain the elements of the study to them. Recruitment emails and flyers (Appendix B) outlining study eligibility were distributed to prospective participants prior to study involvement. From there, a snowball sampling method was used, relying on participants who joined the study to recruit additional participants if needed. Voluntary representatives from various occupational fields served as recruitment leaders for their designated fields. Once the target number of desired participants was reached and participants were provided further details of the study, individual interviews were scheduled. Qualitative data was collected through individual, in-depth, semi–structured interviews that followed a pre-determined interview protocol (Appendix D). If participants were not able to schedule an in-person interview at a private location, the option of a Skype interview was offered. Study eligibility was confirmed via phone or email prior to scheduling interviews. The PHQ-9 was administered via phone or provided via email and was to be returned to the PI before 27 participating in the interview process. A total of 15 women were assessed for depression via the PHQ-9, the results of which indicated acute to mild depression. Of the 15 participants, 12 had their interviews conducted in person and 3 were interviewed via Skype. Interviews ranged from 50 minutes to 100 minutes in length. Data analysis The researcher followed the tenants of constructivist grounded theory with a three-part analysis process using NVIVO software (Charmaz & Mitchell, 2001; QSR International, 2016). Grounded theory was used as an inductive method and was formatted by meticulous research techniques, guiding the researcher through data collection, analysis, and the production of conceptual categories (Charmaz & Belgrave, 2012). Qualitative grounded theory stimulates the researcher to explore phenomena and propose a theoretical rationale confirming the cause of the phenomena and the context in which the phenomena occurred and is maintained. Grounded theory also confirms the ideas researched for intervening purposes (Strauss & Corbin, 1998). The first step of analysis began with open coding, followed by axial coding. The final stage consisted of selective coding, and the conceptual framework emerged during this analytical step. During the analysis, the researcher used reflexivity and worked to allow the voices of the participants to come through. The PI who conducted this study is also a member of the population and used her familiarity with these experiences to both understand and interpret the phenomena. Trustworthiness. Researcher Cope (2014) highly recommends that researchers ensure credibility in qualitative research by documenting descriptions of their own experiences. Again, these documented descriptions are supported by reflexivity. The term reflexivity defines the process of knowledge development from the researcher’s point of view (Morrow, 2005). In 28 addition to reflexivity, the PI also used memoing and an audit trail. Maintaining a clear distinction between the PI’s predispositions and opinions, the audit trail served as a tool to affirm that confirmability criteria had been met. For credibility, the PI briefly documented her experience of each interview. According to Morrow (2005), the term credibility in qualitative research assures that the findings have not been tampered with and have a substantial level of reliability and honesty. Credibility bluntly refers to the researcher’s ability to truthfully interpret the participant’s responses, securing accurate representation (Polit & Beck, 2014; Cope, 2014). Due to the PI identifying with the racial and gender demographics of the participants, there was a level of familiarity that served as a primary basis for securing the parallels between the human experiences being researched and the reality of those experiences. Maintaining trustworthiness and credibility, the PI and second author provided insights by reviewing transcripts and coding data together. Further ensuring credibility, this qualitative research design sought to explore the experience of self-reported depression among AAPW representing various positions in different labor fields. This idea closely follows the instruction of triangulation. By gathering data from AAPW in different occupations, the PI ensured the analysis of multiple perspectives and experiences. Consistency across data despite the variety of professions validates the findings and guarantees credibility (Carter, Bryant-Lukosius, DiSenco, Blythe, & Neville, 2014). The relationship between the theoretical frameworks and the research questions are illustrated in Table 1.0, which also presents the guided theoretical framework in support of the interview protocol (Appendix D). Results demonstrate how the constructs of resilience theory and ethno-gendered socialization influence, inform, and aid the experience of depression among 29 AAPW, while black feminist theory was a supportive theory, assuring that the narratives of AAPW were at the center of the analysis. TABLE 1.0 STUDY ONE TABLE OF THEORY AND RESEARCH QUESTIONS Theory Primary Research Secondary Research Questions Questions What are the intersections of being AA, a woman, and a professional? Protective: What are the influences of racial socialization? What are the influences of familial, social support? What are the influences of spirituality? Black Feminist Theory How does intersectionality influence the experience of Resilience Theory Racial and Ethno- Gendered Socialization AAPW? What are the protective factors for AAPW coping with depression? 30 FIGURE 1.0 MAP OF FORMAL THEORY Black Feminist Theory SUPPORTS Ethno-gendered Socialization INFLUENCES Resilience Theory ENCOUNTER Depression among AAPW Results This study revealed prominent and descriptive data illustrating how AAPW understand, experience, and cope with depression as it is informed and influenced by their identity as black, female professionals. The goal of this grounded theory study was to appropriately represent participant experiences and cultural views, to foster an explanatory framework and model that accounts for the culturally influential, informative, and protective constructs involved in the process of understanding, experiencing, and coping with depression as AAPW. Subsequently, an 31 ethno-gendered socialization grounded theory framework was developed to explain the influential and protective relationship between concepts of cultural resilience and AAPW with depression. This study was informed by black feminist theory and uses resilience theory and racial and ethno-gendered socialization as a primary construct and concept. The proposed emergent theoretical framework describes the culturally influential, informative, and protective elements that affect how AAPW understand, experience, and cope with depression. Findings Open and axial coding. The first step of data analysis (open coding) generated over 100 open codes that showed shared experiences among the participants. This stage involved coding the transcripts line-by-line and being mindful of potential themes emerging within the data. The length of each transcript and the richness of information resulted in a large number of abstract and frequent open codes that were collapsed into three major categories during the axial coding process. The three primary axial codes were organized by the understanding, experience, and coping styles related to depression among AAPW. The researcher then supported each axial code with selective codes, which emerged in the form of ethno-gendered socialized messages. According to Corbin and Strauss, axial codes can be developed based on “causal conditions, contextual conditions, and/or intervening conditions” (2014). For this study, the ethno-gendered socialized axial codes integrated these conditions. Each message was then further supported by a secondary selective code, denoting the ethno- gendered socialized message with more specific themes. Major grounded theory findings displaying direct quotes from participant experiences can be found in Table 1.1. Findings are organized in three primary categories: socialized understanding of depression, socialized experience of depression, and socialized coping with 32 depression. Each primary category is presented with the corresponding ethno-gendered socialized messages, which appeared to influence the secondary category (Table 1.1). To ensure accuracy for reported results, participant quotations are represented by participant identification numbers (ID) and ages. For example, “ID 007, Age 45” indicates that the participant’s ID number was 7 and that she was 45 years of age. These emerging results reveal the intimate and detailed experiences of depression among AAPW and show that resilience theory and ethno- gendered socialization are influential and protective constructs for examining depression among AAPW. Socialized understanding of depression. When asked, “How do you define the term depression?” and “How does your family or community talk about depressions feelings?” each participant defined the term with the aid of a secondary theme (familial, socio-cultural, or individual). The secondary themes surfaced from a general ethno-gendered socialized message that emerged from the data to inform how AAPW make sense of the term depression. For AAPW, depression is understood based on what they have observed from their family or social and professional networks or have experienced individually. Ethno-Gendered Socialized Message: Depression is an experience that has been observed as severe but not experienced as debilitating for AAPW. Familial: “I know my brother suffers from depression, but he doesn’t want to talk about it . . . he does what he needs to do, he works and provides for his kids, he does all the things . . . so you know my family unit is becoming more accepting to talk about [depression] but back then . . . no.” (ID 002, Age 50) Socio-cultural: “So my best friend . . . after she had her first and only child . . . she fell into a state of depression. She had post-partum and fell into a severe bout of depression . . . and she is a pediatrician . . . so now mind you her job is dealing with other people’s children’s lives, so that was a big struggle for her.” (ID 001, Age 51) 33 Individual: “If I was depressed to the point where I couldn't get out of the bed, or I was depressed to the point where I couldn’t function and take care of my family and I couldn’t go to work, or, you know, if I had suicidal thoughts and I’d be like ‘OK something’s not right here, maybe I need to talk to someone.’” (ID013, Age 50) Socialized experience of depression. Each participant in this study expressed having feelings and/or formal symptoms of depression at some point during their professional careers. Questions like “How do you understand the experience of depression feelings?” and “What is happening around you to contribute to those types of feelings?” were asked to determine the types of experiences of depression that emerge among AAPW. The reported experiences were revealed, expressing an internalized, silenced experience, a stress-related experience, or an emotional experience that was guided by a socialized message. Ethno-Gendered Socialized Message: The experience of depression is an internal and often a silenced feeling, sometimes of sadness, stress, or general change in mood. Internalized/Silenced: “I remember calling off work, I knew that I was [depressed] and could not get to work. And I was so embarrassed to tell my boss the real reason; I felt like that would make me look weak, like I couldn't handle the pressures of my job.” (ID014, Age 39) Stress induced: “Professionally, I am overjoyed, but it is a crazy amount of stress.” (ID006, Age 49) Emotional: “I was sad all of the time—outburst of tears, just very unhappy, I knew something was wrong. I didn’t necessarily tie that with depression, but I had overwhelming sadness, and I had a lot of things I just didn't feel good about.” (ID008, Age 50) Socialized coping with depression. Participant ability to cope with reported understanding and experiences of depression was ascertained through questions such as, “How do you cope with everyday stress?” and “What helps you when you are feeling depressed?” Participant responses provided salient insight into what AAPW need and what they tend to 34 access when grappling with depression based on what they have observed and/or what has been shared via socialized messages about coping with depression. Ethno-Gendered Socialized Message: Coping with depression involves informal support and healing methods more so than traditional treatment. Spirituality: “I am very spiritual, very religious, I will go to church on Sundays and go to the alter and just pray, and that for me became my therapy— to just go and pray and say ‘Lord I need your help.’” (ID004, Age 50) Sisterhood: “Because, you know, your relationships with women are different from your relationships with men, and you can talk differently with a woman. I guess maybe because she understands more, but without your girlfriends, I don't even know, we would all be on medication.” (ID010, Age 48) Mentorship: “Time had progressed, and they were bringing in another employee who was an AA woman, and of course I was like, ‘yeah, bring her in,’ and they hired her, and, like I said, I was a big advocate for her, and I was like ‘come here; I am going to mentor you.’” (ID001, Age 53) Physical activity: “When I am feeling that way, I really try to keep to myself, or I try to exercise or keep busy, because I think physical health, exercise, and movement are very important to one’s state and well-being.” (ID015, Age 51) 35 TABLE 1.1 STUDY ONE EMERGING QUOTES TABLE Primary Category Socialized Understanding of Depression Ethno-Gendered Socialized Message Depression is a mental health state that has been observed as diverse in severity but not as debilitating for AAPW Socialized Experience of Depression The experience of depression is internal and often a silenced feeling, sometimes of sadness or stress. Secondary Category Supporting Quote Familial Socio-Cultural Individual Internalized/Silenced Stress induced “So, I think over the years I have grown to understand depression more and more, when it hit, you know, my family that way, for me to better be able to understand” (ID 003, Age 45) “You don't want people to see you as being weak, especially a professional woman” (ID011, Age 48) “I do have moments when I can’t seem to get out of what I think is a funk, but I don’t have time, but I know that I have it and I know I need to address it” (ID002, Age 50) “It’s very silenced. We don’t talk about it. I don’t know how the other person will understand how I feel because it’s not talked about” (ID012, Age 50) “Like, there is a lot of pressure on me. I don’t know, like someone is pressing on my chest, and I can’t breathe, it’s very heavy, like I’m struggling to put one foot in front of the other” (ID001, Age 51) 36 TABLE 1.1 (cont’d) Emotional charged Socialized Coping with Depression Coping with depression involves informal support and healing methods more so than traditional treatment. Spirituality Sisterhood Mentorship Physical activity “You have a lower level of happiness in your life, you have lower energy, crying, a propensity for anxiety, very out of character” (ID007, Age 47) “Through prayer, faith—it's the truth; it’s how I start my day … I was raised by a very spiritual mother” (ID009, Age 53) “My girlfriends—I think we’ve got a great circle, a great community, where we lift up each other” (ID013, Age 50) “I would really say like the support and encouragement from other women” (ID005, Age 47) “Running is a huge coping tool. It’s almost preemptive” (ID006, Age 49) 37 FIGURE 1.1 MAP OF GROUNDED THEORY Depression among AAPW Ethno-Gender Influence Message: Depression is a mental health state that has been observed as diverse in severity but not as debilitating for AAPW. Message: The experience of depression is internal and often a silenced feeling, sometimes of sadness or stress. Message: Coping with depression involves informal support and healing methods more so than traditional treatment. Socialized Understanding of Depression 1. Familial 2. Socio- Cultural 3. Individual Cultured Protective Occurrence Socialized Experience of Depression 1. Internalized/Silenced 2. Stress Induced 3. Emotionally Charged Socialized Coping with Depression 1. Spirituality 2. Sisterhood 3. Mentorship 4. Physical Activity 38 Theoretical Concepts linked to the findings and Grounded Theory The present study resulted in an emergent theoretical framework for understanding the cultural, protective influences of ethno-gendered socialization and resilience theory for depression among AAPW. Results demonstrate how the constructs of resilience theory and ethno-gendered socialization influence, inform, and protect the overall encounter of depression among AAPW. The grounded theory framework is presented in Figure 1.1. Grounded theory The emergent grounded theory framework conceptualizes the understanding, experiences, and coping mechanisms among AAPW with depression, placing AAPW at the core of the analysis. By analyzing this experience in an inclusive manner, it cannot be misguided by Eurocentric ideologies. Each participant shared an experience of oppression and mental health adversity while navigating their professional identities alongside their black female identity. Therefore, the experience of being black, female, and a working professional, lies at the foundation of the influential and informative ethno-gendered socialized messages received. The socialized messages comprised from the data are specifically targeting black professional women and their relationship with depression. Socialized understanding of depression. For the AAPW in this study, group membership has the greatest influence on their racial identities, sex identities, and professional identities. The women interviewed described culturally specific understandings and experiences of depression that were special to their social positions as AA, females, and professionals. The findings indicate that, for AAPW, understanding depression is primarily grounded in the way they have been socialized to understand depression, which is influenced by their familial network, social networks, socio-cultural and individual-self. The socialized message from 39 participants implied that depression is a mental health state that has been observed and experienced as diverse in severity but as not debilitating for AAW. This message defines depression for black professional women and influences how it can manifest. Displaying a level of protective, socialized influence, this message almost suggests a limit that AAPW place on the experience of depression symptoms based on their cultural relationships to mental health and their understanding of the term. The participants reported understanding depression based on their experiences within their families, what they observed growing up, or what they were or were not told as children, adolescents, or adults. In a socio-cultural context, the understanding of depression stemmed primarily from their interactions within the communities they navigate. Understanding mental health and, more specifically, depression as it is narrated by the black community and by their professional community, guided their own understanding of what depression means to them as AAPW. Lastly, their own individual beliefs about depression encouraged a predominate definition conclusively rooted in their racial and gender identities. Socialized experience of depression. In addition, the participants each described a similar manifestation of depression symptoms and their overall experience. Closely aligning with research on the SBW persona, the experience of depression resulted in three different expressions. The ethno-gendered message supporting the experience of depression among AAPW was that the experience of depression is internal and is often a silenced feeling, sometimes of sadness or stress, sometimes causing an internal, silenced, emotionally charged, or stress-induced experience. While this specific reported experience can be researched among other racial/ethnic backgrounds and sex identities, the AAPW in this study reported the validity of this internalized and silenced experience of depression based on the culture of depression and overall mental health at work and within their black communities. Most participants reported a 40 lack of conversation concerning depression and mental health concerns at work, ultimately making its rapid manifestation silent. Moreover, each participant reported a concern of appearing as the "angry black woman" if they were to disclose at work the stressful and emotional turmoil of a mental health constraint such as depression. Therefore, for AAPW, depression is often defined by an intense level of stress and pressure and accompanied by unfamiliar emotional responses. Conclusively, the understanding and experiences of depression supported by ethno- gendered influential messages ultimately informed the development of protective and cultural resilient responses to the adverse mental health occurrence of depression. Socialized coping with depression. Portraying a high functioning level of resilience, the AAPW in this sample described specific coping mechanisms for grappling with depression. The coping styles reported both supported and enhanced current research on coping styles among AAW. Coping with depression among AAPW was influenced by the ethno-gendered message that coping with depression involves informal support and healing methods more so than traditional treatments. For the women in this sample, coping with depression involved spirituality, sisterhood, mentorship, and physical activity. First, for the AAPW in this study, religion, church, and prayer emerged as significant coping mechanisms for the experience of stress and depression across the designated age cohort. While this finding is not nuanced, what sets AAPW apart from this pre-determined result is the educational understanding that while spirituality is a form of coping, it will not heal or treat a mental health condition. This understanding was clear across the dataset. Equally important, the AAPW in this study each reported the importance of mentorship as a coping mechanism for depression symptoms. While their professional identities provide the opportunity for mentorship, the specific relationship between the experience of stress and depression and having a mentor for relief surfaced as quite 41 prevalent among the participants. Most women expressed a sincere feeling of privilege and appreciation for the mentors they had as they journeyed through their respective professions. The salience of mentorship was so pertinent that several participants reported the desire to become mentors themselves. While the importance of community and relationship can be observed through mentorship, for AAPW, the concept of sisterhood also emerged as a cultured form of protection and coping. Participants reported an experience with depression, either as a result of their work or personal life, that required the aiding attention of their fellow AA female cohort members. Having female acquaintances, either in the form of a biological sister or a platonic female friend or coworker, served as crucial tool for coping with depression for the AAPW in this study. Most women that reported on their male companions defined their relationships as vital but different from their relationships with other females. Lastly, AAW and exercise have been found to have a negative correlation, finding that haircare practices are potential barriers to physical activity (Jackson, Yates, & Blanchard, 2010: Zimmerman, Hudson, & Pozehl, 2013). Yet, among these AAPW, exercise and physical activity had a unanimous influence on the way they cope with depression. Some participants reported developing an exercise regimen at the onset of entering their professional fields, while others expressed using exercise to directly combat stress and depression late into their careers. This positive relationship between AAPW and physical activity can be further researched because of their middle to high socioeconomic statuses and perceived increased access to a regular haircare and overall self-care routine. The ways in which AAPW understood depression, experienced reported depression symptoms, and coped with depression appeared to be greatly informed by ethno-gendered socialized messages and experiences throughout their lives and professional careers, conclusively encompassing protective elements supported by resilience theory. 42 Discussion and Implications This study sought to explore and explain the cultural influence of resilience theory and ethno-gendered socialization as protective constructs for AAPW coping with depression. An emergent conceptual framework was constructed representing the ways the professional women in the sample understood, experienced, and coped with depression, supported by the present, protective influence of resilience theory and ethno-gendered socialization. The AAPW in this study can be described as resilient, resourceful, internally driven, and persistent, despite the socio-historical barriers each participant reported encountering throughout their professional development and careers. Although racial socialization can be a buffer, there are variations of the concept that can at times serve as a risk (Taylor, Chae, Lincoln, & Chatters, 2015; Saleem & Lambert, 2016). AAPW understand that depression as a mental health state that can be constraining. Yet, the socialized message received, which influences the definition of depression and accounts for being black, a female, and a professional, appears to protect AAPW by acknowledging the effects of depression while placing a limit or boundary on how constraining depression can be. Displaying unmoving emotional resilience, AAW are assumed to be able to endure the psychological stress of loss, traumatic events, and oppression without an emotional response (Walker-Barnes, 2009). A study by Abrams, Maxwell, Pope, and Belgrave (2014) exemplifies the superwoman schema, the Sojourner Truth syndrome, and the Sisterella complex, proving to be immune to the burdens of navigating multiple roles (Abrams et al., 2014). The thematic findings from reported ideologies of SBW were that a woman 1.) embodies and displays multiple forms of strength, 2.) possesses self-ethnic pride despite intersectional oppression, 3.) embraces being every woman, and 4.) is anchored by religion and spiritualty (Abrams et al., 2014). The 43 experience of depression for AAPW is internal/silenced, stress-induced, and/or emotional, but it is never described as debilitating. Supporting the risks of the SBW persona, the experience of depression can be harmful, yet the protective elements of this socialized message for AAPW imply that the experience of depression is not one that AAPW often succumb to. Research supports that coping and resilience mechanisms often require community for AAs. Among the research focusing on protective factors for AAW, the common theme of family and community support remains a consistent finding (Taylor et al., 2015). In a study focusing on extended family and friendship support networks as buffers for AAW and Afro-Caribbean women with major depressive disorder, researchers found that for AAW experiencing depressive symptoms, closeness to both friends and family are primary coping systems (Taylor et al., 2015). These results hold salience in this present study as well, acknowledging the importance of sisterhood. According to Neal-Barnett and colleagues (2011), AAPW are currently seeking help regarding their mental health concerns from health professionals trained in life coaching and spiritual leading before they contact a traditional mental health expert, such as a psychotherapist or psychiatrist. That finding has cultural grounding in that, historically, AAs have had little trust in western, institutionalized mental health care (Sue, Capodilupo, Torino, Bucceri, Holder, Nadal, & Esquilin, 1998). Among AAPW, alternative methods for treating anxiety and panic attacks, such as “sister circles,” have been used to promote awareness and education regarding mental health, highlighting the importance of social support among AAW (Neal-Barnett et al., 2011). Presenting a more specific examination of protective factors among AAs experiencing mental health issues, researcher Crockett (2017) found that middle class AAs find consolation in the conceptual framework of respectability. According to his findings, middle class AAs who practice the tenets of respectability disavow the social strain of discrimination and stigma, 44 ultimately reclaiming a sense of control and power (Crockett, 2017). While this concept is controversial, AAs from a specific socioeconomic status have assumed a culturally competent coping strategy that appears to have some success (Crockett, 2017). For AAW as a population, resilient coping mechanisms for depression are rooted in culture, and the findings from this study indicate that this is true for AAPW as well. The relationship between AAW and depression requires further investigation in order to adequately begin to assess for cultural implications and inform treatment. The multiplicity of black female identity can unveil a variety of experiences of mental health constraints. Primarily examining the identity of AAPW, their risk of mental health concerns is quite high when compared to their white female counterparts (Snapp, 1992). AAPW present with potential mental health risks resulting from their identities as a racial/ethnic minority, as women, and as professionals. Research on the psychological effects of workplace discrimination and sexual harassment have begun to expose the risks of recurrent encounters with racism and sexism (Hirsh & Lyons, 2010; Buchanan & Fitzgerald, 2008). This study contributes to the sparse amount of research available to better assess for mental health concerns among racial/ethnic minorities and addresses the diversity within racial/ethnic populations. By understanding the ethno-gendered socialized influences regarding how communities’ approach mental health disorders, research can begin to effectively respond to concerns, such as poor mental health engagement among AAs and overall inadequate treatment, using cultural competence care. Concerning limitations, although this sample is taken from a large metropolitan area, the sample size does not represent a substantial number of AAPW residing in the United States. In addition, the sample size does not encompass a relatively equal representation of age due to the age restriction set for the study. 45 Conclusion There is sparse research exploring culturally protective factors for AAPW experiencing mental health concerns such a depression. AAW are already less likely to engage in mental health services, and they have fewer resources and support systems for coping. More research is needed on protective factors for AAW experiencing mental health concerns. When theorizing about the protective cultural influences of resilience theory and ethno-gendered socialization, AAPW appear to understand, experience, and cope with depression as it relates to their black, female, and professional identities. Understanding depression among AAPW requires knowledge of the pertinent socio-historical oppressions they face. The navigation of their own multiple identities and the socially constructed images of AAW requires attention when investigating depression among AAPW. Protective factors for depression among AAW are predominately researched in relationship to low socioeconomic status, substance abuse, and comorbid disorders. While their experiences may have similarities to the generalized research on depression among AAW, it is crucial to investigate the multiplicity of black identity as it relates to the experiences of mental health to address mental health concerns such as depression in AAPW. 46 APPENDICES 47 APPENDIX A: Study Consent Form Exploring the Risk and Protective Factors Among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study Michigan State University Department of Human Development and Family Studies/Couple and Family Therapy Consent Form- Interview Participants A study entitled Exploring the Risk and Protective Factors among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationship with mental health, specifically depression. This study will consist of individual interviews with members of the Chicago, IL African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace navigation, with the goal of expanding the research on African American women and mental health treatment. Interviews will take place in person and within an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The inventive in participating in this study is the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how those factor into the workplace experience. Participants will receive one $10.00 Starbucks gift card after completion of the interview. The potential risks of participating in this study may include any distress and/or discomfort regarding discussion of mental health experiences and/or workplace incidents. Any study participant experiencing distress or discomfort will be provided with a referral to local mental health clinicians. If this applies to you please contact the Primary investigator (PI) Heather C. Lofton (708) 816-4405. If you agree to participate, a fourth- year graduate student, from Michigan State University will conduct interview protocol. Each interview will be audio recorded, unless refusal of the arrangement. If you agree to be audio recorded, please circle your response and initial on the line below. I agree to allow audio recording of the interview. YES NO Initials ______ Any responses you offer during the interview will be combined with other others, making your responses confidential, and your privacy will be protected to the full extent allowable by the law. Identifying information will not be attached to any of your individual responses, when reporting results from interviews. All material will be kept in a password- 48 protected laptop and only the principal investigator, her advisor and the University Research Protection staff will have access to the data. Each interview will take approximately 45-60 minutes to complete. If you have concerns or questions about this study, such as scientific issues, how to participate, or to report an injury please contact: - Dr. Marsha T. Carolan, Michigan State University, Human Ecology, East Lansing, MI 48823, (517) 432-3327, carolan@msu.edu - Dr. Deborah J. Johnson, Michigan State University, Human Ecology, East Lansing, MI 48823, 517-432-9115, john1442@hdfs.msu.edu - Heather C. Lofton, Doctoral Candidate, Michigan State University, Human Ecology, East Lansing, MI 48823, loftonhe@msu.edu If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University's Human Research Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824. Your signature below indicates your willingness to participate in this study. Thank you for your time. I look forward to talking with you about your experiences. Signature: ______________________________________ Date: ____________________ 49 Department of Human Development and Family Studies/Couple and Family Therapy Michigan State University Participation-Consent to Use a Direct Quote The form gives your consent to use direct quotes from this interview, for the purposes of publishing this study. Your identity will be kept confidential and an identification number will be used to protect you. Only the researchers will know the number assigned to you. By signing this form, you allow for the use of direct quotes in publications of this study and understand that your privacy will be protected to the maximum extent of the law. Your signature below indicates your willingness to voluntarily consent to the use of direct quotes in the publication of this study. Thank you for your time. Signature: ______________________________________Date: __________________ 50 APPENDIX B: Study Recruitment Form Dear Prospective Participant, A study titled The Risk and Protective Factors for Depression among African American Professional Women: A Grounded Theory Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationships with mental health and specifically depression. This study will consist of individual interviews with members from the a large Midwestern metropolitan area, with a substantive African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace experience, with the goal of expanding on the diversity of African American female identity by acknowledging professional women and informing research on mental health needs and treatments of African American women. Interviews will take place in person or via Skype, with an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The incentive in participating in this study are the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how those factor into the workplace experience. Participants will receive one gift card after completion of the interview. If you would like to participate or inquire about any more information regarding the study please email Primary investigator Heather C. Lofton, loftonhe@msu.edu or by phone. 51 APPENDIX C: Patient Health Questionnaire (PHQ-9) Patient Health Questionnaire-9 (PHQ-9) Over the last two weeks, how often have you been bothered by any of the follow problems? (Use to indicate your answer) Not difficult at all Somewhat difficult Very difficult Extremely difficult ☐ ☐ ☐ ☐ 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or over eating 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way For office coding ______ + ______+ ______+ ______ = Total Score ______ If you checked any of the problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all Several Days 0 1 More than half the days Nearly everyday 2 3 52 APPENDIX D: Interview Protocol INTRODUCTION TO THE STUDY The African American Professional Women’s (AAPW) community is rapidly growing. African American Women (AAW) are climbing corporate ladders, securing tenure professional appointments, practicing as medical doctors and upholding the law in political positions. This study seeks to explore the experience of being an AAW, while navigating the presence of intersectionality, as it transitions to the workplace. Focusing on mental health and specifically depression, this study plans to inform the future of mental health research, expanding the knowledge on treatment for AAPW. R1.) What are the protective and risk factors for AAPW coping with depression? Protective R1a). What are the influences of racial socialization? R1b). What are the influences of familial, social support? R1c.) What are the influences of spirituality? 1. How do you cope with everyday stress? 2. Have you ever tried or considered trying psychotherapy to cope with stress? 3. How would you describe your current emotional state? 4. What is happening around you when you are feeling that way? 5. How do you understand the feelings that you experience? 6. How does your family or community talk about those types of feelings? 7. What helps you when you are feeling down? 8. Can you please tell me what your understanding of depression? Risk R1d.) What are effects of discrimination? R1e.) What are the effects of sexual harassment? R1f.) What are effects of microaggressions in the work place environment? 9. How do you experience discrimination at work? 10. How do you experience microaggressions at work? 11. Can you please describe your response? 12. How do you cope with those types of experiences? 13. How do you experience sexual harassment at work? 53 14. Can you please describe your response? 15. How do you cope with that experience? 16. How would you describe your workplace environment? R2.) How does intersectionality influence the experience of AAPW? R2a. What are the intersections of being AA, a woman and a professional? 17. What has your experience been as an AA and a woman in a professional setting? 18. Have you ever felt professionally disadvantaged due to your race and gender? 19. How do you understand mental health in the workplace as an AA and a woman? 20. Thinking about the AA community/culture, do people discuss the experience of workplace racial/gender discrimination? 21. As an AA, female professional, what is your perception on workplace support mental health concerns? 22. Do you think the Patient Health Questionnaire is a culturally responsive and adequate tool to screen for depression symptoms? 54 REFERENCES 55 REFERENCES Abrams, J. A., Maxwell, M., Pope, M., & Belgrave, F. Z. (2014). Carrying the world with the grace of a lady and the grit of a warrior: Deepening our understanding of the “Strong Black Woman” schema. Psychology of Women Quarterly, 38(4), 503-518. doi:10.1177/0361684314541418 American Psychological Association (2015). Publication manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association. Banks, K. H., & Kohn-Wood, L. P. (2002). Gender, ethnicity and depression: Intersectionality in mental health research with African American women. African American Research Perspectives, 174. Beauboeuf-Lafontant, T. (2007). You have to show strength: An exploration of gender, race, and depression. Gender & Society, 21(1), 28-51. doi:10.1177/0891243206294108 Beauboeuf-Lafontant, T. (2008). Listening past the lies that make us sick: A voice- centered analysis of strength and depression among Black women. Qualitative Sociology, 31(4), 391-406. doi:10.1007/s11133-008-9113-1 Bell, E. L. E., & Nkomo, S. M. (2003). Our separate ways: Black and White women and the struggle for professional identity. Harvard Business Press. doi:10.5465/AMR.2003.10899472 Brown, T. N., & Lesane-Brown, C. L. (2006). Race socialization messages across historical time. Social Psychology Quarterly, 69(2), 201-213. doi:10.1177/019027250606900205 Brown Givens, S. M., & Monahan, J. L. (2005). Priming mammies, jezebels, and other controlling images: An examination of the influence of mediated stereotypes on perceptions of an African American woman. Media Psychology, 7(1), 87-106. doi:10.1207/S1532785XMEP0701_5 Buchanan, N. T., & Fitzgerald, L. F. (2008). Effects of racial and sexual harassment on work and the psychological well-being of African American women. Journal of Occupational Health Psychology, 13(2), 137. doi:10.1037/1076-8998.13.2.137 Buchanan, N. T., & Ormerod, A. J. (2002). Racialized sexual harassment in the lives of African American women. Women & Therapy, 25(3-4), 107-124. doi:10.1300/J015v25n03_08 56 Carrington, C.H. (2002). Depression in African American women: A complex phenomenon. International Journal of Integrative Psychiatry, 2, 21–25. doi:10.1002/jclp.20289 Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014, September). The use of triangulation in qualitative research. Oncology nursing forum, 41(5). doi:10.1188/14.onf.545-547. Charmaz, K., & Belgrave, L. (2012). Qualitative interviewing and grounded theory analysis. In The SAGE handbook of interview research: The complexity of the craft (2nd ed., pp.347-365). Chow, J. C. C., Jaffee, K., & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public Health, 93(5), 792- 797. doi:10.2105/AJPH.93.5.792 Cole, E.R. (2009) Intersectionality and research in psychology. American Psychologist, 64(3), 170-80. doiz:10.1037/a0014564 Collins, P. H. (1986). Learning from the outsider within: The sociological significance of Black feminist thought. Social Problems, 33(6), s14-s32. doi:10.2307/800672 Cope, D. G. (2014). Methods and meanings: Credibility and trustworthiness of qualitative research. In Oncology Nursing Forum, 41(1). doi:10.1188/14.ONF.89-91 Corbin, J., Strauss, A., & Strauss, A. L. (2014). Basics of qualitative research. Sage. Crockett, D. (2017). Paths to respectability: Consumption and stigma management in the contemporary Black middle class. Journal of Consumer Research, 44(3), 554-581. doi:10.1093/jcr/ucx049 Davis, S. M. (2014). The “Strong Black Woman Collective”: A Developing theoretical framework for understanding collective communication practices of Black women. Women's Studies in Communication, 38(1), 20-35. doi:10.1080/07491409.2014.953714 Davis, S., & Tucker-Brown, A. (2013). Effects of Black sexual stereotypes on sexual decision making among African American women. Journal of Pan African Studies, 5(9), 111-128. Denton, T. C. (1990). Bonding and supportive relationships among Black professional women: Rituals of restoration. Journal of Organizational Behavior, 11(6), 447-457. doi:10.1002/job.4030110606 Donovan, R. A., & West, L. M. (2015). Stress and mental health: Moderating role of the strong Black woman stereotype. Journal of Black Psychology, 41(4), 384-396. doi:10.1177/0095798414543014 57 Dwight-Johnson, M., Unutzer, J., Sherbourne, C., Tang, L., & Wells, K. B. (2001). Can quality improvement programs for depression in primary care address patient preferences for treatment? Medical Care, 934-944. doi:10.1097/00005650-200109000-00004 Gillum, T. L. (2002). Exploring the link between stereotypic images and intimate partner violence in the African American community. Violence Against Women, 8(1), 64-86. doi:10.1177/10778010222182946 Gosine, K. (2008). Living between stigma and status: A qualitative study of the social identities of highly educated Black Canadian adults. Identity: An International Journal of Theory and Research, 8(4), 307-333. doi:10.1080/15283480802365304 Hall, J. C., Everett, J. E., & Hamilton-Mason, J. (2012). Black women talk about workplace stress and how they cope. Journal of Black Studies, 43(2), 207-226. doi:10.1177/0021934711413272 Hirsh, E., & Lyons, C. J. (2010). Perceiving discrimination on the job: Legal consciousness, workplace context, and the construction of race discrimination. Law & Society Review, 44(2), 269-298. doi:10.1111/j.1540-5893.2010.00403.x Howard‐Hamilton, M. F. (2003). Theoretical frameworks for African American women. New Directions for Student Services, 2003(104), 19-27. doi:10.1002/ss.104 Huang, F. Y., Chung, H., Kroenke, K., Delucchi, K. L., & Spitzer, R. L. (2006). Using the patient health questionnaire‐9 to measure depression among racially and ethnically diverse primary care patients. Journal of General Internal Medicine, 21(6), 547-552. doi:10.1111/j.1525-1497.2006.00409.x Hughes, D., Rodriguez, J., Smith, E. P., Johnson, D. J., Stevenson, H. C., & SSIcer, P. (2006). Parents' ethnic-racial socialization practices: A review of research and directions for future study. Developmental Psychology, 42(5), 747. doi:10.1037/0012-1649.42.5.747 Hunn, V. L., & Craig, C. D. (2009). Depression, sociocultural factors, and African American women. Journal of Multicultural Counseling and Development, 37(2), 83. doi:10.1002/j.2161-1912.2009.tb00093.x Jackson, H., Yates, B. C., Blanchard, S., Zimmerman, L. M., Hudson, D., & Pozehl, B. (2016). Behavior-specific influences for physical activity among African American women. Western Journal of Nursing Research, 38(8), 992-1011. doi:10.1177/0193945916640724 Jeffries, R. (2015). Editor's introduction: Fortitudinous femininity: Black women's resilience in the face of struggle. Western Journal of Black Studies, 39(2), 81. Lesane-Brown, C. L., Brown, T. N., Tanner-Smith, E. E., & Bruce, M. A. (2010). Negotiating 58 boundaries and bonds: Frequency of young children’s socialization to their ethnic/racial heritage. Journal of Cross-Cultural Psychology, 41(3), 457-464. doi:10.1177/0022022109359688 Masten, A. S. (2014). Invited commentary: Resilience and positive youth development frameworks in developmental science. Journal of Youth and Adolescence 43.6 1018- 1024. doi:10.1007/s10964-014-0118-7 Mattis, J. S. (2002). Religion and spirituality in the meaning–making and coping experiences of African American women: A qualitative analysis. Psychology of Women Quarterly, 26(4), 309-321. doi:10.1111/1471-6402.t01-2-00070 McGrath, E., Keita, G., Strickland, B., & Russo, N. (Eds.). (2001). National Depression Summit. Washington, DC: American Psychological Association. Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52(2), 250. doi:10.1037/0022-0167.52.2.250 National Institute of Mental Health (NIMH) (2018) Depression Neal-Barnett, A. M., Stadulis, R., Payne, M. R., Crosby, L., Mitchell, M., Williams, L., & Williams-Costa, C. (2011). In the company of my sisters: Sister circles as an anxiety intervention for professional African American women. Journal of Affective Disorders, 129(1), 213-218. doi:10.1016/j.jad.2010.08.024 Neighbors, H. W., Jackson, J. S., Bowman, P. J., & Gurin, G. (1983). Stress, coping, and Black mental health: Preliminary findings from a national study. Prevention in Human Services, 2(3), 5-29. doi:10.1300/J293v02n03_02 Noble, C. L., Ashby, J. S., & Gnilka, P. B. (2014). Multidimensional perfectionism, coping, and depression: Differential prediction of depression symptoms by perfectionism type. Journal of College Counseling, 17(1), 80-94. doi:10.1002/j.2161- 1882.2014.00049.x Ogbu, J. U. (1981). Origins of human competence: A cultural-ecological perspective. Child Development, 413-429. doi:10.2307/1129158 Pearson, S. M., & Bieschke, K. J. (2001). Succeeding against the odds: An examination of familial influences on the career development of professional African American women. Journal of Counseling Psychology, 48(3), 301. doi:10.1037/0022-0167.48.3.301 Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins, 515-528. QSR International (2014). NVIVO 10 for Windows. Retrieved from 59 http://www.qsrinternational.com/products_nvivo.aspx Saleem, F. f., & Lambert, S. (2016). Differential effects of racial socialization messages for African American adolescents: Personal versus institutional racial discrimination. Journal of Child & Family Studies, 25(5), 1385-1396. doi:10.1007/s10826-015-0326-0 Schulz, A. J., Gravlee, C. C., Williams, D. R., Israel, B. A., Mentz, G., & Rowe, Z. (2006). Discrimination, symptoms of depression, and self-rated health among African American women in Detroit: Results from a longitudinal analysis. American Journal of Public Health, 96(7), 1265-1270. doi:10.2105/AJPH.2005.064543 Scottham, K. M., & Smalls, C. P. (2009). Unpacking racial socialization: Considering female African American primary caregivers' racial identity. Journal of Marriage and Family, 71(4), 807-818. doi:10.1111/j.1741-3737.2009.00636.x Sellers, R. M., Smith, M. A., Shelton, J. N., Rowley, S. A., & Chavous, T. M. (1998). Multidimensional model of racial identity: A reconceptualization of African American racial identity. Personality and Social Psychology Review, 2(1), 18-39. doi:10.1207/s15327957pspr0201_2 Smith, P. R. (2009). Resilience: Resistance factor for depressive symptom. Journal of Psychiatric and Mental Health Nursing, 16(9), 829-837. doi:10.1111/j.1365- 2850.2009.01463.x Snapp, M. B. (1992). Occupational stress, social support, and depression among Black and White professional-managerial women. Women & Health, 18(1), 41-79. doi:10.1300/J013v18n01_03 Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271. doi:10.1037/0003-066X.62.4.271 Taylor, R. J., Chae, D. H., Lincoln, K. D., & Chatters, L. M. (2015). Extended family and friendship support networks are both protective and risk factors for major depressive disorder and depressive symptoms among African-Americans and Black Caribbeans. Journal of Nervous & Mental Disease, 203(2), 132-140. doi:10.1097/NMD.0000000000000249 Thomas, A. J., & King, C. T. (2007). Gendered racial socialization of African American mothers and daughters. The Family Journal, 15(2), 137-142. doi:10.1177/1066480706297853 Thomas, A. J., Witherspoon, K. M., & Speight, S. L. (2008). Gendered racism, psychological distress, and coping styles of African American women. Cultural Diversity and Ethnic Minority Psychology, 14(4), 307. doi:10.1037/1099-9809.14.4.307 60 Turner, K. L., & Brown, C. S. (2007). The centrality of gender and ethnic identities across individuals and contexts. Social Development, 16(4), 700-719. doi:10.1111/j.1467- 9507.2007.00403.x Walker-Barnes, C. (2009). The burden of the strong Black woman. Journal of Pastoral Theology, 19(1), 1-21. doi.org/10.1179/jpt.2009.19.1.002 Warren, B. J. (1997). Depression, stressful life events, social support, and self-esteem in middle class African American women. Archives of Psychiatric Nursing, 11(3), 107-117. doi:10.1016/S0883-9417(97)80033-7 West, C. M. (1995). Mammy, Sapphire, and Jezebel: Historical images of Black women and their implications for psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 32(3), 458. doi:10.1037/0033-3204.32.3.458 61 CHAPTER THREE: STUDY TWO Exploring the Risks of Microaggressions, Racial Discrimination, and Sexual Harassment for Depression among African American Professional Women: A Theoretical Perspective ABSTRACT By analyzing the experience of depression among African American professional women (AAPW) through culturally appropriate theoretical lenses, some of the gaps in the literature can be addressed. This manuscript is the second installment of a multiple manuscript study diversifying the experience of depression among African American women (AAW). With the goal of informing the future of mental health research, this study expands upon racism and sexism as workplace risks for mental health constraints like depression among AAPW. For example, new research on microaggressions has brought to light subtle discrimination that largely affects racial/ethnic minorities (Sue, Capodilupo, Torino, Bucceri, Holder, Nadal, & Esquilin, 2007). Researching the effects of microaggressions within the professional realm is important when studying AAPW to help uncover the relationship between the severity of discrimination and mental health outcomes. In this study, qualitative interviews were conducted with 15 AAPW from a large Midwestern city. Using a constructivist grounded theory approach, interviews exposed the risks present in the workplace among AAPW experiencing depression. Results are organized using stress theory and critical race theory as supportive constructs to explain the reported risks. Findings from this investigation have mental health research relevance, as they indicate a more socio-culturally specific experience of depression and the risks of each discriminatory encounter. 62 Introduction There is evidence that recurrent exposure to discriminatory environments, such as the professional workplace, can induce psychological distress and the onset of depression for many African American professional women (AAPW) (Buchanan & Fitzgerald, 2008; Brown, Williams, Jackson, Neighbors, Torres, Sellers, S., & Brown, 2000). Given the weight of intersecting systems of oppression and vulnerabilities concerning ethno-gendered subjugation, the experience of depression among African American women (AAW) needs more diverse and inclusive mental health research attention. Using the principles of qualitative research methodology and the conceptual framework of grounded theory, this study seeks to build a more accurate representation of the African American (AA) female identity in mental health research by focusing on depression among the more distinct community of AAPW. Factors such as discrimination, racism, and sexism surface as elements of poor mental health outcomes for this community of women and their cohort members (Mays, Coleman, & Jackson, 1996). Researchers Williams, Neighbors, and Jackson (2003) have provided evidence that empirical data on the experience and prevalence of the relationship between perceived racism, discrimination, and mental health is minimally represented in mental health research. It is evident that the effects of discrimination are associated with multiple indicators of poor mental and physical health (Williams et al., 2003). AAW are at a high risk for experiencing the symptoms of mental health concern, such as depression in the form of decreased interest in regular activity, mood fluctuation, high blood pressure, and isolation. This high risk may be the result of their interactions with racism and sexism (Pieterse, Todd, Neville, & Carter, 2012; Katon, 2003; NIMH, 2018). Considering the weight of oppression and its negative effects on mental health, specific identities within the AA female population should be explored. 63 Literature Review The Relationship between African American professional women and Mental Health Depression. According to Nicolaidis and colleagues (2010), to understand a woman’s experience with depression, it is crucial to uncover her social context and identities. Historically, AAPW have spent their careers recognizing that race and sex have determined their career paths in many ways, creating obstacles and barriers for potential advancement (Bell & Nkomo, 2001). AAW have a long-standing relationship with societal victimization (Buchanan & Ormerod, 2002). In addition to experiencing racism in the workplace, AAPW also experience sexual harassment, which has been viewed as a psychological process affecting mental health status (Buchanan & Ormerod, 2002). A study exploring the experience of depression among black West-Indian Canadian women uncovered that many of these women manage depression by embodying the “strong black woman” persona, displaying invulnerability (Schreiber, Stern, & Wilson, 2000). AAPW are among those strong black women daily transitioning through roles and identities while quietly battling the injustices of society that surface in many aspects of their lives. AAW embody varying roles and identities, each having a different relationship to mental health concerns such as depression (Denton, 1990). For example, the experience of depression among low-income AAW may focus more on the relationship between socioeconomic factors and access to mental health services (Nadeem, Lange, & Miranda, 2008). However, depression among AAPW may include a more advanced look at occupational stress and the experience of transitioning between their professional, social, and familial identities (Snapp, 1992; Bell & Nkomo, 2003). To fully understand the experiences of mental health and inform mental health research, it is imperative to recognize the social context and roles that all AAW claim (Nicolaidis et al., 2010). 64 Mental health engagement. Historically, AAs have had a poor relationship with the United States’ health care industry. AA men and women have detailed traumatic experiences with institutionalized health care systems, exposing events such as the Tuskegee Syphilis Experiment and the routine non-consensual sterilization of AAW (Freimuth, Quinn, Thomas, Cole, Zook, & Duncan, 2001; Beal, 2008). The result of these events has left AAs skeptical of the United States’ governing health care system, as it has exploited people based on race and sex (Kennedy, Mathis, & Woods, 2007). Consequently, AAs are less likely to engage in help-seeking behaviors for their mental and physical health needs (Nadeem, Lange, Edge, Fongwa, Belin, & Miranda, 2007). While help-seeking behaviors are naturally informed by individual and cultural beliefs, there are also societal barriers placing AAs at risk for limited access and over all assistance (Holden, McGregor, Thandi, Fresh, Sheats, Belton, & Satcher, 2014; Mojtabai, Evans- Lacko, Shomerus, & Thornicroft, 2016). People in the AA community battling mental health constraints and grappling with a distrust of health care systems are more likely to receive help from clergy, non-mental health professionals, community members, and family before trying traditional treatments (Barksdale & Molock, 2009). Ultimately, these historical events have led to variations in treatment utilization among AAW and have placed emphasis on the strength of culturally influenced beliefs about disclosing personal problems to mental and/or physical health professionals (Banks & Kohn-Wood, 2002). AAW report displeasure with the current state of mental health care, and they often do not have their mental health needs met. The likelihood of AAW engaging in mental health care treatment is negatively affected by the strong black persona, stigma, a conditioned sense of strength and unrelenting resilience, suppressed emotions, resistance to feelings of dependence, and weakness (Woods-Giscombe, Robinson, Carthon, Devane-Johnson, & Corbie-Smith, 2016). 65 Stigma. The field of mental health has been closely associated with the term stigma for decades. Stigma is a vehicle that systemically maintains the presence of stereotypes, discrimination, and prejudice in a manner that suggests social exclusion and a decrease in social status, ultimately vilifying individuals with mental health issues (Ungar, Knaak, & Szeto, 2016). Researchers have found that individuals battling mental health issues and faced with community stigma are subject to untimely and inaccessible care, decreased possibility of recovery, and poor overall health outcomes (Ungar et al., 2016). Mental health has been silenced by society, as a concern, often suppressing the emotional turmoil of many women and creating a barrier to positive health and well-being (Fripp & Carlson, 2016). AAPW are particularly vulnerable to the disadvantages of social stigma that come from the voices of their ethnic and professional cultures (Alvidrez, Snowden & Kaiser, 2008; Dumas & Sanchez-Burks, 2015). Desensitization of symptomatology. AAW are most vulnerable to depression symptoms and ineffective coping behaviors, such as desensitization and internalization (Carr, Symanski, Taha, West, & Kaslow, 2014). AAW have varying experiences with treatment options when faced with the stressors of mental health constraints and when combating the barriers of intersectionality. In many cases, the experience of mental health issues can be overlooked and/or tolerated through desensitization (Carr et al., 2014; Ward, Wiltshire, Detry, & Brown, 2013). An exploratory, cross-sectional survey, analyzing general AA beliefs about mental health found that AAW are not very likely to validate the presence of their psychological distress (Ward et al, 2013). The study was based on their overall attitudes on health-seeking behaviors, treatment, and preferred coping styles (Ward et al., 2013). It can be hypothesized that many AAPW experiencing daily race-related stress could begin to be impervious to racial and sexual 66 discriminatory encounters and pressures, but they would not become impervious to the inevitable nature of an emotional response. African American Professional Women and Workplace Discrimination Risk factors. AAPW present with potential risks that result from their identities as minority women and professionals. Research on the psychological effects on interactions with workplace discrimination and sexual harassment have begun to expose the risks of recurrent encounters with racism and sexism (Hirsh & Lyons, 2010; Buchanan & Fitzgerald, 2008). In addition to the blatant acts of racism and sexism, AAPW also experience more subdued offenses in the form of microaggressions. Microaggressions are unintentional, unconscious acts of discrimination (Derald, Capodilupo, Nadal, & Torino, 2008). For many, these pressures can lead to poorer quality of life due to “workplace disruptions and high rates of absenteeism and occupational impairment” (Carrington, 2002). The stress of workplace, race-related issues could transfer to other areas of life as well. Enduring the stressors of workplace discrimination and/or harassment can cause mental health symptomatology to manifest physically, resulting in impairment in functions associated with common medical conditions (Carrington, 2002). AAW have been historically at a high risk for cardiovascular issues, such as hypertension, due to high blood pressure (Krieger, Chen, Waterman, Hartman, Stoddard, Quinn, & Barbeau, 2008). Now that AAW with depression are being diagnosed with comorbid health concerns, more thorough investigations on the side effects of workplace discrimination and harassment need to take place (Krieger et al., 2008). Guided Theoretical Frameworks Critical race theory. Critical race theory exposes the disparities of power and privilege that are present in many institutions and corporations and that are rooted in race relations 67 (Haskins & Singh, 2015). For AAPW, powerlessness and lack of privilege can lead to a number of outcomes, ranging from unequal wage disbursement to lack of opportunity for advancement (Holder, Jackson, & Ponterotto, 2015). As noted, AAPW confront the oppressions of their gender identity as women while simultaneously addressing the challenges of their racial identity as AAs (Beal, 2008). Critical race theory articulates these obstacles by exposing the deeply entrenched nature of racism and racial identity (Delgado & Stefanic, 2017). Research on racial identity is ambiguous in relation to psychological outcomes (Settles, Navarrete, Abdou, Pagano, & Sidanius, 2010). However, research on the relationship between AAs and their racial identity has revealed that black men and women take an evaluative stance on their personal perceptions and emotional responses to how AAs are viewed by society, and this stance can have positive or negative effects on their psychological well-being (Settles et al., 2010). The more negative the societal, group-based perception of AAs, the more at-risk AA individuals are of internalizing the perceived social rejection and experiencing adverse mental health issues such as depression (Settles et al., 2010; Bynum, Best, Barnes, & Burton, 2008). Stress theory. Stress theory addresses the systemic constraints of stress and the various ways it can be experienced, internalized, and/or expressed. According to researcher Aneshensel (1992), stress can be socially determined because of an individual’s social placement. The elements of stress have been researched in relationship to the negative effects of socio- environmental demands and the struggle to attain resources (Anehensel 1992; Lazarus & Folkman, 1984). Stress often comes from multiple directions, including work. For many AAW, the experience of stress is multiplex, coming from various systems each woman navigates on a regular basis. This stress can be a result of work or family matters, ultimately amplifying ramifications of multiple macro-level stressors (Murry, Butler-Barnes, Mayo- Gamble, & Inniss- 68 Thompson, 2018). The navigation of external stressors promotes an elevated, internal response and is often dependent on an individual’s values, perceptions, resources, and skill set (Anehesnel, 1992). While stress is informed by psychological thought, stress also informs psychological thought, along with the other aforementioned factors (Hobfoll, 2004). Further analyzing the presence of external stressors such as, race, socioeconomic status, and sex, can also serve as factors for addressing stress while simultaneously experiencing stress, conclusively influencing coping and resilience processes (Slavin, Rainer, McCreary, & Gowda, 1991; Folkman, 2013). Participants Method A total of 15 AAPW working in a large Midwestern city participated in this study. Eligibility for participation required: (1) racial identification with African American decent, (2) identification with being a biological female, (3) being between 35–55 years old, (4) having college/university experience or obtaining a bachelor’s degree, (5) having two or more years of active employment in the white–collar labor force, and (6) reporting acute to moderate depression based on the Patient Health Questionnaire (PHQ-9) assessment (Appendix C). The PHQ-9 assessment tool was chosen based on the extensive empirical validity of the tool and current research findings suggesting its effective use with minority populations (Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006). Prospective participants were excluded if they verbally confirmed a serious mental health diagnosis (e.g. bipolar disorder, borderline personality disorder) or a substance abuse issue. Participants ranged from 39 to 53 years of age, with a mean age of 50 years old. All were 69 employed in high-status professional positions, and each participant self-reported acute to moderate depression according to the PHQ-9. Data collection The Institutional Review Board of Michigan State University deemed this study protocol exempt. The recruitment process was implemented with the help of social network assistance from a professional female network. Female professional network assistance defines the previously developed relationships with various AAPW and requesting access to their professional female network. The goal was to solicit participants by contacting community leaders of elite minority organizations and active professionals in corporations and institutions/universities and explaining the elements of the study to them. Recruitment emails and flyers (Appendix B) outlining study eligibility were distributed to prospective participants prior to study involvement. A snowball sampling method was employed, relying on participants who joined the study to recruit additional participants if needed. Voluntary representatives from varying occupational fields served as recruitment leaders for their designated fields. Once the target number of desired participants was reached and participants were provided further details of the study, individual interviews were scheduled. Qualitative data was collected by facilitating in-depth, semi–structured, individual interviews that followed a pre-determined interview protocol (Appendix D). If participants were not able to schedule an in-person interview at a private location, the option of a Skype interview was offered. Participant eligibility was confirmed via phone or email prior to interview scheduling. The PHQ-9 (Appendix C) was administered via phone or provided via email and was to be returned to the primary investigator (PI) before participating in the interview process. A total of 15 women were assessed for depression via the PHQ-9, and each test found acute to mild 70 depression. Of the 15 participants, 12 had interviews conducted in person, and 3 had interviews conducted via Skype. Interviews ranged from 50 minutes to 100 minutes in length. Data analysis The researcher followed a constructivist grounded theory method with a three-part analysis process using NVIVO software (Charmaz & Mitchell, 2001; QSR International, 2016). Grounded theory was used as an inductive method, formatted by meticulous research techniques, that guided the research through data collection, analysis, and the production of conceptual categories (Charmaz & Belgrave, 2012). Qualitative grounded theory leads the researcher to explore phenomena and propose a theoretical rationale confirming the cause of the phenomena, the context in which the phenomena occurred and is maintained, and the researched ideas for intervention (Strauss & Corbin, 1998). The first step of analysis began with open coding, followed by axial coding. The final stage consisted of selective coding, and the conceptual framework emerged during the final analytical step. During the analysis process, the researcher employed the multiple tenants of trustworthiness to engage the voices of the participants while appropriately representing their reports. The PI that conducted this study is also a member of the population and used her cultural affiliation and ethno-gendered identification with this community to aid meaning and interpretations of this specific phenomena. Trustworthiness. Researcher Cope (2014) highly recommends that researchers document descriptions of their own experiences to ensure the credibility and trustworthiness of their qualitative research. These documented descriptions are supported by reflexivity, which is the process of knowledge development from the researcher’s point of view (Morrow, 2005). In addition to reflexivity, the PI also used memoing and an audit trail. Maintaining a clear 71 distinction between the PI’s predispositions and opinions, the audit trail served as a tool to confirm that confirmability criteria had been met. For credibility, the PI briefly documented the experience of each interview. According to Morrow (2005), in qualitative research, the term credibility assures that the findings have not been tampered with and that they have a substantial level of reliability and honesty. Credibility bluntly refers to the researcher’s ability to truthfully interpret the participants’ responses, securing accurate representation (Polit & Beck, 2014; Cope, 2014). Due to the PI identifying with the race and sex of the studied demographic, there is a level of familiarity that can serve as primary basis for securing the parallels between the human experiences being researched and the reality of those experiences. Maintaining trustworthiness and credibility, the second author provided insights as an expert coder, reviewing transcripts and coded data. Further ensuring credibility, this qualitative research design sought to explore the experience of self-reported depression among AAPW from various positions in different labor force fields. This idea closely follows the instruction of triangulation. By gathering data from AAPW identifying with different occupations, the PI assured the analysis of multiple perspectives and experiences. Consistency across data despite the variety of professions validates the findings and guarantees credibility (Carter, Bryant-Lukosius, DiSenco, Blythe, Neville, 2014). The relationship between the theoretical frameworks and research questions can be reviewed in Table 2.0 and Figure 2.0, which presents the theories and research questions used in support of the interview protocol (Appendix D). 72 TABLE 2.0 STUDY TWO TABLE OF THEORY AND RESEARCH QUESTIONS Theory Primary Research Questions Secondary Research Questions Stress Theory Critical Race Theory What are the risk factors for What are the effects of AAPW coping with depression? discrimination? Risk How does intersectionality influence the experience of AAPW? What are the effects of sexual harassment? What are the effects of microaggressions in workplace environments? What are the intersections of being AA, a woman, and a professional? FIGURE 2.0 MAP OF FORMAL THEORY Stress theory Critical race theory Support Depression among AAPW Encounter Racial Discrimination Microaggressions Sexual Harassment 73 Results Our research revealed salient and descriptive data that exemplifies the types of risks for depression that are present among AAPW. The goal of this grounded theory study was to accurately represent participant experiences of racial discrimination, sexual harassment, and microaggressions at work to develop an explanatory framework and model and explain the risk factors involved with such daily interactions. In due course, a culturally relevant emergent framework was developed to outline the types of stress risks that transpire from racial and sexual oppressions experienced at work. This study was informed throughout by critical race theory and used stress theory as a primary construct. The proposed emergent theoretical framework describes the culturally specific forms of stress risks that are pertinent to AAPW who are exposed to racial and sexual subjugation in the workplace. Findings Open and axial coding. The initial step of data analysis, open coding, created more than 100 open codes displaying shared experiences among the participants. This stage involved coding the transcripts line-by-line and being mindful of potential themes emerging within the data. The length of each transcript and the quality of information resulted in many abstract and frequent open codes, which were collapsed into three major categories during axial coding. The three primary axial codes were organized by stress risk, mental health risk, and professional risk for depression among AAPW. The researcher then supported the three primary axial codes with supportive selective codes that emerged in the form of pronounced sub codes and supported each primary category. These axial codes explain the contextual conditions of experiencing racial and sexual 74 oppressions at work. These conditions are furthered exemplified by the supportive selective codes outlining the type of stress-presenting that places AAPW with depression at risk. Table 2.1 presents direct quotes from participants regarding their interactions with workplace racial discrimination, microaggressions, and sexual harassment. Findings are organized by the three types of reported risk: stress risk, mental health risk, and professional risk. Each primary category is listed with a more descriptive, secondary category. To ensure the precision of reported results, participants’ quotations are represented by participants’ identification numbers (ID) and ages. For example: “ID 004, Age 50” indicates that the participant’s ID number was 4, and she was 50 years of age. The findings that emerged from the data expound the experience of depression among AAW. Stress risk. When asked, “How do you cope with everyday stress?” and “Have you ever tried or considered trying psychotherapy to cope with stress?” participants described stress- induced work and life events. The experience and risk of stress among AAPW with depression is supported by the secondary theme, allostatic load. Stress related to depression appears to accumulate from multiple forms of oppression experienced as a black female professional and from managing inventible life events, such as aging parents, parenthood, or marriage. Allostatic load: “There are so many moving parts right now. I am still dealing with the loss and grief of my mother, and now we are throwing this caveat into the mix [professional tension], and I just felt earlier that I was completely overwhelmed.” (ID001, Age 51) Life events: “Intellectually, I understand that right now is a stressful time, like when my daughter got sick, she stopped eating; she had to have a feeding tube and everything. Next thing I knew, my hair started falling out—I was so stressed and did not know what was happening.” (ID007, Age 47) Mental health risk. When discussing the mental health concerns experienced among AAPW with depression, participants narrated personal experiences of racial discrimination, 75 microaggressions, and sexual harassment. Questions such as, “How do you experience discrimination and/or microaggressions at work?” and “How do you experience sexual harassment at work?” elicited responses of stress and momentary mental health hardship. Everyone detailed the mental health constraints associated with interactions related to race and gender in and outside of their work environments, revealing a risk of depression and an individual’s professional identity, the risk of desensitization, and overall poor mental health engagement. Depression spectrum: “Depression has a stigma on it; you don’t want to seem like you are the person that needs to be medicated.” (ID011, Age 48) Desensitization: “I think sometimes you can just get numb to it and think, ‘This is just how it is.’” (ID010, Age 48) Poor Mental Health Care Engagement: “I was a department chair and in graduate school, and I felt like I was really losing it and I needed to talk to somebody, but I felt like I just did not have time.” (ID004, Age 50) Professional risk. As conversations on mental health slowly become socially acceptable, the unstable relationship between professionalism and mental health maintains relevance among AAPW experiencing depression. Participants reported vivid memories of workplace risk when addressing questions such as “Have you ever felt professionally disadvantaged due to your race and gender?” and “As an AA, female professional, what is your perception on workplace support of mental health concerns?” Encountering workplace harassment/discrimination, in addition to feelings caused by workplace isolation and navigating racial tensions, puts AAPW at a high risk for experiencing depression. Workplace oppression: “You know, the fact that he thought that was ok, that I would be that easy—I was so angry—and then to have felt so violated.” (ID003, Age 45) Workplace isolation: “There would be patients who said they don’t want 76 me to be their doctor because I am a black woman, blatant racist things, or subtle things like when your professor says a racist joke in front of the whole class and you are one of two black people in the class.” (ID005, Age 47) Navigating Racial Tensions: “Every battle in the corporate world is not meant to be fought because at some point they’re going to say, ‘She’s never happy about anything; she’s just an angry black woman.’” (ID013, Age 50) TABLE 2.1 STUDY TWO EMERGING QUOTES TABLE Primary Category Secondary Category Supporting Quote Stress Risk Mental health Risk Allostatic load Life events “Sometimes I think, ‘Wow, you've done great at handling all of these things,’ but other times I can’t help but think about the stress and anxiety that I feel sometimes and how overwhelmed I am.” (ID011, Age 48) “My mom has Alzheimer’s, so now it’s a lot of pressure on me because I am not there . . . they live in the city; I live out here. I am the oldest, which is a big part of it too. I feel like everything is on my shoulders.” (ID002, Age 50) Depression spectrum “There are different kinds of Desensitization Mental Health Engagement depression (grief, stress, situational). It was unexpected I did not see that coming.” (ID008, Age, 50) “And if you don't deal with that particular topic or issue that has occurred, it gets worse and worse, you know. So, then that becomes your norm—just the norm that you start to live. (ID009, Age 53) “I was going through stress, and I needed to talk to someone, and I didn't.” (ID013, Age 50) 77 Professional Risk TABLE 2.1 (cont’d) Workplace oppression “I walked to the bathroom. I just sobbed and sobbed and sobbed because I’m thinking I am 23, I am just starting my career, and this man is definitely harassing me, he is the client. You know, what am I supposed to do?” (ID001, Age 51) Workplace isolation “There were only two black people in a company of thousands.” (ID010, Age 48) Navigating Racial Tensions “I may go to visit a client or, you know, go to do a presentation or—I mean it’s not only the fact of me being a woman. But it’s also the fact of me being a black woman. You already have mysterious stereotypes, so you have to battle all of that all of the time.” (ID002, Age 50) 78 FIGURE 2.1 MAP OF GROUNDED THEORY Depression among AAPW Workplace Encounter Racial Discrimination Sexual Harassment Microaggressions Stress Risk 1.Allostatic load 2.Life Events Types of Risk Mental health Risk 1.Depression Spectrum 2. Desensitization 3.Mental Health Engagement Professional Risk 1. Workplace Oppressions 2. Workplace Isolation 3. Navigating Racial Tensions 79 Theoretical Concepts linked to the Findings and Grounded Theory This study was used to create an emergent theoretical framework for expanding upon the risks of racial discrimination, microaggressions, and sexual harassment among AAPW experiencing depression. Results demonstrate how stress theory and critical race theory support the experience of depression among AAPW, while expanding on the type of risks present when encountering acts of oppression. The grounded theory framework is presented in Figure 2.1. Results from this study confirm and define the risks of navigating racism and sexism in the workplace as AAPW with depression. AAPW have endured the stressors of being selfless and powerless, both inside and outside the accepted spaces of the dominant culture, creating an image of the “outsider-within” (Collins, 1986). This image contributes to the normalization of psychological distress in order to maintain a perception of strength (Beauboeuf-Lafontant, 2007). Among the AAPW in this study, three types of risks emerged: stress risk, mental health risk, and professional risk. These risks further illustrate the psychological demands of racism and sexism among AAPW with depression. Grounded theory In Figure 2.1, the map of grounded theory framework provides a more representative analysis of depression among AAPW, highlighting the risks present when addressing the intersecting experiences of race, sex, and professional identities. The concept of stress theory is used to highlight the systemic, cultural, and socially influenced nature of stress. The AAPW in this study each reported experiences of general stress and race/gender-based stress related to their identities as professional black women, acknowledging the intersections of race and gender. Critical race theory further exemplifies the relationship between AAPW, mental health, and their professional experience. Accounts of workplace discrimination, microaggressions, and sexual 80 harassment were revealed as stressful encounters, risking the onset, maintenance, or advancement of mental health concerns such as depression. Participants outlined the stress of being undermined as a black female in an advanced professional setting, exposing the risks involved when lacking historical power and privilege. Stress risk. Exploring depression among this community of high-achieving women revealed a stress risk when encountering workplace discrimination, microaggressions, and sexual harassment. Being a double minority creates a diverse but experience of oppression for AAW in many ways. The concept of stress is multifaceted for AAPW. The secondary category (allostatic load) helps define the physiological and psychological responses of accumulated stressors in various contexts for these women. The accumulation of stressful events and interactions supports the idea that life events are stressors as well. While stress is endured based on professional experience, many of the participants reported managing additional stressful events separately from their professional lives. Many of the participants reported family transitions, spousal challenges, and/or personal issues, all of which required their undivided attention. Racial tensions at work added to that stress, creating an additional layer of concerning elements affecting their overall experiences with depression. The severity and prevalence of stress events greatly affect mental health outcomes when accounting for race and sex (Jackson, Knight & Rafferty, 2010). Mental health risk. Research on psychological functioning, race, and general life stress among AAW has distinguished between the effects of racism-related stress and general life stress, finding that oppressive encounters have a positive relationship with general stress, conclusively affecting mental health outcomes (Pieterse, Carter, & Ray, 2013). Mental health risks emerged for the AAPW in this study when navigating oppressions in the workplace. The 81 overall experience of being black, female, and professionals resulted in a spectrum of depression severity. Most women expressed observing and living a depression that either appeared the same or different than that of their professional female cohort members. Yet, most, if not all, participants exposed a lack of awareness to the onset of their experience with depression as a mental health constraint. Given the status of the participants’ occupations, many reported unconsciously and consciously repressing or desensitizing the symptoms of depression, in addition to not having the time to engage with mental health services. When asked, “Have you ever tried or considered trying psychotherapy?” many of the participants said they have considered that outlet but felt like there was no opportunity to do so given their attempts for work–life balance. Given the high-status occupations of the AAPW in this study, resources without cultural constraints appear to be readily available. Yet, the stress of accessing culturally appropriate care (and time-permitted care) around challenging work and social schedules further contributes to poor mental health engagement and possible desensitization to depression symptoms for AAW and the AA population. Professional risk. A professional risk was revealed when participants were asked, “What has your experience been as an AA and a woman in a professional setting?” and “Have you ever felt professionally disadvantaged due to your race and gender?” Participants discussed moments of invisibility and isolation and the burden of navigating racial tension in the workplace. For the AAPW in this study, navigating racial tensions appeared to be a regular occurrence. Participants also discussed general feelings of isolation in the workplace (referring to the lack of black presence in the workplace) and ethno-gendered oppressions as professional black women. Participants reported having to address racially and sexually charged offenses at work while being concerned about risking their professional identities. Each woman expressed a sense of 82 powerlessness when reporting frequent encounters with racism and sexism despite the perceived privilege of their high-status occupations, which does not appear to serve as a shield against these encounters. In addition, participants reported the challenge and stress of having to defend their identities as both women and black women. We have formed a more accurate understanding of the risks faced by AAPW by using theoretical frameworks such as stress theory and critical race theory to dissect the continuous interactions AAPW have with oppressive events. When observing depression among AAPW through the lens of critical race theory, AAW must transition through racially adverse domains and that they need spaces that offer greater protection (Henry & Glenn, 2008). Mental health concerns such as depression remain consistent as a potential risk to AAPW, which supports current research on the effects of discriminatory events against AAPW. This study sought to explore the risks faced by AAPW with depression when Discussion and Implications encountering racial and gender-based oppressions. An emergent conceptual framework was developed to define the risks using stress theory and critical race theory as constructs to help further represent this under-developed yet unique experience. The AAPW in this study can be described as high-achieving individuals who have broken through glass ceilings and have demanded a seat at the dominant table. Yet, the oppressions they have endured have resulted in stress and mental health concerns that need to be addressed with culturally responsive solutions. Further supporting the need for additional work on AAPW, researchers Hall, Everett, and Hamilton-Mason (2011) conducted a grounded theory study examining the work-related stress experienced by black women and the coping tools they use to address racism and sexism. While AAPW and their female Caucasian counterparts experience similar forms of stress (as reported), 83 when accounting for the experience of racism and sexism, stressors concerning diversity and inequality emerge as further obstacles specific to AAPW (Hall et al., 2011). The themes reported from the data reveal challenges in being “hired or promoted in the workplace, defending one’s race and lack of mentorship, shifting or code switching to overcome barriers to employment, coping with racism and discrimination, and being isolated and/or excluded” (Hall et al., 2011). While the present study considers the experience of mental health constraints such as depression and is more specific to an elite group of professional black women, researcher Hall and his colleagues demand attention in a more general form, recognizing the stress present among working black women. The differences present in both studies acknowledge the diversity within racial/ethnic group membership. Trying to maintain a presence in mental health research for AAPW, quantitative work has also been conducted with the intention of exposing the risks of perceived discrimination and workplace racial composition (Maddox, 2013). Perceived discrimination and workplace composition were examined in association with psychological distress, life dissatisfaction, and job dissatisfaction between AA and Caucasian professional women (Maddox, 2013). A comparison between AAPW and non-professional AAW was made to solidify the correlations between race, sex, workplace discrimination, and mental health outcomes (Maddox, 2013). Study results reveal that there is a substantive relationship between race and job dissatisfaction among AAPW, and yet there was a larger correlation between perceived discrimination among Caucasian professional women and their AA female colleagues (Maddox, 2013). This interesting finding may be related to the salience of identity association and how it manifests in the workplace. Overall, the research conclusions highlight the necessity of decreasing and eliminating discrimination in the workplace, encouraging an increase in positive mental health 84 outcomes among AAPW (Maddox, 2013). More specifically, given the informative and yet unusual nature of these findings, this study reveals a need for more systemic research on discrimination and mental health outcomes among AAPW with higher socioeconomic statuses (Maddox, 2013) This need is primarily due to the rapid growth of AAPW as a sub-population the United States (Maddox, 2013). Concerning limitations, although this sample is taken from a large metropolitan area, the sample size does not represent a substantial number of AAPW residing in the United States. In addition, the sample size does not encompass a relatively equal representation of age due to the age restriction of the study. Although there is research on the effects of discriminatory events against AAW, more Conclusion research is needed that looks at the variations of these experiences. AAPW have endured an extensive and damaging number of socio-historical barriers in the form of interlocking systems of oppression, both in and out of the workplace. Yet, they continue to prevail, climbing occupational ladders once thought to be impossible. By exploring the types of risks involved when encountering racial discrimination, microaggressions, and sexual harassment in the workplace, stress theory and critical race theory can analyze and explain this experience. The goal is to expand mental health treatment among minority populations, encouraging more culturally competent attention to assessment and treatment of mental health concerns such as depression. The systemic nature of mental health requires a more inclusive and comprehensive understanding of socio-historical barriers present among marginalized populations. Without such inspection, treatment among AAW and other minority groups will continue to be ineffective, especially when treating conditions like depression among AAPW. While AAPW continue to 85 successfully obtain corporate, institutional, and organizational jobs, it is important to look at the psychological stipulations of that journey. By researching the experience of depression among AAPW through qualitative methodology, the relationships between mental health, professionalism, race, and gender can be more clearly understood in mental health research. 86 APPENDICES 87 APPENDIX A: Study Consent Form Exploring the Risk and Protective Factors Among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study Michigan State University Department of Human Development and Family Studies/Couple and Family Therapy Consent Form- Interview Participants A study entitled Exploring the Risk and Protective Factors among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationship with mental health, specifically depression. This study will consist of individual interviews with members of the Chicago, IL African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace navigation, with the goal of expanding the research on African American women and mental health treatment. Interviews will take place in person and within an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The inventive in participating in this study is the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how those factor into the workplace experience. Participants will receive one $10.00 Starbucks gift card after completion of the interview. The potential risks of participating in this study may include any distress and/or discomfort regarding discussion of mental health experiences and/or workplace incidents. Any study participant experiencing distress or discomfort will be provided with a referral to local mental health clinicians. If this applies to you please contact the Primary investigator (PI) Heather C. Lofton (708) 816-4405. If you agree to participate, a fourth- year graduate student, from Michigan State University will conduct interview protocol. Each interview will be audio recorded, unless refusal of the arrangement. If you agree to be audio recorded, please circle your response and initial on the line below. I agree to allow audio recording of the interview. YES NO Initials ______ Any responses you offer during the interview will be combined with other others, making your responses confidential, and your privacy will be protected to the full extent allowable by the law. Identifying information will not be attached to any of your individual responses, when reporting results from interviews. All material will be kept in a password- 88 protected laptop and only the principal investigator, her advisor and the University Research Protection staff will have access to the data. Each interview will take approximately 45-60 minutes to complete. If you have concerns or questions about this study, such as scientific issues, how to participate, or to report an injury please contact: - Dr. Marsha T. Carolan, Michigan State University, Human Ecology, East Lansing, MI 48823, (517) 432-3327, carolan@msu.edu - Dr. Deborah J. Johnson, Michigan State University, Human Ecology, East Lansing, MI 48823, 517-432-9115, john1442@hdfs.msu.edu - Heather C. Lofton, Doctoral Candidate, Michigan State University, Human Ecology, East Lansing, MI 48823, loftonhe@msu.edu If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University's Human Research Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824. Your signature below indicates your willingness to participate in this study. Thank you for your time. I look forward to talking with you about your experiences. Signature: ______________________________________ Date: ____________________ 89 Department of Human Development and Family Studies/Couple and Family Therapy Michigan State University Participation-Consent to Use a Direct Quote The form gives your consent to use direct quotes from this interview, for the purposes of publishing this study. Your identity will be kept confidential and an identification number will be used to protect you. Only the researchers will know the number assigned to you. By signing this form, you allow for the use of direct quotes in publications of this study and understand that your privacy will be protected to the maximum extent of the law. Your signature below indicates your willingness to voluntarily consent to the use of direct quotes in the publication of this study. Thank you for your time. Signature: ______________________________________Date: __________________ 90 APPENDIX B: Study Recruitment Form Dear Prospective Participant, A study titled The Risk and Protective Factors for Depression among African American Professional Women: A Grounded Theory Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationships with mental health and specifically depression. This study will consist of individual interviews with members from the a large Midwestern metropolitan area, with a substantive African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace experience, with the goal of expanding on the diversity of African American female identity by acknowledging professional women and informing research on mental health needs and treatments of African American women. Interviews will take place in person or via Skype, with an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The incentive in participating in this study are the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how those factor into the workplace experience. Participants will receive one gift card after completion of the interview. If you would like to participate or inquire about any more information regarding the study please email Primary investigator Heather C. Lofton, loftonhe@msu.edu or by phone. 91 APPENDIX C: Patient Health Questionnaire (PHQ-9) Patient Health Questionnaire-9 (PHQ-9) Over the last two weeks, how often have you been bothered by any of the follow problems? (Use to indicate your answer) Not difficult at all Somewhat difficult Very difficult Extremely difficult ☐ ☐ ☐ ☐ 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or over eating 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way For office coding ______ + ______+ ______+ ______ = Total Score ______ If you checked any of the problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all Several Days 0 1 More than half the days Nearly everyday 2 3 92 APPENDIX D: Interview Protocol INTRODUCTION TO THE STUDY The African American Professional Women’s (AAPW) community is rapidly growing. African American Women (AAW) are climbing corporate ladders, securing tenure professional appointments, practicing as medical doctors and upholding the law in political positions. This study seeks to explore the experience of being an AAW, while navigating the presence of intersectionality, as it transitions to the workplace. Focusing on mental health and specifically depression, this study plans to inform the future of mental health research, expanding the knowledge on treatment for AAPW. R1.) What are the protective and risk factors for AAPW coping with depression? Protective R1a). What are the influences of racial socialization? R1b). What are the influences of familial, social support? R1c.) What are the influences of spirituality? 1. How do you cope with everyday stress? 2. Have you ever tried or considered trying psychotherapy to cope with stress? 3. How would you describe your current emotional state? 4. What is happening around you when you are feeling that way? 5. How do you understand the feelings that you experience? 6. How does your family or community talk about those types of feelings? 7. What helps you when you are feeling down? 8. Can you please tell me what your understanding of depression? Risk R1d.) What are effects of discrimination? R1e.) What are the effects of sexual harassment? R1f.) What are effects of microaggressions in the work place environment? 9. How do you experience discrimination at work? 10. How do you experience microaggressions at work? 11. Can you please describe your response? 12. How do you cope with those types of experiences? 13. How do you experience sexual harassment at work? 93 14. Can you please describe your response? 15. How do you cope with that experience? 16. How would you describe your workplace environment? R2.) How does intersectionality influence the experience of AAPW? R2a. What are the intersections of being AA, a woman and a professional? 17. What has your experience been as an AA and a woman in a professional setting? 18. Have you ever felt professionally disadvantaged due to your race and gender? 19. How do you understand mental health in the workplace as an AA and a woman? 20. Thinking about the AA community/culture, do people discuss the experience of workplace racial/gender discrimination? 21. As an AA, female professional, what is your perception on workplace support mental health concerns? 22. Do you think the Patient Health Questionnaire is a culturally responsive and adequate tool to screen for depression symptoms? 94 REFERENCES 95 REFERENCES Alvidrez, J., Snowden, L., & Kaiser, D. (2008). The experience of stigma among Black mental health consumers. Journal of Health Care for the Poor & Underserved, 19(3), 874-893. doi:10.1353/hpu.0.0058 Aneshensel, C. S. (1992). Social stress: Theory and research. Annual Review of Sociology, 18(1), 15-38. doi:10.1146/annurev.so.18.080192.000311 Banks, K. H., & Kohn-Wood, L. P. (2002). Gender, ethnicity and depression: Intersectionality in mental health research with African American women. African American Research Perspectives, 174. https://digitalcommons.iwu.edu/psych_scholarship/6 Barksdale, C. L., & Molock, S. D. (2009). Perceived norms and mental health help seeking among African American college students. The Journal of Behavioral Health Services & Research, 36(3), 285-299. doi:10.1007/s11414-008-9138-y Beal, F. M. (2008). Double jeopardy: To be black and female. Meridians: Feminism, Race, Transnationalism, 8(2), 166. https://www.jstor.org/stable/40338758 Beauboeuf-Lafontant, T. (2007). You have to show strength: An exploration of gender, race, and depression. Gender & Society, 21(1), 28-51. doi:10.1177/0891243206294108 Bell, E. L. E., & Nkomo, S. M. (2003). Our separate ways: Black and White women and the struggle for professional identity. Harvard Business Press. doi:10.5465/AMR.2003.10899472 Brown, T. N., Williams, D. R., Jackson, J. S., Neighbors, H. W., Torres, M., Sellers, S. L., & Brown, K. T. (2000). “Being Black and feeling blue”: The mental health consequences of racial discrimination. Race and Society, 2(2), 117-131. doi:10.1016/S1090-9524(00)00010-3 Buchanan, N. T., & Fitzgerald, L. F. (2008). Effects of racial and sexual harassment on work and the psychological well-being of African American women. Journal of Occupational Health Psychology, 13(2), 137. doi:10.1037/1076-8998.13.2.137 Buchanan, N. T., & Ormerod, A. J. (2002). Racialized sexual harassment in the lives of African American women. Women & Therapy, 25(3-4), 107-124. doi:10.1300/J015v25n03_08 Bynum, M. S., Best, C., Barnes, S. L., & Burton, E. T. (2008). Private regard, identity protection 96 and perceived racism among African American males. Journal of African American Studies, 12(2), 142-155. doi:10.1007/s12111-008-9038-5 Carr, E. R., Szymanski, D. M., Taha, F., West, L. M., & Kaslow, N. J. (2014). Understanding the link between multiple oppressions and depression among African American women: The role of internalization. Psychology of Women Quarterly, 38(2), 233-245. doi:10.1177/0361684313499900 Carrington, C.H. (2002). Depression in African American women: a complex phenomenon. International Journal of Integrative Psychiatry, 2, 21–25. doi:10.1002/jclp.20289 Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of Charmaz, K., & Mitchell, R. G. (2001). Grounded theory in ethnography. Handbook of triangulation in qualitative research. In Oncology Nursing Forum, 41(5). doi:10.1188/14.ONF.545-547 Ethnography, 160, 174. Sage. Collins, P. H. (1986). Learning from the outsider within: The sociological significance of Black feminist thought. Social Problems, 33(6), s14-s32. doi:10.2307/800672 Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction. NYU Press. Denton, T. C. (1990). Bonding and supportive relationships among Black professional women: Rituals of restoration. Journal of Organizational Behavior, 11(6), 447-457. doi:10.1002/job.4030110606 Derald Wing, S., Capodilupo, C. M., Nadal, K. L., & Torino, G. C. (2008, May). Racial microaggressions and the power to define reality. American Psychologist, 277-279. doi:10.1037/0003-066X.63.4.277 Dumas, T. L., & Sanchez-Burks, J. (2015). The Professional, the personal, and the ideal worker: Pressures and objectives shaping the boundary between life domains. Academy of Management Annals, 9(1), 803-843. doi:10.1080/19416520.2015.1028810 Folkman, S. (2013). Stress, coping, and hope. In Psychological Aspects of Cancer (pp.119-127). Boston, MA: Springer. Freimuth, V. S., Quinn, S. C., Thomas, S. B., Cole, G., Zook, E., & Duncan, T. (2001). African Americans’ views on research and the Tuskegee Syphilis Study. Social Science & Medicine, 52(5), 797-808. doi:10.1016/S0277-9536(00)00178-7 Fripp, J. A. and Carlson, R. G. (2017). Exploring the influence of attitude and stigma on participation of African American and Latino populations in mental health services. Journal of Multicultural Counseling and Development, 45: 80–94. doi:10.1002/jmcd.12066 97 Hall, J. C., Everett, J. E., & Hamilton-Mason, J. (2011). Black women talk about workplace stress and how they cope. Journal of Black Studies, 43(2), 207-226. doi:10.1177/0021934711413272 Haskins, N. H., & Singh, A. (2015). Critical race theory and counselor education pedagogy: Creating equitable training. Counselor Education and Supervision, 54(4), 288- 301. doi:10.1002/ceas.12027 Henry, W. J., & Glenn, N. M. (2009). Black women employed in the ivory tower: Connecting for success. Advancing Women in Leadership, 29. doi:10.18738/awl.v29i0.271 Hirsh, E., & Lyons, C. J. (2010). Perceiving discrimination on the job: Legal consciousness, workplace context, and the construction of race discrimination. Law & Society Review, 44(2), 269-298. doi:10.1111/j.1540-5893.2010.00403.x Hobfoll, S. E. (2004). Stress, culture, and community: The psychology and philosophy of stress. Springer Science & Business Media. Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., & Satcher, D. (2014).Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities. Psychological Services, 11(4), 357, doi:10.1037/a0038122 Holder, A., Jackson, M. A., & Ponterotto, J. G. (2015). Racial microaggression experiences and coping strategies of Black women in corporate leadership. Qualitative Psychology, 2(2), 164. doi.org/10.1037/qup0000024 Jackson, J. S., Knight, K. M., & Rafferty, J. A. (2010). Race and unhealthy behaviors: Chronic stress, the HPA axis, and physical and mental health disparities over the life course. American Journal of Public Health, 100(5), 933-939. doi:10.2105/AJPH.2008.143446 Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54(3), 216-226. doi:10.1016/S0006-3223(03)00273-7 Kennedy, B. R., Mathis, C. C., & Woods, A. K. (2007). African Americans and their distrust of the health care system: Healthcare for diverse populations. Journal of Cultural Diversity, 14(2), 56. Krieger, N., Chen, J. T., Waterman, P. D., Hartman, C., Stoddard, A. M., Quinn, M. M., & Barbeau, E. M. (2008). The inverse hazard law: Blood pressure, sexual harassment, racial discrimination, workplace abuse and occupational exposures in US low-income Black, White and Latino workers. Social Science & Medicine, 67(12), 1970-1981. doi:10.1016/j.socscimed.2008.09.039 98 Lazarus, R. S., & Folkman, S. (1984). Coping and adaptation. In The Handbook of Behavioral Medicine, 282325. New York: Guilford. Maddox, T. (2013). Professional women's well-being: The role of discrimination and occupational characteristics. Women & Health, 53(7), 706-729. doi:/10.1080/03630242.2013.822455 Mays, V. M., Coleman, L. M., & Jackson, J. S. (1996). Perceived race-based discrimination, employment status, and job stress in a national sample of Black women: Implications for health outcomes. Journal of Occupational Health Psychology, 1(3), 319. doi:10.1037/1076-8998.1.3.319 Mojtabai, R., Evans-Lacko, S., Schomerus, G., & Thornicroft, G. (2016). Attitudes toward mental health help seeking as predictors of future help-seeking behavior and use of mental health treatments. Psychiatric Services, 67(6), 650-657. doi:10.1176/apSI.ps.201500164 Murry, V. M., Butler‐Barnes, S. T., Mayo‐Gamble, T. L., & Inniss‐Thompson, M. N. (2018). Nadeem, E., Lange, J. M., Edge, D., Fongwa, M., Belin, T., & Miranda, J. (2007). Does Excavating new constructs for family stress theories in the context of everyday life experiences of Black American families. Journal of Family Theory & Review, 10(2), 384-405. doi:10.1111/jftr.12256 stigma keep poor young immigrant and US-born Black and Latina women from seeking mental health care? Psychiatric Services, 58(12), 1547-1554. doi:10.1176/ps.2007.58.12.1547 Nadeem, E., Lange, J. M., & Miranda, J. (2008). Mental health care preferences among low-income and minority women. Archives of Women's Mental Health, 11(2), 93-102. doi:10.1007/s00737-008-0002-0 National Institute of Mental Health (NIMH) (2018) Depression Nicolaidis, C., Timmons, V., Thomas, M. J., Waters, A. S., Wahab, S., Mejia, A., & Mitchell, S. R. (2010). “You don't go tell White people nothing”: African American women's perspectives on the influence of violence and race on depression and depression care. American Journal of Public Health, 100(8), 1470-1476. doi:10.2105/AJPH.2009.161950 Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1-9. doi:10.1037/a0026208 QSR International (2014). NVIVO 10 for Windows. Retrieved from http://www.qsrinternational.com/products_nvivo.aspx 99 Schreiber, R., Stern, P. N., & Wilson, C. (2000). Being strong: how Black West‐Indian Canadian women manage depression and its stigma. Journal of Nursing Scholarship, 32(1), 39-45. doi:10.1111/j.1547-5069.2000.00039.x Settles, I. H., Navarrete, C. D., Pagano, S. J., Abdou, C. M., & Sidanius, J. (2010). Racial identity and depression among African American women. Cultural Diversity and Ethnic Minority Psychology, 16(2), 248. .doi.org/10.1037/a0016442 Slavin, L. A., Rainer, K. L., McCreary, M. L., & Gowda, K. K. (1991). Toward a multicultural model of the stress process. Journal of Counseling & Development, 70(1), 156-163. doi:10.1002/j.1556-6676.1991.tb01578.x Snapp, M. B. (1992). Occupational stress, social support, and depression among Black and White professional-managerial women. Women & Health, 18(1), 41-79. doi:10.1300/J013v18n01_03 Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271. doi:10.1037/0003-066X.62.4.271 Ungar, M. (2008). Resilience across cultures. British Journal of Social Work, 38, 218-235. doi:10.1093/bjsw/bcl343 Ward, E. E., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing Research, 62(3), 185-194. doi:10.1097/NNR.0b013e31827bf533 Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93(2), 200-208. doi:10.2105/AJPH.93.2.200 Woods-Giscombe, C., Robinson, M. N., Carthon, D., Devane-Johnson, S., & Corbie-Smith, G. (2016). Superwoman schema, stigma, spirituality, and culturally sensitive providers: Factors influencing African American women's use of mental health services. Journal of Best Practices in Health Professions Diversity: Education, Research & Policy, 9(1), 1124-1144. 100 CHAPTER FOUR: CONCLUSION The findings from studies 1 and 2 both present with a general theme, exposing the multiplicity of racial and ethnic identity and the generalizations placed on minority communities in mental health research. Group membership and identity salience each had significant roles, when exploring common phenomena among a unique and underrepresented population, such as AAPW with depression. It is important to acknowledge the results of socio historical barriers present among AA populations when researching the effects of mental health constraints, such as depression. For AAPW, the concept of ethno-gendered socialization, and the SBW schema reveal important roles when analyzing the ways in which AAPW understand, experience and cope with depression symptoms. While current research has sparingly dissected these concepts individually alongside the health and well-being of AAPW, when researching them together, culturally relevant and appropriate theoretical frameworks such as black feminist theory is a necessity to uncover cultural resilient mechanisms popular among this marginalized community. This notion continues to maintain importance when accounting for the harmful effects of racism and sexism in the workplace. While AAPW can be among the elite, their high-status occupations do not shield them from racial discrimination, micro-aggressions and sexual harassment. Yet, this group of women continue to prevail despite the more negative the societal group-based perception of AAs, the more at-risk AA individuals are of internalizing the perceived social rejection and experiencing adverse mental health issues like depression (Settles et al., 2010; Bynum, Best, Barnes, & Burton, 2008). Based on research results, target outcomes address the need for culturally competent psychological assessments and treatment of AAs and more specifically AAW (Sosluski, Buchanan, & Donnell, 2010; Betancourt, Green, Carrillo, & Owusu Ananeh-Firempong, 2016). 101 By broadly identifying risk and protective factors for depression among AAPW, the results can help our understanding of what AAPW need when experiencing mental health issues and the societal and work-based constraints involved. For example, participants shared their cultured understandings of the term depression, and then revealed a consensus on what they use to cope with such experiences. According to the AAPW in this study, coping tools such as activity and exercise were quite prevalent, presenting a difference in the current research available, exposing the challenges black women express with working out and hair care regimens (Versey, 2014) In addition, while AAPW continue to report the need for spiritual connection and involvement when coping with depression, there was an educated awareness regarding the need for more than spirituality to treat mental health concerns, such as depression. Overarching Implications for Practice and Research Both studies 1 and 2 reveal suggestions to improve mental health practice and research based on the findings reported from each manuscript. A brief overview of the overarching implications accumulated from both manuscripts present a need for culturally competent mental health care, concerning assessment and overall treatment and research for minority populations. Culturally competent care. The topic of cultural competence has been researched extensively, creating a large body of literature around the importance of health care providers becoming well versed in the differences between client/patient demographics. The working body of literature defines cultural competency as the ability of health care providers to communicate and effectively provide high quality care to clients/patients from diverse racial and ethnic backgrounds, not excluding the effects of socioeconomic status and gender (Betancourt & Green, 2010; Like, 2011). The current trends of the United States population have increasingly diversified, creating a need for health care providers to become more aware and educated about 102 the cross-cultural variations of client/patient backgrounds (Elminowski, 2015). The purpose of culturally competent providers is to ensure that all clients/patients are receiving the best possible treatment that not only tends to treat the medical/clinical-presenting problem but also considers the cultural factors related to the presenting problem and its treatment. Racial and ethnic health disparities within the health care field have exposed the need for an in- treatment tool for acknowledging the present differences between clients and health care providers. There have been documented cases where health care providers have provided sub-standard care due to cultural misunderstandings within the clinical setting, resulting in misdiagnoses and overall poor treatment prompting legal involvement (Campinha- Bacote, Campinha-Bacote, 2009). In addition to the malpractice concerns, there are other implications for cultural competence including addressing health disparities within the health care field and increasing the quality of care. The program for continuing medical education has placed a sense of urgency on the matter of cultural competence (Like, 2011). For communities such as AAPW, culturally relevant mental health care is crucial to uncovering potential treatment methods and concerns that may not be available in generalized assessments and modals based one Eurocentric value. Study strengths. Current research on AAs has presented an overwhelming need for culture to sit as a determining factor for not only mental health treatment but physical health care as well (Bentancourt et al., 2016; Sue, Nadal, Capodilcupo,Torino, & Rivera, 2008). This present study provides the detailed and intimate cultural groundings for mental health concerns, such as depression, among a multiplying, yet underrepresented population of marginalized individuals. By exploring the risk and protective factors for depression among AAPW, this study negates the monolithic tone placed on minority research, and expounds on the lived experiences of AAW, suggesting that there is more to be learned and applied to mental health research. Thus, mental 103 health care practitioners, such as marriage and family therapists, counselors and psychologists must make it a point to learn from theoretical studies such as this, to start considering factors that serve as a risk or protection that are outside of manual based assessment tools and treatment methods and reared in culture. While there are several culturally competent care models available to practitioners, it is time to bridge the gap between theory and application in mental health among racial ethnic minority populations (Like, 2011). 104 APPENDICES 105 APPENDIX A: Study Consent Form Exploring the Risk and Protective Factors Among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study Michigan State University Department of Human Development and Family Studies/Couple and Family Therapy Consent Form- Interview Participants A study entitled Exploring the Risk and Protective Factors among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationship with mental health, specifically depression. This study will consist of individual interviews with members of the Chicago, IL African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace navigation, with the goal of expanding the research on African American women and mental health treatment. Interviews will take place in person and within an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The inventive in participating in this study is the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how those factor into the workplace experience. Participants will receive one $10.00 Starbucks gift card after completion of the interview. The potential risks of participating in this study may include any distress and/or discomfort regarding discussion of mental health experiences and/or workplace incidents. Any study participant experiencing distress or discomfort will be provided with a referral to local mental health clinicians. If this applies to you please contact the Primary investigator (PI) Heather C. Lofton (708) 816-4405. If you agree to participate, a fourth- year graduate student, from Michigan State University will conduct interview protocol. Each interview will be audio recorded, unless refusal of the arrangement. If you agree to be audio recorded, please circle your response and initial on the line below. I agree to allow audio recording of the interview. YES NO Initials ______ Any responses you offer during the interview will be combined with other others, making your responses confidential, and your privacy will be protected to the full extent allowable by the law. Identifying information will not be attached to any of your individual responses, when reporting results from interviews. All material will be kept in a password- 106 protected laptop and only the principal investigator, her advisor and the University Research Protection staff will have access to the data. Each interview will take approximately 45-60 minutes to complete. If you have concerns or questions about this study, such as scientific issues, how to participate, or to report an injury please contact: - Dr. Marsha T. Carolan, Michigan State University, Human Ecology, East Lansing, MI 48823, (517) 432-3327, carolan@msu.edu - Dr. Deborah J. Johnson, Michigan State University, Human Ecology, East Lansing, MI 48823, 517-432-9115, john1442@hdfs.msu.edu - Heather C. Lofton, Doctoral Candidate, Michigan State University, Human Ecology, East Lansing, MI 48823, loftonhe@msu.edu If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University's Human Research Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824. Your signature below indicates your willingness to participate in this study. Thank you for your time. I look forward to talking with you about your experiences. Signature: ______________________________________ Date: ____________________ 107 Department of Human Development and Family Studies/Couple and Family Therapy Michigan State University Participation-Consent to Use a Direct Quote The form gives your consent to use direct quotes from this interview, for the purposes of publishing this study. Your identity will be kept confidential and an identification number will be used to protect you. Only the researchers will know the number assigned to you. By signing this form, you allow for the use of direct quotes in publications of this study and understand that your privacy will be protected to the maximum extent of the law. Your signature below indicates your willingness to voluntarily consent to the use of direct quotes in the publication of this study. Thank you for your time. Signature: ______________________________________Date: __________________ 108 APPENDIX B: Study Recruitment Form Dear Prospective Participant, A study titled The Risk and Protective Factors for Depression among African American Professional Women: A Grounded Theory Study, is being executed by a doctoral candidate at Michigan State University, with the intent to hear and learn from the African American professional women’s community, concerning their relationships with mental health and specifically depression. This study will consist of individual interviews with members from the a large Midwestern metropolitan area, with a substantive African American professional women’s population. Interviews will focus on the experience of mental health, ethno-gendered identity and workplace experience, with the goal of expanding on the diversity of African American female identity by acknowledging professional women and informing research on mental health needs and treatments of African American women. Interviews will take place in person or via Skype, with an expected time frame of approximately 45-60 minutes in length. Please note that participation in this project is completely voluntary. Participants may withdraw from the study at any time and/or refuse to answer any questions they do not want to answer. Refusal to participate and/or withdrawal from the study will not affect participants in any form. The incentive in participating in this study are the opportunity to candidly discuss your experiences with mental health, the intersection of being a woman and being African American and how that factors into the workplace experience. Participants will receive one gift card after completion of the interview. If you would like to participate or inquire about any more information regarding the study please email Primary investigator Heather C. Lofton, loftonhe@msu.edu or by phone. 109 APPENDIX C: Patient Health Questionnaire (PHQ-9) Patient Health Questionnaire-9 (PHQ-9) Over the last two weeks, how often have you been bothered by any of the follow problems? (Use to indicate your answer) Not difficult at all Somewhat difficult Very difficult Extremely difficult ☐ ☐ ☐ ☐ 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or over eating 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way For office coding ______ + ______+ ______+ ______ = Total Score ______ If you checked any of the problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all Several Days 0 1 More than half the days Nearly everyday 2 3 110 APPENDIX D: Interview Protocol INTRODUCTION TO THE STUDY The African American Professional Women’s (AAPW) community is rapidly growing. African American Women (AAW) are climbing corporate ladders, securing tenure professional appointments, practicing as medical doctors and upholding the law in political positions. This study seeks to explore the experience of being an AAW, while navigating the presence of intersectionality, as it transitions to the workplace. Focusing on mental health and specifically depression, this study plans to inform the future of mental health research, expanding the knowledge on treatment for AAPW. R1.) What are the protective and risk factors for AAPW coping with depression? Protective R1a). What are the influences of racial socialization? R1b). What are the influences of familial, social support? R1c.) What are the influences of spirituality? 1. How do you cope with everyday stress? 2. Have you ever tried or considered trying psychotherapy to cope with stress? 3. How would you describe your current emotional state? 4. What is happening around you when you are feeling that way? 5. How do you understand the feelings that you experience? 6. How does your family or community talk about those types of feelings? 7. What helps you when you are feeling down? 8. Can you please tell me what your understanding of depression? Risk R1d.) What are effects of discrimination? R1e.) What are the effects of sexual harassment? R1f.) What are effects of microaggressions in the work place environment? 9. How do you experience discrimination at work? 10. How do you experience microaggressions at work? 11. Can you please describe your response? 12. How do you cope with those types of experiences? 13. How do you experience sexual harassment at work? 111 14. Can you please describe your response? 15. How do you cope with that experience? 16. How would you describe your workplace environment? R2.) How does intersectionality influence the experience of AAPW? R2a. What are the intersections of being AA, a woman and a professional? 17. What has your experience been as an AA and a woman in a professional setting? 18. Have you ever felt professionally disadvantaged due to your race and gender? 19. How do you understand mental health in the workplace as an AA and a woman? 20. Thinking about the AA community/culture, do people discuss the experience of workplace racial/gender discrimination? 21. As an AA, female professional, what is your perception on workplace support mental health concerns? 22. Do you think the Patient Health Questionnaire is a culturally responsive and adequate tool to screen for depression symptoms? 112 APPENDIX E: IRB Exempt Status December 14, 2017
 To: Marsha T Carolan EXEMPT DETERMINATION Office of Regulatory Affairs Human Research Protection Program 4000 Collins Road Suite 136 Lansing, MI 48910 517-355-2180 Fax: 517-432-4503 Email: irb@msu.edu www.hrpp.msu.edu Re: MSU Study ID: STUDY00000034 Principal Investigator: Marsha T Carolan Category: Exempt 2
Exempt Determination Date: 12/14/2017 Title: Exploring The Risk And Protective Factors Among African American Professional Women Experiencing Depression: An Exploratory Qualitative Study This project has been determined to be exempt under 45 CFR 46.101(b) 2. Principal Investigator Responsibilities: The Principal Investigator assumes the responsibilities for the protection of human subjects in this project as outlined in Human Research Protection Program (HRPP) Manual Section 8-1, Exemptions. Continuing Review: Exempt projects do not need to be renewed. Modifications: In general, investigators are not required to submit changes to the Michigan State University (MSU) Institutional Review Board (IRB) once a research study is designated as exempt as long as those changes do not affect the exempt category or criteria for exempt determination (changing from exempt status to expedited or full review, changing exempt category) or that may substantially change the focus of the research study such as a change in hypothesis or study design. See HRPP Manual Section 8-1, Exemptions, for examples. If the project is modified to add additional sites for the research, please note that you may not begin the research at those sites until you receive the appropriate approvals/permissions from the sites. 113 Change in Funding: If new external funding is obtained for an active human research project that had been determined exempt, a new initial IRB submission will be required, with limited exceptions. Reportable Events: If issues should arise during the conduct of the research, such as unanticipated problems that may involve risks to subjects or others, or any problem that may increase the risk to the human subjects and change the category of review, notify the IRB office promptly. Any complaints from participants that may change the level of review from exempt to expedited or full review must be reported to the IRB. Please report new information through the project’s workspace and contact the IRB office with any urgent events. Please visit the Human Research Protection Program (HRPP) website to obtain more information, including reporting timelines. Personnel Changes: After determination of the exempt status, the PI is responsible for maintaining records of personnel changes and appropriate training. The PI is not required to notify the IRB of personnel changes on exempt research. However, he or she may wish to submit personnel changes to the IRB for recordkeeping purposes (e.g. communication with the Graduate School) and may submit such requests by submitting a Modification request. If there is a change in PI, the new PI must confirm acceptance of the PI Assurance form and the previous PI must submit the Supplemental Form to Change the Principal Investigator with the Modification request (http://hrpp.msu.edu/forms). Closure: Investigators are not required to notify the IRB when the research study is complete. However, the PI can choose to notify the IRB when the project is complete and is especially recommended when the PI leaves the university. For More Information: See HRPP Manual, including Section 8-1, Exemptions (available at https://hrpp.msu.edu/msu-hrpp-manual-table-contents-expanded). Contact Information: If we can be of further assistance or if you have questions, please contact us at 517-355-2180 or via email at IRB@ora.msu.edu. Please visit hrpp.msu.edu to access the HRPP Manual, templates, etc. Exemption Category. This project has qualified for Exempt Category (ies) 2. Please see the appropriate research category below from 45 CFR 46.101(b) for the full regulatory text. 123 Exempt 1. Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as (i) research on regular and special education instructional strategies, or (ii) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods. 114 Exempt 2. Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless: (i) information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and (ii) any disclosure of the human subjects' responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation. Exempt 3. Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior that is not exempt under paragraph (b)(2) of this section, if:
(i) the human subjects are elected or appointed public officials or candidates for public office; or (ii) federal statute(s) require(s) without exception that the confidentiality of the personally identifiable information will be maintained throughout the research and thereafter. Exempt 4. Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects. Exempt 5. Research and demonstration projects which are conducted by or subject to the approval of department or agency heads, and which are designed to study, evaluate, or otherwise examine: (i) Public benefit or service programs; (ii) procedures for obtaining benefits or services under those programs; (iii) possible changes in or alternatives to those programs or procedures; or (iv) possible changes in methods or levels of payment for benefits or services under those programs. Exempt 6. Taste and food quality evaluation and consumer acceptance studies, (i) if wholesome foods without additives are consumed or (ii) if a food is consumed that contains a food ingredient at or below the level and for a use found to be safe, or agricultural chemical or environmental contaminant at or below the level found to be safe, by the Food and Drug Administration or approved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S. Department of Agriculture. 1Exempt categories (1), (2), (3), (4), and (5) cannot be applied to activities that are FDA- regulated.
2 Exemptions do not apply to research involving prisoners.
3 Exempt 2 for research involving survey or interview procedures or observation of public behavior does not apply to research with children, except for research involving observations of public behavior when the investigator(s) do not participate in the activities being observed. 115 REFERENCES 116 REFERENCES Abrams, J. A., Maxwell, M., Pope, M., & Belgrave, F. Z. (2014). Carrying the world with the grace of a lady and the grit of a warrior: Deepening our understanding of the “Strong Black Woman” schema. Psychology of Women Quarterly, 38(4), 503-518. doi.org/10.1177/0361684314541418. Alvidrez, J., Snowden, L., & Kaiser, D. (2008). The experience of stigma among Black mental health consumers. Journal of Health Care For The Poor & Underserved, 19(3), 874-893.doi:10.1353/hpu.0.0058. American Psychological Association (2015) Publication manual of the American Psychological 6th edition. Washington, DC: American Psychological Association. Aneshensel, C. S. (1992). Social stress: Theory and research. Annual review of sociology, 18(1), 15-38. doi: org./10.1146/annurev.so.18.080192.000311 Banks, K. H., & Kohn-Wood, L. P. (2002). Gender, ethnicity and depression: Intersectionality in mental health research with African American women. African American Research Perspectives, 174. Barksdale, C. L., & Molock, S. D. (2009). Perceived norms and mental health help seeking among African American college students. The Journal of Behavioral Health Services & Research, 36(3), 285-299. doi:10.1007/s11414-008-9138-y Beal, F. M. (2008). Double jeopardy: to be black and female. Meridians: feminism, race, transnationalism, 8(2), 166. Retrieved from https://www.jstor.org/stable/40338758 Beauboeuf-Lafontant, T. (2007). You have to show strength an exploration of gender, race, and depression. Gender & Society, 21(1), 28-51. doi.org/10.1177/0891243206294108 Beauboeuf-Lafontant, T. (2008). Listening past the lies that make us sick: A voice- centered analysis of strength and depression among black women. Qualitative Sociology, 31(4), 391-406. doi 10.1007/s11133-008-9113-1 Bell, E. L. E., & Nkomo, S. M. (2003). Our separate ways: Black and white women and the struggle for professional identity. Harvard Business Press. doi:10.5465/AMR.2003.10899472. Betancourt, J. R., & Green, A. R. (2010). Commentary: Linking Cultural Competence Training to Improved Health Outcomes: Perspectives From the Field. Academic Medicine, 85(4), 583-585. doi: 10.1097/ACM.0b013e3181d2b2f3 117 Berdahl, J. L., & Moore, C. (2006). Workplace Harassment: Double Jeopardy for Minority Women. Journal Of Applied Psychology, 91(2), 426-436. doi: 10.1037/0021- 9010.91.2.426 Brown, C., Bromberger, J. T., Schott, L. L., Crawford, S., & Matthews, K. A. (2014). Persistence of depression in African American and Caucasian women at midlife: findings from the Study of Women Across the Nation (SWAN). Archives of women's mental health, 17(6), 549-557. doi.org/10.1007/s00737-014-0444-5 Brown, T. N., & Lesane-Brown, C. L. (2006). Race socialization messages across historical time. Social Psychology Quarterly, 69(2), 201-213. doi.org/10.1177/019027250606900205 Brown, T., Linver, M., Evans, M., & DeGennaro, D. (2009). African--American parents' racial and ethnic socialization and adolescent academic grades: teasing out the role of gender. Journal of Youth & Adolescence, 38(2), 214-227. doi:10.1007/s10964-008-9362- z Brown, T. N., Williams, D. R., Jackson, J. S., Neighbors, H. W., Torres, M., Sellers, S. L., & Brown, K. T. (2000). “Being black and feeling blue”: The mental health consequences of racial discrimination. Race and Society, 2(2), 117-131. https://doi.org/10.1016/S1090-9524(00)00010-3 Brown Givens, S. M., & Monahan, J. L. (2005). Priming mammies, jezebels, and other controlling images: An examination of the influence of mediated stereotypes on perceptions of an African American woman. Media Psychology, 7(1), 87-106. doi.org/10.1207/S1532785XMEP0701_5. Buchanan, N. T., & Fitzgerald, L. F. (2008). Effects of racial and sexual harassment on work and the psychological well-being of African American women. Journal of occupational health psychology, 13(2), 137. doi: 10.1037/1076-8998.13.2.137. Buchanan, N. T., & Ormerod, A. J. (2002). Racialized sexual harassment in the lives of African American women. Women & Therapy, 25(3-4), 107-124. doi: 10.1300/J015v25n03_08. Bynum, M. S., Best, C., Barnes, S. L., & Burton, E. T. (2008). Private regard, identity protection and perceived racism among African American males. Journal of African American Studies, 12(2), 142-155. doi.org/10.1007/s12111-008-9038-5 Campinha-Bacote, A., & Campinha-Bacote, J. (2009). Extending a Model of Cultural Competence in Health Care Delivery to the Field of Health Care Law. Journal of Nursing Law, 13(2), 36-44. doi.org/10.1891/1073-7472.13.2.36 Carr, E. R., Szymanski, D. M., Taha, F., West, L. M., & Kaslow, N. J. (2014). 118 Understanding the link between multiple oppressions and depression among African American women the role of internalization. Psychology of Women Quarterly, 38(2), 233-245. doi: https://doi.org/10.1177/0361684313499900 Carrington, C.H. (2002). Depression in African American women: a complex phenomenon. International Journal of Integrative Psychiatry, 2, 21–25. doi.org/10.1002/jclp.20289. Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of triangulation in qualitative research. In Oncology nursing forum Vol. 41, No. 5. doi: 10.1188/14.ONF.545-547 Caughy, M. O. B., Nettles, S. M., & Lima, J. (2011). Profiles of racial socialization among African American parents: Correlates, context, and outcome. Journal of Child and Family Studies, 20(4), 491-502. doi.org/10.1007/s10826-010-9416-1 Charmaz, K., & Belgrave, L. (2012). Qualitative interviewing and grounded theory analysis. The SAGE handbook of interview research: The complexity of the craft, 2, 347- 365 Charmaz, K., & Mitchell, R. G. (2001). Grounded theory in ethnography. Handbook of ethnography, 160, 174. Sage. Chavous, T. M., Rivas-Drake, D., Smalls, C., Griffin, T., & Cogburn, C. (2008). Gender matters, too: The influences of school racial discrimination and racial identity on academic engagement outcomes among African American adolescents. Developmental psychology, 44(3), 637. doi: 10.1037/0012-1649.44.3.637 Chow, J. C. C., Jaffee, K., & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public Health, 93(5), 792- 797. doi: 10.2105/AJPH.93.5.792 Cole, E.R.(2009) Intersectionality and research in psychology. American Psychologist 64 (3)170-80. doi.org/10.1037/a0014564 Collins, P. H. (1986). Learning from the outsider within: The sociological significance of Black feminist thought. Social problems, 33(6), s14-s32. doi: 10.2307/800672. Collins, P. H. (1990). Towards an Afrocentric feminist epistemology. Routledge. Cope, D. G. (2014). Methods and meanings: credibility and trustworthiness of qualitative research. In Oncology nursing forum, Vol. 41, No. 1. doi:10.1188/14.ONF.89-91. Corbin, J., Strauss, A., & Strauss, A. L. (2014). Basics of qualitative research. Sage. Creswell, J. W., Hanson, W. E., Clark Plano, V. L., & Morales, A. (2007). Qualitative research 119 designs: Selection and implementation. The counseling psychologist, 35(2), 236-264. doi.org/10.1177/0011000006287390 Crockett, D. (2017). Paths to respectability: Consumption and stigma management in the contemporary black middle class. Journal of Consumer Research, 44(3), 554-581. doi.org/10.1093/jcr/ucx049 Cross Jr, W. E. (1991). Shades of black: Diversity in African-American identity. Temple University Press. Davis, S. M. (2015). The “Strong Black Woman Collective”: A Developing theoretical framework for understanding collective communication practices of black women. Women's Studies in Communication, 38(1), 20-35. doi:10.1080/07491409.2014.953714. Davis, S., & Tucker-Brown, A. (2013). Effects of black sexual stereotypes on sexual decision making among African American women. Journal of Pan African Studies, 5(9), 111-128. Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction. NYU Press. Denton, T. C. (1990). Bonding and supportive relationships among black professional women: Rituals of restoration. Journal of Organizational Behavior, 11(6), 447-457. doi.org/10.1002/job.4030110606. Derald Wing, S., Capodilupo, C. M., Nadal, K. L., & Torino, G. C. (2008, May). Racial Microaggressions and the Power to Define Reality. American Psychologist. pp. 277-279. doi:10.1037/0003-066X.63.4.277. Dodgson, J. E. (2017). About research: qualitative methodologies. Journal of Human Lactation, 33(2), 355-358. doi.org/10.1177/0890334417698693 Donovan, R. A., & West, L. M. (2015). Stress and mental health: Moderating role of the strong Black woman stereotype. Journal of Black Psychology, 41(4), 384-396. doi.org/10.1177/0095798414543014 Dumas, T. L., & Sanchez-Burks, J. (2015). The Professional, the Personal, and the Ideal Worker: Pressures and Objectives Shaping the Boundary between Life Domains. Academy Of Management Annals, 9(1), 803-843. doi:10.1080/19416520.2015.1028810 Dwight-Johnson, M., Unutzer, J., Sherbourne, C., Tang, L., & Wells, K. B. (2001). Can quality improvement programs for depression in primary care address patient preferences or treatment?. Medical care, 934-944. https://www.jstor.org/stable/3767773 Elminowski Sanchez, DNP, ANP-BC, N. (2015). Developing and Implementing a Cultural Awareness Workshop for Nurse Practitioners. Journal of Cultural Diversity, 22(3), 105-113. 120 Fischer, C. T. (2009). Bracketing in qualitative research: Conceptual and practical matters. Psychotherapy Research, 19(4-5), 583-590. doi.org/10.1080/10503300902798375 Folkman, S. (2013). Stress, coping, and hope. In Psychological aspects of cancer (pp. 119-127). Springer, Boston, MA. Fordham, S., & Ogbu, J. U. (1986). Black students' school success: Coping with the “burden of ‘acting white’”. The urban review, 18(3), 176-206. doi.org/10.1007/BF01112192 Freimuth, V. S., Quinn, S. C., Thomas, S. B., Cole, G., Zook, E., & Duncan, T. (2001). African Americans’ views on research and the Tuskegee Syphilis Study. Social science & medicine, 52(5), 797-808. doi.org/10.1016/S0277-9536(00)00178-7 Fripp, J. A. and Carlson, R. G. (2017), Exploring the Influence of Attitude and Stigma on Participation of African American and Latino Populations in Mental Health Services. Journal of Multicultural Counseling and Development, 45: 80–94. doi:10.1002/jmcd.12066 Gillum, T. L. (2002). Exploring the link between stereotypic images and intimate partner violence in the African American community. Violence Against Women, 8(1), 64-86. doi.org/10.1177/10778010222182946 Glaser, B. G. (2002). Constructivist grounded theory?. In Forum qualitative sozialforschung/forum: Qualitative social research (3 )3. doi.org/10.17169/fqs-3.3.825 Gosine, K. (2008). Living between stigma and status: A qualitative study of the social identities of highly educated black Canadian adults. Identity: An International Journal of Theory and Research, 8(4), 307-333. doi.org/10.1080/15283480802365304. Hall, J. C., Everett, J. E., & Hamilton-Mason, J. (2011). Black women talk about workplace stress and how they cope. Journal of Black Studies, 43(2), 207-226. doi.org/10.1177/0021934711413272 Haskins, N. H., & Singh, A. (2015). Critical race theory and counselor education pedagogy: creating equitable training. Counselor Education and Supervision, 54(4), 288- 301. doi:10.1002/ceas.12027. Henry, W. J., & Glenn, N. M. (2009). Black women employed in the ivory tower: Connecting for success. Advancing Women in Leadership, 29. doi: https://doi.org/10.18738/awl.v29i0.271 Hirsh, E., & Lyons, C. J. (2010). Perceiving Discrimination on the Job: Legal Consciousness, Workplace Context, and the Construction of Race Discrimination. Law & Society Review, 44(2), 269-298. doi:10.1111/j.1540-5893.2010.00403.x 121 Hobfoll, S. E. (2004). Stress, culture, and community: The psychology and philosophy of stress. Springer Science & Business Media. Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., & Satcher, D. (2014).Toward culturally centered integrative care for addressing mental healthdisparities among ethnic minorities. Psychological services, 11(4), 357, doi: 10.1037/a0038122 Holder, A., Jackson, M. A., & Ponterotto, J. G. (2015). Racial microaggression experiences and coping strategies of Black women in corporate leadership. Qualitative Psychology, 2(2), 164. doi.org/10.1037/qup0000024. Howard‐Hamilton, M. F. (2003). Theoretical frameworks for African American women. New directions for student services, 2003(104), 19-27. https://doi.org/10.1002/ss.104. Huang, F. Y., Chung, H., Kroenke, K., Delucchi, K. L., & Spitzer, R. L. (2006). Using the patient health questionnaire‐9 to measure depression among racially and ethnically diverse primary care patients. Journal of general internal medicine, 21(6), 547-552. doi.org/10.1111/j.1525-1497.2006.00409.x Hughes, R. L., & Howard‐Hamilton, M. F. (2003). Insights: Emphasizing issues that affect African American women. New directions for student services, 2003(104), 95-104. doi: 10.1002/ss.110. Hughes, D., Rodriguez, J., Smith, E. P., Johnson, D. J., Stevenson, H. C., & SSIcer, P. (2006). Parents' ethnic-racial socialization practices: a review of research and directions for future study. Developmental psychology, 42(5), 747. doi:10.1037/0012- 1649.42.5.747 Hunn, V. L., & Craig, C. D. (2009). Depression, sociocultural factors, and African American women. Journal of Multicultural Counseling and Development, 37(2), 83. doi https://doi.org/10.1002/j.2161-1912.2009.tb00093.x Jackson, J. S., Knight, K. M., & Rafferty, J. A. (2010). Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course. American journal of public health, 100(5), 933-939. doi: 10.2105/AJPH.2008.143446 Jackson, H., Yates, B. C., Blanchard, S., Zimmerman, L. M., Hudson, D., & Pozehl, B. (2016). Behavior-specific influences for physical activity among African American women. Western journal of nursing research, 38(8), 992-1011. doi: https://doi.org/10.1177/0193945916640724 Jeffries, R. (2015). Editor's Introduction: fortitudinous femininity: black women's resilience in the face of struggle. Western Journal Of Black Studies, 39(2), 81-83. 122 Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological psychiatry, 54(3), 216-226. doi.org/10.1016/S0006-3223(03)00273-7. Kennedy, B. R., Mathis, C. C., & Woods, A. K. (2007). African Americans and their distrust of the health care system: healthcare for diverse populations. Journal of cultural diversity, 14(2), 56. Krefting, L. (1991). Rigor in qualitative research: The assessment of trustworthiness. American journal of occupational therapy, 45(3), 214-222. doi: 10.5014/ajot.45.3.214 Krieger, N., Chen, J. T., Waterman, P. D., Hartman, C., Stoddard, A. M., Quinn, M. M., & Barbeau, E. M. (2008). The inverse hazard law: blood pressure, sexual harassment, racial discrimination, workplace abuse and occupational exposures in US low-income black, white and Latino workers. Social science & medicine, 67(12), 1970-1981. doi.org/10.1016/j.socscimed.2008.09.039 Lazarus, R. S., & Folkman, S. (1984). Coping and adaptation. The handbook of behavioral medicine, 282325. New York, Guilford. Lesane-Brown, C. L., Brown, T. N., Tanner-Smith, E. E., & Bruce, M. A. (2010). Negotiating boundaries and bonds: Frequency of young children’s socialization to their ethnic/racial heritage. Journal of Cross-Cultural Psychology, 41(3), 457-464. doi.org/10.1177/0022022109359688 Like, R. (2011). Educating clinicians about cultural competence and disparities in health and health care. Journal of Continuing Education in the Health Professions Journal of Continuing Education. Health Professions. 31(3), 19 206. doi:10.1002/chp.20127. Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for program evaluation, 1986(30), 73-84. doi.org/10.1002/ev.1427 Maddox, T. (2013). Professional women's well-being: The role of discrimination and occupational characteristics. Women & health, 53(7), 706-729. doi.org/10.1080/03630242.2013.822455 Masten, A. S. (2014). Invited commentary: Resilience and positive youth development frameworks in developmental science. Journal of Youth and Adolescence 43.6 1018-24. doi:10.1007/s10964-014-0118-7 Mattis, J. S. (2002). Religion and spirituality in the meaning–making and coping experiences of African American women: A qualitative analysis. Psychology of Women Quarterly, 26(4), 309-321. doi.org/10.1111/1471-6402.t01-2-00070 Mays, V. M., Coleman, L. M., & Jackson, J. S. (1996). Perceived race-based 123 discrimination, employment status, and job stress in a national sample of Black women: Implications for health outcomes. Journal of Occupational Health Psychology, 1(3), 319. doi:10.1037/1076-8998.1.3.319. McCubbin, L. D., & McCubbin, H. I. (2013). Resilience in ethnic family systems: A relational theory for research and practice Handbook of Family Resilience (pp. 175-195): Springer. McGrath, E., Keita, G., Strickland, B., & Russo, N. (Eds.). (2001). National Depression Summit. Washington, DC: American Psychological Association. Miller, D. C., & Salkind, N. J. (2002). Handbook of research design and social measurement. Sage. Mojtabai, R., Evans-Lacko, S., Schomerus, G., & Thornicroft, G. (2016). Attitudes toward mental health help seeking as predictors of future help-seeking behavior and use of mental health treatments. Psychiatric Services, 67(6), 650-657. doi:10.1176/apSI.ps.201500164 Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of counseling psychology, 52(2), 250. doi: 10.1037/0022- 0167.52.2.250 Murry, V. M., Butler‐Barnes, S. T., Mayo‐Gamble, T. L., & Inniss‐Thompson, M. N. (2018). Excavating New Constructs for Family Stress Theories in the Context of Everyday Life Experiences of Black American Families. Journal of Family Theory & Review, 10(2), 384-405. doi.org/10.1111/jftr.12256 Nadeem, E., Lange, J. M., Edge, D., Fongwa, M., Belin, T., & Miranda, J. (2007). Does stigma keep poor young immigrant and US-born black and Latina women from seeking mental health care?. Psychiatric Services, 58(12), 1547-1554. doi:10.1176/ps.2007.58.12.1547 Nadeem, E., Lange, J. M., & Miranda, J. (2008). Mental health care preferences among low-income and minority women. Archives of women's mental health, 11(2), 93-102. doi: 10.1007/s00737-008-0002-0. National Institute of Mental Health (NIMH) (2018) Depression Neal-Barnett, A. M., Stadulis, R., Payne, M. R., Crosby, L., Mitchell, M., Williams, L., & Williams-Costa, C. (2011). In the company of my sisters: Sister circles as an anxiety intervention for professional African American women. Journal of affective disorders,129(1), 213-218. doi: 10.1016/j.jad.2010.08.024. Neighbors, H. W., Jackson, J. S., Bowman, P. J., & Gurin, G. (1983). Stress, coping, and black 124 mental health: Preliminary findings from a national study. Prevention in Human Services, 2(3), 5-29.doi.org/10.1300/J293v02n03_02 Nicolaidis, C., Timmons, V., Thomas, M. J., Waters, A. S., Wahab, S., Mejia, A., & Mitchell, S. R. (2010). “You don't go tell white people nothing”: African American women's perspectives on the influence of violence and race on depression and depression care. American journal of public health, 100(8), 1470- 1476.doi:10.2105/AJPH.2009.161950 Noble, R.E., (2005). Depression in women. Metabolism Clinical and Experimental, (54) 5 pp.49-52. doi.org/10.1016/j.metabol.2005.01.014. Noble, C. L., Ashby, J. S., & Gnilka, P. B. (2014). Multidimensional perfectionism, coping, and depression: Differential prediction of depression symptoms by perfectionism type. Journal of College Counseling, 17(1), 80-94. doi.org/10.1002/j.2161- 1882.2014.00049.x Ogbu, J. U. (1981). Origins of human competence: A cultural-ecological perspective. Child development, 413-429. doi: 10.2307/1129158 Pearson, S. M., & Bieschke, K. J. (2001). Succeeding against the odds: An examination of familial influences on the career development of professional African American women. Journal of Counseling Psychology, 48(3), 301. doi: 10.1037/0022- 0167.48.3.301. Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1-9. doi.org/10.1037/a0026208. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins, 515-528. QSR International (2014). NVIVO 10 for Windows. Retrieved January 16, 2017, from http://www.qsrinternational.com/products_nvivo.aspx. Richie, B. S., Fassinger, R. E., Linn, S. G., Johnson, J., Prosser, J., & Robinson,S.(1997). Persistence, connection, and passion: A qualitative study of the career development of highly achieving african American–Black and white women. Journal of Counseling Psychology, 44(2), 133-148. doi:dx.doi.org.proxy2.cl. Saleem, F. f., & Lambert, S. (2016). Differential Effects of Racial Socialization Messages for African American Adolescents: Personal Versus Institutional Racial Discrimination. Journal Of Child & Family Studies, 25(5), 1385-1396. doi.org/10.1007/s10826-015- 0326-0 Schreiber, R., Stern, P. N., & Wilson, C. (2000). Being strong: how black West‐Indian 125 Canadian women manage depression and its stigma. Journal of Nursing Scholarship, 32(1), 39-45. doi: 10.1111/j.1547-5069.2000.00039.x. Schulz, A. J., Gravlee, C. C., Williams, D. R., Israel, B. A., Mentz, G., & Rowe, Z. (2006). Discrimination, symptoms of depression, and self-rated health among African American women in Detroit: results from a longitudinal analysis. American Journal of Public Health, 96(7), 1265-1270. doi:10.2105/AJPH.2005.064543. Scottham, K. M., & Smalls, C. P. (2009). Unpacking racial socialization: Considering female African American primary caregivers' racial identity. Journal of Marriage and Family, 71(4), 807-818. doi.org/10.1111/j.1741-3737.2009.00636.x Sellers, R. M., Smith, M. A., Shelton, J. N., Rowley, S. A., & Chavous, T. M. (1998). Multidimensional model of racial identity: A reconceptualization of African American racial identity. Personality and social psychology review, 2(1), 18-39. doi.org/10.1207/s15327957pspr0201_2. Serry, T., & Liamputtong, P. (2013). The in-depth interviewing method in health. Research methods in health: Foundations for evidence-based practice, 39-53. http://handle.uws.edu.au:8081/1959.7/uws:34972 Settles, I. H., Navarrete, C. D., Pagano, S. J., Abdou, C. M., & Sidanius, J. (2010). Racial identity and depression among African American women. Cultural Diversity and Ethnic Minority Psychology, 16(2), 248. .doi.org/10.1037/a0016442 Sinkovics, R. r., & Alfoldi, E. (2012). Progressive Focusing and Trustworthiness in QualitativeResearch. Management International Review (MIR), 52(6), 817-845. of Marriage and Family, 71(4), 807-818. doi.org/10.1007/s11575-012-0140-5 Slavin, L. A., Rainer, K. L., McCREARY, M. L., & Gowda, K. K. (1991). Toward a multicultural model of the stress process. Journal of Counseling & Development, 70(1), 156-163. doi.org/10.1002/j.1556-6676.1991.tb01578.x Smith, P. R. (2009). Resilience: resistance factor for depressive symptom. Journal of Psychiatric and Mental Health Nursing, 16(9), 829-837. DOI: 10.1111/j.1365- 2850.2009.01463.x. Snap, D., & Spencer, L. (2003). The Foundation of Qualitative Research In: Ritchie, J. and Lewis, J. eds. Research Practice: A Social Guide for Social Science Students and Researchers. Snapp, M. B. (1992). Occupational stress, social support, and depression among black and white professional-managerial women. Women & health, 18(1), 41-79. doi.org/10.1300/J013v18n01_03. Sosulski, M. R., Buchanan, N. T., & Donnell, C. M. (2010). Life history and narrative analysis: 126 Feminist methodologies contextualizing Black women's experiences with severe mental illness. J. Soc. & Soc. Welfare, 37, 29. https://scholarworks.wmich.edu/jssw/vol37/iss3/4 Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American psychologist, 62(4), 271. doi:10.1037/0003-066X.62.4.271. Taylor, R. J., Chae, D. H., Lincoln, K. D., & Chatters, L. M. (2015). Extended family and friendship support networks are both protective and risk factors for major depressive disorder and depressive symptoms among African-Americans and black Caribbeans. Journal of Nervous & Mental Disease, 203(2), 132-140. doi:10.1097/NMD.0000000000000249 Thomas, A. J., & King, C. T. (2007). Gendered racial socialization of African American mothers and daughters. The Family Journal, 15(2), 137-142. doi.org/10.1177/1066480706297853. Thomas, A. J., Witherspoon, K. M., & Speight, S. L. (2008). Gendered racism, psychological distress, and coping styles of African American women. Cultural Diversity and Ethnic Minority Psychology, 14(4), 307. doi: 10.1037/1099-9809.14.4.307. Turner, K. L., & Brown, C. S. (2007). The centrality of gender and ethnic identities across individuals and contexts. Social Development, 16(4), 700-719. doi.org/10.1111/j.1467-9507.2007.00403.x Ungar, M. (2008). Resilience across cultures. British Journal of Social Work, 38, 218- 235. doi:10.1093/bjsw/bcl343. Walker, D., & Myrick, F. (2006). Grounded theory: An exploration of process and procedure. Qualitative health research, 16(4), 547-559. doi.org/10.1177/1049732305285972 Walker-Barnes, C. (2009). The burden of the strong black woman. Journal of Pastoral Theology, 19(1), 1-21. doi.org/10.1179/jpt.2009.19.1.002 Walsh, F. (2003). Family Resilience: A Framework for Clinical Practice. Family Process, 42(1) pp. 1-18. DOI: 10.1111/j.1545-5300.2003.00001.x Ward, E. E., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing Research, 62(3), 185-194. doi:10.1097/NNR.0b013e31827bf533 Warren, B. J. (1997). Depression, stressful life events, social support, and self-esteem in middle class African American women. Archives of psychiatric nursing, 11(3), 107-117. doi: 10.1016/S0883-9417(97)80033- 127 Weller, S. (2017). Using internet video calls in qualitative (longitudinal) interviews: some implications for rapport. International Journal of Social Research Methodology, 20(6), 613-625. doi.org/10.1080/13645579.2016.1269505 West, C. M. (1995). Mammy, Sapphire, and Jezebel: Historical images of Black women and their implications for psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 32(3), 458-466. http://dx.doi.org/10.1037/0033-3204.32.3.458 Whiting, L. S. (2008). Semi-structured interviews: guidance for novice researchers. Nursing Standard, 22(23). doi:10.7748/ns2008.02.22.23.35.c6420 Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: findings from community studies. American journal of public health, 93(2), 200- 208. doi: 10.2105/AJPH.93.2.200. Woods-Giscombe, C., Robinson, M. N., Carthon, D., Devane-Johnson, S., & Corbie-Smith, G. (2016). Superwoman Schema, Stigma, Spirituality, and Culturally Sensitive Providers: Factors Influencing African American Women's Use of Mental Health Services. Journal of Best Practices In Health Professions Diversity: Education, Research & Policy, 9(1), 1124-1144. Versey, H. S. (2014). Centering perspectives on Black women, hair politics, and physical activity. American journal of public health, 104(5), 810-815. doi: 10.2105/AJPH.2013.301675 128