UNDERSTANDING THE EXPERIENCES OF AFRICAN AMERICANS IN COUPLE THERAPY By Travis Johnson 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 2020 UNDERSTANDING THE EXPERIENCES OF AFRICAN AMERICANS IN COUPLE ABSTRACT THERAPY By Travis Johnson In the field of marriage and family therapy, there is still more to learn about African Americans in couple therapy. The purpose of this study was to shed light on the lived experiences of African Americans in couple therapy. This qualitative method of inquiry is phenomenological and transcendental. Individual interviews of ten individuals, six women and four men who identified as previous or current participants in couple therapy were analyzed. In the results of this study, it was evident that African Americans endorse couple therapy, perceive culturalism to be an influential factor in their experiences, and view the influence of the therapeutic alliance as critical. When African Americans have a favorable relationship with their couple therapist their perspective of couple therapy and its usefulness is perceived positively. Couple therapy is shown to be a useful experience in facilitating relational, individual, and societal issues. The results of this study show a need for couple therapists working with this population to realize there is an inextricable link between the therapeutic alliance and the usefulness of couple therapy for African Americans. Copyright by TRAVIS JOHNSON 2020 I dedicate this dissertation to my deceased mother, Johnsie Johnson. Your dedication, kindness, love, and humor could fill the universe. Thank you and rest in peace. iv ACKNOWLEDGEMENTS Thank you to my defense committee. Firstly, thank you so much Adrian! You have been so patient, supportive, challenging, and so much more in my life in the short time that I have known you. Thank you for being a secure base. I am extremely grateful for you! Dr. Carolan, your supervision, insights, and sincerity across my academic journey is irreplaceable. You have been a rock for me and so many others. Dr. Johnson, you have been a fueling source of insight, in so many ways. I will be forever touched by your offerings, dinners, and encouraging words. Dr. McNall, thank you for your eloquent and direct guidance. I can always depend on you for a great chat, a hearty laugh, and an innovative idea. You all have been invaluable throughout my study and academic endeavors and I cannot thank you enough for your edits, your tireless efforts, healing words, and perseverance! Thank you to my dear cohort and program, you have loved me, cried with me, and at times carried me through something that I did not see the end of! The bond that we share is truly unbreakable. I am wishing peace, wellness, and so much for each of you! To my dearest and best friends: Amy, Craig, Erica, Megan, Adam, Jasmine, Isaiah, Jarrett, Connie, Deshonda, Destiny, Shell, Joe, Terry, Brynn, Tess, Nicole, Drew, Tara, Daphne, Teresa, Emily, Kazi family, Paul, Liz (“Franabeth”) and Michelle (“Rochelle”). Literally, where would I be without you?! Probably somewhere with a full head of hair! Thank you for everything! Thank you for all the laughter that one person can tolerate, tons of dinners, breakfasts, murder mystery games, a crying shoulder, escape rooms, coffees, laughs, games, conferences, building furniture for private practices, gossip, book club, Harvey & Maebel, Parker & Murphy, Skypes, medical billing, medical billing advice, study groups, boundaries, 5k/10 mile races, coronavirus scares, housing, v weddings, wedding officiatings, and so much more. All of the love that you have given could be several dissertations! Thank you AAMFT Family! Thank you Karlin, Jesslyn, Heather, Sheena, and Anike for being my “black family.” You have been a lifeline for me sooooo many times. You have kept me grounded, inspired, and a better version of me! Thank you Lisa Tedeschi, Dyane Watson PhD, Jill Weldum, Sara Stockton, Andrea Wittenborn PhD, Temple Odom PhD, Rocío Escobar-Chew, PhD, Sara Dupuis PhD, Tianna Rooney PhD, Isha Williams, PhD, and First Baptist Church for your supervision and guidance! There was a time that each of you were a rock and a lighthouse in my ambiguous, and at times, scary world. And last, but not least, I thank my devoted parents, Willie and Johnsie Johnson. Although you neither of you had a high school education, you poured your heart and soul into mine. Your vision for me came true and I will carry the torch on for you. Although I have lost you as parents, I will always hold your memories in my heart. vi TABLE OF CONTENTS LIST OF FIGURES ........................................................................................................................ x CHAPTER ONE: Introduction ....................................................................................................... 1 Statement of the Problem ............................................................................................................ 1 Rationale ..................................................................................................................................... 4 Purpose ........................................................................................................................................ 5 Theoretical Underpinnings.......................................................................................................... 6 Ecological Theory - Individual, Relational, Social, Cultural, and Temporal Levels ..............6 Critical Race Theory ............................................................................................................... 8 Research Paradigm...................................................................................................................... 9 Qualitative Inquiry ................................................................................................................ 10 Research Questions ................................................................................................................... 11 Conclusion ................................................................................................................................ 12 CHAPTER TWO: Literature Review ........................................................................................... 13 Historical and Cultural Context ................................................................................................ 13 Unmet Needs and Need for Contemporary Intervention ...................................................... 14 Couples Therapy as a Form of Treatment for Relational Problems ......................................... 14 African Americans Utilizing Relational Treatment .............................................................. 14 Underutilization of Mental Health and Couple Therapy Services Amongst African Americans ............................................................................................................................. 15 Influential Factors and Barriers in Seeking Therapy ................................................................ 15 Stigma ................................................................................................................................... 16 Cultural Mistrust ................................................................................................................... 16 Treatment Seeking Behaviors and Accessibility ...................................................................... 18 Treatment Seeking Behaviors ............................................................................................... 18 Finances and Accessibility to Mental Health Services ......................................................... 18 African American Women in Mental Health Settings .............................................................. 19 African American Men in Mental Health Settings ................................................................... 20 CHAPTER THREE: Methodology ............................................................................................... 22 Introduction and Overview ....................................................................................................... 22 Design ....................................................................................................................................... 22 Rationale ............................................................................................................................... 22 Phenomenology ..................................................................................................................... 23 IRB ............................................................................................................................................ 23 Informed Consent .................................................................................................................. 24 Protocol ..................................................................................................................................... 24 Sampling ............................................................................................................................... 24 Recruitment ........................................................................................................................... 26 Inclusion Criteria .................................................................................................................. 28 Bracketing ............................................................................................................................. 28 vii Member Checking ................................................................................................................. 29 Setting ................................................................................................................................... 30 Participants ................................................................................................................................ 30 Participant’s Descriptions .................................................................................................... 32 Interview ................................................................................................................................... 35 Development of Interview Questions .................................................................................... 36 Data Analysis ............................................................................................................................ 37 Colaizzi’s Method ................................................................................................................. 38 Trustworthiness ......................................................................................................................... 40 Researcher Positionality ....................................................................................................... 40 Trustworthiness of Findings ................................................................................................. 41 Conclusion ................................................................................................................................ 42 CHAPTER FOUR: Results ........................................................................................................... 43 Main Theme Number One: African Americans Endorse Couple Therapy and Experience it Favorably .................................................................................................................................. 43 Couple Therapy was a Resource for Treating Relational Issues. ......................................... 44 Couple Therapy Led to the Enhancement of Communication Skills..................................... 45 Focus on Solutions ................................................................................................................ 46 Endorsement of Mental Health Care Treatment for Individual Issues While Being Treated in Couples ................................................................................................................................. 47 The Value of Having a Provider Offering Insight ................................................................ 47 Main Theme Number Two: The therapeutic alliance has a central role in couple therapy with African Americans .................................................................................................................... 49 Importance of Safety and the Therapeutic Alliance .............................................................. 50 Disclosure and the Therapeutic Alliance .............................................................................. 53 Hopefulness in the Therapeutic Alliance .............................................................................. 54 I was Feeling Connected when Acclimating to the Process of Couple Therapy. ................. 55 Partner Involvement.............................................................................................................. 57 Main Theme Number Three: Therapists Addressing Culturalism and Racism in Couple Therapy ..................................................................................................................................... 60 The Couple Therapist and Participant’s Racial Likeness .................................................... 60 Cultural Sensitivity and Cultural Factors in the Process of Couple Therapy ...................... 61 Racial Stigma .........................................................................................................................63 Conclusion ................................................................................................................................ 64 CHAPTER FIVE: Discussion ....................................................................................................... 66 Introduction ............................................................................................................................... 66 Interpretation of Findings ......................................................................................................... 66 African Americans Endorse Couple Therapy. .......................................................................... 66 This Study Indicates that the Therapeutic Alliance is Important for African Americans in Couple Therapy ......................................................................................................................... 67 African Americans are Willing to Establish Trusting Relationships with Competent Providers. .............................................................................................................................. 70 Cultural Attunement and Couple Therapy ................................................................................ 70 Transcendental Phenomenological Framework ........................................................................ 71 viii Assumptions and Interpretation ............................................................................................ 71 Limitations ................................................................................................................................ 73 Recommendations for Future Research .................................................................................... 76 Recommendations for Clinical Practice .................................................................................... 77 Conclusion ................................................................................................................................ 78 APPENDICES .............................................................................................................................. 79 APPENDIX A: Interview Guide ............................................................................................... 80 APPENDIX B: Flyer and Advertisement ................................................................................. 85 APPENDIX C: Demographic Questionnaire ............................................................................ 87 APPENDIX D: Informed Consent ............................................................................................ 89 REFERENCES ............................................................................................................................ 98 ix LIST OF FIGURES Figure 1: Flyer and Advertisement: This figure shows the advertisement ....................................85 x CHAPTER ONE: Introduction "We have convinced ourselves that we can perform our craft without regard to color or race. Therapy is an intimate experience. We cannot be color blind because it gets us into a color bind."~ Kenneth Hardy (1993). Hardy’s powerful words emphasize the need for mental health providers to understand and competently treat underrepresented groups, including African Americans, with mental health interventions relevant to their specific individual and relational needs. This dissertation is a qualitative study exploring the lived experiences of African Americans in couple therapy. This dissertation takes a phenomenological approach to gather and present the experiences of the participants who have experienced the phenomenon. Phenomenological studies seek to present the essence of the phenomenon (Husserl, 1970). The research findings offer my analysis of the participant's experiences and direct quotes about couple therapy experiences. This study adds to a void in the literature and best practices, considering no phenomenological studies are exploring African Americans' experiences in couple therapy. This study utilized both phenomenology and Critical Race Theory to analyze current literature and maintain perspective across research procedures. The Critical Race Theory perspective facilitates exploration of the phenomenon and conceptualization for how African Americans have unique experiences compared to their counterparts. Statement of the Problem Most current literature specific to African American experiences in mental health counseling is theoretical and lacks empirical evidence to support claims. In response to these gaps in the literature, the purpose of this study is to investigate the lived experiences of African American mental health clients and their meanings. The study also seeks to contribute to the 1 current counseling literature by providing a narrative that highlights African Americans' experiences who have chosen to seek couple therapy. This study will analyze statements from previous and current mental health clients regarding their experiences in couple therapy. There have been some theoretical and training articles, but limited research on how to competently treat African Americans in couple therapy (Bean, Perry & Bedell, 2002; Davey & Watson, 2008). However, despite these articles, the field of marriage and family therapy (MFT) struggles to recognize and understand the best ways to treat African American clients in couple therapy (Awosan, 2011). Research efforts have emphasized that African Americans are underrepresented in individual and relational therapy, utilize it inconsistently, and dropout prematurely (Breland- Noble et al., 2006; Priest, 1991; Thompson et al., 2004); and because the likelihood of treating African Americans in mental health settings is increasing, there is still a need to understand the utility, perceptions, and experiences of mental health treatments for African American individuals and African American couples (Bargarozzi, 1980). Compared to their counterparts, African Americans continue to be overlooked in research across the mental health system (Snowden, 1999), and barriers to utilizing mental health care continue to exist. Research is clear that minorities underutilize mental health services, especially in the private sector (Neighbors et al., 1992; Snowden, 1999), including couple therapy. As an indirect consequence, the experiences of African Americans in couple therapy remains a phenomenon that has yet to be understood and continues to be underrepresented in the academic literature. As a result, there is a need to understand the experiences of African Americans in couple therapy. As aforementioned, despite increased use of mental health services among minorities since the 1960s (O'Sullivan, 1989; cited in Neighbors, Bashshur, Price, Donavedian, Selig, & 2 Shannon, 1992; Zhang & Snowden, 1999), African Americans, including couples, continue to be underrepresented in the mental health system and scholarship (Leong, 2001; Snowden, 1999) and barriers to seeking help continue to exist (Leong, 2001). There has been some speculation about the reasons for the under-representation of African Americans in couple therapy research and their underutilization of mental health services. Researchers and clinicians have posited that a strong reliance upon traditional social supports (church, friends, and family), mistrust of a predominately White American mental health system, fear of the mental health paradigm/treatment, stigma, and a history of racism and discrimination from the mental health system have contributed to the observed low use of mental health services of minority groups (Boyd-Franklin, 1989; Hines & Boyd-Franklin, 1996; Kurilla, 1998; Neighbors et al., 1992; Surgeon General, 1999). It has also been suggested that a lack of minority mental health professionals has influenced the underuse of mental health services (Neighbors et al., 1992; Thompson, Worthington, & Atkinson, 1994; cited in Okonji, Ososkie, & Pulos, 1996). Clinical scholars have observed that minorities tend to drop out of mental health treatment (Bischoff & Sprenkle, 1993; Neighbors et al., 1992). Some in the field have discoursed that the lack of African American mental healthcare professionals may contribute to the underuse of mental health services (Neighbors et al., 1992; Thompson, Worthington, & Atkinson, 1994; cited in Okonji, Ososkie, & Pulos, 1996). It appears that most of the discourse is speculative about premature dropout, with no qualitative studies investigating the experiences that could result in dropout and low usage of mental health services for African Americans. With much of the research focusing on the underutilization of therapy, there is extraordinarily little research focused on African Americans’ experiences of couple therapy. 3 Rationale Couples' counseling is an effective modality of mental health treatment (Lebow et al., 2012). Evidence suggests that many clients with relational issues will utilize individual therapy for relationship issues if a partner refuses conjoint therapy (Gurman & Burton, 2014). From this, the emerging question is, "What are the help-seeking behaviors of African American individuals who utilize couple therapy?" Future studies could also explore if help-seeking behaviors vary across partners in African American relationships. Moreover, studies could explore what underlying perceptions shape help-seeking behaviors for African American individuals and couples. Most current literature specific to African American experiences in mental health counseling is theoretical and lacks empirical evidence to support claims. In response to these gaps in the literature, the purpose of this study is to investigate the lived experiences of African American mental health clients, and the meanings they make of those experiences. Specifically, this study seeks to contribute to the current counseling literature by providing a narrative that highlights the experiences of African Americans who have chosen to seek couple therapy. This study will analyze statements from previous and current mental health clients regarding their experiences in couple therapy. Awosan (2011) investigated the African American experience in relational therapy using a semi-structured interview approach with eleven participants residing across the United States. The findings revealed three themes that are important in clinical work with African Americans in couple therapy: (a) consideration of the lived experiences of African Americans, (b) lack of culturally responsive clinical practice, and (c) developing an understanding for what works in therapy; this research should be continued. Discussion in this study commented on what 4 contributes to a positive experience, including the therapist's character, the therapist's regard and respect for the client, and the skill demonstrated as part of the therapeutic work. Commentary from the article supports that African Americans typically do not utilize external interventions like therapy (Awosan et al., 2011). The implications of this study point to the importance of understanding what happens after African Americans enter therapy. This point will be explored more intentionally in this study from African American clients who engage in couple therapy treatment. Some scholarship acknowledges the importance of incorporating religion, discussing racism, including male partners in treatment, doing home visits, and focusing on specific problems identified by the couple in the initial assessment (Aponte, 1978; 1994; Bean et al., 2002; Boyd-Franklin, 2003; Davey & Watson, 2008). While this literature underscores important factors in treating this population, it does not comprehensively capture the subjective meaning and experiences of couple therapy for the African American client. This study illuminates the lived experiences of African Americans who have participated in couple therapy. Purpose This study seeks to understand African American individuals who have participated in couple therapy and understand their experiences in a treatment that is traditionally associated with the dominant culture and society. The literature review will focus on the stigmas, histories, gender differences, and challenges for utilizing mental health services, including couple therapy that encapsulates African Americans' experiences with mental health. Another focus of this study is to provide counter-narratives to those currently guiding the discourse, literature, and clinical work with African Americans and mental health and to explore the lived experiences and meaning-making of those experiences of African Americans who have engaged in couple 5 therapy. Theoretical Underpinnings Given the limited amount of available empirical studies on African Americans in couple therapy, it is impossible to evaluate theoretical frameworks utilized in empirical studies of clinical work with African American individuals in couple therapy. However, in examining relevant theoretical frameworks, Hughes (2015) tests the predictions of two opposing theoretical views for work with African Americans, the Social Identity Theory (Ellemers & Haslam, 2012) and the Internalized Racism Perspective. The research question explored was, "How does racial identity impact self-attitudes and wellbeing among African Americans?" The scholars summarized social identity theory as explaining the way group identification promotes positive self-esteem, mastery, and positive psychological wellbeing" (Hughes, Kiecolt, Keith, David, 2015, p. 30). An Internalized Racism Perspective is the belief that individuals accept and incorporate negative stereotypes about themselves as members of a minority group (Hughs et al., 2015). Like social identity theory, the researchers hypothesized that as African Americans closely identify with their group, their evaluation of their group will be positive (Ellemers & Haslam, 2012). Social Identity theory and Internalized Racism Perspective may be relevant in operationalizing and conceptualizing the phenomenon of African Americans' experience in general and, more specifically, in couple therapy. Nonetheless, given the lack of relevant frameworks, a phenomenological approach will work best to get a fuller picture of the subjective lived experiences of African Americans in couple therapy. Ecological Theory - Individual, Relational, Social, Cultural, and Temporal Levels Couple therapy is an interactive experience. Clients interact with a therapist and each 6 other within sessions. Each of these interactions is part of the client's ecological system. Bronfenbrenner (1979, 1988) developed the theoretical underpinnings of ecological theory, which identifies the various systems found in human development across the lifespan. The ecological theory offers theoretical insight into the factors that influence African Americans' lived experiences. Bronfenbrenner's theory was utilized for early childhood development (1977) and later applied to other populations. The theory is useful as a research tool to develop interventions (Petrie et al., 2007) and conceptualizing the ecological factors, both protective and risk, that influence the experiences of African Americans. The theory also helps conceptualize risk factors. Using the ecological theory to guide my research helped inform questions about the subjective perceptions and experiences of African Americans in couples' therapy. Bronfenbrenner's Ecological theory (1979; 1988) conceptualizes that interrelationships between people and their various ecologies influence experiences and outcomes. The theory describes an individual's process or behavior within various environments and recognizes that individuals' interactions and experiences do not occur solely within one setting (Bronfenbrenner, 1979, 1988). Bronfenbrenner posits that the environment is a critical component of an individual when developing an individual's understanding. While the environment used for this study is couple therapy, couples who attend therapy come from and interact with multiple other systems daily. Bronfenbrenner framed his theory upon five ecologies that influence development. The ecologies are the individual's influence (microsystem-individual); the individual’s interactions and relationships (mesosystem- relational); the immediate settings in which the individual and relationships interact (Exosystem- social); the social settings that influence cultural norms, sensitivities, and beliefs (macrosystem- cultural) and the historical and sociological effects on the development process (chronosystem- 7 temporal). Each of these ecologies influences an individual's development and experience (Bronfenbrenner, 1979, 1988). In conceptualizing African Americans' experience, it is important to think about the interaction of environmental factors and how these factors interact to shape African Americans' experience in and out of therapy. The Ecological theory has been utilized in several studies because of its focus on interrelationships between individuals and context. Critical Race Theory Critical Race Theory is a widely used theory across disciplines and professions. CRT considers the historical, societal barriers for African Americans and African American couples, including balancing multiple social identities, experiences, and intersectionality (Bernal, 2002; Delgado & Stefancic, 2001; Ladson-Billings & Tate, 1998; Yosso, 2005). Several mental health fields generated frameworks for clinical work with couples; however, these frameworks, typically do not consider the unique identity and experiences of African American couples. CRT is useful in conceptualizing the influence of historical, oppressive environmental factors on African American couples' identity and experiences. The section below will outline some of the pillars of CRT. CRT acknowledges race from a historical perspective and considers race to be an organizational principle deeply rooted in the transactions and affairs of daily life in the US (Ladson-Billings & Tate, 1998). CRT upholds that a colorless perspective on race denies the impact of racism on US societal members' experiences. An "equal but different" ordered system disregards the societal consequences of discrimination. CRT provides a theoretical frame for understanding the contemporary and historical significance of racism for African Americans. Critical race theory also problematizes race as a social justice problem with a history of "white supremacy" permeating societal members' daily 8 transactions, including therapists. Critical race theorists challenge and scrutinize applied interventions that are not culturally sensitive or adaptive. Critical race theory attempts to define the invisible norms of racism and oppression in-between races and challenge society to evaluate racial attitudes, racial equity, representation, and social circumstances. “Critical race theory is a social-constructionist stance to understanding race, racial micro-aggressions, and racism; to understand race, even though it is not objective, fixed, or biological, but categories that society invents and historically manipulates when convenient” (Delgado & Stefancic, 2001, p. 7). It is important to consider that the construction of many well-known MFT theories, and evidence- based interventions, were devised within a system that is influenced by racism. Critical race theory is useful in framing the historical and social factors that influence the daily experiences and stresses of black couples and problematizing racial or cross-racial events that occur within mental health settings. Research Paradigm A qualitative research design, specifically phenomenology, guided by the frameworks of Moustakas (1994) and Creswell (2007), is a suitable methodology for exploring the experiences of African Americans in couple therapy. I believe that this methodology produced a comprehensive and rigorous study. This study aimed to investigate the experiences of African American clients in couple therapy and the meaning of those experiences. As the primary researcher, I believe that phenomenology allowed me to understand a fuller picture of African American's experiences and introduced paths forward in research, scholarly discourse, and clinical practice. Qualitative research, including phenomenological research, offers different perspectives on how situational, client, and therapist characteristics interact and shape African Americans' 9 experiences and perspectives. There is also a need for understanding, investigating, and exploring how therapists and clients' intersecting identities may yield different perceptions of couple's therapy. This study utilized open-ended, unstructured interviews (Vagle, 2014). The participants were from different geographic regions in the United States. I conducted one interview and one follow-up review with 10 participants. All participants had participated in couple therapy. Qualitative Inquiry The purpose of this study is to acquire knowledge of the experiences of couple therapy for African Americans. Quantitative research is the inquiry into social or human problems "based on testing a theory composed of variables, measured with numbers, and analyzed with statistical procedures to determine whether the predictive generalizations of the theory hold" (Creswell, 2007). In contrast, qualitative research "is an inquiry process of understanding a social or human problem, based on building a complex, holistic picture, formed with words, reporting detailed views of informants, and conducted in a natural setting” (Creswell, 2007), Qualitative research also allows for the acquisition of new knowledge (Borg & Gall, 1989). To expand cultural understanding of African Americans and competency in treatment, practitioners and scholars should understand the lived experiences of African Americans who engage in mental health care, including couple therapy. Although numerous studies in psychology and MFT have identified the reasons that African Americans have reported for not going into counseling, little analytic attention has been paid to those African Americans who have chosen to utilize non-emergency counseling services. Given the dearth of literature on African Americans' experiences in mental health, couples therapy specifically, this study will investigate the lived experiences of African 10 American couples who take part in couple therapy. Also, researchers and clinicians have observed that minorities tend to prematurely terminate treatment more often than their White counterparts (Bischoff & Sprenkle, 1993; Kurilla, 1998; Neighbors et al., 1992); understanding the experiences of couple therapy from the perspectives of African Americans may shed light on the therapy process and termination. Evidence suggests that overcoming barriers is the biggest challenge for African Americans in couples counseling (Awosan et al., 2011; Boyd-Franklin, 1987; Hall & Sandberg, 2012). Hall and Sandberg (2012) investigated African Americans' experiences who overcame barriers to engaging in marriage and family therapy. They focused on the experiences of African Americans who were able to utilize therapy successfully, instead of underutilizing therapy. Some of the results point towards having the support of family and friends, overcoming stigma, accessibility to treatment, and addressing confidentiality concerns (2012). This is one of the only studies that focus on African American clients in pursuit of couple and family therapy specifically. From the study, it emerged that clients who attend couple therapy may be motivated by significant others. This study provides contextual insight into what motivates individuals to utilize couple therapy. However, this study lacks a focus on African American individuals' experiences while engaged in couple therapy. From the study, an emerging question of the rich lived experiences of individuals who utilize couple therapy emerges. Research Questions The research question is central to the research study. It guides the researcher's focus for the study and can be used to explore, explain, or describe the subject or phenomena being investigated (Creswell, 2007). The research questions for this study were developed to follow the purpose and tradition of phenomenological studies. The following research questions were based 11 on the literature review and created to fulfill the mission of a phenomenological study. The following primary research question will guide this study: "What are African Americans' experiences in couple therapy?" with the following sub-questions: (a) What are the perceptions of couple therapy of African American adults who have previously or currently engaged in couple therapy? (b) How do environmental factors influence the subjective lived experiences of African Americans in couple therapy? (c) How does gender influence the lived experiences of individuals in couple therapy from African Americans' point of view? (d) What are the relational issues of African Americans in couple therapy? (e) What conclusions do African Americans make of their experience in couple therapy? (f) What are the motivations of African Americans that elect to seek couple therapy? g) What therapist factors enhance or create difficulties for couples and individuals in therapy? h) What worked for couples? i) What did not work for the couples? Conclusion In this chapter, I introduced my dissertation. This dissertation highlights a gap within the literature regarding the lived experiences of African Americans in couple therapy. This study's objective is to gather the participants' detailed experiences to shed light on an underserved population and give a voice to individuals who have experienced the phenomenon directly. The findings of this study will inform best practices and scholarship. In the next chapter, I will provide a literature review indicating gaps in the discourse and literature on African Americans' experiences in couple therapy. 12 CHAPTER TWO: Literature Review Historical and Cultural Context The combined cultural values of African Americans, a history of experienced oppression in American society, and discrimination in the mental health system have contributed to a unique response to mental health care. African Americans continue to be underserved in the mental health system (Snowden, 1999), and barriers to utilizing mental health care continue to exist. Research discourses that minorities underutilize mental health services, especially in the private sector (Neighbors et al., 1992; Snowden, 1999); to the best of my knowledge, this includes couple therapy. There is some discourse across fields for this finding with many clinicians and scholars positing strong reliance upon traditional social supports, including churches, friends, and family. Other research efforts have indicated that mistrust of the predominantly White American mental health system, historical fear of the mental health paradigm/treatment, stigma, and a history of racism and discrimination from the mental health system influence the utilization of mental health care (Boyd-Franklin, 1989; Boyd-Franklin, 1995; Neighbors et al., 1992; Surgeon General, 1999). Clinical scholars have observed that minorities tend to prematurely drop out of mental health treatment (Bischoff & Sprenkle, 1993; Neighbors et al., 1992). Some commentaries in the field have also discoursed how the lack of African American mental healthcare professionals may influence the underuse of mental health services (Neighbors et al., 1992; Thompson, Worthington, & Atkinson, 1994; cited in Okonji, Ososkie, & Pulos, 1996). It appears that most of the discourse is speculative about premature dropout with no qualitative studies investigating the experiences that result in dropout and low usage of mental health services for African Americans. 13 Unmet Needs and Need for Contemporary Intervention As the United States diversifies, mental health professionals have become more attentive to underserved, underrepresented, or marginalized groups (Ward & Besson, 2013). The multicultural counseling competence framework by Sue et al. (1982) has served as a guiding framework for working with these populations (Sue et al., 1982). However, rapid development and advancement requires constant adjustment and learning to facilitate a matching progression in the counseling world. In 2014, roughly 7 million African Americans suffered from a mental health disorder (Substance and Mental Health Services Administration, 2015). Couples Therapy as a Form of Treatment for Relational Problems Couples' counseling is an effective modality of mental health treatment (Lebow et al., 2012). Evidence suggests that many clients with relational issues will utilize individual therapy for relationship issues if a partner refuses conjoint therapy (Gurman & Burton, 2014). From the review, it appears that the processes of help-seeking are different for individuals versus couples (Parnell, 2018). From this, the emerging question is, "What are the help-seeking behaviors of African American individuals who utilize couple therapy?" Future studies could also explore if help-seeking behaviors vary across partners in African American relationships. Moreover, studies could explore what underlying perceptions shape help-seeking behaviors for African American individuals and couples. African Americans Utilizing Relational Treatment Evidence suggests that African Americans are more likely to utilize extended family and religion for resources (Vaterlaus et al., 2015), including relational consultation. African American couples who are experiencing marital/relationship issues are likely to consider advice from individuals who have similar life experiences (e.g., poverty, racial discrimination, unfair 14 treatment) (Lincoln & Chae, 2010) and internal and external stressors over relational therapy (Marks et al., 2006). A review of the literature suggests it is critically important that the marriage and family therapy field works to develop a deeper understanding of the experiences of African American couples and the mechanisms of engaging this population in mental health settings. Qualitative research may highlight the unique needs of this population and the subjective experiences of African Americans who engage in mental health services, including couples' therapy. Underutilization of Mental Health and Couple Therapy Services Amongst African Americans African Americans as a cultural group underutilize mental health services and are more likely to inconsistently utilize mental health services (Dave & Watson, 2008). Cultural beliefs and attitudes of mistrust may delay African American clients' engagement in mental health services (Dave & Watson, 2008). African Americans share prevalent beliefs that family and kinship networks are areas where problems can be resolved; and African Americans may be less inclined to trust outside services (Dave & Watson, 2008). Dave and Watson call for systemic changes and culturally relevant approaches that target the mental health beliefs, attitudes, and mistrust of African American clients towards mental health care. Descriptively, no studies are indicating what the cultural beliefs and attitudes of African Americans influencing engagement are. Influential Factors and Barriers in Seeking Therapy Research by Cruz et al. (2008) on African Americans' utilization of mental health care for depression treatment indicated that African Americans use mental health services at a lower rate than whites with similar problems (Cruz et al., 2008). The following were reasons for under- utilization or dropout, including perceived barriers to mental health care: Stigma, dysfunctional 15 coping, shame, denial, and "don't know" (Cruz et al., 2008). While this study supports several barriers to care-seeking reported in the extant literature, their data also underscores the prominence of shame and denial, together with the concern of public stigma and depression, respectively. The study's recommendations include researching the relationships between these factors to mental health experiences and care-seeking behaviors in low-income African Americans and ways of modifying them (Cruz et al., 2008). Stigma Stigma harms and influences the utilization of mental health services in two ways: by keeping individuals from obtaining helpful social opportunities, including helpful mental health care, and by diminishing self-esteem (Corrigan, 2004) which results in diminished motivation to utilize resources. One qualitative research study conducted by Nelson et al. (2001) utilized a phenomenological approach to explore the barriers to African Americans utilizing mental health services from clinicians' perspectives. Results suggest that stigma is perceived as a barrier to utilizing mental health services and the importance of client-centered approaches. Results from interviews with multiple participants provide considerable implications for forming safe therapeutic relationships cross-culturally and the importance of being considerate and sensitive to culture during the initial therapeutic encounters (Nelson et al., 2001). Cultural Mistrust Awosan et. Al (2011) discusses the utilization of therapeutic services by Black clients. Black clients attending therapy services perceive multiple barriers in forming a therapeutic relationship with white clinicians (Awosan et al., 2011). Research by Awosan et al. (2011), utilized questionnaires and responses from self-identified African American clients in a university-based couple-family therapy clinic. 56% of the mailed questionnaires were returned as 16 undeliverable. The study utilized the compiled responses of 35 participants. Half of the samples were never married. Participants were asked the following questions: "Which obstacles to attending therapy are most difficult to overcome," "In what ways was therapy better than you imagined" and "What advice would you give us about removing obstacles for Black families to come to therapy?” African American participants in the study mentioned that concerns about privacy, trust, and cultural belief discrepancies were amongst the list of concerns for working with a white therapist (Awosan et al., 2011). Consequentially, black clients failed to feel understood. Some evidence attributes significant fallout and misdiagnosis as consequences of white therapists misunderstanding black clients. Negative perceptions of therapy are often due to previous racism and oppression on the part of the African American client (Awosan et al., 2011). A meta-review of the literature by Whaley (2001) indicated similar barriers to the utilization of care. A review of the literature indicated that underutilization of mental health services for care by African Americans could be explained by cultural mistrust and cultural attitudes regarding utilizing mental health services (Whaley, 2001). Evidence suggests that African Americans avoid mental health treatment due to cultural mistrust (Nickerson, Helms, & Terrell, 1994; Nicolaidis et al., 2010; Terrell & Terrell, 1984). Review of the literature on cultural mistrust and outcomes for African American clients highlights a relationship between cultural mistrust and attitudes toward counseling for Blacks, especially when the counselor is White (Whaley, 2001). High levels of cultural mistrust influence the expectations of African American clients working with white mental health providers. (Grant-Thompson & Atkinson, 1997; Thompson, Worthington, & Atkinson, 1994; Watkins & Terrell, 1988; Watkins et al., 1989, Whaley, 2001). Cultural mistrust may influence the utilization of mental health services and expectations of services (Cunningham, 2009; 17 Watkins & Terrell, 1988). Culturally adaptive interventions may mediate and possibly neutralize the role of cultural mistrust and may indirectly influence the utilization and helpfulness of mental health services for African American clients. What are the reasons behind the lack of trust? Mistrust of clinicians by minorities arises, in the broadest sense, from historical persecution and present-day struggles with racism and discrimination. It also arises from documented abuses and perceived mistreatment, both in the past and more recently, by medical and mental health professionals (Neal-Barnett & Smith, 1997). Treatment Seeking Behaviors and Accessibility Treatment Seeking Behaviors Studies indicate that minorities tend to turn to informal sources of care such as clergy, traditional healers, and family and friends (Neighbors & Jackson, 1984; Peifer et al., 2000). Often these sources of care are members that have insight on their respective community and background. African Americans, in particular, often rely on ministers who may play various mental health roles as counselors, diagnosticians, or referral agents (Levin, 1986). The extent to which minority groups rely on informal sources and how these influence treatment-seeking behaviors are not well studied. We still know little about the underlying motivations, perceptions, emotions, and thoughts of African Americans who seek treatment, including couple therapy. Finances and Accessibility to Mental Health Services The US Census Bureau (as cited by the American Psychological Association) states that in 2001, almost 25% of African Americans did not have insurance and were more likely to utilize emergency services and primary care specialists for mental health treatment and issues. In 2005, compared to white counterparts, African Americans were 7.3 times more likely to reside in 18 impoverished neighborhoods and have restricted access to mental health care services. (American Psychological Association, 2012). There are several suggestions in the literature about why African Americans do not engage in mental health services, including financial hardship. African Americans in the United States have had a long history of financial hardship and lower access to resources. African Americans are also more likely to make lower salaries on their jobs than their White counterparts (Schwartz & Feisthamel, 2009). This may play a role in the accessibility and utilization of therapy services. In response to financial hardships for several populations, non-profits and universities have opened free or reduced-cost clinics. However, these clinics tend to have barriers for clients, including long waiting lists, and being understaffed with practitioners (Ward, 2005). African American Women in Mental Health Settings Black women are less likely to seek mental health services than their White counterparts (Wise, Adams-Campbell, Palmer, & Rosenberg, 2006). Cultural beliefs and norms may contribute to this disparity in psychological help-seeking. The Strong Black Woman archetype, a salient cultural gender norm that Black women uphold a mask of emotional and physical strength, appear fiercely self-reliant and serve as caretaker for their family, church, and community, is one cultural factor that has been associated with depressive symptoms and the low rates of help-seeking among Black women (Wallace, 1978). Research has shown that Black women who receive specialty mental health services from psychiatrists and therapists use it as a last resort, thereby exacerbating their psychological symptoms over time and presenting more severe symptom pictures upon the initial clinical interview (Snowden, 2001). Strong Black Woman archetype is a cultural gender norm that describes Black women as strong, invulnerable, and able to withstand pressure without showing discomfort (Wallace, 19 1978). This may play a significant role in the utilization and experience of therapy services. I believe this highlights the need to create more research studies designed to explore and understand the experience of therapy for African American women. The incongruence between needing or wanting help and pressure to be strong may inhibit mental health help-seeking among Black women. This may also play a significant role in relationships for African American women and their experiences in couple therapy. African American Men in Mental Health Settings In a qualitative exploration of factors associated with effectively reaching African American males in a community sample, Plowden, Wendell, Vasquez, and Kimani (2011) discovered African American males valued: a) creating a trusting relationship, and b) treatment providers that established a non-judgmental and/or culturally sensitive atmosphere. Snowden (2001) indicated that African American men often denied experiencing symptoms associated with mental health. Watkins and Neighbors (2007) found similar results from qualitative inquiries utilizing focus groups (N= 5), with 46 African American men exploring how they described mental health. These studies were conducted within the general population; however, results revealed experiencing mistrust of providers as a key factor for participants' lack of treatment engagement. Current research does not address the issue of mistrust of providers and beliefs about illness. Understanding African American individuals' beliefs about illnesses are important because ideas about illnesses may inform ideas about treatment and help to seek. For example, stigmatized beliefs about mental illness act as a deterrent to help-seeking (Corrigan, 2007; Ward & Collins, 2010). However, African American men's beliefs about mental illness and their impact on coping are unknown, as most of the previous research examining African Americans' beliefs about mental illness have focused on women (Corrigan, Smith, & Aranda, 20 2004; Ward, Clark, & Heidrich, 2009; Ward & Heidrich, 2009). Given the limited literature about African American men's beliefs about mental illness and help-seeking, further exploration should be conducted using qualitatively designed studies. Such an approach can give voice to African American men, a historically underserved group (Moodley, 2000; USDHHS, 2001). Research focusing on mental illness among African American men is scarce (Watkins et al., 2006). A study by Ward (2012) is the first to use qualitative methodology to examine African American men's underlying representation and beliefs about mental illness, the perceived stigma associated with mental illness and seeking treatment, and barriers to seeking treatment. 21 CHAPTER THREE: Methodology Introduction and Overview This chapter contains the methods of the phenomenological study aiming to explore the following broad research question: What are the subjective lived experiences of African Americans who participated in couple therapy? I also explored the following research sub-question: How do African Americans make meaning of their experiences in couple therapy? This chapter includes an outline of the methodology for the aforementioned research questions and the demographics of the participants who participated in the study. Ten participants participated in the study, made up of both African American men and women. This study aimed to understand the subjective experiences of African Americans who had engaged in couple therapy. This chapter details the methodology used in this research. In this study, participants' subjective experiences were defined as their perceptions and experiences of couple therapy from their point of view. Design Rationale Qualitative researchers "read and wrestle" with their assumptions that shape and frame their philosophy (Kezar, 2004). Kezar (2004) posits that the researcher's philosophy will inform the research questions, challenge theoretical assumptions, identify biases, and influence the research. From a review of the literature, it is evident that the experiences of African Americans in couple therapy is an understudied topic. From the best of my knowledge, there are no phenomenological studies exploring African Americans' experiences in couple therapy and their 22 perceptions of the therapeutic alliance. I believe that this will expand what couple therapists know and understand about African American clients. Quantitative research does not focus on the subjective lived experiences of its participants. Given the goal of this study and purpose, it makes sense to examine this research question with a qualitative approach. Phenomenology Phenomenological research explores participants' subjective lived experiences who share a similar concept or who have experienced a similar phenomenon (Creswell, 2007; Patton, 2015). Phenomenological research highlights the "nature of the shared experience” (Creswell, 2007). Phenomenological research is a popular methodology in health and social science research and has a philosophical component in its design (Creswell, 2007). Hermeneutic phenomenology is not a specific set of steps but a way of research inquiry that stresses there is no method (vanManen, 1990). vanManen posits (1990) that human research should present a phenomenon that sincerely interests us and prioritizes active investigation rather than mere conceptualizing. When considering the hermeneutic phenomenological method, the researcher makes constant adjustments to fit the study (Vagle, 2014). This change and consistent adjusting are representative of how the researcher's meaning-making changes over time-based on their experience and exposure to the data. My study follows the hermeneutic phenomenological method. IRB Prior to collecting data, the Institution Review Board (IRB) of Michigan State University Human Research Protection Program (IRB Office) approved the study (STUDY 00002815, Appendix E). Approval by the IRB was necessary for research activities involving human subjects. I completed the Responsible Conduct of Research (RCR) training that is required by 23 Michigan State. The informed consent form was developed to adhere to IRB and RCR standards and used with all study participants. The study was evaluated to have minimal risks by the IRB board. See (Appendix D) for the consent form. Informed Consent Informed consent was provided to the participants to ensure their understanding of the purpose of the research, confidentiality, right to withdraw, data collection approach, protection of collected data, and incentives for participation. The informed consent outlined the tenets of confidentiality. Participants were informed that their responses would be kept confidential, and the data would be summarized and reported with no identifiers. Prior to beginning the interviews, participants reviewed consent forms acknowledging the process of data collection, their rights, and how the data would be securely stored. At any point during the study, participants could verbally decline participation without penalty. Protocol Sampling A qualitative study of African Americans’ experience of couple therapy was conducted using semi-structured interviews. To answer the research questions, I conducted interviews with ten individuals who participated in couple therapy with a licensed mental health practitioner. All interviews were tape-recorded and varied in length from 45 minutes to one hour and 45 minutes. The interviews were informal and open-ended, and carried out in a conversational style, but were guided by a semi-structured interview guide (Appendix A). The data collection approach was informed by literature, and individual interviews provided less constricted responses, or conceptually, richer responses from participants (Seymore, Dix, & Eardley, 1995). Participants were able to participate in the interview, either in-person or video interviews (i.e., Skype or 24 Zoom). All the participants elected to participate via Zoom. The participants were in complete control of their setting, and all participants participated in the interview at their homes. The participant's natural setting allowed for answers to be open and honest. Participants were encouraged to select an area where they felt comfortable to speak freely about their experiences in couple therapy. The selection of the current study’s participants depended on volunteers with the criteria of race and experience of at least one couples’ therapy session with a partner. The researcher sent participants a letter of interest to participate in the study after they expressed an interest either through social media or Call for Research website. The letter stated the criterion of race, the experience of at least one couples therapy conjointly, and contact information for the potential participants. Once the researcher received the letters of interest back from the participants, the researcher scheduled a time to meet with the participant to proceed with providing informed consent and the interview. The researcher planned to eliminate participants who had only participated in therapy individually. However, all participants who contacted the researcher had participated in at least one session of couple therapy with a partner present. Upon identifying the eligible participants for the study, ten subjects were enrolled in the study. This included individuals in multicultural, interracial, and same-sex relationships who had elected to participate in couple therapy. The essential criterion for all phenomenological research is that the participant experienced the phenomenon that is being explored (vanManen, 1990). Samples are selected because they are illuminative and offer useful reflections of the phenomenon, not to be empirically generalized (Patton, 2002). For this study's purposes, criterion sampling was 25 employed to ensure that the participants fit the needs of the study. Selected participants were current or previous participants of couple therapy. Recruitment Given the research question and objectives of the study, homogenous purposive sampling ensured that the participants provided insightful information on the specific phenomenon to gain comprehension of the experience of the collective (Patton, 2002; Patton, 1996). I purposefully sampled African American participants who participated in couples’ therapy conjointly. I also asked colleagues for recommendations and referrals. These sampling procedures conceptually provided access to individuals who qualified as potential participants. I also distributed digital flyers through posts on social media sites, and I used an online search engine for participants seeking to participate in research, callforparticipants.com. I made advertisements on social media and recruited through letters to therapists, professors, and other mental health professionals to allow potential study participants across mental health settings to know about the study. I also asked participants to inform family, friends, and associates who may meet the inclusion criteria. I utilized these sampling techniques until the minimum number of participants (10) was reached. Of the recruitment efforts, participants reached out from all parts of the country. With four participants from the Western region of the United States, three participants from the southeastern region of the United States, and three from the Midwestern region. Recruitment efforts were stopped once the study reached 10 participants. The sample size of a study can serve as a marker of success for a research study (O'Reilly & Parker, 2012). There are several factors that I considered for the sample size for the proposed qualitative study. The considerations are listed as follows: (a) the intention of the study, (b) the 26 amount of useful information that each participant can provide for the study, (c) the quality of the data, and (d) the method and design utilized within the study (Morse, 2000). Even after consideration of these factors, the number of cases needed for a phenomenological study may vary and cannot be completely predetermined. When selecting the appropriate number of participants for a qualitative study, it is more important to identify, seek, and include the people's participation, who would be the most informative and helpful than to try to include a large population (Simmons et al., 2006). The participants of a qualitative study should be a small and purposive group utilized to acquire an in-depth understanding (Sorensen, 2007). Ten participants allowed for a meaningful understanding of the experiences of individuals in couple therapy. The point of saturation plays a significant role in selecting the appropriate number of participants in a qualitative study. Saturation is the point of the data collection process, where the information becomes redundant (Bogdan & Biklen, 2007). Phenomenological research studies tend to have sample sizes ranging from one to ten participants (Starks & Trinidad, 2007). The researcher sets the number of participants at a level where it is possible to obtain a complete understanding of the research topic (Simmons et al., 2006). One of the most important factors to remember when determining sample size for qualitative studies is that the goal of qualitative research is not statistical generalizability, but rather an approach that gathers detailed and specific data about the phenomena being studied (Creswell, 2007). Polkinghorne (1989; as cited by Creswell, 2007) notes that qualitative researchers should interview 5 to 25 individuals who have experienced the phenomena of interest. In a phenomenological study of how African Americans overcame barriers to participate in family therapy, Hall and Sandberg (2012) had a sample size of nine in their phenomenological study. Given the sample size of similar studies on this topic, based on the desired depth of data and study time frame, I aimed for ten individuals 27 who have experienced the phenomenon of couple therapy. Inclusion Criteria Individuals were eligible for the study if they were African American and either married or divorced. Inclusion criteria included the following: 1) self-identify as African American, 2) English is the primary language; 3) individuals can complete the interview in-person or by digital medium; 4) individuals had experienced at least one session of couple therapy with a partner. Individuals were excluded for the following reasons: if there were any serious mental health issues, physical health issues, or related concerns that might prevent participation in the study. All participants were asked about inclusion criteria when initial contact about participation in the study was made. I planned to eliminate participants who only participated in therapy individually. However, all participants that contacted me had participated in at least one session of couple therapy. Upon identifying the eligible participants for the study, ten subjects were chosen. This included individuals in multicultural, interracial, and same-sex relationships who had elected to participate in couple therapy. Before interviewing, participants were asked to complete a demographic survey containing questions about gender, education, age, relationship status during the process of couples’ therapy, and employment. I also asked participants to identify their race in a blank response. Self-identifying as “African American” or “Black American” was required for participation in the study. Bracketing A major component of phenomenological research is bracketing. Bracketing is the researcher's suspending judgment about the natural world preceding phenomenological analysis 28 (Husserl, 1970). Husserl explained how the perceived state and what is thought to be true of a phenomenon must be stripped away until the study is conducted, and the data are examined and analyzed in a pure form. Bracketing is a way of regulating the researcher as the instrument for analysis across stages of the qualitative study (Creswell, 2007). I maintained awareness of the inevitable influences of my personal biases and assumptions throughout this study (Tufford & Newman, 2010). I consulted with my advisor and peers to check biases and assumptions of which I was unaware. The use of bracketing as part of an audit trail, conceptually, positions the readers and audience of the research study to make their own conclusions about the data and my influence (Hamill & Sinclair, 2010). In this qualitative phenomenological study, the focal point was on collecting and analyzing data in such a way as to amplify the understanding of the experiences of African American individuals in couples’ therapy. My way of bracketing was identifying my beliefs of the phenomenon, as well as my personal processes, experiences, and assumptions that could influence my views on the data (Creswell, 2007). I kept record in a physical journal of my beliefs and reflections about African Americans in couple therapy, as they emerged, across the study. In correspondence with Tufford and Newman’s (2010) discourse, my bracketing process was at the start of the research stage. Hamill and Sinclair (2010) discussed that the bracketing process should be limited to the studied phenomenon or my view of the world. For this study, I discussed only the studied phenomenon. Member Checking Participants were sent summaries of the research findings after the data analysis was completed. With member-checking, the transcripts and findings are returned to participants to verify the results of the study (Birt et al., 2016). Birt et al. (2016) posit that member checking 29 allows for checking for accuracy and is often considered the foundation of high-quality qualitative research. After the interview and transcript were completed, the transcripts were edited and reframed to reflect the participant's stories. Then I asked all the participants to review their transcripts and identified themes to add validity to the findings. I asked each participant if they would be willing to share their opinion about the findings of their interview. They were not obligated to do this. All participants verified the transcript and findings of their interview. For this study, allowing member checking was not only a way to enhance the credibility of the study but also ensured that the findings accurately reflected the voices of the participants. Setting Interviews began in October 2019, shortly after finding two participants and continued through January 2020. Seidman (2013) recommends that settings are neutral in that the location of the interview may influence behavior (vanManen, 1990). The choice of location was made by the participants, although they were encouraged to select a place that was confidential and safe. As a result, all interviews were held digitally and while the participants were in selected rooms of their homes. Ethical considerations were made regarding utilized digital and video recordings. All backups and recordings were password protected and recorded with a secure version of Zoom. Participants Ten participants were interviewed for this study. Participants identifying as male and female are represented in the sample, with 6 (60%) female and 4 (40%) male individuals. Criterion sampling helped narrow down the population for this study and helped with accessing African Americans who experienced at least one session of couple therapy. All the participants in the study self-identified as African American. One of the ten participants identified as bisexual 30 and reported participating in couple therapy for both a heterosexual a same-sex relationship at different times. Of the participants referred to the study, ten were selected that met the criteria. One individual was turned away because the data collection process was over. Seven of the 10 participants had formerly been in the form of individual therapy before entering couple therapy. Seven of the participants remained in their relationship throughout the process of couple therapy. Seven of the participants were actively involved with couple therapy at the time of the interview. Two of the ten participants who reported not participating in couple therapy at the time of the interview were participating in individual therapy. Of the ten participants, two ended their relationship after the couple therapy was completed. Four of the participants reported ne previous unsuccessful couple therapy attempt, meaning either logistically therapy was not possible, or they ended their relationship with the couple therapy. One participant reported three unsuccessful attempts at couple therapy. Five of the participants were married with children at the time of the interview. Seven of the 10 participants entered couple therapy for marital issues. One participant was single at the time of the interview and was a joint custodial parent of three children. The relationship statuses varied among the participants sampled at the time of the interviews. While all participants had been in couple therapy previously, at the time of the interview, five of the participants were currently married, and 8 of the 10 participants were in committed relationships at the time of the interview. The length of time in therapy varied amongst the participants, with all participants participating in more than three sessions of couple therapy. At the time of the interviews, eight participants were still in the relationship that they most recently went to couple therapy for. Seven of the participants reported that they were in therapy at the time of the interview and still working with their most recent couple therapist. Six 31 of the ten participants spoke about more than one couple therapist, including their most recent couple therapist. In the interview, they were not required to distinguish which therapist they were referring to when sharing their experiences. All participants in the study identified as Black or African American, non-Hispanic. Participant ages ranged from 26 to 50. Seven of the ten participants were between 30 and 50, and three participants were between 20 and 30 years of age. The sample of six African American females and four African American males provided a blend of individuals from all over the US and various experiences in couple therapy. All the participants expressed having notable experiences in couple therapy. Participant’s Descriptions For this study, the lived experiences of the participants provided depth to the explored phenomenon. There were ten individuals who shared experiences of couple therapy with different providers. The following section contains brief overviews of the individuals that participated in the study. Note that names are changed to protect the identity of participants. Janet is a 36-year-old, mental health counselor. Janet is a married mother of two and was raised in the southeastern United States in a primarily single-parent household. Janet has been in therapy on several occasions for varied presenting problems, including infertility struggles, individual issues, and relational issues with her partner. She feels that therapy has helped, including difficult areas in her relationship. She described her couple therapist as relatable, culturally sensitive, and someone that does his “work” regarding cultural issues that arise in couple therapy. Elle is a married, 39-year-old, blue-collar worker. She was raised in a blended family in the southeastern region of the United States. She is a married mother of three children. Elle has 32 been in couple counseling on and off for about two years. She entered couple therapy for premarital counseling to deal with issues in a proactive way. She describes her therapist as relatable and non-biased. She entered couple therapy with the preconceived notion that the therapist would take her side in navigating relational conflict. She is a college graduate and has two kids with her partner. She details that therapy has changed her perspective of her relationship, and she advises that it is useful for all people. Lisa is a divorced, 46-year-old woman; she currently is on disability, and sporadically works part-time. She resides in the Midwest. She entered a couple of therapy between 2015- 2017. She and her ex-partner ended their relationship shortly after couple therapy was completed. Afterward, she saw her couple therapist for some individual sessions. She speaks about the nuances of being multiracial and navigating race both within her relationship and her family. She also advised that her previous partner had a strong preference for a person of color. Terry is a married, 41-year-old from the Western United States. Terry attended couple therapy with her partner to improve their communication and for relational discernment. She describes that she entered couple therapy with her partner to prevent a divorce. Terry’s experience in therapy included discussions about previous relational issues, communication, and deciding if the relationship was sustainable. She is no longer in couple therapy but optimistic about eventually entering individual therapy to address some personal issues related to occurrences in her marriage. Terry advised that she ended therapy because of financial reasons and hopefully can find a provider that is in-network with her insurance. Renee is a married mental health therapist that lives in the western region of the United States. She has two children with her partner. She went to two different couple therapists, with the latter being more successful than the first. She entered therapy to improve communication 33 between her and her partner. She went to couple therapy was after been married for one year and wanted to use therapy to enhance understanding within the relationship. She saw a female therapist in the beginning, and the second time she saw a male. She noted that the first therapist did not connect very well with her partner. She advised that he rarely talked with the first therapist. She is currently working with an African American male therapist whom she believes is a great fit for her and her partner. Tesha is a 28-year-old that is in a committed, non-married relationship. She entered couple therapy to learn tools to enhance communication and discussing tough conversations about feelings. She described her therapist as a good listener and skillful in enhancing the communication between her and her partner. She mentioned searching for quite some time for her couple therapist and was luckily provided a direct referral after failing to find an African American female therapist. Both she and her partner wanted an African American female therapist. She and her partner are still in therapy, and overall noted that the therapist is a good fit. Trey is a 40-year-old male, from the western region of the United States, in couple therapy with his current partner. He is previously married and was in couple therapy for his earlier relationship as well. He described his relationship with both couple therapists as good. His current relationship with his therapist has improved over time after starting off rocky. He entered couple therapy to address the relationship hurts and experienced the second therapist as more helpful. He describes his relationship with his current therapist as open, caring, and challenging at times. He is currently working with an African American couple and family therapist. William is a 38-year-old male, from the southeastern region of the United States, who is married with two kids. He used couple therapy for premarital counseling. He continued to go to the same couple therapist after premarital counseling ended. He offers that his therapist is 34 relatable, easy-going, and comfortable. He is currently participating in couple therapy. He mentions that he has consistently felt positive about his couple's therapist and was hesitant to participate at first. Evan is a 27-year-old who is in counseling with his committed partner. He is from the Midwestern region of the United States. Evan is currently in counseling with his partner to work through relational issues related to career changes. He described his therapist as relatable and shared that he believes he connects better with her because she is female. He also offered that couple therapy allows him to focus on personal issues as well as relational. He advised that television and media were influencers for why he and his partner decided to try counseling. Phillip is a 35-year-old male, from the western region of the United States, who is single after ending his last relationship with the assistance of therapy. Phillip mentions that what brought him into couple therapy was an ultimatum from his partner, but after three couple therapy treatments, he values how therapy has helped him end a relationship and find his emotional voice. Phillip is one of two participants that has only worked with a non-African American provider in couple therapy. Phillip participated in couple therapy with two previous partners. He found that couple therapy helped him decide to end his relationship more than once. Interview The interview protocol remained the same across the ten interviews, although additional questioning occurred for clarification and more depth in responses. The interview guide is provided in Appendix A. Interviews were transcribed and de-identified utilizing an online transcription service, "Way with Words." "Way with Words" is a professional transcription service provider since 2001 and offers private, secure, and fast data transcription services. The Demographic surveys were scanned and uploaded to a password-protected digital file. All paper 35 copies of the surveys were destroyed after upload. The interviews were conducted by the lead researcher, Travis Johnson, throughout the entire process to ensure consistent interviews. I conducted all semi-structured interviews with preconceived questions directed toward exploring the perceptions and experiences of African Americans who participated in couples’ therapy. All recordings collected from the study were stored on password-protected hardware, and passwords were assigned to each of the participants' digital files. All transcribed files were de- identified and stored with a participant number, instead of the participant’s name. Development of Interview Questions Interviews were the primary source of gathering data for this study. The objective of a phenomenological interview is to gather the participants' experience of the phenomenon from their point of view (Seidman, 2013). The participants' shared lived experiences ways of understanding their meaning-making of the complex social interactions (Seidman, 2013). Phenomenological interviews are non-structured face-to-face open-ended interviews, where the flow of the interview is guided by the researcher, who asks the participants to share their feelings, thoughts, and experiences of the phenomenon (Vagle, 2014). Phenomenological interviews appear like everyday conversations. (Dahlberg et al., 2001). A semi-structured interview protocol was used in this study. All participants were asked a standard set of questions, and the interviewer typically followed up with additional topics that emerged from responses. This approach allowed for flexible responses and follow up questions (Josselson, 2013). Interviews mostly consisted of open-ended questions with debriefing and closed-ended questions at the end. The interview concluded by asking participants about their reflections of the interview as well as motivations for participation in the study. 36 Given the nature of the study and population, asking participants to discuss their experiences of therapy, and given the cultural climate of mistrust regarding mental health and research, I engaged participants in an open way and made it clear that they could elect to stop participating in the study at any point. This was important with this population, given the historical barriers and systemic trauma of participating in research and clinical settings. To find answers to the research question, “What are the experiences of African Americans who have participated in couple therapy?” The researcher utilized the following broad interview questions listed as follows: (a) What was your perception of your therapist?, (b) What about the experience of couple therapy was productive?, (c) What about the experience of couple therapy was unproductive?, (d) What do you remember most vividly about the experience? (e) What informed your decision to utilize couple therapy? and (f) What about couple therapy helped your relationship? These questions provided data for both research sub- questions and the broader research question. Data Analysis After the interviews were completed, the interviews were coded manually by the researcher. Following Colaizzi’s method, the researcher reviewed the transcripts for emerging themes related to the research questions. The transcripts were analyzed one by one, and the analysis process spanned across the Spring of 2020. The researcher reviewed each transcript, identifying codes and themes related to the research questions. Considering the design of the proposed study, Creswell (1998) outlines steps for sound data analysis. The initial stages of data analysis require a description by the researcher of the phenomenon (couple’s therapy). All identifying information from transcripts was removed. Transcripts were formatted to have numbered lines and were organized into a notebook for each 37 participant. The data analysis process for this phenomenological study was a multistage process. There are multiple parts to phenomenological data analysis including (a) a description of personal experiences with the phenomenon under examination via a statement of positionality and a bracketing interview; (b) transcribing the audio recorded interviews into written transcripts, (c) reviewing the written transcripts multiple times to compile a list of significant statements; (d) identifying significant sentences and codes that relate to the experience; (e) interpreting meanings and chunking them into common themes across all the transcripts; (f) integrating the results into an all-inclusive description of the phenomenon; and (g) validating the findings with participants (Creswell, 2013; Moustakas, 1994). Colaizzi’s Method For this study, I followed Colaizzi’s (1978) phenomenological method of data analysis to analyze transcripts. Colaizzi’s method is a framework for data analysis (Creswell, 2007). Colaizzi’s method of data analysis is helpful for inexperienced researchers (Moustakas, 1994; Sanders, 2003). I also maintained a listing of the unique experiences, perceptions, and words from the participants, also known as horizontalization. Each utterance was considered to have equal value (Creswell, 1998). Moustakas (1994) discourses similarly, in granting each similar comment value and encouraging flow between the participant and research. To the best of my knowledge, this facilitated my comprehension of the participants’ experience. Using Colaizzi’s method, I attempted to get a sound understanding of the transcripts and considered every utterance for coding. This typically occurred after the interviews were transcribed and checked for accuracy. This method also includes checking for literal and implied significance (Creswell, 2007; Moustakas, 1994; Sanders, 2003). 38 Using Colaizzi’s method, I extracted and recorded significant statements (Moustakas, 1994; Sanders, 2003). At this stage in the analysis process, I reviewed the transcripts again and the significant statements. All the highlighted statements were copied and pasted into a new digital document, organized by the participant, with hopes that they represent the essence of the respective participant interview and experience of couple therapy (Sanders, 2003). The third stage of Colaizzi's method involves postulating the meaning behind significant statements (Moustakas, 1994; Sanders, 2003). For this stage of the analysis process, I made short reflections beside each significant statement to summarize my interpretation of the statement. I took notes if participants made multiple statements with similar meanings, indicating that this was coming up more in the respective participant’s transcript. Lastly, in correspondence with the last stages of Colaizzi’s method, I engaged in a more extensive reflection and summary (Moustakas, 1994). Sanders (2003) mentions that this is where the researcher integrates all the findings and returns the new descriptions of the phenomenon to the participants. At this point, I emailed my final description to all participants. Connections between categories and themes and checking with participants were used to further my understanding of African American couples’ experience of therapy and to shape the organization of the data for portrayal in my final document. Textural and structural descriptions were used to develop a comprehensive narrative of the interview (Creswell, 2013). The development of a comprehensive narrative of the interview paired with bracketed reflections from the researcher conveys the researcher's meaning-making process and transparency. The reflections come from the researcher’s process during the interview. The research established trustworthiness by openly sharing reflections throughout the research process written in journals. 39 Trustworthiness To manage biases, Padgett (1998) suggests that qualitative studies develop a set of strategies to enhance trustworthiness. For the study I considered the following to enhance trustworthiness: (1) credibility, or how close the research findings are to the reality of the situation; 2) member checking, which means that the active participants check the findings and confirm that the researcher understood the meaning of their words and experiences; 3) triangulation, which is the degree to which the findings are credible ; and 4) confirmability, which is the extent to which the findings are unbiased by the researcher (Lincoln & Guba, 1985). Checking the data and themes ensured that what I noted were not just isolated events, but true indications of the experiences of the research participants (Creswell, 2007; Patton, 2015). I used direct quotes from participants as evidence of shared meaning and checked for themes across interviews. I also used my advisor as a research auditor to review themes that I identified in the data (Creswell, 2007). I examined my findings and compared them to my advisor’s reflections and findings. I ask the advisor to look for any themes that I have identified, which could be a result of bias as opposed to themes that are occurring in the raw data. Researcher Positionality I am an African American male graduate student in a Human Development Family Studies program at a large Midwestern university. I was born and raised in the Southeastern part of the United States and completed secondary education in this region. I completed a master’s degree in Marriage and Family Therapy at a Central New York University, and I have provided therapy for clients for over five years. I have worked with American adults, couples, families, adolescents, African American individuals and couples, and children clients, as well as served as supervisor for therapists who have worked with this same population. I have previously been a 40 mental health client. I am responsible for developing or adapting this research study, the interview questions and protocols, the data collection, data analysis, and dissemination. I believe that the African American experience in couple therapy is unique because African Americans are typically considered an overlooked population when developing interventions of change for clientele in mental health settings. I wanted to do a study focused on understanding the experiences of African Americans who have completed couple therapy. To the best of my knowledge, there were no studies exploring the experiences of individuals who participated in couples' therapy. Trustworthiness of Findings To ensure the trustworthiness of findings, Lincoln and Guba (1985) state that the findings of a qualitative study should be credible and honest. By member checking, I ensured that my biases are checked, honest, and the data interpretation is correct. I also utilized peer debriefing and participant debriefing to ensure credibility. During these processes, I explained my analysis process with individuals not affiliated with the study and participants to assess my interpretation of the study. Lincoln and Guba (1985) posits that using thick descriptions provide transferability and transparency. To ensure transferability, I provided detailed descriptions of the findings and my research process for the study. This included providing any logs, receipts, journal entries, and the transcripts that document my process and perceptions through the study (Lincoln and Guba, 1985). To ensure dependability, I purposefully chose a sample that fits the phenomenon being investigated and allowed an auditor to verify the results, which was Dr. Adrian Blow (Lincoln & Guba, 1985). Lastly, to enhance the quality of the study and ensure the trustworthiness of findings, I provided confirmability; the representation that the findings are not biased, by 41 following techniques discoursed by Lincoln and Guba (1985) and keeping an extensive audit trail, a journal, and adhering to the research plan. Following these techniques enhances rigor, checks researcher biases, and demonstrates reflexivity (Lincoln and Guba, 1985). Conclusion The next chapter will present findings from the study. In the next chapter, I detail the themes that emerged from the participant interviews. 42 CHAPTER FOUR: Results The research question guiding this study is, "What are the experiences of African Americans who participated in couple therapy?" The participants in this study utilized couple therapy after dealing with various relational issues that spanned from infidelity, communication issues, domestic violence, relationship discernment, parenting issues, and finances. The participants decided to use couple therapy, as opposed to individualized modes of treatment, after experiencing breakdowns in their relationship and an inability to work through their relational issues. All the participants met regularly with their therapists, and each had participated in at least three couple therapy sessions. While this was not an initial inclusion criterion for this study (the original criterion was only one session), this sample had experienced couple therapy enough to be able to comment on their experiences This chapter contains several key findings from the interviews with the 10 participants. The results of this study shed light on the experiences of African Americans in couple therapy and center on the uncovered meanings and experiences organized as three central themes. The themes are: (a) African Americans endorse couple therapy and experience it favorably; (b) The therapeutic alliance has a central role in couple therapy with African Americans, (c) and Therapists addressing culturalism and racism in couple therapy. Main Theme Number One: African Americans Endorse Couple Therapy and Experience it Favorably The focus of this study is to examine the lived experiences of African Americans in couple therapy. All participants within the study endorsed couple therapy. Participants in this study experienced comfort when navigating, setting up, and experiencing couple therapy. Participants described an appreciation for mental health services. They shared that during their 43 couple therapy experience, they learned many communication strategies that helped improve their relationship. My study generated new findings of African Americans offering verbal support for couple therapy and other modalities of mental health treatment. Endorsing Couple therapy and perceiving it favorably was derived from the participants' statements regarding how they experienced couple therapy. All the participants shared the reasons why they were in couple therapy with some of the participants offering that they had participated in couple therapy more than once with the same or different partners. When endorsing therapy and speaking about positive experiences in couple therapy, the participants described valuing when the therapist focused on resolving real issues and enhancing communication. There were specific aspects of couple therapy that these participants reported as especially helpful; therapy was viewed as a resource providing important skills. Couple Therapy was a Resource for Treating Relational Issues. All participants described their overall impression that couple therapy was a positive resource for treating African Americans' relational issues. Across the participants, this was a consistent response to addressing couple-related issues, including communication, trauma, impasses, infidelity, and financial incompatibilities. "It was eye-opening because he was able to give me a different perception…he helped us a lot because we realized we were not prepared [for marriage]. We had lived together for a long time. However, we were not prepared for our next step in the journey." (Elle) “I had been experiencing some traumatic things in the relationship, and the couple therapist helped both my partner and I address it.” – (Terry) Another participant reflected on notable lessons that they learned about listening to their partner in couple therapy. 44 “Some of the big moments was learning to listen. Once I started listening, I understood him better. I learned that I was not receiving information in the way he intended to give it to me…I realize that I cannot be mad at him about something he did not do. I think that helped us argue better.” – Elle All the participants reported that they discussed legitimate relational issues in couple therapy and experienced the process of addressing those issues. Couple Therapy Led to the Enhancement of Communication Skills. All the participants perceived therapy as a resource for enhancing communication. Many of the participants shared surprise at how helpful couple therapy was in enriching their communication. “The therapist just opened the conversation more…the therapist was able to step in and diffuse the whole thing [conflict] and kind of explain to my husband what he was hearing me say. From that point, my husband was able to say that is not what I meant. I was just trying to say we are going to work this out; we got to get past this. So, it just opened us up.” – Terry Tesha and Terry provided the most comprehensive explanation of the tools that the therapist utilized to enhance their communication: “One of our sessions we had to write down things that are important to us in a relationship, and she encouraged us to just speak more kindness to each other, just complimenting two times a day. We are working on that, and I can see a change, and just like simple little things like that, they go a long way. She helped me see that sometimes we can project our feelings on to the other person, and I think that was eye-opening because of how she explained what I do. It helped me be aware of something that I could 45 address and try to change.” Tesha "I have had some good experiences in couple therapy, it opened up many possibilities for discussion…it helped us come up with ways to better communicate with each other." Evan Participant Trey mentioned that couple therapy helped him improve in communication in general, and the skills he learned in couple therapy also translated to improved communication with family members and friends. Focus on Solutions Three of the participants shared that the most helpful part of couple therapy sessions had a provider offering solutions for their relational problems. “She is [referencing the couple therapist] good at listening and then figuring out a course of action.” - Tesha One participant, Renee, reflected that she really appreciated her therapist’s solution- focused approach and recommended this approach in working with African American couples. When describing the focus on solutions, most participants discussed how the therapist not only verbally mentioned solutions but helped model and co-create solutions through client enactments. "So there were some moments that were super helpful, and it was when she was more action-oriented and solution-focused, asking both of us: "what would you like to do?" and "What would you feel more connected?" What would you like for them to understand?" – Renee 46 Endorsement of Mental Health Care Treatment for Individual Issues While Being Treated in Couples Seven of the ten participants endorsed couple therapy as affirmative and helpful in addressing many different issues ranging from the couple, individual, and racial issues. Many of the participants shared that couple therapy helped them improve their self-care and inspired them to pursue personal endeavors. These were not necessarily a focus of couple therapy but were positive outcomes. Some of the participants mentioned personal changes occurring because of couple therapy that influenced their relational behaviors. “Along with the couple therapy sessions, we started talking about things that would make us good individually too. My partner started having her nails and her hair done. She also mentioned getting her pharmacy school applications submitted, stuff like that. I aimed to slip down and focus more on having my hair cut more often and getting clothing that I like. And following the session, I start going to the gym quite often. I lost eleven pounds…and I have seen a big benefit to my mood, and now I approach for cuddles and kisses.” – Evan Often these personal changes led to participants experiencing an overall improved mood. As a result, some of the participants commented about how that influenced various relational behaviors, including reaching out to their partners for connection. “We talked about my anxiety in bringing up things early to my partner…this cleared up misunderstandings before they happened…I learned that if I face my anxiety and get my feelings out there, my partner's response to it would not be as bad.” – Phillip The Value of Having a Provider Offering Insight While all the participants shared that they experienced moments of helpfulness in couple therapy, 47 this was not removed from the therapist, providing a positive experience for these couples. All participants described the process of couple therapy positively. Most of the participants valued having a third person offer guidance on how they communicate with their partner. “We needed that person to say, "Hey, you are both wrong." Let me show you some steps and techniques to improve what you're doing.” - Elle Elle also shared her appreciation of having her therapist usher in new perspectives and validate her point of view in couple therapy. “He would say, "I hear you. I understand, but let me give you another perspective. He didn't validate you without challenging you.” - Elle In another example, Lisa and Tesha describe positive therapy moments facilitated by her competent and knowledgeable clinicians. “I felt that they were knowledgeable, and then if there were any areas where they weren't quite confident, they were very willing to research and experiment and try new things, and that I think especially, well in any situation is good, but especially in my past marriage experience, because it was very common for us to reach dead ends…we'd try a new tactic weekly...and I appreciate that they were willing to do that.” – Lisa “I liked my couple therapist credentials, and I thought she was the real deal…we could be comfortable and pretty much talk about anything. I felt really good about her, and I felt comfortable sharing.” - Tesha All the participants shared that the couple therapist was helpful, and their competency played a critical part in their experience in couple therapy. Most of the participants valued having a competent provider offer guidance in improving communication with their partner. Many participants offered that many changes in the way they communicate with their partners were 48 facilitated by working with a competent and knowledgeable clinician. Some participants also examined their practitioner’s credibility by examining their credentials. “I liked my couple therapist credentials, and I thought she was the real deal…we could be comfortable and pretty much talk about anything. I felt really good about her, and I felt comfortable sharing.” - Tesha When speaking of competency, the participants mentioned that when there were limitations within the therapist’s experience or knowledge, they acknowledged that limitation, asked questions, and utilized resources. One of the participants expressed that they experienced the couple therapist as having done their homework related to racial and couple issues. Some of the participants also mentioned valuing when the couple therapist directed them towards resources that could be supportive outside of the session. “If he didn’t know something, he admitted it and did his homework.” – Janet Main Theme Number Two: The Therapeutic Alliance has a Central Role in Couple Therapy with African Americans From the literature review, it is evident that African Americans experience significant relational, interpersonal, and personal barriers in therapy. Corresponding with the literature, the second main theme that emerged recognizes features of the therapeutic relationship between African Americans and the couple therapist that are influential in their experiences of couple therapy. This section presents findings from the participants regarding how the therapeutic alliance is a protective relationship that helps African Americans in couple therapy. Three subthemes from the participant statements are listed as follows 1. African Americans Endorse Couple Therapy and Experience it Favorably; 2. The therapeutic alliance has a central role in couple therapy with African Americans; 49 and the meaning of 3. Therapists addressing culturalism and racism in couple therapy The synthesizing and analysis of this finding will also include the participant's sayings about uncomfortable experiences in couple therapy and therapeutic alliance with either themselves or their partners. In general, the participants shared that uncomfortable experiences were usually a result of how the therapist handled problematic behaviors or outbursts from their partner. When examining how the participants made meaning of the therapist responses in the couple therapy process, it appears that their relationship with their therapist played a role in creating a comfortable space for both partners to speak openly. Importance of Safety and the Therapeutic Alliance When asked to speak about unproductive moments in therapy, a few participants revealed that there were significant communication or emotional issues that were not managed well by the couple therapist during sessions of couple therapy, and that created mistrust or a lack of safety in the therapeutic process. These were related to events in therapy that became emotionally charged, and then the therapist did not respond in ways that made the individuals feel resolved about these issues. One participant shared that sometimes couple therapy made matters worse in their relationship because there were significant issues not being addressed in couple therapy, leaving the couple hanging and feeling exposed and unsure. When asked about unhelpful moments, this participant stated that her partner had an emotional reaction to an event in therapy. “In one meeting, my ex completely lost his temper…the counselor got to see that side of him…I felt like I had to pick up the pieces. I had no idea how to pick up the pieces in a setting like that…it was good that they got to see that side, but it was also scary for me… We had to end the session, and I thought maybe the counselor was going to drop us, and I wouldn't have any outside help anymore.” – Lisa 50 For some of the participant’s the timing of how therapy ended was important considering that they may have discussed emotional or vulnerable topics and may not have the available tools to regulate heightened emotions in the aftermath of couple therapy. This is particularly important considering that these couples may only interact with their therapist every week. When discussing vivid memories that she has about her couple therapy experience, Terry brought up the importance of debriefing at the end of the sessions as a way for therapists to responsibly handle African Americans that are discussing vulnerable relational issues. "We would talk about difficult things that occurred within the marriage. I would not say this was unproductive, but I did not like where things were when we ended sometimes… like we did not resolve things. I felt like topics triggered certain emotions. Then it was just left like that. We did not debrief, and we were left to just go home at the height of whatever we were discussing." – Terry Terry is clear that it is not the discussion of difficult topics that was a challenge, but rather, it was the feeling of exposure that was not comfortable and that she wanted the therapist to process these events more so that there was some feeling of safety. Post interview, two participants shared reflections on debriefing after couple therapy and safety in the therapeutic alliance. While debriefing after the interview, although this was not indicated to be a part of their experiences in couple therapy, two of the 10 participants commented on how they can see how opening up about difficult issues can be an uncomfortable part of the therapeutic experience. Janet offered that within the African American community, there is an understanding that you do not “air out your dirty laundry.” This is an important statement given that several couples reported feeling vulnerable or exposed after therapy. In their recollections of the experiences of couple therapists, the participants made statements that seem 51 to imply that even though they themselves felt comfortable and trusting with their therapist, they worried about their partner’s comfort during the process of couple therapy. 52 Disclosure and the Therapeutic Alliance Closely related to the idea of safety is the process that occurs when participants take risks and disclose things like secrets in therapy. When asked about unproductive moments in couple therapy, three of the participants shared that they intentionally excluded disclosing couple-related information in the couple therapy process. From the participant's perspective, this was either due to the therapist’s approach to relational problems or the understanding of the consequences of disclosure in the couple therapy process. Trey shared that the "no-secrets" policy, common practice, and tenet of systems therapy, was problematic in their experience of couple therapy. To support open communication, couple therapists often refused to hold secrets between members of the couple. Trey commented on how these common rules for couple therapy can openly impose on the client's willingness to share important couple-related information. She had this rule. I 'm not going to hold any secrets. I remember that being a conversation, and I remember feeling a lack of control there…[a better approach]…I think to help one understand the value of sharing information that has been said in individual sessions as opposed to making it very clear that you don't hold secrets…That makes you feel somewhat guilty or shameful…I didn’t feel supported in that conversation…I felt like she was saying that I need to know that whatever I say to her, she’s going to tell it eventually and that for me just felt wrong. – Trey Hearing the consequences of sharing information had a significant impact on Trey’s perspective of the couple therapist and brought him to the conclusion that he could not risk sharing information that he wanted to disclose confidentially to the couple therapist. Most of the participants reflected that they were willing to open about issues with the couple therapist directly. One participant shared that they experienced discomfort with being 53 vulnerable in the process of couple therapy due to relational problems with their partner. Lisa mentioned hesitancy with sharing vulnerabilities in the process of couple therapy. Lisa discussed hating being vulnerable with her partner because of the implications within her relationship after the therapy process ended. “I hated being that vulnerable with him because I had learned through the course of our relationship that it never ended well for me, letting him in. I had to walk this line of participating but not participating enough that he would be able to hurt me with the information later. That is why the homework was so stressful. I could not answer the questions. I had to be very calculated and careful so that the homework didn't give him more weapons.” – Lisa These participants shared struggles related to taking risks in therapy and disclosing vulnerable information while fearing partners' and therapists' reactions. Some of the rules of therapy were perceived as barriers. Hopefulness in the Therapeutic Alliance The impressions that the participants held of their therapist’s hopefulness for their relationship also came up in processing unproductive moments during the experience of couple therapy. These participants discussed how they felt more (or less) hopeful based on the alliance they had with their therapist. One participant shared two different experiences with two different couple therapists, one that they experienced as hopeful and the other as not. The participant and the ‘hopeful’ therapist still have an ongoing couple therapy relationship. The participant’s perception of the non-hopeful therapist is that the couple therapist was questioning the viability of the relationship. The participant mentioned that the therapist would openly ask if they thought their relationship was going to work. It is interesting that the participant describes this exchange 54 between the therapist as unproductive, considering that the couple therapist asks clients reflective questions about their relational patterns, including if they are sustainable. I think I felt more of hopefulness from Therapist B. At times, my first therapist implied, through questioning us, that they were wondering if our relationship was going to sustain itself… maybe that was helpful, but I did not experience it that way. I found myself wondering why I am here…” - Trey Terry and William also offered that the therapist use of meaningful, reflective questioning about conflict and communication was important. "We'd start every session with the therapist gauging our level of communication over the previous week. He would say, 'Communication. Are you full, halfway, or running on empty?" He would then go off that and gauge how much work we needed. It was an eye- opening exercise because me and my husband's answers were sometimes off from one another. Then the therapist would help us talk about that more." – Terry “Our couple therapist helped us understand our conflict and communication by showing us a feedback loop. Within the loop, you get to see how you are responding to each other. – William These and other experiences led to couples feeling hope, and it stemmed from the relationship with the therapist. I was Feeling Connected when Acclimating to the Process of Couple Therapy. Terry, a 41-year-old middle-class African American participant in couple therapy, reported that feeling connected to the therapist was a critical dimension for success. Terry’s partner had previously been in couple therapy on a few different occasions but reportedly did not have a great fit with the earlier therapists. As a result, they moved around until they found a 55 connection to their current couple's therapist. Their first therapist was reportedly nice, but Terry suspected that the therapist was not passionate about their work. She also reported that the main reason they utilized this therapist was that it was free and was provided through her partner's job. Terry mostly spoke about her most current therapy experiences, which she paid out-of-pocket for. Their current therapist is an African American male, and Terry talked about her first impressions. He was an African American male…we really did like him…my impression of him…I really did [like him] because I felt he was able to connect with my husband a bit more. Even more so than the first time we did counseling. I feel like this therapist…I do not know what it was, but I just felt like he [husband] was able to connect with him more. My husband has a lot of reservations about couple's therapy for some reason…He does not really like it. But that therapist, we really liked him. He is cool. I like some of the tasks and assignments he had us do… Terry did not explain why their impressions of the therapist were different, but she did state that both she and her partner enjoyed the different tasks. She said that she usually gravitates towards someone with a spiritual background and that she researched the therapist to confirm their spiritual practices before booking them for couple therapy. When I spoke with him and kind of read on him, it made me more comfortable knowing that he has his degrees and has some biblical knowledge, which lines up with what I believe. It just made me more comfortable. – Terry These participants all talk about their processes of becoming comfortable. They reported initial mistrust and even shopping around or researching their therapists until they found a good fit for the goals of their therapy. 56 Partner Involvement The participants shared that balancing the involvement and alliance with both partners is a critical part of making a couple of sessions productive. Lisa spoke about how her couple therapy sessions would, at times, be heavily focused on her partner, which prevented work from happening in their relationship. She mentioned that the therapy process, at times, felt it was preparing her partner for actual couple therapy. Lisa reflected that she experienced it as a mix of positive and unproductive. “Most of our couple sessions ended up becoming individual sessions for him, just so we could get him to the point where he could have a productive conversation… On the one hand, it was positive, it was good, but it also felt like a waste of time…because he never would hold on to the information…. he had no idea what I was talking about and would get frustrated and angry…the counselors did a tremendous job because he actually listened to them and learned a bit about himself.” Lisa Phillip spoke about how their partner verbally dominated sessions and how that influenced his emotional experience leading up to sessions and during couple therapy sessions. Phillip reflected that the therapist's attempts to help with communication were unproductive due to their partner’s mental health. What became apparent in the first couple of sessions was that she was very commandeering…she would dominate the entire session and would just speak over me, and kind of speak over everyone, therapists included. I was so intimidated that I could not speak my piece…it was really rough…I had a massive wall of anxiety days leading up… - Phillip Phillip offered that his partner’s mental health was not part of the treatment plan for couple 57 therapy. After several unproductive sessions, this participant elected to end their relationship with their partner with the assistance of the couple therapist. While mental health challenges within a relationship certainly can be the reasons a couple elects to utilize couple therapy, this participant’s experience of couple therapy was precipitated by a verbal imbalance during sessions and growing anxiety symptoms between couple therapy sessions. The experience of sensitivity toward the partner-therapist relationship was derived from the participants' statements regarding how they perceived the relationship between the therapist and their partner. The female participants all evaluated the therapist's ability to build a relationship with their partner. All the female participants shared that part of the successful first encounter with their couple's therapist was how therapy went for their partner and their partner's relationship with the couple therapist. Eight of the ten participants commented on actively monitoring the couple therapist’s relationship with their partner while in couple therapy. Some of the participants discussed their partner’s hesitation in participating in couple therapy, and this upped the stakes for the initial sessions to go well for the partner. Commentary about the partner’s relationship with the couple therapist was a recurring theme for participants, especially for those who began working with the couple therapist prior to their partner. All of the female participants talked about the positive experiences their partners had while in therapy. Janet spoke about how she experienced sensitivity to the therapist's relationship with her partner. Both Janet and Elle acknowledged that the therapist's first-made impression, and developing a relationship with their partner was a major component of the couple therapy process. They also both stated that there are preconceptions about going to therapy, and their partners expressed reservations about couple therapy. However, despite these stigmas, their 58 partners' impressions of their therapy reportedly changed once they began their relationship with the couple therapist and resulted in multiple positive experiences that enhanced their relationship communication. "I feel like he understands my husband. He was concerned about minorities, and I always felt that way...my husband liked him too…at first, he did not want to go, and now he wants to go anytime there is an issue. He's like, well let us talk about it in therapy…he's [partner] always saying really nice things about him [the couple therapist] …" Participants described how therapists overcame mistrust on the part of the partner, especially when it came to the cultural differences between the therapist and her partner. Janet detailed how she and her partner felt uncertainty in the beginning but felt that the therapist helped work through this in couple therapy. Elle described that the therapist approach was not assumptive but was openly willing to discuss their racial differences and how it helped facilitate a bond for both her and her partner. Elle reflected on the time that she has been in couple therapy with her partner for two years. She also detailed sensitivity to the therapist's relationship with her partner: There's a lot of mental health issues, whether it's anxiety or depression…that people don't want to talk about because they're scared of being labeled…my husband went into couple therapy kind of saying…Oh, you only go therapy when you’re crazy…after a few sessions with the couple therapist, the therapist opened up and shared some of his experiences… I think it put him more at ease for my husband because it was somebody who looked like and a person who has gone through similar things as well… when the [the therapist] opened up and shared some of his experiences. As for me, his age, gender, race, none of that played a part for me…seeing that he was relatable [to my husband] 59 made me feel better…” Elle While for some, it was positive in that the partner was put at ease and engaged in therapy; for others, it created negativity. For example, Trey perceived the partner-therapist relationship to be in an alliance that was not helpful, but imbalanced and negatively influenced their experience of couple therapy. “My partner felt more connected with the therapist…my partner didn't have to step into accountability necessarily…I didn't find it to be productive" - Trey. Main Theme Number Three: Therapists Addressing Culturalism and Racism in Couple Therapy The Couple Therapist and Participant’s Racial Likeness The participants shared that racial likeness could be an important factor in forming a relationship with African Americans during the early stages of therapy. This seemed to be especially true for African American males in couple therapy. All the female participants stated that their partner preferred a couple therapists of the same race. It was important for my ex to have counselors that look like him. He is a black man, so it was especially important for him to have that. So that was huge because we had seen other counselors before and they were white women and white men, and he didn't even give it a try…he was just convinced that they would never understand him or they just couldn't do what he needed because they didn't look like him. –Lisa Some of the participants mentioned that racial likeness might put individuals at ease in couple therapy and help with easing worries about relatability. “My husband had reservations about couple therapy for some reason. I don’t know why but he doesn't really like it. But our particular therapist, we really liked him. He's African 60 American, and I think that helped my husband get comfortable in the beginning…we read up on him too and seeing his degrees, knowing he had biblical knowledge, and seeing that he was African American helped him be okay with couple therapy. -Terry I think, for my husband, it put him at ease because it was somebody who looked like him. I think the most important part is seeing that he was relatable. That made me feel better. - Renee Eight of the 10 participants worked with a therapist of color. Nine of the 10 participants commented on the importance of the couple therapist’s racial background, as it relates to either the participant or their partner. In general, the participants described racial likeness as an indicator that the therapist will understand their racial experiences and background. Nine of the 10 participants also commented on the consideration of the therapist's racial background as a critical part of their search criteria when seeking their therapist. Cultural Sensitivity and Cultural Factors in the Process of Couple Therapy Cultural sensitivity relates to reflecting upon, understanding, and respecting cultural norms and rituals of various ethnic groups. Participants shared commentary on the importance of cultural sensitivity in the couple therapist. This section provides a synthesis of racial experiences that occurred in couple therapy for the participants. A few participants expressed utilizing varied ways to gauge how culturally sensitive their therapist was, including their couple therapist’s choice of words, usage of humor, the couple therapist’s office decorations, and their couple therapist’s usage of interventions. The sensitivity to culture seemed important for the participants or their partners, with one participant mentioning explicitly that their partner would only see a therapist of color, with the understanding that a therapist of color would be sensitive to the participant’s cultural background. 61 “I think it’s important that clinicians understand what it means to be a black couple in America…what it means to be a black woman and how that influences the relationship…what it means to be a black man in American and how that influences the relationship.” – Trey While commenting on different cultural experiences that African Americans may discuss in couple therapy, one participant shared a powerful contextual backdrop of some of the complex issues that African Americans experience. “-- as a woman of color, I know a lot of therapists are drawn to people who look like them and understand their, um, um, ethnic makeup. The first time, I started working with him, I was there for infertility. But as I stated earlier, now we (with a partner) have worked with him three or four times. Infertility is like, probably painful for anybody, but I think as a black woman that holds a huge barrier being able to make kids and reproduce… like that's huge and to think that you can't do that… it's almost like, as a black woman we're expected to… while at the same time you know society I think a lot of times looked at us just like we're super sexual or super sexual promiscuous and that's layered...” – Janet The participants reflected on the couple therapist relationship with their own culture is important as well. “I don’t know if she acknowledges ethnicity or race, but she’s just got like a vibe. I feel comfortable speaking to the therapist because she is proud of her culture.” - Tesha Although the racial background is a consideration that the participants make in their search, it appears that it was not something explicitly discussed in most of the participants’ couple therapy experiences. Only one of the 10 participants discussed race with their couple 62 therapist, and the participant commented that the conversation was implicit. I do not even know if African Americans even think it is all right to even think about their experiences in couple and family therapy. I think I have not found where there are group practices where it is predominantly black therapists working and promoting their voices to kind promote this idea of family and couples. I think there needs to be some type of database where people can get access to and know where therapists of color maybe are because psychology today doesn't even give you an advanced way of saying you would like a therapist of color. – Trey Racial Stigma The participants also talked about how therapy was useful and if they held any reservations or stigmatized beliefs going into couple therapy. “Understand that there are still some stereotypes and stigmas about Black people coming into therapy.” - William Elle shared that she was utilizing couple therapy for premarital support, to address any issues before they surfaced in the relationship and develop functional communication strategies. Elle also mentioned that her husband is currently participating in couple therapy, yet initially, her husband did not want to participate in couple therapy due to the perception that it was not needed. My husband did not want to go. He was just like; hey, I love you; you love me. That is all we need. We do not need anybody to tell us how to love each other. But after therapy was said and done, he was like, I enjoyed it was good that we went.” – Elle Further, in the interview, she offered that he held stigmatized beliefs that influenced his perspective of counseling and offered that no one in either of their families had ever considered 63 using therapy in any modality prior to couple therapy. In some cases, the therapists and the therapy process worked to overcome stigma. However, in others, unproductive therapy led to a confirmation of stigma concerns. Lisa shared that their partner's perception of couple therapy worsened after attending couple therapy, after attending three times previously to help with communication and to prevent the relationship from ending. Lisa stated that she interviewed several couple therapists, and she and her partner met with two before meeting with their final couple therapist. Lisa stated that she observed shifts in her partner's perspective regarding therapy, but after attending unproductive sessions, he perceived the process to be a waste of time. “We tried to find other people before we found the two that we stuck with for a little over a year at the end of our marriage, but we only went to see them for a few sessions, and then he said this is a waste of time. I did what you asked; we're not getting anywhere I am not going anymore.” – Lisa After attending couple therapy a few times, from Lisa’s perspective, her partner still has stigmatized beliefs regarding the process. Conclusion This chapter presented the findings from the study exploring African Americans' experiences in couple therapy and how they perceive the experience. In this study, I interviewed ten individuals that self-identified as African American and analyzed their statements. The participants in this study entered couple therapy for various reasons, including navigating communication issues, infertility, infidelity, financial issues, and other relational issues. It is evident that the relationship the participants built with their couple therapist is critical and can heavily influence their experience of couple therapy. The experience of couple therapy left them 64 endorsing mental health treatment and couple therapy. In the next chapter, I will discuss the implications, limitations, and how this study adds to couple and family therapy literature. 65 CHAPTER FIVE: Discussion Introduction This chapter will provide a discussion about the qualitative study exploring the experiences of African Americans in couple therapy. For this chapter, I will address how this study fills in a void in the discourse and research surrounding African Americans' experiences in mental health settings and couple therapy specifically. I will also discuss how the findings in this study correspond with or expand previous and current knowledge about the practice of couple and family therapy. I will also discuss the limitations of this study. Lastly, I will discuss my recommendations for future research efforts and the implications of this study for clinical practice and research. The answer to the research question of "What are the experiences of African Americans in couple therapy?" was drawn from ten participants who self-identified as African American and participated in multiple sessions of couple therapy. The experience of couple therapy left these participants with impressions that couple therapy is a helpful process for strengthening African Americans' relationships, including communication, creating lasting change, and coping with personal and relational issues. Interpretation of Findings This study was a transcendental phenomenological study that explored the following research question: What are the experiences of African Americans in couple therapy? The findings provide clarity to African Americans' experiences of the studied phenomenon, couple therapy. African Americans Endorse Couple Therapy. The findings in this study illuminate that the lived experiences of African American 66 individuals participating in couple therapy were profound, affecting all aspects of these individuals' lives and relationships. Participants entered couple therapy to address a myriad of problems and often exited couple therapy with a perceived myriad of improvements. Several participants detailed that couple therapy helped improve their personal lives, their intimate relationship, family relationships, and overall well-being. All of the study participants reported positive outcomes and experiences in couple therapy. Several of the participants shared that couple therapy was a resource for addressing problems for both the relationship and personal challenges. Several of the participants who were not actively involved in therapy were currently open to utilizing therapy in the future and wanted messages about the helpfulness of couple therapy to be mainstream. This finding is contrasted to the literature on African Americans in therapy which punctuates issues of stigma and barriers to therapy (Hall, 2012) for African American couples, by emphasizing the multiplicity in attitudes towards couple therapy for African Americans. There is also a lack of clarity in the literature related to the experience of couple therapy specifically. These findings highlight that when African Americans participate in couple therapy, it is beneficial for both the individual and the relationship, no matter the modality of couple therapy provided. Couple therapy is an important therapeutic option for African Americans if barriers to attendance can be minimized. This Study Indicates that the Therapeutic Alliance is Important for African Americans in Couple Therapy The findings in this study support that African Americans experience a wide array of experiences in couple therapy, mostly positive with some negative. The therapeutic alliance is seemingly an important factor related to the positive experiences of African Americans in couple 67 therapy. Additionally, this study's findings suggest that the therapist plays a critical role in the experience of African Americans in couple therapy through multiple ways, but especially through establishing a firm alliance with the couple. This corresponds with Knobloch and Fedders (2004) findings, who emphasize the importance of the therapeutic alliance in ongoing care with participants in couple therapy. This study adds to the discourse by shedding light on key factors contributing to African Americans' continued involvement in couple therapy, as opposed to early dropout. Most participants stated that the therapist has some form of influence on their experience of couple therapy, and this was evident in the therapist working to build a safe therapeutic environment. This was particularly important given the experiences of African Americans with therapy and the mistrust that may exist in this population towards therapy. The establishment of safety is an important early step in therapy to help couples to relax into the process. Couples reported that emerging from this was a feeling of connection to the therapist and more hopefulness about their situation. Closely related to the topic of safety was the topic of vulnerability and how this plays out in the alliance. The African American couples in the study described feelings of vulnerability, especially after disclosing sensitive information in the therapy room. This study broadens the understanding of African American individuals' attitudes about couple therapy. While all couples may feel more exposed after discussing difficult or painful topics, African American couples maybe even more sensitive to these topics given historical oppression. Participants suggested that therapists build in extra time to process these issues with couples, and this extra time builds in additional layers of safety. Finally, in relation to the alliance, the split alliance, i.e., the balancing of the alliance between both partners, emerged as an issue (see Sprenkle & Blow, 2004 and Sprenkle, Blow, & 68 Dickey, 1999 for a full discussion of the split alliance). This issue was brought up by all study participants. Interestingly, almost all female participants stated that they experienced some form of sensitivity or thoughts about how the couple therapist built a relationship with their partners. For many, this seemed to be related to their concerns about their partner and his engagement in treatment. They were concerned about their partners' stigmatized beliefs and were wanting them to feel comfortable in therapy. To reiterate, almost all the participants stated participation in couple therapy changed their stigmatic beliefs or their partners' stigmatic beliefs of therapy in general. The participants who stated this discussed the relatability of the couple therapist playing a key role; this finding corresponds with Lincoln and Chae's (2010) study examining how African American couples are more likely to consider counsel from individuals who have similar life experiences. The therapists' connection with many of these partners led to a higher engagement of both partners. In a few cases, the opposite was true, with one member of the couple feeling "jealous" if the therapist spent too much time with the partner. These findings highlight the need for the therapist to be sensitive to various emergent issues of a split alliance as well as to the within couple alliance and to be overt in discussing these issues. Understanding how to manage split alliances with African American couples can enhance the care that providers offer with this population. There has been continued discourse in the field about how split alliances influences the outcomes of therapy with couples (Knobloch & Fedders, 2004; Pinsof & Catherall, 1986), and this is an important consideration in working with African American couples. From the interviews, it is evident that the therapists' natural skillset in building relationships and other qualities positively influence perceptions of these participants. These participants mentioned the use of language, cultural sensitivity of the therapist, the use of homework, amongst other clinical factors that demonstrate an understanding of the participants. 69 The therapist's ability to form positive relationships with clients left a seeming lasting impression on the participants and their partners. These couples may be presenting in therapy with a high level of fear and mistrust, and this plays out in the relationship that they have with each other. African Americans are Willing to Establish Trusting Relationships with Competent Providers. This study's findings challenge discourse and research that African Americans share prevalent beliefs that problems are resolved exclusively within a family/kinship network. This study provides a counter to the discourse and research suggesting that minorities prematurely drop out of mental health treatment, with most of the participants in this study either still involved with couple therapy or electing to work with their provider for individual mental health care. When a trusting relationship is provided to couple clients, they stay in therapy, but they flourish. Cultural Attunement and Couple Therapy Although not directly correlated with other studies' findings, this study sheds light on a void regarding how cultural beliefs and attitudes play a role in African American couples' experiences while engaging in couple therapy. This study confirms that perceived cultural sensitivity is an important consideration in the selection of mental health providers. Contrasting the research that culture is only meaningful in the initial stages of therapy, African Americans are gauging their couple therapist's cultural attunement by non-direct and direct encounters, non- verbal cues, and verbal cues. The race of the therapist was an important factor, especially for male participants, and they reported feeling more relaxed and more understood when they were able to work with a therapist of the same race. This is a call to our field to engage more therapists of color in the field and provide direct services to African American couples. This study's findings of the role of stigma in couple therapy correspond with research 70 detailing the barriers that African Americans must overcome to participate in mental health settings (Awosan et al., 2011; Boyd-Franklin, 1987; Hall & Sandburg, 2012). The majority of participants stated that their partner held stigmatized beliefs before participating in couple therapy. Specifically, from the findings, it appears that African American men may have more stigmatized beliefs about discussing mental illness and the utilization of couple therapy; however, this is not a deterrent from engaging in couple therapy with some of the male participants initiating couple therapy or expressing a willingness to participate. The therapists seemed to play a role in helping these couples/individuals feel at ease and comfortable in the therapy process. Some participants implied that the helpfulness of therapy seems to be influenced by the partner's behavior and relatability to the couple therapist. Transcendental Phenomenological Framework Assumptions and Interpretation When interpreting the data, I tried to keep an open mind and suspend biases about this population and phenomenon. To raise the trustworthiness of my findings, any prior understandings of African Americans were suspended. My assumptions were suspended through the process of bracketing. During the interview process, when I became aware of my assumptions, I asked the participants about my assumptions to keep them in check. I also checked with my advisor to process my assumptions and interpretations. In my interpretation of the data, I attempted to step back and allow my participants to speak. If the data spoke to me in ways that were not demonstrated within the data, I checked with participants and advisors to clarify or relearn my participant's stories rather than project my own assumptions onto the data. From my point of view, the most provocative finding is that racial likeness is an 71 important factor in couple therapy, although it is not an exclusive determinant if the couple therapist is perceived as culturally attuned; it appears that most African American participants prefer working with a therapist of color, at least at the commencement of treatment. I was also very intrigued to see that all participants participated in more than one session of couple therapy and that all participants were willing to engage in multiple modalities of mental health treatment. I was also intrigued that the participants who ended their relationship either during or after couple therapy still held high regard for the process of couple therapy, with some participants utilizing couple therapy multiple times. As I uncovered different experiences within the data, I also found that most participants were utilizing couple therapy to address both individual and relational concerns. Another finding within the data was that certain "best practices" that are often considered to be widely applied within couple and family therapy, for example, the no secrets policy, may not be a helpful intervention in its current form and may even add more stress to African American clients, because it requires that clients be ready to immediately share vulnerable information. Therapists may need to take time to discuss this and similar policies with their clients more thoroughly, allowing for deeper conversations about how they perceive these therapy processes. After following through with the participant to explore why they thought this could be an important consideration, participants stated that the therapist could consider ways to encourage more conversation about secrets and could put more emphasis on the importance of being communicative. The participants shared that disclosing may already shameful, and a therapist should be sensitive to unintentionally further shaming clients. The participants also shared that African Americans may not be comfortable with vulnerability in couple therapy, and therapists should be sensitive to the risk of disclosure. I found this to be novel information. 72 Another finding I found interesting was that African Americans examine their therapist's cultural attunement before the actual process of couple therapy begins. This may be in information such as advertised online or items in the therapist's office space. Most participants shared that they searched intentionally for a couple therapist of African descent, and this prerequisite was often for the comfortability of their partners. While participants shared having a therapist that looked like them was important, this was not a rigid preference, and some participants preferred clinicians who were interracial. All participants preferred a therapist that presented in a culturally attuned way. Limitations There are limitations to this study. This study is quite limited by the modality of the interview. None of the videos were carried out face-to-face, which could influence the researcher-participant relationship and influence how participants reflect on and share their experience of couple therapy. Another limitation of this study is the influence of researcher biases. With this study, large amounts of information were collected from the participants, given constraints, the study's results can be influenced by researcher biases. As an African American and couple therapist, I believe that many of the questions I asked were intended to provide counter narratives to how African Americans are understood in mental health settings and to enhance the level of care that African Americans receive by couple and family therapists. in a qualitative study (Creswell, 2014; Patton, 2002). Further, the individual circumstances that data is collected from cannot be generalized (Maxwell, 2013; Patton, 2002). Finally, there are limitations linked to credibility and reliability; or as Rudestam and Newton (2015) advise, it is the researcher's responsibility of convincing oneself and one's audience that the findings are 73 based on the critical investigation (p. 131). Patton (2002) argues there are no straightforward tests that can be applied for reliability and validity. Therefore, the researcher must do their best in the interview phase to present the data and communicate what the data reveal, given the purpose of the study (Patton, 2002, p. 433). Strengths of using asynchronous interview process are establishing rapport and honing in the details of the interview (Creswell, 2015; Jacobs & Furgerson, 2012; Rudestam & Newton, 2015). Face-to-face interviewing can monitor non-verbal cues and clarify ambiguous responses (Maxwell, 2013; Laureate Education, Inc., 2010). Getting the participants involved in the process can yield positive results and large amounts of rich data (Creswell, 2015; Maxwell, 2013). Interviewing is not a perfect method. First, enormous amounts of data are collected that will require analysis; this is time-consuming (Choy, 2014; Creswell, 2015). Next, interviewer influence can be a limitation which is why triangulation is needed to manage biases (Creswell, 2015). Lastly, participants can opt-out of the study, leaving one to scramble for additional participants (Jacobs & Furgerson, 2012; Patton, 2002; Rudestam & Newton, 2015). a qualitative study (Creswell, 2014; Patton, 2002). Further, the individual circumstances that data is collected cannot be generalized (Maxwell, 2013; Patton, 2002). Finally, there are limitations linked to credibility and reliability; or as Rudestam and Newton (2015) advise, it is the researcher's responsibility of convincing oneself and one's audience that the findings are based on the critical investigation (p. 131). Patton (2002) argues there are no straightforward tests that can be applied for reliability and validity. Therefore, the researcher must do their best in the interview phase to present the data and communicate what the data reveal, given the purpose of the study (Patton, 2002, p. 433). Another limitation of this study is that the results may not be generalizable. All the 74 participants in the study shared unique experiences that could have been useful concepts to explore in other interviews. The results may not have been replicated enough to reach saturation. I observed that each participant provided new information. Given the time constraints of the study, I suspect that if this study was replicated, the researcher may need to interview more than the sample population of this study. The participants were recruited online, and this may also exclude participants who are limited in their accessibility of technology. Also, all participants reported a positive experience in couple therapy. Interviewing participants who had negative experiences would shed a different light on the process. This study also did not have participants older than 50 years of age. This could limit the results. In this study, there were more female participants than male. Expanding the sample to include more African American men could expand the voice of African American experiences in couple therapy. Another limitation of this study is the recruitment strategy utilized to gain the data. Perhaps some individuals were hesitant to participate in the study because of stigmatized beliefs in participating in research or digital research, considering the history of cultural mistrust among providers and researchers. Many participants were excited to speak about their experiences in couple therapy; however, the recruitment took quite some time. One of the most common limitations with smaller studies is the number of participants and generalizability (Merriam, 2009). A large participant pool would allow saturation to occur and would possibly provide even more depth in the results regarding answers to the research question. Although the results offer descriptions of couple therapy's African American experiences, the results may not mirror the experiences of all African Americans in couple therapy. The interviews were the mode of data collection. Each participant only completed one 75 interview and interviews were approximately one hour, given time constraints. There is a possibility that even richer data would emerge with more interviews occurring or longer interviews. Also, self-reporting can be subject to bias from the interviewer and researcher. Recommendations for Future Research Participants in this study chose to continue to utilize both individual and couple therapy as a form of treatment or are open to beginning therapy again. This finding is interesting because it is not mirrored in the discourse and research on African Americans in mental health settings. It is notable that after a long traumatic history of abuse in healthcare settings, there is an emerging openness to receive care; this suggests possible shifts in cultural mistrust, at least with this group of participants. Although there are gender differences about African Americans' willingness to participate in couple therapy, there appears to be a willingness to participate in couple therapy amongst all the participants. Further phenomenology studies on this topic may illuminate more explanations on why there are gender differences in willingness to participate in couple therapy and across gender, the differences in experiences related to the studied phenomenon. Uncovering the influence of stigma and reasons for engagement (or lack of) in couple therapy will enhance the understanding of African Americans' willingness to participant in couple therapy and the various mechanisms that will enhance retention, particularly with this population. The participants that were studied were not limited to geographical location. It could be useful to collect data from participants specific to certain regions to uncover geographical specific attitudes that inform willingness to participant in couple therapy and actual experiences of African Americans participating in couple therapy; this will enhance the depth within the findings of this phenomenological research. 76 Recommendations for Clinical Practice One of the areas of consideration for couple therapists is the effect of vulnerability on individuals and couples. The participants disclosed that vulnerability could be difficult to display and requested debriefing at the end of sessions instead of an abrupt ending. This is directly related to the alliance's favor of safety. Many African Americans have a great deal to overcome as they enter therapy, including numerous barriers and stigma. Working on creating a supportive and safe environment where the therapist continually processes the couple's experience seems important. My study included both female and male participants. Almost all of the participants disclosed that stigma is a significant factor in their experience or their partner's experience in couple therapy. It is important for clinicians to recognize how stigma may influence African Americans in couple therapy behavior. In that same vein, a study examining the experience of stigma across therapy may provide insight into how to change stigmatized beliefs and enhance joining with this population. Clinically, therapists need to be overt in addressing stigma and fears about attending therapy. Another area of consideration for clinical practice would be considering the historical trauma of African Americans in mental health settings. The participants reflected that they are gauging their therapist’s competency and cultural attunement. These factors should be taken into consideration in office design, marketing efforts, joining, language use with clients, and clinical interventions. This phenomenological study demonstrates several key factors of consideration for clinicians and researchers in examining African Americans' experiences in couple therapy. Most approaches in working with the population are informed by interventions that are generalized to apply to this population but are assumptive. From a critical race theoretical perspective, this is 77 problematic, African Americans' experiences are distinct and influenced by oppressive societal structures. Hence, best practices within the field of couple and family therapy are oppressive if they are not cross-examined by research and practices considering the experiences of African Americans. Beneficial change can only happen through perspective shifts by educators, researchers, and clinicians moving to change this oppressive mental health system. Researchers must consider that interventions should not come as "one size fits all," and that African Americans indeed have unique experiences that may challenge the best practices of individuals working with this population in couple therapy. Conclusion Through this phenomenological study, I offered an in-depth analysis of African Americans' lived experiences in couple therapy through personal reflections. African Americans appreciate couple therapy because they appreciate learning various communication strategies to enhance their relational interactions. Despite the barriers that they navigated personally and relationally, these individuals chose couple therapy even in times when they perceived their relationships were beyond repair. They worked with providers who, at times, helped repair what seemed irreparable demand strategies to end a relationship while addressing significant communication issues, personal traumas, and significant life events. It is recommended that couple therapists consider these clients as willing to participate in couple therapy despite stigmatized beliefs, and couple therapists should place importance on debriefing when having vulnerable conversations. When working with African Americans in couple therapy, therapists may find themselves suspending some of the "universal" interventions. I hope that a couple therapist will consider this investigation done in good faith and consider these participants' experiences. 78 APPENDICES 79 APPENDIX A: Interview Guide 80 INTRODUCTION TO THE STUDY INTERVIEW GUIDE Thank you for choosing to participate in this study to share your perceptions of couple therapy. I look forward to hearing you share your experiences. By participating in this study you are promoting growth and understanding within the field of couple and family therapy. My name is Travis Johnson and I am currently enrolled to receive my doctorate in Couple and Family Therapy from Michigan State University. I obtained my Masters degree from Syracuse University, specializing in the field of Marriage and Family Therapy. I am fully licensed as a Marriage and Family Therapist. I am trained to work with individuals, couples, and families, in providing services tailored to meet each client’s unique needs. I am very excited to hear from you today. This interview will take approximately 50 minutes to complete. The interview will be taped and transcribed. All identifying information will be removed from the transcripts. All the information you provide us will be kept securely and only used for dissertation and research purposes. Your name will not be connected to the interview information. After the interview has been transcribed, I would like for you to be able to see the transcript and make any requests for revisions. In order to do so, I’ll need current contact information for you (Preferably email). Let’s discuss how the interview will transpire. I am interested in your experiences related to couple therapy. The interview will consist of you sharing your experiences. I will try to not get involved. I will only intercede for clarification or a request for elaboration. After the interview, I 81 will ask a few direct debriefing questions. I will take notes during the interview to track moments that need clarification. I will time the interview to try to keep as close to 50 minutes as possible. I suspect that discussing your experiences of therapy can bring up different emotions. If at any point you feel overwhelmed or would like to simply stop, we can suspend the interview temporarily or stop altogether. Any questions before we continue? QUESTIONS AND PROMPTS FOR THE INTERVIEW Questions Prompts for the interview 1. First, I want to understand about your experiences of couple therapy. I’d also like to hear from your point of view how you perceived your therapist, as well as, the productivity of the sessions. Next, I’d like to hear more about the decisions that you regarding using therapy as a form of treatment. I’m hoping to learn more about your impressions of couple therapy and what lead to your decision to go to couple’s therapy. I’d also like to know more about your perception of therapist and their fit for working with clients that are African American. I’m also hoping to learn about your selection process when choosing a couple therapist. 1) Tell me about your perception of your couple’s therapist. 2) Tell me about your experiences in couple’s therapy. 3) What do you remember most vividly about the experience? 4) Tell me about unproductive things that happened in therapy. 5) Tell me about the helpful moments in therapy. 1) Have you heard of other’s utilizing couple’s therapy? 2) Have you been treated in couple’s therapy more than once? 3) Tell me about how you chose to use couple’s therapy. 4) What do you feel contributed to your being in couple’s therapy? 1) How did you select your therapist? 2) Tell me how you met your therapist. 3) What restrictions did you experience in your relationship with the therapist? 4) What would you like to change about your therapist style? 5) How was the therapist helpful? 6) How was the therapist unhelpful? 82 7) Describe your relationship with your couple therapist during the time you were in therapy. 8) How did the therapist acknowledge ethnicity or race in therapy? 9) How did the therapist’s identity influence your experience of couple’s therapy? 10) How did your therapist demonstrate an understanding of your presenting concerns? to to 1) What do you feel would have helped your relationship while in couple’s therapy? 2) What do you think we should be doing to help African Americans in couple therapy? 3) What do you think we should doing be engage African Americans couple’s select therapy? 4) In what ways does the setting influence your experience of couple’s therapy? 5) Did the gender of the therapist play a role in your experience? 6) How did external factors play a role in your perception of therapy? 7) How did external factors play a role in your experience of therapy? 8) How did external factors play a role in your perception of the therapist? 9) Describe any barriers you experienced in the couple’s therapy process. Lastly, I am hoping to learn more about details of the experience that are important but not covered by the previous questions. I’m mostly trying to gauge if there are important details about your experience that you would like for providers to know. 83 DEBRIEFING STATEMENT AND QUESTIONS Thank you for taking the time to talk about your experiences in couple therapy. I think that it is brave to share experiences about such a vulnerable process. I have a few moment questions, I’d like to ask you. This statement will be followed by subsequent questions: a. What was it like discussing your experiences today? b. Is there anything you missed telling me or anything else you would like to talk about? c. Did you experience any discomfort while sharing your experiences that you would like for me to know. d. Do need to talk with a clinician alone or with your partner/spouse/family about any of the issues we talked about today? e. I can offer a list of providers that are resources and should be able to see you for a session within the next few weeks. If you need any support, please let me know. f. Thank you very much for taking the time to share your story. If it is alright with you, I would like to call you in a few weeks to follow-up with you. Can I have current contact information from you? 84 APPENDIX B: Flyer and Advertisement 85 Figure 1: Flyer and Advertisement: This figure shows the advertisement 86 APPENDIX C: Demographic Questionnaire 87 Demographic Questionnaire: Demographics Questionnaire Participant Code_____________ Directions: Please answer the following questions. Today’s Date: ________________________________________________________ Name: ______________________________________________________________ Phone Number: _______________________________________________________ Email Address: _______________________________________________________ How would you like to be contacted?:______________________________________ How did you learn about the study?:_______________________________________ Age:________________________________________________________________ Race/Ethnicity: _______________________________________________________ Gender: _____________________________________________________________ Highest level of education: ____ Middle School or younger ____ High School diploma or GED ____ Some College but did not finish ____ Two-year Degree/Associate’s Degree ____ Bachelor’s Degree ____ Master’s professional degree or higher 88 APPENDIX D: Informed Consent 89 Informed Consent Form: Informed Consent Research Participant Information and Consent Form Study Title: A phenomenological investigation of the experiences of African Americans in couple therapy Researcher and Title: Travis Johnson, Adrian Blow PhD (Primary) Department and Institution: Human Development and Family Studies, Michigan State University Contact Information: Travis Johnson, john3948@msu.edu, 315-313-5979 Sponsor: BRIEF SUMMARY You are being asked to participate in a research study. Researchers are required to provide a consent form to inform you about the research study, to convey that participation is voluntary, to explain risks and benefits of participation including why you might or might not want to participate, and to empower you to make an informed decision. You should feel free to discuss and ask the researchers any questions you may have. You are being asked to participate in a research study of the experiences of African Americans in couple therapy. Your participation in this study will take collectively about 120 minutes. (min., hours, wks., mos., or yrs.). You will be asked to describe your experiences of couple therapy. 90 The most likely risks of participating in this study are (re)experiencing difficult emotions. There are resources available to support you if difficult emotions emerge. You will not directly benefit from your participation in this study. However, your participation in this study may contribute to the understanding of African Americans in couple therapy (Ask Adrian about benefits) PURPOSE OF RESEARCH The purpose of this research study is to understand the subjective experiences of African Americans who have engaged in couple therapy with a licensed mental health practitioner. To expand cultural understanding of African Americans and competency in treatment, it is 91 imperative that practitioners and scholars understand the lived experiences of African Americans who engage in mental health care, including couple therapy. WHAT YOU WILL BE ASKED TO DO You have been asked to participate in an audio recorded semi-structured interviews with Travis Johnson. Each interview may last around 60 minutes depending on the depth of responses. Location: This research study will take place at 1550 Watertower Pl., Suite 100; or digitally via “Secure video.” Time required: We expect that you will be in this research study for approximately 4 months. You will be asked to participate in an audio recorded interview. Each interview should last approximately 60 minutes. These interviews will be conducted during a time that will be mutually agreed upon by the researcher and the participant. Audio recording: You will be audio recorded during this study. If you do not want to be audio recorded, you will not be able to be in the study. Discuss this with the researcher or a research team member. If you are audio recording, the recording will be kept in a locked, safe 92 place. The audio recording will be erased or destroyed a year after the completion of this research study. BENEFITS There are minimal direct benefits for taking part in this study, however your participation in the study may benefit the community by sharing information on an area that is often overlooked in research. POTENTIAL RISKS There are minimal risks or discomforts involved in taking part in this study. During the interviews, we will be discussing sensitive issues, like those you may be discussing with your mental health counselor. Interviews are not intended to cause anxiety; however, anxiety may result from interviews. If after the interview you need to discuss any of these issues further, please notify Travis Johnson for referrals. Travis Johnson is a licensed couple and family therapist and is available to discuss any concerns that may come up as a result of participation in this study. The main risk of this study is breach of confidentiality. In order to minimize risk, you will be asked how you 93 would like the researcher to contact you. To also minimize risk, information collected will be de- identified. PRIVACY AND CONFIDENTIALITY All physical data including, videotapes, audio recordings, collected data and identifying information, including signed consent forms, will be kept in a secure location with lock and key behind two secure barriers to enhance security. All digital information, including video and audio recordings, typed data, and materials will be kept on a computer. Digital information will be password protected on a computer with a secure account and firewall. Digital information may also be stored by password protected cloud storage. Research materials, including video and audio recording will be kept for up to two years after the interviews are completed before being destroyed. If the researcher leaves MSU, the storage of research materials and data will remain specific to MSU. We cannot promise complete anonymity. We will limit access to your personal data collected in this study to only people who have a need to review this information. We will not be sharing information about you to anyone outside of the research team. The information collected from this research project will be kept as private as possible. Any information about you will be deidentified and assigned a number. The information will also be locked up with lock and key. It will not be shared anyone except Travis Johnson and Adrian Blow Ph.D., and IRB board (if requested for review). The information collected in the study will be presented as research findings in a doctoral dissertation, for presentations at annual conferences for the American 94 Association for Marriage and Family Therapy and may be used for future research without anyone knowing it is information from the participant. YOUR RIGHTS TO PARTICIPATE, SAY NO, OR WITHDRAW You have the right to say no to participate in the research. You can stop at any time after it has already started. There will be no consequences if you stop and you will not be criticized. You will not lose any benefits that you normally receive. COSTS AND COMPENSATION FOR BEING IN THE STUDY For your participation in the study and time loss, you will receive a $40 Visa gift card. This will not be retrieved if the participant elects to prematurely stop their participation in the study. FUTURE RESEARCH Information that identifies you might be removed from the demographic information collected. After such removal, the information collected via interview could be used for future research 95 studies or distributed to another investigator for future research studies without additional informed consent from Travis Johnson or Adrian Blow, PhD. CONTACT INFORMATION If you have concerns or questions about this study, such as scientific issues, how to do any part of it, or to report an injury, please contact the researcher (Travis Johnson: 1550 Watertower Pl., Ste. 100, East Lansing, MI 48823, travisjohnsonlmft@gmail.com, 315-313-5979). OR Adrian Blow, PhD., Faculty Supervisor, College of Human Development and Family Studies of Michigan State University at 517-432-7092 or by email at blowa@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 4000 Collins Rd, Suite 136, Lansing, MI 48910. DOCUMENTATION OF INFORMED CONSENT. Your signature below means that you voluntarily agree to participate in this research study. 96 _______________________________ _____________________________ Signature Date _______________________________ _____________________________ Signature of Assenting Child (13-17; if appropriate) Date PERMISSION TO AUDIOTAPE OR VIDEOTAPE SUBJECTS I agree to allow audiotaping/videotaping of the interview. Yes No Initials____________ *You will be given a copy of this form to keep. * 97 REFERENCES 98 REFERENCES Abrams, L. S. , Dornig, K. , & Curran, L. ( 2009). Barriers to service use for postpartum depression symptoms among low-income ethnic minority mothers in the United States. Qualitative Health Research, 19, 535-551. Allgood, S. M., & Crane, D. R. (1991). Predicting marital therapy dropouts. Journal of Marital and Family Therapy, 17(1), 73–79. Alvidrez, J. ( 1999). 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