In the Company of my Sisters: Sister Circles As An Anxiety Intervention For Professional African American Women

INTRODUCTION

Little information is available about the mental health needs of professional African American women (Jones & Shorter-Gooden, 2003; Neal-Barnett, 2003; Neal-Barnett et al., in press). The vast majority of published research focuses on low-income and working class African American women. Yet, the ranks of professional Black women are growing and the available data indicate their mental health needs are going untreated (Brown & Keith, 2003; Goforth, 2005; Jones & Shorter-Gooden, 2003; Neal-Barnett, 2003; Neal-Barnett et al., in press).

Recognizing that many professional African American women seek help from sources other than mental health providers (Brown & Keith, 2003), experts trained in areas other than mental health such as life coaches and spiritual counselors have stepped in to bridge the gap. A proliferation of corporate-sponsored professional African American women retreats and leadership summits have also emerged as a way to address this population’s emotional needs (Essence, 2008; Women of Color Foundation, 2010).

Whereas seminars on managing stress and living single almost always appear to be included, seminars focusing on mental health issues such as anxiety, fear, and depression are rarely on the agenda. However, mental health issues arise in a variety of contexts at professional development meetings of African-American women. These topics are voiced in sessions focusing on career advancement, on balancing career and family, as well as during informal conversations at meals and other social gatherings (Neal-Barnett, 2003).

In these settings, women express their reluctance to utilize employer-sponsored assistance programs or to seek the assistance of mental health professionals. They describe situations in which they have “anxiety attacks” in a variety of work and social environments. Their verbal descriptions are consistent with the clinical definition of panic attacks.

Panic attacks are among the most prevalent form of anxiety experienced by professional African American women. In any given year, over 100,000 African American women will experience their first panic attack (Brown & Keith, 2003). Lack of knowledge about the phenomenon combined with reluctance to seek help, results in many African American professional women viewing panic attacks as something they must “live with.”

Sister circles are support groups that draw upon the strength and courage found in African American women’s friendship networks. Originating within the Black church and the Black women’s club movement, numerous African American organizations have used sister circles with varying degrees of success to raise awareness about physical health (Black Women’s Health Imperative, 2000; Neal-Barnett, 2003). The possibility exists that if embedded within the professional African American female community, sister circles may provide a viable way to educate this population about panic attacks and teach strategies that will lessen the number, intensity, and impact panic attacks have on their lives.

Using a mixed method design, in this paper we examine professional Black women’s conceptualization of panic attacks and other related anxiety issues. Then, we explore the feasibility of sister circles as a psycho-educational anxiety intervention for African American professional women. Specifically, we generate information regarding the key content and research components of a sister circle for Black female professionals.

METHOD

Participants

Four focus groups consisting of a total of 37 professional African American women were conducted. For the purpose of this study, professional was defined as having or working towards an undergraduate degree or holding a professional certification. Participants were recruited from attendees at three Women of Color Retreats sponsored by the Women of Color Foundation. This mid-western based organization fosters networking and provides personal and professional development, education and training to professional women of color. Focus groups were embedded in the Women of Color Retreat program and the research opportunity was included in pre-event publicity. A recruitment table was placed in the vendor area to maximize traffic. During each retreat, a member of the research team and a community advisory board member staffed the table to answer questions and register participants. Potential focus group (FG) participants indicated their willingness by initialing the sign-up sheet. Attendees who visited the table but did not sign-up (N=81) completed a short demographic form and identified a reason for non-participation. Demographic data from the FG participants and non-participants are found in Table 1. Written consent was obtained in accordance with the Kent State Institutional Review Board procedures.

Table 1.

Focus Group Participants and Non-Participants Demographics.

Focus Group Participants (n = 37)*				Non-Participants (n = 81)
Age Range		n	%	n	%
21–29 years		3	8.1	6	7.5
30–39 years		6	16.2	21	26.3
40–49 years		14	37.8	23	28.8
50–59 years		7	18.9	24	30.0
60+ years		6	16.2	6	7.5
Not reported		1	2.7	0	0.0
Education		n	%	n	%
Some college		10	27.0	22	27.5
College degree		9	24.3	27	33.8
Some grad school		1	2.7	4	5.0
Graduate degree		12	32.4	24	30.0
Professional certification		6	16.2	6	7.5
Marital Status	n	%		n	%
Single		11	29.7	26	32.5
Divorced		7	18.9	23	28.8
Separated		0	0.0	2	2.5
Married		17	45.9	24	30.0
Widowed		2	5.4	5	6.3
Occupation		n	%	n	%
Business owner		12	32.4	17	21.3
Administrative/Managerial		9	24.3	34	42.5
Technical/Clerical/Sales		2	5.4	10	12.5
Other		14	37.9	19	23.8
Experienced difficulties with anxiety?
Yes	25	67.6		51	63.8
No	12	32.4		29	36.3
Sought help for anxiety-related difficulties?
Yes	12	33.3		31	39.0
No	25	67.6		49	61.0

^*For some items, respondents selected more than one choice or no choice selected

Procedure

The FG protocol was developed by the academic and community research team using the protocol recommended by Morgan, Krueger and King (1998). Six categories of questions were developed icebreakers, transitions, introductory, key, ending and closure. Questions in the key category centered on sister circles and perceptions of anxiety and panic. Each participant was given a paper 8 in x 8 in booklet with one question per page and asked to provide written answers.¹ Responses were then discussed.

Each focus group was led by an African American female licensed psychologist assisted by a member of the community advisory Board. Using the focus group protocol, each facilitator guided the group through the questions. A seating chart was kept. For transcription purposes, the groups were audio and videotaped. During the focus group, the community advisory board member took notes. At the conclusion, the notes were summarized for the entire group. For their participation, the women received a Sisters Offering Support bookmark.

An African American female licensed psychologist familiar with the culture and idiom of professional African American women and blind to the study’s purpose transcribed the audio and videotapes. To analyze the focus group responses, three coders were utilized. One coder was the lead author (African American woman), another a Ph.D counselor (African American woman), and the third a MPH and psychology doctoral student Caucasian woman). The analysis process was supervised by an Ed. D statistical consultant (Caucasian male) with expertise in qualitative analyses.

A coding form was developed to assess each interview question for each of the four groups. Coders read the four transcripts and categorized responses into one of three categories: a) a major theme; b) a minor theme; or c) an off-topic comment. Coders were also asked to included quotes that helped define the identified themes. In addition, coders determined if the identified themes related to either of the primary research questions: whether sister circles were feasible and could sister circles serve as a psycho-educational intervention.

The analysis process commenced with an organizational meeting at which guidelines for coding and the overall process were discussed and finalized. Transcripts and coding forms were distributed to coders in both electronic and hard copy forms. Coders initially analyzed two interview sections for one focus group. The completed coding forms were sent to the supervisor who combined the three coder forms into a composite. At a second meeting, the composite was discussed with the intention that all coders were completing their analysis in a similar fashion. All coder questions were answered and once all coders had demonstrated agreement concerning the process, the coders completed their independent analysis of all four focus groups on their own. As with the preliminary coding, completed coding forms for each focus group was sent to the coding supervisor. A composite form for each focus group, sharing verbatim theme and off-topic entries from each coder, was developed. At subsequent coder meetings, the coders reviewed the composites and discussed any differences in their coding. Ultimately, the themes that emerged were the consensus of the three coders. The supervisor prepared a summary of the coder consensus themes, which, was shared with the coders for final confirmation. After two modifications, all coders were in agreement that the final themes were correct. To further check reliability of the coding process, a fourth person (African American woman) coded a randomly selected focus group. The agreement in the themes identified between the reliability coder and the coder group was 80%.

RESULTS

A comparison between the participants and the non-participants on age, highest level of education, occupation, and marital status indicated the two groups were similar. Particularly important was the similarity in anxiety background. Contingency Table Chi Square analysis indicated that the anxiety background experience of participants and non-participants was minimally different as both X² values were less than 1.0. Therefore, it appears that our sample was not different from the population of professional African American women invited to participate. Most women (65%) who declined participation did so because the meeting time for the focus groups was not convenient.

The Focus Group Experience

When asked to evaluate their focus group experience, most participants rated it as “very positive” (M = 9.0, SD = 1.2). A higher positive response (M = 9.3, SD = 1.0) was given when asked if the participants felt they had been able to share their ideas and suggestions. The majority(88.2%) said “Yes” to future participation, the remaining(11.8 %) said “Maybe.”

Professional Black Women’s Perceptions of Panic and Anxiety

Participants were asked how they defined the terms “anxiety” “anxiety attack” and “panic attacks.” Table 2 presents a summary of the major themes that emerged. Anxiety and panic attacks were characterized by physical symptoms/reactions, as well as overwhelming fear and emotions. A number of other responses emerged within individual groups.

Table 2.

Major emergent themes concerning anxiety and panic attacks.

Anxiety & Panic Attacks

The mental health issues facing African American women are: a) stress; b) anxiety; and c) depression.

African-American women are overworked and expected to uphold the household chores/responsibilities.

Anxiety and panic attacks are characterized by physical symptoms/reactions, including overwhelming fear and emotions.

Panic attacks involve physical responses and immobilization.

Anxiety and panic are not the same things.

Panic attacks are not prevalent.

Causes for anxiety and/or panic attacks include: expectations, lack of support, pressure and insecurities.

Avoidance seemed to be the major way to manage anxiety and/or panic attacks. Other strategies mentioned included social support and prayer.

Barriers to management included: masking, unhealthy or poor coping strategies, self-medication, cover-up, and denial.

Mental and physical health problems were seen as the short-term and long-term effects of anxiety or panic attacks.

Challenges to seeking help or support were seen as primarily dealing with the stigma attached when one seeks help. Also expressed were concerns for confidentiality and the lack of resources (e.g., insurance) information/knowledge. A variety of additional challenges were expressed by individual groups including pride, time and denial.

Emergent Themes concerning Sister Circle Feasibility

Programs or services to which professional women might be open were support groups (including “sister circles”) such as at church and/or the community.

One major concern for the Sister circle idea was confidentiality.

Two groups saw the endeavor as “natural” for African American women and validation for professionalism.

Some resistance to doing homework was expressed.

Two groups expressed the need for multiple recording and reporting.

Concern for the amount of time being taken by the focus group process was expressed. This concern for time was expressed frequently, by all groups, to different questions.

The stigma associated with seeking treatment for mental health was a strong concern.

Keep sister circles warm and informal, using various advertising methods, and produce results. A relaxed environment was suggested.

Need to provide empathetic facilitators who care.

What will keep women attending the sister circle includes the atmosphere, having a positive experience and seeing results.

Limit the group size and provide refreshments.

Two focus groups validated the concept of the Sister circle approach and the need to get involved and share “your story.” Commitment is needed.

“I see that a little differently. I see it like anxiety attack is, is like a real low level. When I read panic attack, I just think of somebody that’s way up here as, as opposed to having some anxiety about an issue. When I think of panic, I just think out of control, immobilized that kind of thing.”

When soliciting definitions from the focus groups, one group agreed that the definition provided in the focus group booklet, that is, “Panic attacks are the sudden onset of intense anxiety, characterized by feelings of intense fear and apprehension accompanied by palpitations, shortness of breath, sweating and trembling.” Two groups provided extensions of the definition and saw a panic attack as a person “being immobilized.” The fourth group also stressed the difference between anxiety and panic. Interestingly, the groups did not perceive panic attack as prevalent among African American women, as demonstrated by the following:

“Well, I would say one or two [panic attacks experienced] because the only women that I’ve known who have had panic attacks have not been African American women”

When asked what causes anxiety and panic attacks in professional African American women, a variety of responses emerged. Causes identified included expectations, lack of support, pressure and insecurities.

“I think another reason it is because we don’t use our support systems. Or we don’t have really good support systems in our lives, so everything is dependent upon us to do it or get it done. Or we don’t delegate, which is something we don’t do a lot.”

Women judged the long-term effects of panic attacks and anxiety to be mental and physical health decrements. At least nine of the participants indicated they had experienced a panic attack; four others reported witnessing a panic attack.

Feasibility of Sister Circles

A primary aim of the focus group process was to examine the feasibility of sister circles as a psycho-educational intervention for African American professional women. As seen in Table 2, a variety of questions posed to the focus groups generated responses that provide qualitative data that support feasibility. Specific suggestions concerning aspects of making a sister circle successful were offered.

When asked about the types of programs/services African American women might need to help cope with anxiety and panic attacks, community and church “support groups” were frequent responses by participants in the focus groups. One focus group even used the term “sister circle” in their response

“The sister circle that I mentioned, I wasn’t just speaking in terms of sister friends um there’s a meeting tonight and I’ve been apart of it for eight years where um sister circle meets on the first and third Monday of the month, every month and there’s approximately twenty-five women that participate on a regular basis um, it’s seventy-five women but you know, they just come and go. But, those kind of forums where we talk freely like this and we um establish the un-guarded rule where I can say whatever I feel like saying and it doesn’t go out of this circle and if it’s heard that it has and you said it, then you’re not invited back. So that allows people to feel like they can let their guard down and share freely. And so, things like that are important.”

A consistently reported challenge to seeking help was the “stigma” others attached to a help seeking process especially for professionals. Women agreed that there is a stigma attached to seeking mental health services and this stigma may be intensified for professional women.

“There’s some people that can allowed, that you allowed to be transparent but when you’re a leader in, in, in a community, um a lot of times um, um, um a weakness will destroy your credibility as a, a leader”

Sister circles however, were seen as having less stigma because they are perceived as a “natural” endeavors for African American females.

“I like the concept because to me it mirrors what I’m trying to do and that is provide a forum for women of color and that in this case is, more specifically African-Americans to share experiences often. Like this is meaningful to me because it’s the same thing, I’m not the only one in the room having panic attacks or feeling overwhelmed you hit it on the head for me, like wow, that’s exactly what I felt like.”

For a sister circle to be successful, a number of requirements were expressed by focus groups. The most prevalent were that the sister circle be confidential and that time was an important concern.

“And I would be um, you mentioned a good word, confidentiality. You would want to know that it was a confidential setting.”

Some resistance to doing “homework” as part of the sister circle intervention was stated.

“Cause when you give someone homework, that’s like a task, they’re supposed to perform that’s going to add more stress.”

Ninety-one percent of the FG participants felt the sister circle size should be between 5 and 10 members. Two groups validated the concept of the sister circle approach and the need to get involved and share “your story.” Two groups did not have the opportunity to answer the question

Sister Circles as a Psycho-Educational Intervention

A sub-goal for the focus group process was to generate information regarding the theory that sister circles would work as a psycho-educational intervention for African American women. Focus group participants expressed confidence in the potential effectiveness of sister circles a way to deal with anxiety and panic attacks. Participants viewed sister circles as an outgrowth of existing relationships with other professional women at work or church. One group saw sister circles as a natural form of engagement

“I just had a question. Well, whether or not it’s informal or formal? Just because I have, I think I have friends that I treat, I think we kind of do this thing but it’s an informal.” “Church groups, like a church type, you know. Some type of church program or retreat type program”

When asked how effective participants viewed sister circles’ potential in assisting women with managing anxiety and panic attacks, the group’s response was quite positive (M = 8.8, SS = 1.5).

DISCUSSION

The focus groups underscore the need for anxiety interventions tailored to the needs and concerns of professional African American women. Most participants saw themselves as leaders, balancing multiple roles, and as strong black women. But as more than one focus group member pointed out, the qualities that make professional Black women strong also make them anxious.

“I think a lot of those things that we said that we admire about African-American women are those same things that lead to it”

Whereas many acknowledge that Black women experienced anxiety, the perception existed that the number of African American women who experienced panic attacks was low. The focus group discussion about anxiety and panic attacks highlighted the need for information and education about panic and anxiety for this population.

Overall, sister circles were seen as feasible interventions for African American professional women. Sister circles were viewed, as a natural part of one’s live. Confidentiality, a supportive atmosphere and a positive experience were key to a successful sister circle interventions.

The data from the focus groups were used to enhance a sister circle intervention for anxious professional African American women. Data from the intervention will be available within the next 12 months.