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. Author manuscript; available in PMC: 2016 Aug 1.
Published in final edited form as: Psychol Serv. 2015 Mar 30;12(3):330–338. doi: 10.1037/a0038702

African American and European American Veterans’ Perspectives on Receiving Mental Health Treatment

Frank Castro 1,2,3, Christopher G AhnAllen 4,5, Shannon Wiltsey-Stirman 1,2, Kristin Lester-Williams 1,6, Julie Klunk-Gillis 4, Alexandra M Dick 7, Patricia A Resick 1,8
PMCID: PMC4516607  NIHMSID: NIHMS673054  PMID: 25822316

Abstract

Little is known about client attitudes, especially Veterans’, toward the types of structured interventions that are increasingly being offered in public sector and VA mental health clinics, nor is the possible impact these attitudes may have on treatment engagement well understood. Previous work indicates that attitudes of African Americans and European Americans toward treatment may differ in important ways. Attitudes toward treatment have been a proposed explanation for lower treatment engagement and higher dropout rates among African Americans compared to European Americans. Yet to date, the relationship between race and attitudes toward treatment and treatment outcomes has been understudied, and findings inconclusive. The purpose of this study was to explore African American and European American Veteran attitudes toward mental health care, especially as they relate to structured treatments. Separate focus groups were conducted with 24 African American and 37 European American military Veterans. In general, both groups reported similar reasons to seek treatment and similar thoughts regarding the purpose of therapy. Differences emerged primarily regarding therapist preferences. In both groups, some participants expressed favorable opinions of structured treatments and others expressed negative views; treatment preferences did not appear to be influenced by race.

Keywords: Attitudes, Mental health treatment, Evidence-based practices, African Americans, Veterans

Recent advances in mental health interventions have yielded efficacious results in decreasing symptoms and improving quality of life. In spite of these advances, meta-analyses of clinical trials suggest that low levels of treatment engagement and premature termination remain serious barriers to effective treatment (Swift & Greenberg, 2012). A number of factors have been associated with lower levels of treatment engagement. For example, a recent meta-analysis found that dropout rate was moderated by client diagnosis, age, and education level, and provider experience level (Swift & Greenberg, 2012). Other studies have found additional variables associated with poor engagement such as lower socioeconomic status (SES; P. S. Wang et al., 2005; Wierzbicki & Pekarik, 1993) and minority status (Neighbors et al., 2007; J. Wang, 2007; P. S. Wang et al., 2005; Wierzbicki & Pekarik, 1993).

African Americans have received particular attention in the literature on treatment engagement because when compared with European Americans, they are less likely to seek psychotherapy, are more likely to terminate prematurely, and/or attend fewer sessions (Neighbors et al., 2007; J. Wang, 2007; P. S. Wang et al., 2005; Wierzbicki & Pekarik, 1993). For example, in a recent treatment outcome study for Cognitive Processing Therapy (CPT), a structured evidenced-based practice (EBP) for Posttraumatic Stress Disorder (PTSD), African American participants terminated treatment earlier and attended fewer sessions than European Americans (Lester, Resick, Young-Xu, & Artz, 2010). Despite this difference in treatment engagement, African American and European American treatment outcomes did not significantly differ, and in fact, African Americans exhibited a trend towards better outcomes on PTSD symptomatology. Although the Lester et al. (2010) study suggests that African Americans may be less likely to engage in or complete structured treatments such as CPT, it is not evident if this tendency is due to cultural factors, certain aspects of these types of interventions, general views about mental health treatment, experiences with their clinicians, or some combination therein.

A number of factors have been theorized to account for racial differences in treatment engagement including cultural issues and stigma regarding mental illness; attitudes toward treatment; and poor service provision (Ayalon & Alvidrez, 2007; R. Thompson et al., 2013; V. L. S. Thompson, Bazile, & Akbar, 2004). Researchers have also speculated that there may be a relationship between racial or ethnic minority status and style of therapy on treatment engagement. In particular, some researchers (Aisenberg, 2008; Hall, 2001) argue that because many EBPs, nearly all of which are structured or manualized interventions, have not been developed or adequately empirically tested with minority populations, they are not culturally sensitive, and therefore may not be appropriate for these persons without modification.

Others have argued that there has not been sufficient dissemination and evaluation of existing structured EBPs with minority populations to demonstrate the necessity for adaptation of treatment (Lau, 2006). Reviews of the evidence base suggest that EBPs are efficacious for these groups without modification (Huey & Polo, 2008; Miranda et al., 2005). Lau (2006) suggested that treatment adaptation may be merited in two cases: 1) if a problem arises only in a specified cultural context or 2) when an intervention is not socially valid, in which case a culturally unacceptable intervention will be associated with lower treatment engagement and higher attrition, therefore weakening efficacy of treatment. Although research findings in support of the second case are limited (Lau, 2006), a lack of cultural acceptability has been suggested as a possible explanation for the extant evidence for racial differences in EBP treatment engagement (Kendall & Sugarman, 1997; Lester et al., 2010).

As mental health clinics across the country implement EBPs, it is unclear what impact, if any, these interventions will have on treatment engagement among African Americans. This issue is important to understand especially now that a number of healthcare systems that are implementing EBPs on a large scale (McHugh & Barlow, 2010). The Veteran's Health Administration (VHA), the largest healthcare system in the United States (U.S. Department of Veterans Affairs, 2014), has begun implementing EBPs nationwide, providing trainings and requiring clinics to provide access to these treatments for Veterans with PTSD, major depressive disorder, and other disorders (Karlin et al., 2012; McHugh & Barlow, 2010). Approximately, 8.8 million Veterans used at least 1 VA benefit or service in FY2012 (U.S. Veterans Eligibility Trends and Statistics, National Center for Veterans Analysis and Statistics, 2012). Because African Americans make up approximately 12% of the Veteran population (U.S. Department of Veterans Affairs, 2012) and considering the lower rates at which African Americans seek public mental health services compared with European Americans (González et al., 2010; Neighbors et al., 2007), efforts to understand potential facilitators and barriers to engagement in EBPs for this population are warranted. In addition to issues related to race, there may be some barriers to seeking mental health care that are unique among military personnel and Veterans, in part related to the influence of military culture (Britt, Wright, & Moore, 2012; Hoge et al., 2004). Stigma may negatively impact help seeking among service members. During and even after active duty, it is possible that many service members are ambivalent about seeking mental health treatment due to negative stigma, believing that others (including leadership, peers, friends, and family) will think differently of them, will see them as weak, or blame them for their problems.

To explore the relationships amongst race, treatment engagement, and treatment preferences in a Veteran population, we conducted focus groups with African American and European Americans who received care in the VHA. We sought to investigate possible differences in treatment attitudes that might contribute to treatment engagement. This study represents an advancement of previous research by simultaneously studying African American and European American attitudes towards mental health treatment and examining Veteran consumers’ attitudes toward the structured forms of therapy offered through the VHA's EBP rollouts.

Methods

In the present study, we used a mixed methods research strategy to elicit an in-depth understanding of the relationships amongst race, treatment engagement and treatment preferences (Palinkas et al., 2011). To explore these relationships through qualitative research strategies, we conducted focus groups with African Americans and European Americans who received care in the VHA. To further inform our analyses and interpretation of the qualitative data, we used quantitative measures to assess the demographic and clinical characteristics of our sample and to determine whether the African American and European Participants differed in terms of their depression, alcohol use, life satisfaction and PTSD symptoms.

Participants

Participants were recruited through a variety of means, including flyers at three Boston-area VA hospitals, one Veteran Center, one VA community-based outpatient center, two local Veteran homeless shelters, internet postings (e.g., Craigslist), and the National Center for PTSD Behavioral Science Division recruitment database. Because we wished to oversample African American Veterans relative to the general population and population of Veterans in the area, we explicitly targeted African American Veterans in some of our recruitment materials. Prospective participants were screened by telephone by a member of the research team to determine eligibility. Inclusion criteria included: self-identifying as African or European American; self-identifying as being a male or female honorably discharged Veteran eligible for VHA services; and being a recipient of, considering, or having previously considered seeking mental health treatment. Our only exclusion criterion was significant cognitive impairment as evidenced by inability to understand and answer questions during the telephone screen. The study was approved by the VA Boston Healthcare System Institutional Review Board. Recruitment and focus groups were conducted during the fall of 2009.

Assessment Tools and Quantitative Analyses

Participants filled out demographic and clinical questionnaires to assess current mental health symptoms and service usage including mental health treatment history and lifetime number of therapy or medication management sessions. Demographic variables included race, age, gender, Veteran status, and military service era. Questionnaires included: Alcohol Use Disorders Identification Test (AUDIT; Babor, Biddle-Higgins, Saunders & Monteiro, 2001); Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 1996); Boston Life Satisfaction Inventory (BLSI; Smith, Niles, King, & King, 2001); and the PTSD Checklist – Specific Version (PCL-S; (Weathers, Litz, Herman, Huska, & Keane, 1993). We conducted t-tests and chi-square analyses to determine whether there were any demographic or diagnostic differences, or differences in treatment engagement between the African American and European American participants.

Focus Groups and Qualitative Analyses

An interview guide that included open-ended questions was designed by study personnel for the purposes of this study, with influence from the literature on prior explorations of race and treatment engagement (V. L. S. Thompson et al., 2004). Questions in the interview guide focused on the following areas: General Information; Personal/Individual & Structural/Institutional Factors; Stigma-related Factors, including Attitudes about Help-Seeking for Mental Health Problems and Preferences Regarding Psychosocial Treatment Strategies. Given the heterogeneity across EBPs, and because we did not expect focus group participants to be familiar with the term “evidence-based psychotherapies,” we decided to use the term “structured treatments.” Our description of these treatments and many of our probes focused on factors we believed participants would find salient to the EBPs being implemented in the VA. These included time-limited protocols, out-of-session assignments, psychoeducation, and pre-established goals and interventions for each session as opposed to more open-ended conversation. Sample questions and probes are shown in Table 1.

Given the researchers’ prior experience in conducting research and facilitating interviews/focus groups and working with African American and European American Veterans in both research and clinical contexts, their training and preparation for focus group facilitation in this study emphasized the exploration of issues of race and mental health treatment experiences through focus groups. The study team consulted the literature and identified readings on these topics. Meetings were then held to establish an approach and plan for conducting the groups. The facilitators developed and reviewed the list of questions and, potential follow-up probes. Informed by literature review, they discussed strategies to guide the focus groups and reviewed interview guides with other study personnel prior to beginning the focus groups.

A total of eight focus groups were conducted including four African American and four European American groups, with between five and nine participants attending each group. Groups were conducted with participants of the same race. Each focus group lasted approximately two hours, with 30 minutes dedicated to initiating the written informed consent process, signing informed consent forms, and completing demographic and clinical questionnaires. Focus group discussions were semi-structured and led by two VA clinical psychologists of the same race as the group members, one of each gender. Interviewer race was matched because we suspected participants might be more comfortable speaking with facilitators of the same race. Participants were given the opportunity to elaborate on issues that they considered particularly relevant or for which they expressed strong sentiments. Focus group participants were paid $50 for their participation at the end of the focus group. The discussions were digitally recorded and professionally transcribed. Focus groups were held until we achieved theoretical saturation, or the point at which no new themes or information emerged during the meetings.

The analytic strategy was developed to be appropriate for the exploratory nature of the study (Palinkas et al., 2011). Transcripts were analyzed in a multi-step process rooted in grounded theory, a research methodology that emphasizes the generation of theories from collected/observed data (Glaser & Strauss, 1967). Recordings were reviewed to ensure that the questions were asked consistently. Interviews were first coded to condense the data into analyzable units. Segments of text ranging from a phrase to several paragraphs were assigned codes on the basis of a priori themes (i.e., focus group questions) or by identifying emergent themes through open coding. Codes were assigned to describe connections among categories and between categories and subcategories (also known as axial coding). The final codebook consisted of 25 codes, which were categorized under 7 broad categories and included a list of themes and opinions associated with mental health treatment. Categories were derived by the research team after focus groups were conducted. Participants’ input on identification of the categories was not solicited because their participation in the study ended after their attendance in the focus group. Using the codebook and the computer program NVivo 2 (QSR), text segments were grouped into separate categories or nodes. Authors participated in the development of the codebook, two authors coded the data, and a third author audited their work, using a process of discussion to build consensus when disagreements emerged (c.f., Stewart et al., 2012; Brookman-Frazee et al., 2011). This study focused on key final themes directly related to mental health treatment; results of coding related to these final themes are reported in the present study.

Results

Demographics and Quantitative Surveys

One hundred twenty-nine individuals called in response to recruitment materials. Four individuals were excluded because they were not Veterans, three because they did not identify as Caucasian or African American, and four who had never considered or received mental health treatment. The remainder interested participants were invited to participate in focus groups, and 52% of those eligible attended a focus group. The remainder either opted not to participate, did not attend scheduled focus groups (typically after being scheduled for at least two different groups), or were unable to be scheduled. Descriptive data for participants are presented in Tables 2 and 3.

A total of 24 African American (8 female, 33%; age M = 52.38, SD = 9.28 years) Veterans and 37 European American Veterans (4 female, 11%, age M = 55.03, SD = 10.95 years) completed the study. Overall, the sample of Veterans in this study was similar in age (81% > 45 years of age) and gender distribution (87% male) to Veterans who received benefits or VHA services (Office of Policy and Planning, National Center for Veterans Analysis and Statistics, 2009). Contrary to expectations, participants did not differ by race on lifetime number of therapy or medication management sessions (t(58) = −1.12, p = .27; European American M = 8.74, SD = 2.40; African American M = 9.0, SD = 2.14), nor did they significantly differ on their mental health treatment use history (Table 2; χ2(1) = 2.41, p = .12). In addition, participants did not differ on their use of alcohol (AUDIT scores; t(57) = -.07, p = .95), level of depressed mood (BDI-II scores; t(59) = -.12, p = .91), overall life satisfaction (BLSI scores; t(55) = -.02, p = .99) or PTSD symptoms (PCL-S scores; Table 3; t(51) = .28, p =. 78). On average, participants presented with mild depressive symptoms and alcohol use, and PCL-S scores indicated that at least 40% of the participants would likely screen positive for PTSD in a VA PTSD specialty mental health clinic (U.S. Department of Veterans Affairs, 2011). Veteran participants reported their military service era to be mostly during the Vietnam and post-Vietnam era (Table 4).

Focus Group Findings

Seven primary final themes were identified after analysis of the interviews: when to seek treatment; purpose of therapy; therapist characteristics; impact of race; style of therapy; alternatives to treatment; and pragmatism. Our analysis confirmed that we achieved theoretical saturation, as no new final themes were identified in the final transcripts that were analyzed. The findings are organized into 2 broader categories: factors influencing the decision to seek treatment and therapist/therapy factors. Each of these final themes is described and discussed below with representative quotations. Where differences between the European American and African American groups were observed, they are noted after general findings that apply to both groups. Race is noted for final themes that emerged as more salient by one group.

Factors Influencing the Decision to Seek Treatment

When to seek treatment

Participants perceived mental health treatment as a last resort for their problems, to be used when they could no longer solve them on their own.

I know I don't seek help unless I'm in a lot of mental pain and anguish and trouble, and if I'm not in trouble, and I'm not feeling like that, I just keep going until I have to come in. I hardly ever come in on my own volition, because I'm just feeling bad that day. It takes a lot.

In addition to these reasons for seeking mental health assistance, European American participants mentioned three problem areas as reasons for seeing a therapist: isolating oneself; substance abuse; and suicidal ideation. European American participants spontaneously generated the problem areas. In contrast, African American participants did not identify additional common reasons for seeking treatment.

Purpose of therapy

When asked the purpose of therapy, the prevailing sentiment was that the function of mental health treatment is generally to improve one's life. This broad theme included goal setting, symptom management, or just having an outside perspective on one's difficulties. For some, therapy was described as a place to gain concrete skills to manage symptoms. “It's to learn a tool, the tools to effectively deal with the obstacles which life offers.” In addition, some respondents voiced the opinion that therapy is a place to gain insight into one's own mental processes.

Now, the therapy that I received, when I was in my initial throes of finding out about my alcoholism, the therapist, psychiatrist, psychologist, whatever it was, he let me examine, he gave me insight into examining myself, my directions, motives, and the feelings, so that I could, I was part of the cure. He let me rediscover a lot of things about myself, and that I found very interesting and very insightful. It was, it gave me something to work on, and discovery of oneself.

Conversely, other participants focused primarily on the interpersonal aspects of treatment, viewing therapy as a place to “vent” or gain social support in general, with much less discussion about self-exploration. These themes were expressed by both groups of participants.

Therapist/Therapy Factors

Therapist characteristics

Participants identified three therapist characteristics they felt influenced treatment: gender; interpersonal skills; and shared experience. Participants of both genders indicated a preference for female therapists.

. . .the reason I feel more comfortable with women, I think, is I can be myself. I don't have to be a macho [expletive], and I can tell them things that I would not tell a man. I mean, that's me.

However, while almost no participants stated a preference for a male therapist, some noted that they did not have a preference for therapist gender.

For me, when it comes to therapists, gender really doesn't matter...All I want is someone that can just respect me as a person in regards to my own personal decision as far as lifestyle. So the gender really doesn't matter for me.

While some European-American participants also expressed a preference for therapists with similar life experiences or who were at a similar stage in life, interestingly, participants did not mention seeking a therapist with prior military experience. Veterans in both racial groups expressed the belief that a therapist should be a good communicator, empathic, and trustworthy. Some suggested these qualities could override other traits or differences.

Impact of race

Beyond general life experiences, African American participants explicitly mentioned the role of race influencing the therapy experience. In particular, African American participants mentioned that some of their previous mental health providers lacked cultural sensitivity.

What I're seen is that, during my lifetime, I guess, that, you know, white therapists, so to speak, Ph.D. white doctors can't—they don't take note when they're being biased. They have no clue.

Other comments indicated that African Americans’ preference for racial matching may be related to past instances of clinician bias, rather than general attitudes about providers. Some suggested that racial differences could be overcome by therapist's ability and willingness to help.

See, it doesn't matter what the agenda are, what their race is; my thing is, are they really concerned about helping me with my issue? And how far would they go, you know, the distance that they would go to assist me, or into continuing to get the help that I need, and to give me all of what they have to assist me with? That's what I look at.

Issues of race were not discussed by European American participants.

Style of therapy

Participants were asked their thoughts about different types of psychosocial treatment modalities, including individual or group treatment, as well as structured versus more open-ended treatment. In general, participants did not state a particular preference for group or individual treatment. Contrary to the suggestion of Hall (2001), across both groups, participants expressed positive sentiments about structured or manualized treatment, and in some cases, negative opinions about less structured treatments. Cultural differences by race did not emerge in preferences for structured or unstructured treatments.

I don't like the open-ended thing. I think that it creates enough room where you can get off-task, and then you leave, and you're like, trying to figure out what the message was, or what you got, or where the work is, or what you're supposed to be doing. I think it's not a good direction for me.

Participants favoring structured treatments stated that they liked the order it provided, having a plan, the opportunity to set goals which could be broken into stages, taking action, and that it is concise and to the point. Some participants also indicated that they found homework useful.

While participants generally expressed positive views of structured treatments, some negative feelings about structure were apparent among some individuals in both groups. These participants expressed resistance to structure in general. They equated structured therapy with either the structure of school, growing up, being in the military, or work, and indicated structure is something to be rebelled against or put up with, not sought out and paid for in a therapeutic context. For example, one participant echoed a sentiment that structured treatment represented a type of pressure in which s/he was expected to perform.

Yeah, see, in therapy, though, I mean, for me, personally, absolutely not. I mean, I go to work every day. You can put the pressure on me there, because I know I got to perform, because you're paying me to do a certain job, and I understand that, but for me, just for me, even though it's for my mental health, to get me better, I'll put up a wall, and I'll walk out on you.

In both the African American and European American focus groups, among those who had negative opinions of structured treatments, participants expressed dislike for homework, either because it introduced a level of pressure into the therapy, or simply because they knew they wouldn't do it. Participants opposing structured treatment expressed a preference for more open ended treatment, in which a participant felt free to discuss events of the week, what was on their mind, and in which they felt really listened to.

Alternatives to treatment

African American participants endorsed a number of activities that they considered comparable to mental health treatment. Many of these interventions were forms of behavioral activation, such as socializing with peers, going on a vacation or exercising. Others were music, faith-based interventions, or other forms of social support. In contrast, European Americans mentioned fewer alternatives to treatment and had less to say about other strategies that they pursued.

Pragmatism

Some Veterans of both racial groups espoused a view of treatment focused on finding a provider who had their best interest in mind, and an intervention that would have the best chance of ameliorating their symptoms.

I'm not going to sit around and be picky, because you're not always going to get your first choice. You're not always going to have that perfect doctor, so you got to be able to follow your instincts and see if they know what they're talking about, and what they're saying relates to what's going on with you, and if it makes you feel better. And if it does, you run with it, you stick with it, and you get the help you need. If you don't, you go find somebody else.

African American participants did not have strong opinions about the race of the provider so long as they found the provider genuine and sincere. Similarly, European American participants were more interested in finding a treatment that helped them alleviate their problems.

Discussion

There is widespread concern that implementation of EBPs may further increase treatment disengagement among racial and ethnic minority clients. In our sample, European American and African Americans generally preferred or felt neutral about treatments that include structured elements that are common to EBPs. Contrary to Hall's (2001) suggestion, the prevalent opinion among both racial groups was openness to structured treatments, although some participants of both races did express negative opinions about structured interventions. The lack of differences between racial groups on their perspectives of psychotherapy supports research suggesting that it may not always be necessary to make systematic modifications to EBPs before offering them to minority populations, provided that they are delivered with cultural competence (Huey & Polo, 2008; Miranda et al., 2005). Our results suggest that therapists should not shy away from providing EBPs for fear that that they do not fit with clients’ worldview or goals. Instead, a direct conversation about the goals of treatment, a discussion of the different styles/types of treatment may promote treatment engagement and improve the fit between therapy type and the client's preferences and goals. The impact of such a discussion on treatment engagement needs to be studied further.

Findings regarding preferences for therapists are consistent with previous studies that have found African Americans to be more likely to prefer racial matching between patient and therapist (Chang & Yoon, 2011), and more likely to terminate prematurely when matched with a European American therapist (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Issues of race did not appear to be salient for European Americans, perhaps because the preponderance of mental health providers in the United States are European American (APA, 2009). In the absence of concerns about racial matching, these persons may focus more on other clinician variables, such as the clinician's gender or age, when forming a relationship with their provider. Given the finding that some people prefer client-to-therapist racial matching, it may be useful to inquire about a persons’ past experience in therapy, in particular around racial matching. If the negative opinion is connected to past experience, it may be useful to discuss the experience along with possible ways to address the issue in the present situation. However, in light of mixed opinions about therapists engaging in conversations about racial matching (Thompson et al., 2004), efforts to train culturally competent therapists should include consciousness-raising and preparation in addressing racial dynamics (Chang & Yoon, 2011) to facilitate the initiation of potentially sensitive discussions with people in therapy to foster engagement.

Our findings regarding racial differences in endorsement of alternatives to psychotherapy align with findings that African Americans place greater importance on alternative treatments to mental health care (Woodward et al., 2008) or other forms of coping (Conner et al., 2010). Higher use of treatment alternatives among African Americans, combined with the finding that all participants viewed treatment as a last resort, suggest a possible explanation for lower levels of engagement among African Americans. In this study, African Americans did not discuss how they came to use alternative treatments, however, one possibility raised in previous literature is that such alternatives are developed in response to barriers to treatment, such as negative mental health stigma, provider mistrust, economic issues, or poor health care access (Ayalon & Alvidrez, 2007; Thompson et al, 2013).

Willingness to engage in alternatives to therapy may imply the potential for a positive experience with treatments that emphasize behavioral activation and the development of coping skills that can be used outside of therapy. However, if African Americans consider alternatives equally viable to mental health treatment, they may remain in treatment as long as necessary to gain mastery and use the tools on their own, regardless of the length of a manualized treatment protocol (Lester et al., 2010). In fact, more recent research on variable length CPT for PTSD suggests that many individuals may not need the originally specified number of CPT sessions to achieve good end state functioning (Galovski, Blain, Mott, Elwood, & Houle, 2012).

In light of the need to engage and effectively treat the population of returning Veterans (Stecker & Fortney, 2011), the focus on Veterans is a strength of the present study. The sample included Veterans of various service eras, including Veterans who served in Iraq and Afghanistan and an oversampling of African Americans (39% of study sample). Because challenges in recruitment of minorities can lead to underrepresentation of minorities in research, we used strategies to help increase minority recruitment (i.e, recruiting in racially and ethnically diverse areas and use of diverse research staff). We were concerned that without adequate African American representation, we may miss relevant findings unique to this group. Additionally, the inclusion of some participants who had chosen not to seek mental health treatment, or who received their care outside of the VA, provides unique perspectives on mental health care among Veterans.

Limitations of the current study should also be noted. Difficulties in scheduling nearly half of those who expressed interest and were eligible for participation resulted in a somewhat low response rate. We have no way of comparing those who participated in interviews with those who did not, and no way of knowing if views expressed by this sample are representative of those of the broader Veteran population. Participants in this study were largely male Veterans who tended to be in their forties and fifties, and most had some prior experience with mental health treatment. Future studies should include a larger sample with a broader age range, particularly younger Veterans returning from recent conflicts, greater inclusion of female participants, and those with no experience with mental health treatment. The focus on Veterans who had at least considered mental health treatment may limit the extent to which these findings generalize to other populations and individuals who would not even consider seeking treatment. Additionally, although we described common elements of EBPs in our questions about structured treatments and participant responses were based on their experiences of the structured treatments they received a the VA where many EBPs have been implemented, we cannot be certain that they would have endorsed the same attitudes if they had been asked directly about EBPs. While they may not have been familiar with the term or definition, they might have responded differently to questions about treatments that are “evidence-based.” Additionally, future research is needed to explore whether there exist racial differences regarding the fit or effectiveness of specific EBPs.

Overall, the present results suggest that among African Americans, Veterans’ use of a broader array of coping strategies, past experience with clinicians of a different race, and additional therapist interpersonal factors may influence attitudes toward treatment, and consequently, may have greater impact on treatment engagement than their attitudes towards structured treatments. Thus, this study is relevant to the growing body of research integrating evidenced-based practices and multiculturalism (Morales & Norcross, 2010) and the call for increased inclusion of ethnic minorities in research using EBPs (Aisenberg, 2008; Hall, 2001). Future studies would do well to continue to explore the connection between racial differences in perspectives on therapy and treatment dropout. In addition, the field would benefit from more research examining mental health clinician behaviors and attitudes as predictors of treatment outcomes, and on the attitudes and interventions that are most likely to enhance therapeutic rapport and engagement. Although our findings did not suggest racial differences in preferences for structured treatments, oversampling African Americans in future psychotherapy outcome studies and assessing attitudes and satisfaction with treatment will facilitate greater understanding of African Americans’ engagement in and response to different psychotherapies and EBPs.

Table 1.

Sample Focus Group Probes on Attitudes Towards Mental Healthcare

Category Probe/Question
Personal/Individual & Structural/Institutional Factors 1. What factors influenced your decision about whether or not to use mental health care?
2. If you were to seek mental health treatment, what style of treatment would you prefer? (e.g., time, limited, structured sessions that focus on specific problem areas and intervention with practice assignments to do in your own time, or supportive treatment where your therapist allows you to take the lead in sessions)
3. How would you feel about a structured treatment that focused on specific problems and allowed you to practice new skills between sessions?
Stigma-related Factors 4. If you were to have a mental health problem (e.g., PTSD, depression, substance abuse), would you seek mental health care? Why or why not?
    A. Attitudes about Help-Seeking for Mental Health Problems
5. When should mental health care be considered? What types of problems require mental health treatment?
6. In what ways have you coped with emotional problems other than receiving psychotherapy?
7. Does race or ethnicity matter in the selection of a therapist? If so, how?
    B. Negative Evaluations for Seeking Care 8. What do you think others would think about you if they knew you had a mental health problem?
9. What do you think they would think of you if they knew you were seeking care for mental health problems (such as PTSD, depression, substance use problems)?
10. Are there certain mental health problems for which you would feel more comfortable seeking care than others?
11. Do you believe there is stigma associated with using mental health care? In other words, do you think that you would be perceived negatively for seeking mental health care? Why or why not?
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Table 2.

Mental Health Treatment History

Treatment Provider Type African Americans European Americans
Total % Total %
No Treatment 5 21 3 8
VHA 9 37.5 20 54
Non-VHA 3 12.5 3 8
VHA and Non-VHA 7 29 11 30
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Note. VHA = Veteran's Health Administration. Treatment included therapy or medication management.

Table 3.

Mental Health Measures

Variable African Americans (n = 24, 8 female) European Americans (n = 37, 4 female)
Mean SD Mean SD p value
Age 52.38 9.28 55.03 10.95 0.33
AUDIT Total 5.00 6.95 4.86 7.91 0.95
BDI-II Total 17.96 12.00 17.59 11.70 0.91
BLSI Total 106.36 28.21 106.20 32.57 0.98
PCL-S Total 46.59 20.01 47.94 14.82 0.78
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Note. AUDIT = Alcohol Use Disorders Identification Test; BDI-II = Beck Depression Inventory-II; BLSI = Boston Life Satisfaction Inventory; PCL-S == PTSD Checklist – Stressor Specific Version.

Table 4.

Service Era

Service Era African Americans European Americans
Total % Total %
Pre-Korean War -- -- 1 2%
Korean War -- -- 2 5%
Between Korean and Vietnam Wars -- -- 2 5%
Vietnam War 9 36% 16 38%
Post-Vietnam War 9 36% 12 29%
Persian Gulf War 3 12% 3 7%
Operation Iraqi Freedom 1 4% 3 7%
Operation Enduring Freedom 1 4% 1 2%
Other 2 8% 2 5%
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Note: 7 participants checked more than one service era. These numbers include double entries.

Acknowledgements

The preparation of this article was funded in part by National Institute of Mental Health grant T32MH019836 and NIMH R00 MH 018100

Footnotes

Disclosures: None for any author

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