Latasha Ellis dissertation

The Institute for Clinical Social Work

Culture into Practice: African American Doctor-Patient Dyad

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Latasha Ellis

Chicago, Illinois 2020

Copyright © 2020 by Latasha M. Quailes Ellis All rights reserved

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Abstract

This qualitative study explored the lived experience of African American General Practitioners (AAGP) and their treatment of depression in African American (AA) patients. Six AAGPs were interviewed utilizing the Interpretive Phenomenological Analysis (IPA) methodological framework. Data revealed insight into the role of race and culture, challenges and treatment options that impact depression care for this AA patients.

Three subordinate themes emerged from the data including: More Than a Physician, Culture into Practice, and I was Trying to Help. Findings of the study were interpreted through the lens of relational theory and relational cultural theory (RCT). The study provides clinical social workers with insight into the same race doctor- patient dyad from the AAGPs perspective and highlights opportunities for clinical social workers to educate and support this group of healthcare professionals.

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For Joyce, Malik, and Antonio

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There is no greater agony than bearing an untold story inside you. ~Maya Angelou

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Acknowledgements

With gratitude, I would like to honor those who have been instrumental in my professional growth and development in the final stage of my academic journey at Institute for Clinical Social Work. To my Dissertation Chair, Dr. Denise Duval Tsioles, who provided gentle encouragement, clear and concise feedback, and all-around support that I needed in a leader; I could not have done this without you. To Dr. James Lampe, who guided me along the path to methodological victory; I am grateful for your research expertise and your insightful input. To Constance Goldberg, whose calming presence provided unspeakable inspiration to the theoretical underpinnings of my research. To my readers, Paula Ammerman and Karen Daiter, who provided thought provoking question and alternate perspectives along my path to success.

LQE

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Table of Contents

Page Abstract………………………………………………………………………………… iii Acknowledgments…………………………………………………………………….... vi List of Tables………………………………………………………………………..…... x List of Abbreviations........................................................................................................xi Chapter I.

Introduction……………………………………………………………………... 1 General Statement of the Purpose Significance for Clinical Social Work Statement of the Problem Research Questions Theoretical and Operational Definitions Statement of Assumptions Foregoing

II.

Literature Review…………………………………………………………….11 African American Beliefs and Barriers to Help-Seeking Depression in Primary Care Relational Theory vii

Table of Contents—Continued Chapter III.

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Methodology…………………………………………………………………… 26 Major Approach/Research Questions Research Sample Research Design Data Collection Data Analysis Ethical Considerations Issues of Trustworthiness Role and Background of the Researcher

IV.

Results………………………………………………………………………….. 45 Study Participants Interviews Being an African American Physician AAGP’s Role in the Lives of AA Patients Impact on sense of self Integrated Care Culture and its Impact on Treatment Summary of Results

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Table of Contents—Continued Chapter V.

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Findings and Implications…………………………………………………….. 97 Theoretical Lens Findings Sub-ordinate Theme I: More Than a Provider Sub-ordinate Theme II: Culture into Practice Sub-ordinate Theme III: I was Trying to Help Conclusion Validity and Limitations of the Study Implications for Clinical Social Work Practice Suggestions for Further Research

Appendices A. Study Flyer………………………...…………………..……….…………. 127 B. Phone Interview Script………………………………………….……….. 129 C. Individual Consent for Participation………………..…………….……. 131 D. Sample Interview Questions………………………………………..……. 135 References…………………………………………………..………………… 138

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List of Tables

Table

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1. Research Participants.............................................................................................46 2. Themes...................................................................................................................99

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List of Abbreviations

AA

African American

AAGP

African American General Practitioner

ASC

Ambulatory Surgical Center

CIHS

Center of Integrated Health Solutions

CMS

Center for Medicare and Medicaid Services

COPD

Chronic Obstructive Pulmonary Disease

HRSA

Health Resources and Service Administration

IPA

Interpretive Phenomenological Approach

PCMH

Patient Centered Medical Home

PCP

Primary Care Physician

RCT

Relational Cultural Theory

SAMHSA

Substance Abuse and Mental Health Service Administration

SNF

Skilled Nursing Facility

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Chapter 1

Introduction

General Statement of Purpose The purpose of this phenomenological study is to expand the body of knowledge related to the experience of African American General Physicians (AAGP) who treat depression in same race patients. Depression is a significant healthcare issue and disparities in care persist for African Americans. General practitioners play a vital role in coordinating patient care throughout the treatment continuum. This study explores the subjective experience of AAGP who treat depression in African American (AA) patients.

Specifically, it will examine how AAGP understand their relationship with and role in treating African American patients with depression, if and how race is involved, the factors that impact treatment, and the AAGP’ sense of themselves.

Significance for Clinical Social Work This study will provide information to expand the knowledge base in the Social Work field and highlight the collaboration between primary care and behavioral health.

This investigation will help social workers understand how AAGP experience their role in the collaboration model when treating African American patients with depression. The

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American Medical Association (2012) noted, “Effective October 14, 2011, Medicare began covering annual depression screenings for adults in primary care settings to assure an accurate diagnosis, effective treatment, and follow-up” (p. 2). Integrated healthcare models support the alliance of physical and emotional health components as an essential part of overall quality of patient care.

As the field of healthcare transitions into an integrated care model, linking primary care and behavioral health services, there is a greater demand for clinical social work services in primary care settings. According to Kathol et al. (2015), “…threefourths of patients with behavioral health disorders are seen in the medical setting but are largely untreated because few medical patients choose to access the behavioral health sector” (p. 95). General practitioners are responsible for coordinating care for their patients, which places them in a vital role for connecting patients to the most appropriate services or treatment options. This study helps social workers understand the AAGP’ experience as an aid to bridging the gap between behavioral health and primary care when treating African American patients with depression.

This study also identifies challenges AAGP face in the delivery of depression care services. AAGP provide a unique perspective as members of the same minority group.

Their experiences in treating African American patients with depression provide invaluable insight on cultural consideration from the providers’ perspective. Additionally, this study aids in identifying potential opportunities for improving education among general practitioners in an attempt to reduce the gap between medical and mental health services, particularly for African American patients. Knowledge about general practitioners’ experience may reveal specific areas of need to improve services and

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coordinating care more effectively. Overstreet et al. (2007) suggested the gap in care for minorities with depression highlights a need for changes in physicians’ behavior to decrease disparities and improve patient outcomes. Westheimer et al. (2008) noted that “…despite primary care providers’ perceived limitations in their ability to treat presenting concerns that are not traditionally psychological in nature and their reported knowledge that behavioral health interventions would be helpful in treating these concerns, providers are not as likely to refer for these conditions” (p.106).

Formulation of the Problem Many people experience multiple stressors contributing to symptoms of depression and a reduction in their overall quality of life. Depression is known to have detrimental effects on one’s emotional and physical wellbeing. The medical community is placing greater focus on patients’ emotional health as the integrative healthcare model advances. For example, accredited cancer centers and cardiopulmonary rehabilitation programs are required to screen patients for psychosocial distress and see that treatment is received (Collins et al., 2014; Commission on Cancer, 2015; Balady et al., 2007).

These programs maintain necessary communication with general practitioners as the coordinators of patient care. General practitioners navigate patients’ treatment throughout the healthcare system; therefore, they play a vital role in the treatment of depression.

Disparities in care for depression among primary care patients persist, particularly for minorities (Miranda & Cooper, 2004). According to Bailey et al. (2011), depression in AA is frequently under-diagnosed and inadequately managed in primary care because of patient, physician, and treatment setting factors. African Americans are less likely to

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receive a proper diagnosis and treatment for depression (Bailey et al., 2011) and, if given a choice, they are more likely to prefer physicians of the same race (Chen et al., 2005).

Consequently, if African American patients are more likely to report symptoms of depression to African American physicians, it is important to explore the subjective experience of African American physicians in an attempt to improve depression care for African American patients. Many studies have focused on the treatment of mental illness by general practitioners, but little is known about the experience of African American physicians exclusively. This study aimed to fulfill the following objectives: 1.

To gain a better understanding of challenges in the delivery of depression care services for AAGP as coordinators of care for African American patients.

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To learn about factors that may impact AAGP’ treatment options when treating depression in African American patients and the impact of those factors on AAGP sense of self.

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To explore how the patient-provider relationship between AAGP and African American patients with depression can be framed using relational theory.

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To provide insight to clinical social workers who work in collaboration with AAGP to bridge the gap in service delivery.

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Research Question This study explored the following research question: What is the subjective experience of African American General Practitioners who treat depression in African American patients?

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How do they view themselves as African American physicians?

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How do they understand their role with African American patients with depression?

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How does the patient-provider relationship impact AAGP’ sense of self?

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What attitudes and beliefs do AAGP have about behavioral health and their role in working with therapists, like social workers, to ensure their patients get treatment for depression?

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What are the feelings, thoughts, and behaviors that depressed African American patients evoke in AAGP, and how do those feelings, thoughts, and behaviors on the part of AAGP affect the treatment process of their patients?

Theoretical and Operational Definitions of Major Concepts Concepts defined in this study include African American General Practitioner, depression, primary care setting, and care coordination. The term African American General Practitioner is defined as an African American medical doctor practicing under the specialty of Internal Medicine or Family Practice. Each specialty area has been selected due to its high probability for encountering patients who seek treatment for symptoms of depression. These professionals are typically the initial point of contact for

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patients and are responsible for coordinating care throughout the healthcare system.

According to the Harvard School of Medicine (2017), these specialties have been conceptually defined as follows: 

Internal medicine physicians “provide long-term comprehensive care, manage common illnesses and problems of adolescents and adults, treat mental health and substance abuse problems, and educate patients on disease prevention and wellness.”



Family practice physicians “diagnose and treat a wide variety of ailments in patients of all ages, incorporating training in surgery, psychiatry, internal medicine, obstetrics, gynecology, pediatrics, and geriatrics.”

For the purpose of this study, depression is identified by using criteria from the DSM-5.

Depression was chosen because of the increased awareness of the relationship between depression and one’s physical health and overall quality of life as well as the disparity in depression care for AA. Several healthcare accreditation bodies require patients with chronic illnesses like heart disease, cancer, or chronic obstructive pulmonary disease (COPD) to receive proper screening and treatment for symptoms of depression (Collins et al., 2014; Commission on Cancer, 2015; Balady et al., 2007). Symptoms of depression may be easily overlooked as medication side effects or other medically related symptoms, resulting in a delay in treatment. According to the DSM-5 (American Psychiatric Association, 2013), major depressive disorder is defined by five (or more) of the following symptoms being present during the same two week period and representing a change from previous functioning; at least one of the symptoms is either a depressed

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mood or loss of interest or pleasure. Symptoms that are clearly attributable to another medical condition are not included: 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). Note: children and adolescents can be described as having an irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. Note: for children, consider failure to make expected weight gain.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). a) Fatigue or loss of energy nearly every day. b) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely selfreproach or guilt about being sick). c) Diminished ability to think or concentrate or indecisiveness nearly every day (either by subjective account or as observed by others).

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d) Recurrent thoughts of death (not fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide (p. 160-161).

The Center for Medicare and Medicaid (CMS) (2012) defines a primary care setting as: One in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, Ambulatory Surgical Centers (ASCs), independent diagnostic testing facilities, Skilled Nursing Facilities (SNFs), inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition.

For the purpose of this study, “care coordinationâ€? is defined as ‌the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care (McDonald et al., 2007, p. 41).

Statement of Assumptions This study was based on the following assumptions:

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1. African Americans are less likely to seek treatment for depression through outpatient mental health professionals.

2. African Americans are more likely to report symptoms of depression to their primary care physicians.

3. General Practitioners are treating a significant number of patients with depression in primary care settings.

4. Stigma with depression among African Americans affects African American General Practitioners’ approach to treating depression in a primary care setting.

Foregrounding As an African American mental health professional, I experienced a curious situation which sparked my interest for this study. Several years ago, I decided to leave my full-time role as a medical social worker at a rural community hospital and move into private practice as a mental health provider. In my role as a medical social worker, I earned the respect and support of the physician community at the hospital. After learning about my resignation and new endeavor, many physicians requested my business card and agreed to make necessary referrals from their primary care practices. To my surprise, I received many referrals from Caucasian physicians, but no referrals from the African American physicians with whom I had held the closest relationships. I assumed the small African American professional circle in the community would somehow result in a closer networking system between the medicine and behavioral health disciplines. I assumed my close relationships would generate a steady referral source, but such was not the case.

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This experience sparked my interest in the study of AAGP’ experience with treating depression in African American patients.

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Chapter II

Literature Review It is my assumption that AAGP are often viewed by other AA as both “products of” and “role models for” the AA community, resulting in a unique experience. In pursuit of understanding AAGP experiences, this study also summarizes literature on AA’ attitudes and beliefs about depression to provide rich cultural considerations while exploring the experiences of AAGP in treating this minority group. Additionally, this study includes existing literature on the treatment of depression in primary care to gain insight into the integrative healthcare model and the role of general practitioners as coordinators of patient care. Finally, this section summarizes literature on relational theory to foster an understanding of the influence that earlier relationships and experiences may have had on the AAGP’ psychological development and perspective with regards to treating depression in their African American patients.

African Americans Beliefs and Barriers to Help-Seeking Health disparities between AA and Caucasians with depression is well documented in literature, indicating that African Americans report depression at lower rates than Caucasians. A meta-analysis of barriers to detection and treatment of depression in AA reveals significant literature that describes the health disparity of AA and depression care (Das et al., 2006). Depression in AA has a low prevalence of

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detection in primary care settings in part because of the African American experience of “strong religious beliefs and community ties” (Das et al., 2006, p. 31). AA’ faith in God and their community ties may be the reason this patient population refrains from sharing concerns with their doctors and instead turn to pray or members of their community.

Religious beliefs.

Research on the management of depression symptoms among African American women and Caucasian women revealed significant differences between the two racial groups. AA were more likely to turn to religious faith to deal with feelings; practices like prayer, reading their bible, and talking to their minister or other church members were utilized (Cadigan & Skinner, 2015). AA viewed prayer and “turning mental health problems over to God” (Conner et al., 2010, p. 980) as their front line of defense against depression, endorsing the belief that one should not speak openly about mental health problems, but keep them in the family as part of African American culture (Conner et al., 2010). These findings highlight the importance of primary care providers’ awareness of the power of religion in the African American culture and could be valuable if primary care providers incorporate this awareness of the patients’ spiritual or religious beliefs into conversations with AA with depression.

Community ties and cultural beliefs.

The impact of the African American community on depression care is powerful.

Some AA believe, as a race, they should be able to handle depression better than other races due to their resilience throughout the history of racial discrimination in this country

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(Conner, 2010). AA often feel weak for not being able to cope with depressive symptoms, which were often viewed as the normal stresses of the African American experience; one just needed to “push through depression” or “get over it” (Conner et al., 2010, p. 979). This belief can make it difficult for one to recognize the need for professional attention (Conner et al., 2010).

Many women in this cultural group believe they are not susceptible to depression due to the “beliefs that depression developed from having a weak mind, poor health, a troubled spirit, and lack of self-love” (Waite et al., 2008, p. 189). Some African American women reported that their perspective on depression and depression care is influenced by pressure to be a “strong Black woman” (Nicolaidis et al., 2010, p.1474).

This belief kept them from seeking medical or mental health care and caused them to view a diagnosis of depression as a contradiction to the “strong Black woman” image (Nicolaidis et al., 2010, 1474). Additionally, members of the African American community often do not view depression as a true medical illness and use self-reliance as a strategy for coping with depression; self- reliance strategies like “keeping busy, staying active in the community, cooking and cleaning and, unfortunately, self-medicating with alcohol and nicotine” (Conner, 2010, p.978).

Multiple stigmas.

AA view depression as an added stigma in their status as a minority race; they see themselves as being more stigmatized than any other race. They feared repercussions of a diagnosis of depression; perhaps a diagnosis could impact the way society would treat them when it comes to advancements like finding a job (Connor, 2010). Conner et al.

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(2010) asserted that AA report being stigmatized and stereotyped by other AA in the community; “You’re worthless” or “You’re crazy” are common messages (Conner, 2010, p. 976).

Lack of faith/trust in providers.

AAs find it difficult to trust mental health providers due to historical experiences of hospitalization and feelings of mistrust of providers who are of a different race from their own (Conner, 2010). Van Voorhess et al. (2003) asserted, “Patients may seek the type of provider who will confirm their belief systems and subsequently reject information offered by the physician that contradicts their beliefs” (p. 998). The provider’s race is seen as an important issue among some AA; they believe providers of other races are unable to effectively treat them or understand the African American experience (Lindsey, 2006). Participants in one study of African American women “expressed a desire to be treated by African American medical providers or to use African American advocates with real-life experiences as a bridge to the White healthcare system” (Nicolaidis et al., 2010, p. 1474).

Another study of the African American elderly population revealed concerns with the providers’ use of antidepressants and felt the medications would only make them sicker (Conner, 2010). However, despite their mistrust in providers, if professional help is sought, AA are more likely than Caucasians to seek treatment in a primary care setting (Das et al., 2006) and from an African American medical provider (Nicolaidis et al., 2010). In their study of black Americans’ preference for black healthcare providers, Malat and Hamilton (2006) concluded, overall, the belief that discrimination is frequent

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in different-race doctor-patient dyads is associated with greater preference for a samerace provider and that these results suggest a complex picture of how perceptions of discrimination influence preferred race of healthcare providers among blacks in the United States. Whaley (2001) found that “... black patients with severe mental illness are more comfortable with African American clinicians, even though they believe that white clinicians are better trained” (p. 255). This supports the idea that AA would more likely prefer a same race healthcare provider over providers of other races.

Difficulty recognizing symptoms.

AA face “…a number of barriers in the recognition of treatment of major depression including clinical presentation with somatization, stigma about diagnosis, competing clinical demands of comorbid general medical problems, problems with the physician-patient relationship and lack of comprehensive primary care services” (Das et al., 2006, p. 30). In fact, “African Americans who have depression may be frequently underdiagnosed and inadequately managed in primary care as a result of patient, physician and treatment-setting factors” (Das et al., 2006, p. 30). Attitudes and beliefs that create barriers to treatment include “distrust in healthcare providers, denial of depression, stigma, lack of finances, and limited knowledge about etiology” (Waite et al., 2008, p. 191). If members of this cultural group present as less symptomatic or symptoms are masked behind other major comorbid general health issues, general practitioners may fail to recognize depression causing a delay in proper treatment. According to Ghods et al. (2008), AA communicated less depression related statements than Caucasians during Primary Care Physician (PCP) office visits and, even when depression communication

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occurred, a lower percentage of African American patients were considered by their PCP to have significant emotional distress. The study revealed racial disparities in communication among primary care patients with high levels of depressive symptoms.

Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care. This study does not indicate the race of the physicians involved; therefore, inquiry about “cultural mistrust� and its role in the African American patients’ comfort level when communicating symptoms of depression is important, especially if the physician is of a different race.

Lack of finances.

Connor et al. (2010) revealed concerns with access to treatment due to limited financial resources or insurance coverage. Participants reported concerns with asking for help only to be rejected, if financial barriers are present. Hence, another reason for the mental health disparity in amongst African Americans with depression.

Depression Treatment in Primary Care The provision of mental health care in the primary care setting continues to grow across the United States (Olfson, 2016). According to the National Summary Tables in the National Ambulatory Medical Care Survey (2015), 10.4% of primary care visits result in a documented diagnosis of depression. Depression care in primary care settings is receiving significant attention on the national level. Integrative healthcare models are drawing the connection between emotional and physical health and placing emphasis on appropriate screenings for depression in primary care and adequate follow up treatment.

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The Department of Health and Human Services (2012) estimated that 25% of older adults with physical illnesses are experiencing signs and symptoms of depression and asserted that “opportunities are missed to improve health outcomes when mental illness is underrecognized and under-treated in primary care settings... 50-75% of older adults who commit suicide saw their medical doctor during the prior month for general medical care, and 39% were seen during the week prior to their death” (p. 2).

Patients who are treated exclusively in primary care settings are more likely to receive a lower quality of depression care in comparison to those seen by mental health specialists due to their differences in attitudes and beliefs (Van Voorhees et al., 2003).

Wang et al. (2002) reported, “Factors significantly associated with not receiving adequate treatment included being in the youngest age group (vs. the oldest) and being black (vs. non-Hispanic white)” (p. 94).

Integrated care.

The Center for Integrated Health Solutions (CIHS), a national center supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA), promoted the collaboration of primary care and behavioral health services. CIHS referred to primary care settings as the “gateway to the behavioral health system” and asserts that these providers need support and resources to better serve individuals and the solution lies in “integrated care” Integrated care is defined by CIHS as “the systematic coordination of general and behavioral healthcare” (SAMHSA, n.d.).

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General practitioners’ role.

Primary care providers are frontline assessors of mental illness (Wang et al., 2002). Patients may report symptoms like changes in sleep patterns and energy level, lack of motivation, changes in eating patterns or weight, and feeling “down.” Nonetheless, Wang et al. (2002) asserted patients who received mental health treatment exclusively in the general medical sector made up the smallest percentage of patients who received minimally adequate care when compared to those who received treatment from the mental health sector or a combination of both. In comparison to those receiving depression treatment by mental health specialists, patients who received depression treatment exclusively by primary care providers have attitudes and beliefs that are more averse to care, which could contribute to low quality depression care (Van Voorhees et al., 2003). According to Waite and Killian (2008), “Blacks are less willing to use psychiatric medications themselves or to administer them to a child for whom they are responsible” (p. 193). This behavior illustrates the importance of collaboration between primary care providers and behavioral health providers.

The Patient Centered Medical Home (PCMH) model, one example of integrated healthcare, holds primary care physicians responsible for coordinating patient care across the healthcare system and includes fostering relationships with mental health specialists for proper management of patients’ mental health needs (Croghan & Brown, 2010). In a study on treatment of depression in older primary care patients, findings indicated providers rarely mentioned a range of treatment options and some providers often viewed their role as the one to convince patients to take medication. The same study suggested older patients are more willing to please and accept the doctor’s orders (Wittink et al.,

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2011). These findings highlight the significance of the providers’ role and influence in patients’ depression care and collaborating with behavioral health providers.

Attitudes and beliefs.

In their study, Primary care doctor attributions for why patients did not receive adequate antidepressant treatment, Pirraglia et al. (2006) found that “primary care doctors may not see themselves as responsible for the quality of their patient’s depression or anxiety treatment, which is inconsistent with being at the center of their patients’ care” (p. 475). Another study looked at barriers to effective management of depression in primary care settings and found that providers held varying attitudes about depression treatment. These varying attitudes were related to prior mental health training, geographical location, and gender of the provider (Richards et al., 2014). The study found that providers who received prior mental health training held more positive attitudes about depression and stronger beliefs in their ability to help depressed patients. The providers were more likely to identify barriers to effective treatment and had higher confidence in their ability to help depressed patients. Geographical location (urban vs. rural) was found to have no significant bearing on providers’ attitudes, but the study revealed that rural providers were more likely to prescribe medication and collaborate with psychiatrists or psychologists as a form of depression treatment than urban providers who were more confident in utilizing non-pharmacological approaches (i.e. counseling and/or education) to depression treatment. The study also reported male providers were more likely than females to believe that little can be done for depressed patients and such patients should not be the responsibility of general practitioners. Though the study

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outlined here offered valuable information about providers’ attitudes and beliefs about depression care, it failed to explore culture factors around the race and ethnicity of the provider. The present study took a closer look into the AAGP’ experience exclusively.

African American general practitioners.

Research indicates that AA are less likely to seek outpatient psychotherapy and more likely to report complaints to primary care physicians, resulting in a lower quality of mental health care that disproportionately affects AA (Snowden & Pingitore, 2002).

Though there is a wealth of research on AA’ lack of utilization of outpatient mental health services, such research fails to explore this problem from the AAGP perspective.

There is limited research that addresses the significance of the relationship between the African American patients and their primary care physicians and its impact on the patients’ decision regarding treatment options for mental health services. Few studies explore the primary care physician’s role in the doctor-patient relationship when exploring potential barriers to AA’ utilization of outpatient mental health services.

In their study on attributes that influence a physician’s clinical decision, McKinlay et al. (2002) found that white general practitioners were nearly twice as likely as African American physicians to diagnose depression in their patients. Interestingly, African American patients rated their overall encounters with AA providers as satisfying and were more likely to share their problems with AA providers (Das et al., 2006). For this reason, there is a need for more information about the experience of the AAGP who are less likely to diagnose depression, but more likely to provide an environment for patients to share emotional concerns.

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This study provides social workers with new knowledge about AAGP attitudes and beliefs which may impact social workers’ understanding of barriers to coordination of care and low utilization rates of outpatient psychotherapy for African American patients with depression. In the integrated care model, social workers serve as effective members of a multidisciplinary team when treating the whole patient.

Relational Theory Relational theory was found to be the most useful theory in providing a theoretical framework for this study because of its focus on the role of relationship in the development of overall well-being. Relational theory holds that individuals are motivated by relationships with others, not by drives, therefore, rejecting Freud’s drive theory in which individuals are thought to be driven by biological drives (Mitchell, 1988). This theory rests on the idea that repetitive patterns in one’s experiences derive from a need to preserve continuity, connections, and familiarity of one’s personal and interactional world (Mitchell, 1988). According to Mitchell (1988), “… individuals have a powerful need to preserve a sense of oneself as associated with or related to a matrix of other people with regard to actual transactions and internal presences” (p. 33). Relational theory values three dimensions of configurations: the self, the other, and the space between the two (Mitchell, 1988). Mitchell (1988) asserted there is no “self” in total isolation of others or outside of relationships with others and these dimensions are interwoven to create an individual’s subjective experience and psychological world.

Relational theory is an outgrowth of earlier works of several prominent theorists in the area of object relations theory, attachment theory, and self-psychology. Earlier

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theorists such as Melanie Klein, W. R. D. Fairbairn, Donald W. Winnicott, John Bowlby, and Heinz Kohut helped shape the development of early relational perspectives (Borden, 2000).

Klein introduced concepts like “internal object,” “projective identification,” and “self-organization,” which contributed to Winnicott and Fairbairn’s development of relational perspectives (Bordon, 2000). Fairbairn, known for his theories of development, personality organization, and psychopathology, viewed development and personality organization as a maturational sequence of relations with others. He placed emphasis on the relationship between mother and child (Bordon, 2000). Winnicott related disorders of the self to disruptions in the “holding environment” of infancy and early childhood and placed significant focus on the quality of the individual’s subjective experience in his understanding of the self. Winnicott highlighted the concepts of inner coherence, personal meaning, agency, initiative, vitality, authenticity, play and creativity (Bordon, 2000).

Bowlby’s study of attachment in infancy and childhood revealed a fundamental need for connection and contact with others and how that need has adaptable roots in biological survival. He believed that earlier relational interactions with caregivers guide the process of relational experiences with others throughout the lifespan (Bowlby, 1988).

Kohut, the founder of self-psychology, emphasized a fundamental need to establish and maintain a sense of self. This need is nurtured by a connection and relationship in human experiences that form the basis of one’s self-worth, confidence, and sense of safety (Bordon, 2000). He argued a cohesive sense of self results from empathic primary caregivers. The caregiver’s attunement of the child’s subjective state

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provides for gradual internalization into the child’s psychic structure, resulting in selfregulation of one’s emotions (Bordon, 2000; Gardner, 1999). Early relationships, as well as those throughout the life span, provide experiences in which the self-object is experienced as providing necessary functions for the developing self. These self-objects are used to develop, what Kohut terms, the tripolar self through an intrapsychic process of mirroring, idealizing, and twinship or alter ego (Baker & Baker, 1987). Mirroring needs are met through the empathic response of the other to provide a sense of value and worth to the self. Kohut asserted a caregiver’s failure to provide an empathic response to the child results in self-deficits, defensive patterns, and disruption of functioning (Gardner, 1999). The individual’s idealizing needs are the need to merge with or be close to someone who makes him feel a sense of safety and calmness (Baker & Baker, 1987).

Twinship needs are met when the individual experiences a sense of sameness or likeness with the other (Baker & Baker, 1987).

Relational theorists believed earlier relationship patterns with others, particularly parents, influences one’s personality, thereby creating lifelong relational patterns. Unlike earlier psychodynamic theories, relational theory is a two-person approach to treatment, where both doctor and patient participate in the unfolding of the patient’s experience, thereby making the doctor’s participation a key factor in the treatment process. In this two-person approach, doctors are fully engaged, taking into account his/her own feelings, thoughts, and behaviors in addition to the patient’s feelings, thoughts, and behaviors. This allows the doctor to operate within the context of social and cultural awareness when treating patients.

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With consideration of cultural and social components, Comstock et al. (2008) asserted Relational Cultural Theory (RCT) supports the notion that the participation in mutual empathy and growth-fostering relationships is vital to one’s human development and psychological well-being and is linked to one’s racial/cultural/social identities. RCT is best understood through the process of moving toward connections, through disconnections, and back to newly transformed or enhanced connections (Comstock et al., 2008). This theory supports a type of relational responsiveness that utilizes anticipatory empathy, a thought process that guides the relationship into a deeper mutual connection by giving forethought to how a patient, as it relates to this study, may be affected by the way the provider chooses to respond (Comstock et al., 2008).

Jordan and Hartling (2010) suggested that all people yearn for connection and that connection has to occur for people to change; therefore, particular emphasis is placed on examining differences informed by imbalances in power and privilege in relationships.

Drawing awareness of such differences in culture identities can allow one to explore a mutual experience with another (Hammer et al., 2016). This idea translates to the doctorpatient relationship, allowing the AAGP to have an enhanced experience of empathy with African American patients.

Disconnection in relationships occurs when dominance and privilege is present, resulting in suppressed authenticity and mutuality. This limits the formation of a growthfostering relationship (Jordan & Hartling, 2010). If managed effectively, disconnections can foster a space where individuals feel safe (Hammer et al., 2016). This study examined the doctor-patient relationship through the experience of AAGP who treat depression in African American patients.

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In summary, the research cited in this section highlights attitudes and beliefs about depression care for African American patients and the significance of relationships through the lens of relational theory. This study explored the relational experience of AAGP given what is understood through research on depression and the AA experience.

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Chapter III

Methodology This chapter outlines the methodology used in the study and provides an overview of the research design, sampling, data collection and analysis. Ethical considerations, issues of trustworthiness, and limitations of the study will also be discussed in this chapter.

Major Approach / Research Questions This study is an exploratory qualitative study about the experience of AAGP who treat African American patients with depression. The researcher employed the Interpretative Phenomenological Analysis (IPA) approach to achieve the following objectives: 1. Gain a better understanding of challenges in the delivery of depression care services for AAGP as coordinators of care for African American patients.

2. Learn about factors that may impact AAGP treatment options when treating depression in African American patients and the impact on AAGP’ sense of self.

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3. Explore how relational theory can help frame the patient-provider relationship between same race providers and African American patients with depression.

4. Provide valuable insight to clinical social workers who work in collaboration with AAGP to bridge the gap in service delivery

Rationale for qualitative research.

Qualitative research refers to a method of social inquiry used to explore and understand how people make sense of their experiences and the world in which they live.

This method of inquiry helps researchers interpret the lived experiences of human beings (Holloway & Galvin, 2017). In this study, the researcher examined the experience of AAGP, particularly around their encounters with African American patients with depression. Participants’ viewpoints helped the researcher gain insight into the phenomenon of treating this specific patient population as a same-race provider.

Additionally, participants’ lived experiences provided deeper levels of understanding of their view of treating depression and working with mental health professionals.

Qualitative research methods are context sensitive in that the researcher takes into consideration all contributing factors in the participant’s story: social, cultural, occupational, and personal contexts that defines one’s lived experiences. Through qualitative research, the significance of the participants’ experiences is revealed through their own descriptions and the researcher’s analysis. This intersubjective process includes strategies like observation, listening, and questioning. The researcher also immerses him/herself in the world of the participants to increase the understanding of their feelings

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and perspectives, rather than imposing his/her own framework on the participants’ experiences (Holloway, 2017).

Exploratory research.

According to Rubin and Babbie (2001), exploratory research is designed “to provide a beginning familiarity with [a topic] …typically when examining a new interest, when the subject of study is relatively new and unstudied, or when a researcher seeks to test the feasibility of undertaking a more careful study or wants to develop the methods to be used in a more careful study” (p. 123). The researchers chose exploratory research to gain new understanding of depression treatment in AA in primary care, from the perspective of AAGP. This study explored the experience of AAGP who treat depression in their African American patients. Though the topic of depression treatment in primary care has been widely researched, there are no studies that focus on the AAGP’ perspective in treating depression in same-race patients. The study aimed to increase the knowledge base of this phenomenon with curiosity and through inquiry, not to prove an outcome.

Epistemology.

Holloway and Galvin (2017) defined epistemology as “the theory of knowledge and is concerned with the question of what counts as valid knowledge” (p. 21). This study will follow a social constructivism approach to validating the experience of AAGP in their treatment of African American patients with depression. Holloway and Galvin (2017) described social constructivism as “A belief or supposition that human beings are

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creating their own social reality, and that the social world cannot exist independent of human beings” (p. 344). The researchers relied heavily on the AAGP’ view of their experiences and meanings derived from those experiences. According to Creswell (2007), these subjective meanings are created “through interactions with others and through historical and cultural norms that operate in their lives” (p. 21).

Rationale for specific method.

To fulfill the purpose of this study, the researcher employed a phenomenological approach. Unlike other forms of qualitative research, the phenomenological approach aims to describe the meaning of a phenomenon based on the experiences of several individuals. In this approach, the researcher’s description is derived from insight into individuals’ lived experiences of the phenomenon. Essentially, this approach of qualitative research “reduces individual experience with a phenomenon to a description of the universal essence” (Creswell, 2007, pgs. 57-58). More specifically, this study will utilize the Interpretive Phenomenological Analysis, or IPA method, outlined by Smith et al. (2009). The authors focus on three key concepts that define this approach to qualitative research: Phenomenology, Hermeneutics, and Idiography.

Phenomenology.

Phenomenology, as defined by IPA, is a detailed examination of the human experience of a phenomenon, particularly, “the things that matter to us, and which constitutes our lived world” (Smith et al., 2009, p.11). Husserl asserted the experience should be examined as it occurs to allow the individual to come to know the experience

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and value its meaning. This approach involves turning away from our everyday experiences and our “natural attitude” to allow space for a detailed understanding of the participant’s experience (Smith et al., 2009). The present study explored the phenomenon of treating depression in African American patients, from the AAGP’ perspective.

Hermeneutics.

Hermeneutics is the second major concept in IPA and refers to the theory of interpretation. Originally used to interpret biblical text, hermeneutics has become more widely used in the interpretation of other documents. For Heidegger, hermeneutics is useful in examining that which may be latent in an individual’s detailed experience. He highlighted the idea that such details are only accessible through interpretation of that which appears or emerges from the individual’s experience of the phenomenon (Smith et al., 2009).

Idiography.

Idiography is the third major concept in the IPA approach to qualitative research.

Idiography focuses on the particular versus the group. Emphasis is placed on details using small, purposively selected samples (Smith et al., 2009). IPA influenced this researcher to thoroughly explore the details of each participant’s experience in his or her own terms.

Research Sample This study utilized a homogeneous purposive sampling, thereby, selecting participants based on the needs of the study. In this study, selected participants met all the

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inclusion criteria. In accordance with the IPA method, this study’s sample size ranged from five to eight participants. IPA sample sizes are relatively small with details on quality, not quantity (Smith et al., 2009). Study participants were recruited using a purposive (or selective) sampling method and met specific inclusion criteria. Participants, 1. Identified themselves as an African American physician who has African American patients with depression, 2. Held a certification from the American Board of Family Medicine or the American Board of Internal Medicine, 3. Had at least three years of post-certification experience, and 4. Agreed to two audio taped interviews.

The significance of board certification and practice experience is to minimize any anxiety or discomfort that may be related to a lack of experience in the field. The original inclusion criterion of five years post-certification experience was changed during the recruiting process to three years of post-certification experience after the Institutional Review Board’s (IRB) approval. This change was to increase the number of qualified participants and was the recommendation of an officer of a local medical society.

Given the inclusion criteria outlined earlier, participants had a minimum age of 34 years (four years of undergraduate school + four years of medical school + minimum three years of residency + five years of post-certification experience). For proximity to the researcher, all participants lived in the southeast region of the country.

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Research Design This section explains the steps to completing the research of this phenomenological study. The process began with the distribution of study flyers to area AAGP offices, by U.S. mail or email. Flyers included contact information for the researcher, inclusion criteria, the purpose of the study, and the anticipated time commitment. Additionally, the researcher’s picture was added to the flyer, with IRB approval, to reduce any resistance or concerns about cultural mistrust (as noted as a barrier to care for AA in the literature review section). The initial flyers that were mailed to the AAGP practices did not yield any interest. As a result, additional flyers were emailed to the researcher’s friends and professional contacts who passed them onto their friends, a pastor of an AA church, presidents of a corporate healthcare organization, and a local medical society. Ultimately, participants were recruited in three North Carolina metropolitan areas: Charlotte, Greensboro, and Winston-Salem. Participants who contacted the researcher received a brief telephone screening to ensure all inclusion criteria were met. Once all inclusion criteria were confirmed, the initial in-person interview was arranged. Interviews were held in a private setting of the participants’ choice. The goal of allowing participants to choose the location of the interview was to enhance their comfort level. These face to face, in-person encounters provided the researcher with additional information obtained through nonverbal communication, such as body language, eye contact, and breathing patterns.

During the interviews, participants were asked a series of predetermined, openended questions to gain a clearer understanding of their experience with the phenomenon.

Questions were designed to avoid assumptions but encourage a detailed discussion. The

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researcher suspended personal beliefs and perceptions to foster a more open perspective to receiving each participant’s true experience. Each participant provided informed consent (see Appendix A).

Data Collection The researcher served as an instrument (or tool) by interviewing participants for the purpose of data collection on the phenomenon. Data was then transcribed, and the descriptions of the phenomenon were studied (Streubert & Carpenter, 2011). “Rich” data was collected through two semi-structured 60-minutes interviews, one face to face and one by telephone or video conference to improve the accuracy of the researcher’s interpretation and to provide additional information. IPA explains that “rich” data is obtained by allowing participants the opportunity to speak freely and reflectively about their ideas and concerns at length, which in turn could provide their detailed thoughts and feelings (Smith et al., 2009, pgs. 56-57). One-on-one interviews provided a setting that encouraged rapport building and were best suitable for in depth discussions (Smith et al., 2009, p. 57). Interviews were designed to gain insight and understanding of the experience of AAGP who treats depression in African American patients.

Interviews were audio recorded for later transcription. During the interview, participants were asked specific open-ended questions about their subjective experience of African American patients with depression. They were encouraged to speak at length and with great details. The following are sample questions designed to encourage open dialog regarding AAGP’ experience with treating depression in African American patients:

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1. What has been your experience as an AA in the field of general medicine?

2. Tell me about how you came to be a physician? Your inspiration?

3. What does it mean to be an AAGP in the era of integrated healthcare?

4. How do you view your overall success in the field at this point in your career?

5. What does it mean to be an AAGP to African American patients?

6. Tell me how race and culture impact your role as a physician?

7. What are the challenges, if any, to being an AAGP to your African American patients? Are there benefits to your African American patients?

8. What message do you receive from your African American patients about your role in their lives?

9. What are your earlier experiences/exposures with depression as part of AA culture?

10. Tell me how you think depression is viewed in the AA culture? (Earlier experience with family, friends, self, etc.)

11. How was depression managed?

12. When it comes to African American patients with depression, what has been your experience?

13. Which type of depression care treatment do you consider for African American patients?

14. How receptive are your African American patients to various depression care treatments?

15. Tell me what it is like for you to have an AA patient who does not respond favorably to treatment?

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16. Please share your thoughts and feelings related to working with and referring African American patients to mental health therapists.

17. What factors play a role in your choice of treatment for depression in African American patients?

Memos were written throughout the interview and later used for the transcription and coding process. Content from the interviews was used to reveal common experiences between all participants.

Data Analysis In this study, the researcher listened to transcribed data from interviews with AAGP and drew from them as common themes emerged. The researcher attentively reviewed each participant’s story in a manner that revealed consistencies and differences in their lived experiences with the phenomenon. Content from the interviews was used to compare data, and the researcher analyzed that data until a clear description was achieved.

Data collected in this study was analyzed using IPA recommendations. IPA highlights a few significant steps to the analysis process: 1.

Reading and re-reading - this initial stage of data analysis involved immersing oneself into the participants’ experience by reviewing the recorded interviews and allowing one’s focus to remain on the data at hand. The researcher paid particular attention to the flow of the interview, matters of trust and rapport building throughout the interview, and the overall tone of the interview (Smith et al., 2009).

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2. Initial noting - in this step, the researcher wrote notes that helped produce a detailed and comprehensive understanding of the data (Smith et al., 2009). Initial noting helped the researcher make sense of the participants’ lived experiences.

3. Developing emergent themes - when developing emergent themes, the researcher began to break up the content of the interview by reducing the volume of details and shifting primary focus to the initial notes rather than the actual recorded interview itself (Smith et al., 2009). From this process, a group of chronological themes were developed.

4. Searching for connection across emergent themes - next, the researcher identified the significance of the previously developed themes and their relationship with one another with the goal of developing a structure that highlighted the most interesting and important aspects of the participants’ stories (Smith et al., 2009).

Smith et al. (2009) explained the following strategies to connecting emergent themes: a.) Abstraction - identify patterns, matching “like with like” in identified themes, and developing a new name for such themes. b.) Subsumption - similar to abstraction but occurs when an emergent theme acquires the need to bring together a series of similar themes. c.) Polarization - the process of analysis that focuses on differences rather than similarities among emergent themes. d.)

Contextualization - identifying contextual or narrative elements of the participants’ stories as it attends to temporal moments or cultural themes. e.)

Numeration - accounting for the frequency of a supported theme. f.) Function analyzing themes for their particular function within the transcript. According to

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Smith et al. (2009), these strategies are not mutually exclusive, but can provide multiple ways of organizing themes, ideally through the uses of tables or figures.

5. Moving to the next case - As this study had multiple participants, this step involved moving to the next case and following the same process as mentioned above while treating the case on its own terms and suspending any ideas that have emerged from the previous case or cases (Smith et al., 2009).

6. Looking for patterns - This final step looked at patterns between participants’ accounts of their experience with the phenomenon and, more specifically, in this study, patterns between AAGP experience with treating depression in African American patients (Smith et al., 2009).

Ethical Considerations This section outlines specific consideration of ethical practice in the following areas: beneficence and nonmaleficence, autonomy and informed consent, confidentiality and anonymity, deception, fidelity/loyalty, and fairness/justice.

Beneficence and nonmaleficence.

Social work research often requires individuals to share personal information about themselves that may be unknown to others; therefore, the issue of beneficence and nonmaleficence must be addressed. Beneficence balances the benefits of the study over the risk and cost (Holloway & Galvin, 2017). Nonmaleficence is the principle of “doing no harm;� risk should be kept at a minimum for individuals and the wider society (Holloway & Galvin, 2017, p. 53).

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Rubin and Babbie (2001) asserted participants can be harmed psychologically during the process of the study, perhaps through sharing unpopular behaviors, attitudes, beliefs, or personal characteristics. Additionally, study participants may have to face an uncomfortable aspect of themselves even if they do not share them with the researcher (Rubin & Babbie, 2001). Participants of this study were informed of potential risk prior to participation.

In this study, AAGP were asked about their personal experiences and practices with regards to treating depression in African American patients. Though social workers cannot guard against all risk (Rubin & Babbie, 2001), this researcher took careful precaution to minimize any risk to the AAGP’ self-image or any risk of psychological distress. AAGP were informed of their right to stop the interview or decline to answer any questions at any time. As a Licensed Clinical Social Worker, the researcher aimed to protect the welfare of study participants by stopping the interview if underlying trauma began to surface. The researcher was also aware of the risk of harm during the data analysis and reporting process, a fact that normally goes unrecognized (Rubin & Babbie, 2001). Additionally, to avoid the risk of participants feeling as though they were portrayed in an unfavorable manner, “member checking� further reduced the amount of risk posed to participants of this study. However, should participants want to further explore feelings aroused as part of this study, a referral was offered to a provider in their local area.

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Autonomy and consent.

Autonomy and consent are important principles in research. The researcher respected each individual’s freedom, or autonomy, to accept or decline the offer to participate in a study. Autonomy refers to the individual’s informed choice without coercion (Holloway & Galvin, 2017). The researcher informed participants of the purpose and extent of the research. This valuable information allowed participants to make an informed decision or give informed consent. Informed consent is an ongoing process in qualitative research (Holloway & Galvin, 2017). Each participant received written consent at the beginning of participation and verbally throughout the course of the study. A copy of the written consent is available in the appendix.

Privacy and confidentiality.

Participants’ privacy is essential to establishing trust in the researcher-participant relationship. Participants were assured that information shared doing the research process is protected and their identities are concealed. Confidentiality assured protection of participants’ identity. Confidentiality is when the researcher vows to keep the participants’ identifiers secret from the public (Rubin & Babbie, 2001).

In this study, confidentiality was maintained by presenting information in a manner that does not provide identifying information to the public. Participants were informed of parameters that assured privacy of all content obtained during the interview. Under no circumstances were participants required to disclose personal information, such as name or other identification facts, about their respective patients. Similarly, participants’ names were replaced with fictitious names. All notes and recordings were kept in a locked file

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cabinet in the researcher’s home. If participants should have any questions about the research project, they were encouraged to call the researcher. The researcher’s contact information was provided to all participants.

Deception.

Creswell (2007) defined deception as the researcher’s intentional act of “masking the identity of the research, withholding important information about the purpose of the study, or gathering information secretively” (p. 242). Deception in research can damage the researcher’s integrity (Streubert & Carpenter, 2011). The researcher in this study clearly outlined the purpose and benefits of the study to allow participants to ask clarifying questions and give informed consent; therefore, deception was not used in this study.

Fidelity and Loyalty.

This research study honored the ethical rule of fidelity/loyalty. According to Holloway and Galvin (2017), this rule of ethics addresses the idea of faithfulness or loyalty toward the participants by protecting their rights and well-being and informing participants of any conflicts of interest. AAGP in this study were informed of the affiliated academic institution governing the process of the study.

Fairness and Justice.

Holloway and Galvin (2017) asserted the principle of justice is the researcher’s effort to “distribute the benefits, risks, and costs fairly” (p. 53). In this study, AAGP were

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asked questions that could result in emotional discomfort. In this case, participants were encouraged to proceed at their own discretion. All necessary attempts to minimize participants’ discomfort or any other risk were made. Participants were given permission to refuse to answer any question or stop the interview at any time.

Issues of Trustworthiness Issues of trustworthiness in research refer to the quality or rigor of the study. The term rigor essentially indicates “thoroughness and competence” in qualitative research (Holloway & Galvin, 2017, p. 304). Holloway and Galvin (2017) defined trustworthiness as “methodological soundness and adequacy” (p. 309). When conducting qualitative research, the researcher assured participants the finished work had high value based on three criteria: credibility, dependability, and transferability. As strategies for ensuring trustworthiness of this study, the researcher utilized the processes of member checking and reflexivity.

Credibility.

Credibility is similar to validity, a terminology used more in quantitative research.

In qualitative research, credibility speaks to the accuracy of the researcher’s description and interpretation of the participants’ experience as explained by the participants (Holloway & Galvin, 2017). To increase the credibility of this study, the researcher checked for accuracy throughout the interview process by summarizing and paraphrasing AAGP’s words and statements and by reporting the findings of the study back to the AAGP for validation. This process is called “member checking” (Streubert & Carpenter,

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2011, p. 48). Member checking will allow AAGP to make corrections or further clarify any inaccuracies.

Dependability.

Holloway and Galvin (2017) asserted dependability is similar to reliability, a term often used in quantitative research. Reliability “refers to the consistency of a research instrument” (Holloway & Galvin, 2017, p. 304-305), indicating that the research can be replicated if repeated. However, in qualitative research, dependability refers to accuracy of the study given that the researcher is the instrument of inquiry and time and contexts are essential components, a replication of the study may produce similar results, but never the same results (Holloway & Galvin, 2017). Streubert and Carpenter (2011) claimed, “Dependability is met once the researcher has demonstrated the credibility of the findings” (p. 49). As a strategy for improving the dependability of this study, the researcher maintained a self-critical stance throughout the research process. This process is called “reflexivity...the responsibility of researchers to examine their influence in all aspects of qualitative research...” (Streubert & Carpenter, 2011, p. 34). In this study, the researcher critically examined personal preconceptions, beliefs, thoughts, and feelings in a manner that improves dependability.

Transferability.

Transferability is similar to generalizability, a term used commonly in quantitative research. In qualitative research, transferability means “the findings of one study can be transferred to similar participants or situations” (Holloway & Galvin, 2017,

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p. 309). Streubert and Carpenter (2011) referred to transferability, or “fittingness,” as “the probability that the findings have meaning to others in similar situations” (p. 49). The transferability of the study is determined by the reader, not the researcher. The researcher’s role is to richly describe the participants’ experiences, so the researcher can effectively apply the data to another context.

Limitation and delimitations.

A common limitation in qualitative research is the lack of generalizability (Holloway and Galvin, 2017). This study was limited to a certain region of the country, therefore, not making a strong representation of the general population of AAGP. Delimitations speaks to the boundaries of the study (Holloway & Galvin, 2017). This study focused on AAGP who practice as Internal Medicine and Family Medicine practitioners, thereby excluding other specialties that may serve as general practitioners for their patients. Those specialties excluded from this study include pediatrics and gynecology.

Role and Background of the Researcher The researcher’s role in this study is interviewer, data collector, and data analyst.

The researcher created an atmosphere that offered a safe environment for AAGP to share their experience of treating depression in African American patients. The researcher transformed the AAGP’ descriptions of their experience into a greater understanding of the phenomenon as part of the data collection process. As data analyst, the researcher used the content of the interviews to develop conceptual categories that revealed the

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essence of AAGP’ experience. As a result, a written document was created that collectively reflects the researcher’s understanding of the AAGP’ experience.

The researcher’s background is important to note as it can play a role in the researcher’s interpretation of the participants’ shared experience. This study was conducted by a researcher who is a Licensed Clinical Social Worker who works as a psychotherapist and also identifies as AA.

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Chapter IV

Results The initial part of the research interview was designed to gather demographic data and foundational level information around personal inspiration for becoming a physician and the participants’ perspective on their level of success in the field. This helped to gain a basic understanding of their experience in the field of general medicine.

A total of six AAGP participated in the study. All participants practiced in one of three nearby metropolitan cities in North Carolina: Greensboro, Charlotte, and WinstonSalem. The gender mix of the participants was made up of majority male physicians; four (67%) were male and two (33%) were female. In terms of specialty, Internal Medicine made up the majority; four (67%) held an Internal Medicine specialty and two (33%) held a specialty in Family Medicine. The participants’ years of post-certification experience ranged from four years to 38 years (mean = 21.83). All six participants identified themselves as Christian at some point during the interview process.

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Table 1. Research Participants

Study Participants Here I will introduce each participant to provide some basic background and current practice information. All participants received their face to face, in-person interview in their private office with the exception of Doctor E who chose to meet in a reserved meeting room at a local restaurant.

Doctor A. Doctor A is a female family medicine physician with 38 years of post-certification experience. She is currently a physician in her privately owned family medicine practice.

She reported that approximately 65% of the patients in her practice are AA. Doctor A is the oldest of six children raised by two college educated parents. Her mother was a

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schoolteacher. She said she doesn’t remember any early encounters with depression in her family or her community.

Doctor A’s inspiration behind becoming a physician was having a childhood friend die from Leukemia. She remembered having a strong desire to help her friend but could not. That experience propelled her into the field of medicine.

Doctor B. Doctor B is a male internal medicine physician with 22 years of post-certification experience and works with a corporate healthcare system. His current setting is an integrated healthcare model where he has access to behavioral health professionals to help manage patients with depression. Doctor B started his career in an underserved area of the city but is now working in a new country club location which serves a very different patient population. In addition to his role as a practicing physician, he also serves as a physician executive who oversees the operations and growth of the healthcare system’s community medicine clinics.

Doctor B is an only child raised by his grandmother. His mother was reportedly around during childhood, but not instrumental in his rearing. She suffered from depression and alcoholism. His uncle was a doctor and the inspiration behind Doctor B becoming a doctor. His uncle would take him along on trips around the world and showed him the lifestyle of a doctor. His uncle encouraged him to enter the medical field after realizing how much he wanted to take care of people and help them get better.

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Doctor C. Doctor C is a female internal medicine physician with four years of postcertification experience. She currently works with a corporate healthcare system as a floater physician. In her role, she provides system-wide coverage for other physicians who need time away from their practice. In addition to her role with the healthcare system, she is also president of a local medical society.

Doctor C’s inspiration to become a physician came from a substitute teacher. She had plans to become a physician assistant until a substitute teacher asked, “Why not become a physician?” Doctor C said, “It just never occurred to me, you know, that you need to shoot for the stars.” Doctor C didn’t recall any early experiences or awareness of depression in her family or community. She reported her first knowledge of depression was during college and then during medical school.

Doctor D. Doctor D is a male internal medicine physician who has 35 years of postcertification experience. He currently works in his privately-owned Internal Medicine practice. His inspiration behind becoming a physician was his older brother. Doctor D shared that his initial focus was pre-law, but his brother encouraged him to take a few pre-med courses, so he did. Surprisingly, he ultimately found the pre-med courses to be easier than his pre-law courses, so he decided to enter medical school. Doctor D denies any earlier awareness of depression in his family or his community, but looking back, he suspects his grandmother was depressed after hearing stories about her “breakdown.”

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Doctor E. Doctor E is a male family medicine physician who has practiced for 23 years and currently works with a corporate healthcare system. In his role, he uses an integrated healthcare model to treating depression in his primary care patients. Doctor E comes from a family of physicians. His father and his aunt are both physicians who influenced his decision to become a physician. Earlier in his career he recalled having a patient population that was approximately 80% AA, but more recently (and in a new role) his patient population changed to 40% AA. Doctor E shared that he has an aunt who lives with schizophrenia. Looking back, he recalled times when she was unstable and hospitalized. He also shared that his family didn’t provide a lot of follow through by encouraging her to take her medications.

Doctor F. Doctor F is a male internal medicine physician who has seven years of postcertification experience in the field. He currently works in a corporate healthcare system which utilizes an integrated healthcare approach. He works as a practicing physician at a community health and wellness clinic and serves as Area Medical Director for the same local healthcare organization. He describes his patient population as the underserved and predominantly AA. Doctor F is a native of Nigeria and came to the United States in 2007. He is the youngest of eight boys. He describes all of his brothers as educated, but he is the only physician. His inspiration for working the medical field came from his high school

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guidance counselor. Growing up in his community, he recalled depression being viewed as a sign of weakness.

Interviews When asked about their inspiration around their decision to become a physician (“Tell me about how you came to be a physician...your inspiration”), three participants reported being inspired by a family member (physicians and non-physicians), two reported being inspired by school affiliated staff (teacher or guidance counselor), and one was inspired by the loss of a loved one to a childhood illness.

When it came to the question of success (“How do you view your overall success in the field at this point in your career?”), all participants expressed some reward in helping their patients and promoting healthy living; however, the level of success in the field of medicine varied among participants.

Doctor D stated the goal of owning a business was achieved, but the field of primary care “hasn’t been as rewarding, financially.” Doctor B, Doctor C, and Doctor E all viewed themselves as successful and having accomplished a lot, while simultaneously pursuing new endeavors in the field (i.e. writing a book, executive duties, and community philanthropy and mentorship). Doctor F responded by saying, “Not quite... healthcare is not where it should be yet...working with the underserved and seeing what they go through...I think we can do better. That’s where the clinical failure is.”

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Being an African American physician.

The next section of the interview was designed to gain an understanding of each participant’s experience as an AA physician and, more specifically, to gather data that will help answer the first research question of the study, which was, “How do AAGP view themselves as African American physicians?” In exploring this research question, participants were asked: 1. What has been your experience as an AA in the field of general medicine?

2. What does it mean to be an AAGP to your African American patients?

3. How does race and culture impact your role as a physician?”

What has been your experience as an AA in the field of general medicine?

Several participants spoke openly, but briefly, about their experiences in the field of general medicine. Others did not address the question directly. Specific responses were around the idea of not being believed to be a doctor. Doctor F said, A lot of people don't believe you're a doctor. They say...Are you a doctor-doctor?

I say, “Yes. I am a doctor -doctor.” Some people when you say you're a doctor, they see you’re black they think maybe it’s PhD. So, when they say “Doctordoctor,” means “Are you a physician or academic doctor?” So, I mean, like, for me I don't see it like being a big deal ... an African American physician...because once you have the qualifications there is really nothing stopping you from practicing to your full scope, in a sense.

Doctor C responded to the question this way: That is a difficult question. Because it's all I've known. It’s the same way of moving through the world. I would say that I don't feel much difference between

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my non-person of color physicians, because we've all been through the trenches.

And essentially, if you made it through medical school, you’re board certified, everyone knows that it takes a lot to do that. So, you're not going to get anybody who isn't, what we call it, “up to snuff” with what we can really do. I think if anything, the challenge may come sometimes, if you are in (pause) for instance, I go to rural areas, as well, and if you are seeing people who have never been seen by a physician of color before, they just assume that you aren’t a doctor, or may assume that you're a nurse, or the medical assistant or something like that.

Doctor B shared a different concern, a concern about not knowing enough: Sometimes it's, it's getting over the initial, "Does he know what he needs to know?" I believe that there's a perception that African American doctors may not be as knowledgeable as non-African American doctors. I think that is not a universal thing, but I think it is a theme within our community.

Doctor B shared this story about one of his Caucasian patients which make him inquisitive about what his colleagues may think of him: ...she said that, you know, “when you became my doctor, I was concerned, because you know, I never had a black physician before. And I didn't know if I was going to stay with you as your patient. And she just said, you know, "It's because you were black." And I said, "Okay", you know, I said "So what changed your mind?" And she said, "It was the care that you provided me. I also had never experienced that kind of care before and that's why I stayed with you." And, you know, I was like...I never experienced racism... I'll say, direct racism, as a provider. So, as a physician, you know, sometimes you wonder if ...what’s being

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said or what you're saying or what you're trying to get your other colleagues and things to try to do or try to see or try to learn from... Are they accepting that from me as a… as a colleague of theirs? Or do they have some reservations, because I'm an African American provider?

Lastly, Doctor E responded by saying, I think that, in most instances, African Americans are proud to be an African American physician, understanding the sacrifices that individuals have undertaken to achieve their position or goal. So, you get some patients, though they’re very few I would say, want to try and take advantage of you because you are African American. For example, if I were to see a patient that I also attended church service with, outside of the office, they want to pull me aside and discuss some of their issue. They potentially ask for medicine or things of that nature.

What does it mean to be an AAGP to African American patients?

Many participants spoke candidly about the meaning of being an AAGP to their African American patients. Their unique experiences, however, hold varying meanings.

Doctor E explained the value he finds in having a primary care focus with African American patients: Well, you know, as an African American physician, I see a wide variety of patients. So, I have a piqued interest for African Americans. But just overall, the most… (pause) I think the most important thing as a primary care provider, which is different from a specialist, I believe, is the time that we should have to interact

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with our patients to get a better understanding, a comprehensive understanding of their overall concerns.

More specifically, Doctor E went on to share a special interest in male patients of the same race and why he finds particular meaning as an African American male physician: I think, as an African American physician and an African American MALE physician, I'm definitely more sensitive to the needs of African American men, especially as I get older, you know. I understand that, as African American men we’re more reticent or suspicious, rightly so, of the healthcare system. So, you know, I like to serve as an advocate and also alleviate a lot of the fears that we have as it relates to healthcare, because I do think that, on average, we are short circuiting ourselves or neutralizing ourselves, in many ways, because we are not seeking preventive care. And when we don't do that, you know, many things get missed...We're still in a field where we're less than 10% of the professionals are African American and if you look at the statistics, now, for African American men entering into medical school, the numbers are horrifying. There's been almost 38% to 40% reduction in African American males that have been admitted into medical school over the last ten years. So that's, so that's very alarming to our own culture.

Two participants highlighted the idea of a shared oneness around being culturally competent with the AA experience as a value-added component to being an AAGP to their African American patients. Doctor B answered the question of what it means to be an AAGP to African American patients this way:

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Umm...gratifying! I mean, I think when I see patients that look like me or they see me that look like them...that they feel more comfortable with those conversations of need or diet or family structure and things of that nature, that we can have more open conversations about what's going on, and what can we do to try to help with those conversations.

Similarly, Doctor C shared the benefit in understanding patient of the same race: I'm a physician who asked a lot of questions. And you know, if you're not culturally competent, you're not going to ask those questions. So, it may be some questions that I ask and [patients] have a look of surprise, like…surprised that I know. That it can be something as simple on the subject of haircare, you know.

“Why am I getting, you know, this type of damage? Why is my hair falling out here and there?” And I know what type of products to ask them are they using, you know, how they’re sleeping, you know, with their hair? Whereas if you don't have that cultural competence, you're not going to know to ask them, you might be like I'm just gonna send you to the dermatologists. I have no clue.

In addition to the value of having a shared experience, Doctor A responded to the question of meaning with a spiritual value. She views her work as a calling, not just a practice: I see it as, as almost as my mission... So, um...I look at it as somewhat of, you know…the way I take care of patients is important. And I look at it as a part of the way I also worship God, you know, as I take care of my patients and make sure they are taken care of properly and make sure that they know that they are valuable and honored. And you know, I remember when I first started out patients

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would tell me that they have never been touched by a doctor; that the doctor would sit on their side of the room and tell them what was wrong with them. They never ever touch them and stuff like that. You know, that's not the way it is now, but back in the olden days that's how it was, you know. So, I look at it. It's more than just a practice. It's almost a calling in a sense for me; the way I look at, you know, taking care of patients.

Tell me how race and culture impact your role as a physician.

In addressing the question about the impact of race and culture on the doctorpatient relationship, participants spoke to the impact on the AA patient’s level of comfort when it comes to opening up and being vulnerable in the doctor-patient relationship.

Doctor F shared his perspective on the impact of race and culture: ... When it comes to patient care and seeing patients of the same color and all those kinds of things, then it’s a different ball game… I think for me, personally, patients will, with the same color, will feel more comfortable opening up, you know, in the sense of confidence. Things that they would otherwise not share with other people, they are more... (pause) maybe more comfortable sharing that with me...I think as a human being, we’re all inherently biased. So, when you see someone of your color, you kind of warm up to them...It’s unconscious, right?

That's why they call it implicit bias. You just kind of quickly warm up with them, and then open up. I want to hear what they have to say. So, in that sense, I think it makes a lot of difference, you know. You get to know them deeply and even know of their secrets.

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Doctor D spoke of the impact of race and culture as it relates to communication and how he understands his African American patients: The basic difference in medical experiments is based on communication, how well the physician understands the patient and how the patient understands what the physician is saying, both in terms of motives and background. So if you're talking to someone whose motives you question because they don't seem to understand you or they don't talk in terms that you can relate to or don't understand, you know, some of the things about how you…(pause) even…(pause) sometimes not even lack of understanding, there’s a fear of not being understood, that I think causes some people to be less open about discussing more personal issues with a fear of someone who’s going to use their bias to make a decision about you, as opposed to actually listening to you and hearing you. And that's, you know, I think physicians of color tend to be more sensitive to that concern.

Doctor A shared her perspective on how race and culture impact the level of comfort in her relationship with African American patients: I think they feel comfortable, because I am black. I think... I was talking to the patient today, about going to see a therapist and we were talking... and I was sending her to see a black therapist and we were talking about there's a reason why all of us can listen to Tom Joyner radio and understand exactly what is going on. Because we had the same, you know, kind of experiences. We understand what he’s talking about, you know. So, you know, I was telling her that, because I wanted her to feel very comfortable, because she said she had some issues that she was talking about, you know, that I felt that, you know, going to this African

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American therapist would help her out and that she didn't have to go through that, you know, jump that kind of river there, you know, understand what we mean by saying certain things and things like that. So, I think that’s part of it.

AAGP’s role in the lives of African American patients.

In an effort to enhance the researcher’s understanding of the second research question (“How do they understand their role with African American patients with depression?”), the researcher asked the following interview question: “What message do you receive from your African American patients about your role in their lives?” This question was used to understand how AAGP view themselves in this phenomenon.

All participants spoke warmly about their role in the doctor-patient relationship, but their responses yielded various messages. The most frequent response was that participants felt their African American patients viewed them as part of their family, while other responses reflected roles like a good listener and an advocate. Here are a few responses that address the role of family in their patients’ lives. Doctor A said: …One of my patients who had a stroke and is in a rest home--I try to go see her once a week. Her mother said to me, you know, you’re part of the family. And, you know, that’s important that they see me not just as a physician. Because they see me as part of the family, they trust me more, I think and I have to make sure I live up to that trust, you know. [They know] I'm not gonna do anything to hurt [them], you know. I'm in [their] corner. I like that I'm part of the family... they treat you like family. We had one patient about six weeks ago...we take care of her, her husband, her brother-in-law, her daughter-in-law and she decided that we

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needed to have lunch. She brought us lunch. We didn't even know she was coming. She put the tablecloth on the table, and she brought us lunch and that was just kind, you know.

Doctor F echoed a similar message from his African American patients: My patients think that I’m like part of their family. Like, I mean, a lot of patients I’ve had the opportunity of taking care of have such a level of confidence that they can tell me anything about themselves about their family, you know. Even when they go through (pause) like husband and wife go through stuff. So, when they go through life, husband and wife go through stuff, they share with me and it’s not like I probe them for any questions. It’s just kind of natural. They can’t wait to tell Doctor F on Tuesday for example. They come and they just share. So, I would say they can really appreciate that kind of level of trust, that level of confidence in the relationship that we build overtime. I have people, show me pictures of children, their grandpa... and they say, Oh, I would like you to meet my son. So, it's like family, you know. It's like they see you as part of them, you know, and when I reduced my clinical days, some of them actually cried. I mean, they told me that, you know, they don’t want to see anyone else. It's like starting a new relationship...I mean one of them describe it as...like, a relationship that is kind of …(pause) How do I say it ... without being thought as crazy?... Like a girlfriend and boyfriend who broke up (laughter).

Doctor D described his role as being a listener and building patients’ trust, despite the time restrictions of a primary care setting.

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Well, a lot of [patients] are very appreciative of the time I have taken to listen. I think that's the biggest difference I make. I hear from patients all the time about the difference I make in their care or what they appreciate in the care that is provided, the willingness to listen to them. I think that's the biggest difference. I listen to them and not look at my watch even though I have the same restrictions, financially, as everybody else does. I try to give them the impression that I’m going to take care of your needs in spite of the time, you know. In the end, once patients trust that I’m doing that, time is not that much of an issue. They take more time or less time, as long as there's enough time. They trust that what needs to be done will be done.

Additionally, Doctor C spoke on the role of advocate in the development of trust in the doctor-patient relationship: I think if anything, it's like this understanding that I have with them that they have an advocate, you know. I'm not going to give you anything that I don't think that's going to work for you, you know. If I think it's going to be too expensive, I'm gonna let you know, you know, double check. So, I think leaving feeling like, “I have a true advocate for me” ... that trust they need in their provider.

Impact on sense of self.

As relational theory focuses on the role of relationships in the development of overall well-being, the third research question (“How does the patient-provider relationship impact AAGP’ sense of self?”) aimed to understand the impact the patientprovider relationship has on the participants’ sense of self. According to Mitchell (1988),

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“… individuals have a powerful need to preserve a sense of oneself as associated with or related to a matrix of other people with regard to actual transactions and internal presences” (p. 33). As mentioned in Chapter Two, one’s need to establish and maintain a sense of self is nurtured by connection and relationship with others that forms the basis of one’s confidence, self-worth, and sense of safety. The corresponding interview questions were: 1. What are the challenges, if any, to being an African American physician to your African American patients?

2. Are their benefits to your African American patients?

3. What is it like for you to have an African American patient who does not respond favorably to depression care treatment?

What are the challenges, if any, to being an African American physician to your African American patients?

In their desire to help their patients, AAGP in this study shared a number of challenges to being an AAGP to African American patients. Reported challenges included managing patients’ socioeconomic issues, mistrust, resistance, and time limitations. These challenges resulted in participants feeling frustrated and overwhelmed in their role as AAGP. Managing patients’ socioeconomic issues was reported in the context of patients who had low education levels, were uninsured or underinsured, or had limited financial resources. Various responses from AAGP’s experiences are listed here. Doctor A shared this:

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Some of the challenges are that we may not have all of the resources we need, you know, or that sometimes we can't get some of the medications I need to give... But I think that I've been here long enough that... people know that they can trust me and that I'm not going to do anything to them that going to harm them. But I think trying to figure out how to get the right medicine, because a lot of our patients don't have, or may not have, the best insurance, you know. [They] may not understand why that’s important, may not understand why, you know, why we've got to change your diet, why that hasn't gotten better, or why it's import to be healthier and eat healthier and what you do affects your kids and stuff like that.

Doctor D spoke about the economic, educational and social challenges of just living in the AA culture, resulting in a greater need for psychological assessments. He suggests, maybe offering an annual psychological assessment as one would get an annual physical: ... African American patients probably have as great, if not greater need for psychological assessment and counseling as the general population, and the burden of disease that is considered to be greater and most every disease you look at seems to have more negative outcomes in African American community, partially probably because of the challenges, economically and educational and social stress that is involved with living in this culture. So, I would suggest that, you know, people should look to offer, and more quickly, support psychological services for people of color. And just educate them. Maybe it’s not, it's not for counseling, just one assessment, but I think there's a great need for, you know, just like people coming in for physical exams, on a yearly basis.

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Doctor F shared the challenge of working with uninsured patients and the barrier that comes with that population. They often come in for treatment when it’s too late, making it difficult for him to adequately help them: In my practice I have more African Americans than… I want to be careful not to stereotype. We are an uninsured clinic and unfortunately, we have more African American that are uninsured so that’s why the clinic has more African American population. So, we see this all the time. And it's kind of turning your brain towards ...that is what my people do, they don't listen, you know, they don't take care of themselves the way they should. Umm... But again, when you asked about a patient, we will see, sometimes, maybe we get to them too late, you know, because they are uninsured. They're scared to go to the doctor, because if they do, they're gonna get a bill they can’t pay ...until they are now forced to come and by the time, they come they are already very sick.

Doctor F shared a description of the challenges he faces with African American patients in his practice. He illustrates how the patient’s social factors impacted his emotional and physical health: It's not just like I said, not a biology, depression with some chemical imbalance.

These are things that are influenced by the environmental factors. You know, this is the anniversary of my son's being shot, dead or something. Or, you know, I'm about to lose my home. You know... or I don't even have a home, you know... No transportation, and then I just don't know how to deal. And there was one of my patients who I remember very vividly, you know it’s very, it's hard. Actually, I don't know if it’s hard or not, but......for men to just cry, you know, that’s not

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common, right? ...And I thought it was going to be a quick visit, you know…I walk into the room... he’s crying...I'm like what happened, you know? He's like, I'm just tired of waking up and have to borrow toothpaste for my neighbor. And I'm like, "Really? I've never heard of that. Is it that bad? So, a lot is going on. I mean, you are a 51-year-old prime man...wake up with nothing to do for 24 hours or 12 hours. It is a lot of things going on. A lot of things impacting why they are in that state when they come to the clinic. And as you know, with all that's going on, anxieties come out and there's a lot of other things that are wrong with all the hormones going around and driving blood pressure up. So, we just have to do what we have to do.

Patient’s mistrust in the healthcare system was a commonly reported challenge shared amongst participants as well. Doctor B and Doctor E both contributed AA patient’s mistrust in the healthcare system to historical events. Doctor B shared, “[Mistrust] goes back from just, just history, and the Tuskegee trials and things of that nature... still known, especially in our older population.” Doctor E shared his perspective: I think historically, if you look at the history of African American men and healthcare, it's been marred by...um, it's uh...unfortunately, African American men have the bad end of the stick so to speak. And with that and the characteristic of African American men or black men, you know, by nature we are... we are not as trusting...I would definitely say that African American men are the most challenging as it relates to mental health because of many variables. One being the color of our skin and the profession is predominantly white...the trust is in many instances is not there, at least not initially. So that can be a barrier

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especially if uh...there's also a cultural piece. There is an issue as it relates to African American men and uh Caucasian males or any provider from a different culture, you know. You know, we have many providers from India, who... who may not... may not understand the African American experience, as much. So, that becomes another barrier of lack of understanding...and for that reason [they’re] even more secretive or reticent.

Challenges around patients’ resistance to care were discussed more specifically in the context of religion, lack of acceptance and stigma. Many AAGP echoed the influence of the church. Doctor A shared her perspective on the church and its impact on patient’s perception of depression care: I think also some of the challenges as far as, especially when you talk about mental health, um ...sometimes the church, depending on what church it is, can be a hindrance. And people will tell you that you can pray this away. And, you know, you don't need to go see anybody about this, you just need to pray harder.

Trying to get rid of some of the myths that we have in our community also can be difficult...So, I think [depression is] much more acceptable than it used to be, but still have people come in and tell me that, you know, they've been told to pray it away and all of that, you know.

Doctor B shared his perspective on the impact of the church on patient’s perception of depression care: For some of our population, they're very ingrained in the church. And that can be a help, but sometimes it can be a hindrance. Because it's depending on their, on their church and with their philosophy on mental, mental health and it may be that

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they feel that they can only be taken care of through prayer or through continuing to do activities related to their religion in order to get better.

Doctor E echoed a similar challenge with patients’ resistance and preference to turn to the church for help with depression instead of seeking help from a mental health professional: A lot of my patients have strong faith or were raised in the church. So, they would, they would sometimes prefer to see their pastor than a psychologist or psychiatrist. And I think that the pastor can play a role. But they cannot replace the psychiatrist or psychologist.

AAGP in this study also reported the challenge of patients’ resistance to treatment due to stigma. They shared a lack of acceptance in the AA community as another challenge presented. Doctor D shared his perspective on patient’s resistance to depression care and non-compliance: One [challenge] is making it more culturally acceptable, that you might need assistance, dealing with things mentally. That's still big in our culture, especially if you have to take medication for that, you know, even just going to send someone to see a therapist, you know. Someone might say, “well, that's just crazy.

Yeah, that's just, that's just for crazy people, I don't do that.” It comes across better if it's someone who is of the same culture, the African American physician that’s seeing you. That's just a fact...I think there is a lot of under diagnosis in terms of patients coming in and not realizing, not wanting to accept that part of their problem is depression. So, I think there's a lot of denial in our community about depression. I think it's just as real as the community at large. Probably a

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huge percentage of our patients deal with it in their own way, but not that many take medication for it...Sometimes patients want to be excused for not being compliant, because, you know, that's something... that ethnic proclivity... and I think the doctors for the same ethnicity would understand why they didn't take the medicine because they know that perhaps a lot of people in our family to take medicines based on symptoms more so than on doctor's recommendation. So., I think sometimes an underlying license to…(pause) you know, to be more negligent based on cultural norms, as opposed to being more strict and compliance based on medical training. So, it sometimes creates a lot of stress between patient and doctor. If the doctors feel this treatment has to be complied with based on medical recommendations, as opposed to patient feels like they need to be taken based on cultural norms or cultural history. So, our culture is not the most accepting of scientific dogma.

Doctor A addressed the stigma of depression as a challenge to getting her African American patients to accept treatment: I think [the word depression] it means that there is something very much wrong with them and they are not ready to hear that. And they may have had experiences in the past where somebody who was depressed, or they have gotten the message from someone in their immediate family or, you know, surroundings that that's not a good thing. So, you know, you don't use that word, you know…you got to use a code word because if you use the word depression, they're gonna shut down on you, so you say “you got melancholy” or something like that. You got to come

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up with a different word depending on who you're talking to and know what word you got to use with them.

Doctor F experienced a similar challenge with patient’s resistance to accept that they are depressed: Some people feel that word depression… it has a stigma and they don't want to be associated with it. They say, "no I'm not depressed. I'm just going through life, you know. It's going to be alright. When I have money, it will be okay” or “when I get this job, I’m gonna get better.

Time limitations posed additional challenges for AAGP. Participants shared that a standard patient visit for primary care is 15-20 minutes with some, but few variations.

Those working in private practice reported having more control over the length of patient visits than those AAGP working with corporate healthcare organizations. Nonetheless, the challenge of time constraints was reported by each participant.

Doctor F spoke to the challenge of time constraints particularly when a patient is opening up about personal struggles and said, “Remember, you're bound with time, you have 15 minutes. The patient is telling a story of what's going on in their life. That’s not a 15-minute conversation.” Doctor E felt his role as primary care to be able to provide whatever the patient needs, but this part of his role is challenged by time constraints: So, whatever [the patient] needs, I should be able to provide that in the scheme of what I'm able to do as a primary care provider. And It shouldn't be a situation where you come in to see me and I'm cutting you off, because I've got to go to the next patient.

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Doctor C spoke about the challenge in her role as a floater physician. She can build the connection with a patient during the visit, and then she has to move on to another practice location: I don't know about what necessarily call it a challenge. But what you may get is that a patient may come in for one thing and then when they get really connected to you, and they want to bring everything they ever wanted to ask, you know, with their previous doctor, but may not have felt comfortable with it, or may have not thought of it. So, the time limitation really becomes a factor with it, or they make a connection. And once you see them, they want me to see them as my regular patient when I have to say I'm not taking regular patients, you know, so it's almost like seeing this really good thing and making this connection, then I'm poop‌on to the next one.

Doctor D shared his challenges with time even in his privately-owned practice: People perceive that you're paying more attention to the clock, then you are to their conversation...I think sometimes you can spend an hour with the patient, and they're frustrated, because they're-- they want even more than an hour. Then uh‌then you just have to kind of let them know you have to, you know, draw the line someplace.

Overall, the AAGP in this study reported several of the same challenges in treating depression in their African American patients. Challenges were connected to factors like low socioeconomic status, mistrust, resistance to treatment (religion, lack of acceptance and stigma), and time constraints.

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Are their benefits to your African American patients?

When asked about the benefits they bring to their African American patients, participants felt that having a similar cultural awareness provided them the opportunity to build more trusting relationship bonds with their African American patients. Having a sense of likeness and understanding of patients’ culture fosters a stronger bond or connection in the doctor-patient relationship, which makes AAGP safe individuals with whom African American patients can share their feelings and stories. Doctor F shared a patient story to explain the level of trust he establishes in his doctor-patient relationships: I have a patient who... was having rough times with his wife and he would come and share with me before he will share with his pastor, I mean, he told me, like, he just feels so comfortable. I mean, to... you know, see what is going on and what was going on in his life, his wife and his marriage and all that. He had shared that with me even before he shares that with his pastor. So, that shows the level of trust, the level of confidence and the level of relationship, you know, how they really feel like it was a psychological safety area, for them to share even that intimate part of their life with their doctor, you know...I mean, not all, I must confess, but there are some patients I do look forward to seeing. Like when they are on my schedule, I feel like I want to kind of continue from where we started. I think that is also part of why people want to continue to be primary care, because it is very rewarding, especially when you do have this bond with your patients.

We went to medical school, we didn't even know what (pause)...like, where life is taking you. So, it is different until you choose your path after medical school and you chose to be an internist or family physician or something. I mean, we have it

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in theory, that you're gonna bond with your patients, you're going to be in their life and we saw examples of mentors who are doing the same thing and that is what we'd like to mirror. But being in it yourself it is different, you know.

Doctor D shared the benefit of cultural similarities as a means of enhancing the level of empathy he may have for his African American patients: Well really (pause)...to care for the sick, [to] care for anybody is a lot more successful if he has some empathy for their condition. Regardless of the person's ethnicity, the empathy is much more likely to be there if there's some cultural connection.

Doctor E shared that he also values the benefit of having the same culture with his African American patients and the impact such similarities have on building strong doctor-patient relationships: Well, typically being from the same culture, having similar experiences, sometimes the same faith-based organization, all those commonalities help to enhance the doctor-patient relationship with our culture, our race.

Doctor B asserted that AAGP provide a unique experience to African American patients that providers of other races may not be able to provide: We also have ah...people in our community that do, however, feel that African American providers provide a unique service, in the aspect that [we] have lived the lives that they live. So therefore, hopefully being able to bring about a personal perspective to their care where non-African Americans may not be able to do that...Being African American, having had the experience of living in an inner city, living in a rural area, growing up without having a whole lot available

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to me and then also being at a... at a point where things have been blessed for me, as well as my family. So I think I come from all of those perspectives, understanding some of the diet constraints or the things that we may like to think that we like to eat, and how that affects our health, and trying to give advice or ways to work around that, instead of just the blanket set of "well this is what you need to take" type deal. I think those are some of the main benefits of that and understanding the psychology of our society. And as growing up as an African American, you know, the struggles, the stressors, the things of that nature that some of our non-African Americans may have learned but may not actually have experienced.

Doctor A valued the benefit of speaking the same language as her African American patients: We know what we mean by saying certain things, you know. I know what it means when, when you're eating certain things. I know what it means when Homecoming comes. I know what all those words mean and, you know, what they also mean as far as the diet and stuff like that, you know. I think we're just more comfortable with each other because we speak the same language.

What is it like for you to have an African American patient who does not respond favorably to depression care treatment?

Participants shared their experience around working with patients who do not respond favorably to depression care. Many of the responses revealed feelings of

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frustration. Doctor B described his struggle with patients’ resistance to care. He said his strategy is to put the onus on his patients to do their part: It's a struggle, because you really... You want them to try to feel better and do better as well. Umm...I do put some onus on my patients, though, and I tell them as part of the team. That means that [they] have a part and a role and how this goes as well. So, it can't be just us, you know, just saying you have to do X, Y, Z, we need to know what you're able and willing to do. So, they are really resistant to therapy, but yet their diabetes isn't getting better. They're not sleeping well.

Their back is always bothering them. They're always having a headache...and these are things that are...can typically related to depression and I try to say that, you know, medicine isn't always going to help all of these issues.

Doctor D shared his frustration with African American patients who are resistant to treatment. In many cases, these patients perceived their condition as physical and rejected the idea that is a psychological need. He stated: Yeah, you know, you see a lot of patients who don't do well, their medical condition continues to flounder, and they see worse complications as time goes by when they have depression issues that interfere with them taking their medicines or keeping appointments. And so, it's frustrating...So, it's hard for them to see [their depression] and it's hard for you to convince them of it during conversation, particularly as an internist. I mean, many of them come here with the idea there's a physical, biological, you know, problem as opposed to a psychological problem.

So, they're convinced of that before they get here and if I try to convince them otherwise, that sometimes is difficult, if not impossible, to do.

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Doctor A describes her experience with resistant patients as difficult. Her strategy is to bring it up a little at a time to avoid losing the patient: That can be really difficult. I have a patient right now, who won't go to therapy and she won't take medicine and when she comes in it's almost like a joke, you know. I say, "well are you ready to do something about this now?" It's almost like a joke. She laughs and says "No, I'm not ready to go." She got a lot of stuff going on and she really needs to get out, but you know, all you can do is try to work them. I find that if you kind of bring it up a little bit...well, it depends on who you are talking too because if you bring it up too much, then they stop coming, okay.

But if you bring it up a little bit at a time maybe right at the end of your visit say a little something about it sometimes you can eventually get them to, you know, do something. Sometimes they'll go and see somebody.

Integrated care.

The Center for Integrated Health Solutions (CIHS) refers to primary care settings as the “gateway to the behavioral health system” and asserts that primary care providers need support and resources to better serve individuals and the solution lies in “integrated care.” Integrated care is defined by CIHS as “the systematic coordination of general and behavioral healthcare” (SAMHSA). The fourth research question (“What attitudes and beliefs do AAGP have about behavioral health and their role in working with therapist, like social workers, to ensure their patients get treatment for depression?”) was designed to better understand each participant’s inner thoughts around integrative healthcare and

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working with behavioral health professionals. During the interview, participants were asked the following corresponding questions: 1. “What does it mean to be an AAGP in the era of integrated healthcare?”

2. “Which type of depression care treatment do you consider for African American patients?”

3. “Share your thoughts and feelings related to working with and referring African American patients to mental health therapists.”

4. “How receptive are your African American patients to various depression care treatment?”

What does it mean to be an AAGP in the era of integrated healthcare?

It is important to note that four of the six participants worked for corporate healthcare organizations that utilized an integrated healthcare model on a daily basis, while the other two participants owned their own primary care practice. Those participants who worked under a corporate healthcare organization had access to behavioral health professionals within the same healthcare organization, while those participants in private practice were responsible for conducting their own networking with behavioral health professionals in the community. Corporate AAGP reported a higher level of comfort and success using the integrated model. Doctor B noted: ...it hasn't been difficult for me to approach that topic with my patients. I think it’s very important to understand about depression and if it's impact on their life because it impacts their health... So, if we can get them to understand that it's

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okay to discuss this and I really need to discuss it, that helps in their overall management of care.

Doctor E, another corporate AAGP, commented on the experience of managing depression in primary care and the integrative care approach, particularly around the idea of teamwork and support: Well, I think now it's not as different, because it's not all on just me, as the physician, you know. So, I share responsibility. So, in that sense, you know, let us as a team, get together and let's decide what's best for this particular patient.

That’s the way we try and maneuver when we’re dealing with patients that are, you know have some mental issues, such as depression, severe depression and anxiety.

He also shared a challenge that he has experienced with the integrated healthcare model: I think one of the things unfortunately, with health care is cost. So, for example, I have a patient whose insurance will only cover six visits for behavioral health therapy. But this person may need 12 to 15 visits, you know, this person needs to be seen initially twice a week, you know, and you're only going to give them six total visits? So managed care is a big hindrance to the integrative model that we tried to present and promote.

The two private AAGP had a different experience with utilizing the integrative healthcare model, particularly around limited access to behavioral health professionals. Doctor D spoke of his challenges with limited behavioral health resources in the community and a desire to have a behavioral health professional in his office:

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Behavior health is a real short supply in this community. And so, finding a model that works for behavioral health has not been… we haven't been able to find anything that works for behavioral health in this office. It would be nice. We have a few…I have a church-members who is a clinical psychologist or social worker.

And so, when we have other people who refer to. It would be better if they were physically part of the practice, or at least, you know, in some much more rigid relationship than what we have. Unfortunately, there's no real authority that, I mean, we've got, for example… we're part of a group of an organization called the North Carolina Primary Care of Network, NCPCN or something like that. And they talked about helping us build relationships with psychology, but it has not panned out. There's no, there's no entity that in this community where there is an effort in the community level to provide psych services for primary care doctors in general. If there is, I'm not been made aware of it.

Doctor A explained her challenge as the need for more black providers who are comfortable having conversations about depression and more healthcare providers who feel comfortable writing prescriptions for depression and, therefore, increasing primary provider’s success in treating depression: We are very lucky and blessed in [this town] that we have, you know, psychologist that we could use. And we do, we do have at least one psychiatrist...you know, black psychiatrist in town that I know of. So, you know, we are lucky that we have these people, but the deal is that. The deal is that a lot of these patients, you know, I can start them on medication and get going and get ‘em in to see the psychologist and it has turned out pretty good, but I just have

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people who don't have skills or the knowledge to know what medication to put them on or what I've put em on hasn't work and I need to get them in to see the psychiatrist and the waitlist to get them in to see him is just too much. And it's just so sad, you know, that that person is suffering, you know, that period of time, you know.

Which type of depression care treatment do you consider for African American patients?

When asked which treatment options each participant offered to African American patients, all participants responded in support of a combination of medication and talk therapy as their preferred treatment method. Doctor D elaborated even more on the importance of counseling in the long run: Primarily, I think that the counseling is important. And it's my perceptions, my insight is that the counseling is more important in the long run than the medication. But they need both, you know, it’s probably because counseling is (pause)‌ because patients, in my experience, don't usually comply with the medicine 100%. So, they'll need some support to make sure that they understand that they need to continue the medicine. But I think the treatment itself is most often times viewed as just taking a pill as opposed to having counseling and a pill.

And I try to encourage patients to just seek some type of psychological support, as well as taking their medications. Some come back three months or three weeks later and say, Hey, I'm doing better now, can I stop [the medicine], or I did stop [the medicine]. They may tell me a year later, or when I see them again, that they

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stopped the medicine and they felt like they didn't need it anymore. And they may be doing well, and they may not, depending upon personal issues. So, I tried to get patients to...(pause) sometimes I'll prescribe that and then refer to counseling because I have a little bit better comfort level, if I know someone's going to get some counseling.

Doctor E shared a story of a patient who was offered both medication and talk therapy as part of the integrated healthcare model. This encounter occurred after several office visits and several attempts from the AAGP: So, with her, you know, I talked to her again about where she is and the need for her to maybe get on something to help elevate her mood. And then getting that person involved with our psychologists and our other members of the team. So, she was willing to start medicine. And I try to make sure that she understands what she's taking, when she's taking it, why she's taking it, and getting her immediately with some of the other members of the team to kind of follow up to support some of the things that I've set in place.

For patients who decline both medication and talk therapy, Doctor C has an alternative approach to treating depression: I usually try to have once a week follow up. So, we kind of establish what's going on...Some people might say, “you know what, I don't want to talk to anyone else but you. I only feel comfortable opening up with you.� And that's fine, and we work through what's going to be your therapy schedule.

Doctor C shared her approach in more detail:

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It is another way to do that. And sometimes people don't think of those ways in terms of lifestyle changes. Are you exercising? What do you do to get your mind off of things, you know, are you sleeping more, are you eating better? It’s just so many factors that go into your mood and depression. It's not just life, you know.

So, if you kind of map it out for them and type it up on their after visit [report]… I would like you to at least try to eat twice a day. I would like you to at least try to get this number hour of sleep. If you can, I’d like you to try this, you know, read a book, you know, write something down. When you come back in a week, I'm going to give you some homework, tell me what you did to try to get better sleep.

Tell me what you did when you started thinking about your mother who passed away, when you couldn't stop crying. So, you give them a little homework a little control of the situation, I think the partnership is a bit better...Most of the time, they're relieved that somebody else noticed it and cared enough and put the label on it for them. Because a lot of people don't come in and say, “I'm depressed.”

They'll give you the entire description. They might be giving you the whole, all the checkbox, until someone says, “You know what, everything that you told me really checks off the box of a major depression.” So, it's a relief for them. Then I'm able to print out information, resources for them. If we haven't decided on medicine, then I tell them what the options are and send them home with information about those different types of medicines and basically just have a more informed choice.

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Share your thoughts and feelings related to working with and referring African American patients to mental health therapists.

Each participant shared experiences with working with and referring their patients to mental health professionals like clinical social workers. They all valued the role mental health professionals serve in the integrative model, but also shared some challenges.

Common responses in this section of the interview included limited providers, lack of feedback/teamwork, and cost barriers.

Overall, a lack of behavioral health providers was the most frequent response for AAGP when discussing their experience with referring patients for talk therapy. Doctor C elaborates on the impact of not having enough behavioral health providers in the field and more specifically behavioral health providers of color: We love our behavioral health professionals. I think the biggest thing is just not a lot of resources... If I was to see a patient today, and I was like this patient needs to be seen someone like today, it can't be done, you know. It can't be done. If I feel like I am concerned that this patient is going to be a harm to themselves, I have to recommend that they go to the emergency room, you know, and then that just opens a whole other can of negotiating with the patient. The need specifically for psychiatrists, and psychotherapists of color is really in need. I think, from my perspective or from the perspective of some practitioners of color, it is that there's something to be said for a patient to be evaluated, treated or managed by someone in their culture that's familiar with their culture, especially when you're dealing with, you know, depression, anxiety, or just needed some guidance on, you know, getting through life. So, I personally integrate [behavioral health] a lot.

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Doctor D shared his experience with referring to behavioral health professionals like clinical social workers. There is a shortage of behavioral health professionals available to independently owned practices and at times when providers are available, he does not feel the relationship is maintained due to lack of commitment on the patient’s end: I think a closer relationship with psychological services providers would be helpful, if I saw someone who I thought was having a problem and they were not convinced and I had a busy schedule and felt like I needed to get on to the next patient, instead of me trying to spend 20 minutes just trying to convince them they have a problems. I’d say, “Look, you got some issues I think we need some help with. I want you to see such and such a person on such and such a date and after you see that person, we can talk some more about what to do about your blood pressure or diabetes or insomnia or pain.” And depending upon their relationship with the therapist, then they may not, may or may not feel comfortable with that.

A lot of people have trouble having good relationships with therapist because of social issues and that empathy issue that I was talking about. So many of them may not follow up with therapy as much as they need to, but they do so during crisis period, but not in the long-term basis.

There’s a lot of psychologists and social workers who will see patients but they don't prescribe and those when I do find someone who does prescribe, it's, it's gotten to the point where my patients come back, Often complaining that they just got a prescription and no real relationship with the psychiatrists. And that's just a problem of psychiatry in general, because that's just the nature of psychiatry.

Sometimes I, again refer to psychiatry, I get the impression that they’re gonna go

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and they're gonna get a brief encounter and a medication. Or if that doesn't happen the first time it will probably happen on follow up visit. So, they will often just get a brief encounter and prescription as opposed to an empathetic discussion that makes them feel like their psychiatric needs are being addressed.

Doctor A shared particular success with mental health professionals who are Christian based: You got to make sure that they know that you're hearing them...you know, some of the therapist that we have in town also have very uh...are Christian based in a sense and that makes [patients]also more acceptable too.

Another common response among AAGP centered around the importance of teamwork and feedback provided by mental health professionals as a means of enhancing continuity of care. Doctor E shared his perspective: I think that the key really is for everyone to work at their highest capacity. With a psychologist or a psychiatrist, the same‌ or social workers, for that matter‌ being able to, to trust that if I refer a patient to you that has issues with some family dynamics need to be explored, so that I can have a better understanding of what this patient needs, so I can help them even more. So I send that person to you and then I get a report back that gives me that understanding that I'm looking for so that I can make a better decision as to sending this person to the psychologist or the psychiatrist are maybe getting them in, instead of outpatient care, this person actually needs some inpatient care or one of the issues is that this person is so impoverished, that they're not eating at night. So, all of those dynamics, you know, I don't see with the view that I have. So, it's so important

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that the social worker, they're able to do what they do and do it at a high level and get those reports back when needed.

I think the biggest, the biggest component that we need to improve [the integrated healthcare] model is when you're referring out to other specialists, and that collaboration, and that's why it's important that you have a set of providers that you feel confident in that you believe in as a sub-specialists, that you've worked with and they've worked with you.

You do what you can do, and you don't get overwhelmed. And understanding that, you know, you're one piece of the puzzle and certainly, you may play a larger role than some of the other pieces. But you know, you have to allow, you have to allow those other pieces to feel like they can, they can add to the equation as well. So, that's my style, I don't want to micromanage, but I like to have very strong individuals around me. So, you delegate responsibility. You know that person is going to get the job done.

Doctor D echoed the need for feedback from behavioral health professionals in collaboration on patient’s behavioral health needs and stated, “I think our best relationship, best care is provided when the specialist does make an effort to send records.” Doctor D further spoke specifically about cost barriers associated with making a referral to a behavioral health professional: That's the problem with a lot of private psych providers is that, you know, they don't accept insurances. I mean, I get paid by all insurances. And then you know, patients who don’t have the resources, you know, I can't pay out of pocket and

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that just decreases the availability of psychic services. That's why I'm sure there's not as many providers available as that could or should be.

How receptive are your African American patients to various depression care treatment?

Despite AAGP’ preference to treat with a combination of medication and talk therapy, many participants share that African American patients aren’t always receptive to their options and are more likely to resist medication than counseling. According to Doctor E, “Most African Americans are resistant to antidepressants or anxiolytic agents...

There is an educational piece that's not there.”

Other responses included the importance of communication and delivery to reduce the stigma and the importance of the relationships between the AAGP and the behavioral health professional on patients’ level of acceptance to a referral. Doctor F explained his challenge and his solution to offering depression care treatment options to his patients: It depends on how you tell them, like I say. If you give them the message like "Oh, I'm gonna send you to a psychiatrist"... now you're dismissing them, or you're pushing their care to someone who may or may not care. If they think you already care about them. You have just broken that trust, you know.

A lot of our patients don't really want to accept that they are depressed. So, when you bring it up that they need to see somebody, it's like "oh." Once you bring that up it takes that conversation to a different level of "Is it, is it that bad?" ... kind of, you know, like "can't you at your level help me? ...when you mentioned

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psychiatry they're also like "Am I crazy?" you know, "Do you think I am crazy?" or something like that. So, and that stigma is one they don't want to associate with. So, you have to have the right way to deliver such message and such care.

And, so what I tell them, you know, my patients are (pause) sometimes psychiatry is not there to see crazy people. These are people in the office who help you go through this hard time, you know, in the best form of way, so that you can have relief quickly. And that’s all I can do at this level is issue medications, but they have other tools that I don't have that they can use to help you. So, if you should say that, they are like..."Oh, okay.

Doctor D asserted his relationship with behavioral health professionals plays a vital role in getting his African American patients to accept a behavioral health referral. He noted, “As long as [patients] know that I have a relationship with that other person, most of them are pretty okay with [a behavioral health referral].”

Culture and its Impact on Treatment Comstock et al. (2008) asserted that Relational Cultural Theory (RCT) supports the notion that participation in mutual empathy and growth-fostering relationships is vital to one’s human development and psychological well-being and is linked to one’s racial/cultural/social identities. This theory supports a type of relational responsiveness that utilizes anticipatory empathy. In an effort to understand the fifth research question (“What are the feelings, thoughts, and behaviors that depressed African American patients evoke in AAGP and how do these feelings, thoughts, and behaviors on the part of

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AAGP affect the treatment process of their patients?”), the following interview questions were asked: 1. What are your earlier experiences/exposures with depression as part of African American culture?

2. Tell me how you think depression was viewed in the African American culture?

(Earlier experiences with family, friends, self, community, etc.)

3. How was depression managed?

4. What factors play a role in your choice of treatment for depression in African American patients?

What are your earlier experiences/exposures with depression as part of African American culture?

In sharing their earlier experiences and exposure to depression, AAGP spoke of various memories that ranged from having little to no awareness of depression in their community to having close relatives who lived with depression or other mental health diagnoses. Doctor A responded, “I don't remember any exposure to [depression], if I was, I didn't recognize it. I'm sure it must have been around, but I really didn’t see it.” Doctor D shared his earlier memories and thoughts of depression: Where I come from depression didn't exist. I remember when I was a kid, we used to think about (pause) hear about people with psych issues on the soap operas and the larger community at large. And I used to even in a conversation with family, get the impression that we just didn't have those kinds of issues in our community.

We were much more solid psychologically, but as I think back on community,

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and the different people in the community: the alcoholics, the single parents, the young kids who ended up going to prison, getting in trouble, I mean, it’s all around us., We just were in denial about it. But as a professional, and you know, I guess that's how I see it now. Again, but at the time, there was no real awareness.

And my grandmother, I believe, had an episode of decompensation not too long after she started having her children. That was before I was born, but my mom oftentimes would mention that she, you know, was in bed for a while, because she had a breakdown.

Doctor F shared his experience growing up in a small family-oriented community with lots of support: So, I did not grow up in a very large environment where people talk about [depression]. In my very, very local confine I could see that people really don't like the word depression. It is like a sign of weakness. Now, "how can you be depressed?" You know, like "what you're talking about, you have all this beautiful family, everybody's here with a lot of support, you know, depression does not run in the family. So why are you depressed?" You know. So, you can say, "Oh, well, I'm going through this" and then with family support, you should be fine. So, it’s not something that, in my opinion and my experience was something people really want to associate with... Because they feel that depression is kind of just a sign of weakness.

I think it is the family-oriented set-up. So, it is very hard to find a homeless person in [my community]. I’m not saying they don’t exist, but for someone to (pause) if you lose your home, someone is going to take you home no matter

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what, you know. Like you have a kid, say you have a baby and you are a single mom or something like that, somebody's gonna move in and help you out. So even if it’s not your mom, not your sister or someone, you will see someone’s sister or great uncle who will tell their sister go help your sister or go help your cousin out. Someone to help you, you know. So, the thing is helping people. You have someone to talk to. You have people around you. People call you to find how you’re doing. And of course, we also religious. So, you go to church, you see people, you talk to your pastor. So, a lot of things going on, there is a lot of conversation, chains of conversation, that is preventing people from getting to that level of like…like I’m going to kill myself.

Doctor E shared his earlier experience with mental health in the family and his family’s response to mental illness: You know, there's always that one person in the family that, you know... that something's not right. And Grandma just kind of keeps to the side or your uncle's really, you know, or your cousins. I had that person in my family, it was my aunt.

But she never did really get the treatment that she deserved. And I came from a family that was in healthcare, which was sad to see. You know, with schizophrenia, they have periods where, you know, they're stable, and then they spiral. And they are stable, and then they spiral. And when she was lucid, clear, she was so phenomenal. But when she had those moments, I mean, she was dangerous. She was dangerous to herself, and to, you know, the people that loved her. So, you know, during those periods, where she wasn't really mentally stable and alert, you know, she was highly functional. And there will be events, there

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will be situations and circumstances that will cause her to go into that altered persona. And, you know, our family would, at that time, you know, they would have mental health institutions that readily available She would go in and she would come out on certain meds. She wouldn't take her medicine.

I do think that uh...you know, family and mental health...While they, they try and help the individual in one instance, they don't want it to become public in another instance. So, as long as we can keep Uncle Charles in a certain space and time, then we will do what we can as long as it doesn't embarrass the family.

Doctor B shared his earlier experience with depression in his family: During my childhood, it just wasn’t spoken about, but as an adult looking back, I can see that several people in my family were depressed. I was raised by my mom and grandmother. My mom was depressed, looking back. She joined the military and left me with my grandmother. She also had an alcohol problem.

Tell me how you think depression was viewed in the African American culture (earlier experiences with family, friends, self, community, etc.)?

Doctor E spoke candidly about the stigma around depression in AA culture and the impact that stigma and cultural beliefs around depression has on him as an AAGP and on his patients, particularly his male patients: I think overall, we have a stigma in our culture, about mental health, whether we're dealing with anxiety, depression, schizophrenia, bipolar disorder. African Americans, many times, because of the stigma, there is not a belief that there is a neuro-chemical imbalance. And that's the first thing that I tried to get them to

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understand that this is something that you can't control on your own many times, you know. There is an imbalance there. So I try to walk them through what that means and in spite of your prayers, in spite of your exercise, and all the things that you're trying to do, you can still have this chemical imbalance, that which puts you at greater risk for mood instability.

Depression (pause)... you know, we're, we're taught early on, especially with men to (pause), to be strong and not to show certain emotions, and not to show certain weaknesses. And that's perpetuated throughout our whole culture. Yeah, that's a sign of weakness. So, it's really hard. Even now, I've been practicing for 23 years.

And it's hard to see African American men and women come in and readily open up. But specifically, African American men.

He shared a story of a male patient who was hesitant to share symptoms of depression.

This is an example of the impact of cultural teachings against men showing emotions: So, he would come in very stoic. [His wife] was always concerned about her husband, and he would come in, he was so quiet. It was like pulling teeth to get him to talk and then one visit they came in together and she finally said... I'll just use the name of Tom. “Tom tell Dr. ________, what's going on,� and he just broke down. He started crying. And this is a man that I had been seeing for years, who was a picture of strength. And when he came in with his wife, and his wife had to pry him and beg him to open up, and he broke down and start crying. So that was that was pretty strong. I just, I felt I felt empathy for him, you know, as a part of me, you know, because, as men we are taught to be strong we are, we are taught to, to be to be stoic and to hold things close to the chest, you know. So, so

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that's a part of our mantra. So, to see him, to see him break down I almost wanted to cry with him. He was not suicidal. He was just severely depressed and had been depressed for quite some time.

Doctor A said, It really depends, because there are going to be some people who recognize it, they want something done about it. They're going to be others that know something’s wrong, but you got to use a code word because if you use the word depression, they're gonna shut down on you.

How was depression managed? (Earlier experiences with family, friends, self, community, etc.)

The most common response to the question of how depression was managed was through spiritual means. Doctor D shared that his grandmother may have turned to her faith to help manage her breakdown, a term he said was used in place of depression years ago: [Grandma] probably [dealt with depression] with just God and time. So, it’s throughout our community. It’s probably a lot more serious than they we're willing to accept, because of all the social pressures that it takes to, to live in a community like the communities we live in. [There’s] so many different stresses that are poured into people of color that don't affect the population at large. So, there are a lot of things that get swept under the rug or ignored.

Doctor E shared the same is true for his current patients. Religion is the preferred approach to managing depression for a lot of his patients. He noted, “A lot of my patients

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have strong faith or were raised in a church. So, they would, they would sometimes prefer to see their pastor than a psychologist or psychiatrist.”

What factors play a role in your choice of treatment for depression in African American patients?

When considering a choice of treatment for African American patients with depression, many AAGP in this study shared their approach is to determine it on a case by case basis. They said it really depends on the patient’s preference and what they will accept. Doctor D prefers to gain insight into his patient’s existing practice of managing stress, including the role of spirituality in the patient's life, prior to determining which treatment option to recommend. He stated, ...a lot of times I’ll ask, you know, as part of my kind of general insight into how they deal with stress…Do they have any worship experiences or worship relationship or meditation experience? What do they do when they realize they need to seek help through meditation and prayer as opposed to some taking some medicine…So, I try to gain insight into them from that...what I think is the best way to try to pursue that is to, when I talk to patients about talking to someone about psychological counseling, is that they have some sense that the counselor is going to have some faith awareness, as part of their efforts to help people it's not just medications and in whatever other tools that are recommended, for, you know, counseling, then it also some, some prayer effort involved in some awareness of the need for spirituality and patients, so that they don't just get pushed off into the non-spiritual field without any references to that. I think it's

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just not helpful for patients to ignore the need for some spiritual awareness in order to deal with all the health issues.

Doctor C shared her approach to determine which treatment options to consider for her patients. She tried to meet patients where they are: I think the difference is what I think they'll be more receptive to, in terms of are we going to go to therapy route first? Are we going to go to medical route first? I think that's a big difference that I see, in addition to a lot of my patients in the Caucasian population have already been on medicines for a really long time. I kind of meet the patient where they are. Sometimes I get patients that come and say, I don't need any medicines at all, I just need somebody to talk to, because that's the first question I have for them. You hear all of what they're taking on, and it may not come in as depression or anxiety. It just might be, I'm just under so much stress and when you start peeling back the layers of what's going on and what they're doing for everybody else, just asking the question, who do you get to talk to? How are you helping yourself? Who's looking out for you? You'd be surprised at most people have no one, you know, they're kind of just managing on their own. So, once you peel back that layer, and really bring the focus of you're doing all this for everybody else in your family, what are you doing for you? And how can I help you? So that's where you figure out where they are some people like I don't want any medicines, I need someone to talk to other people are (pause) I don't need‌ I've been talking to everybody, you know, and it's still not helping, I'm really ready to start taking some medications now. So, it really is all individualized, but always try to start with the therapy role of it.

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Doctor B said he chooses to build trust in the relationship prior to having a conversation about treatment options for depression. Options that he considers include therapy, medication, and/or religion: I think that's a great question. And it's a matter of once you really build that trust is able to have open conversations with that patient. I think that's where you really know how to try to help guide them in a certain way. That may be either through therapy. It may be therapy and/or medication. For some of our population, they're very ingrained in the church. And that can be a help, but sometimes it can be a hindrance.

Doctor A reported her approach depends on patients’ preferences and their ability to pay for therapy: I try to do a dual approach if I can. It depends on, you know, what's going on. I'll try to do some medication, but I really do believe in, you know, therapy. And I tried very hard to get those who have the means to go to therapy... You're gonna have some who won't go to talk therapy and say, I want medication and I just don't have time to do the talk therapy. People still have, you know, issues about, “Is somebody going to see me walk into this office or something like that.”

Summary of Results Interview content discussed in this session reveals participants’ lived experiences with treating depression in same race patients. Participants spoke candidly about their experience as an AAGP and treating depression in African American patients. Each participant shared details about their perceived benefits and challenges of working with

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patients and mental health professionals alike. Essentially, participants defined their role in the doctor-patient relationship as more than a physician. They are viewed as part of the patient’s family, which aids in building a higher level of trust in the doctor-patient relationship. They elaborated on the impact of having similar cultural experiences, particularly around issues of communication and spirituality. Significant challenges were also shared amongst the group of participants, including issues of resistance due to stigma, lack of education and awareness and a lack of behavioral health resources in the community. AAGP also shared their feelings around such challenges in their practice of treating depression in their African American patients.

Interview data was analyzed and organized in three subordinate themes. The first theme was “More than a Physician,” the second was “Culture into Practice,” and the third was “I was Trying to Help.” Each subordinate theme is discussed in the next section.

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Chapter V

Findings and Implications The focus of the study was to explore the subjective experience of African American General Practitioners (AAGP) who treat depression in African American (AA) patients. The study consisted of six AAGP who shared their personal narratives about treating depression in African American patients. Each participant’s in-depth narrative about their role in treating depression in African American patients addressed challenges, benefits, and the impact of culture. This chapter will theorize each emerged theme through a relational theory lens. The chapter will conclude with a discussion of validity and limitation of the study, implications for clinical social work, and suggestions for further research.

This study resulted in similarities and differences as it relates to themes from existing research on AA’ attitudes and beliefs about depression as well as existing research on primary care physicians’ experience with treating depression in a primary care setting. Similarities include: the importance of spirituality and taking one’s problems to God (Cadigan & Skinner, 2015; Conner et al., 2010), inadequacies in treatment-setting factors and barriers to managing depression in primary care (Das et al., 2006), and challenges of the stigma attached to a diagnosis of depression for AA (Conner et al., 2010). One significant difference that emerged was the physician as being more than a

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physician; more specifically, the physician is like family. This concept was not noted in any of the reviewed literature.

Theoretical Lens This section will revisit relational theory as outlined in Chapter Two as the theory of choice for this study. Relational theory asserted individuals are motivated by relationships with others and values three dimensions of configurations: the self, the other, and the space in between (Mitchell, 1988). As a result of this notion, relational theorists believe the “self” cannot function outside of relationships with others and these dimensions are interwoven to create an individual’s subjective experience and psychological world (Mitchell, 1988).

With a focus on cultural consideration, Comstock et al. (2008) asserted participation in mutual empathy and growth-fostering relationships is vital to one’s human development and psychological well-being, and is linked to one’s racial/cultural/social identities (hence, the significance of the AAGP’s role in same race doctor-patient relationships with their African American patients).

Findings Throughout the interview process, AAGP shared their lived experiences with treating depression in their African American patients. Each participant expressed an interest in the research topic and support for the researcher’s work. Though each participant appeared slightly guarded and unsure of what to expect at the start of their initial interview, they soon appeared more comfortable in discussing their experience

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with the researcher. During the data analysis phase of the study, three subordinate themes emerged: 

More than a Physician (familial trust & unwavering commitment)



Culture into Practice (communication & spirituality)



I Was Trying to Help (barriers to care & failure)

Table 2. Themes Sub-Ordinate Themes

Associated Component Themes

More Than a Physician

● Familial Trust ● Unwavering Commitment to Serve

Culture into Practice

● ●

Communication Spirituality

I Was Trying to Help

● ●

Barriers to Care Failure

Sub-Ordinate Theme I: More Than a Physician In analyzing the data, I gained insight into how AAGP view their role with African American patients who have depression. AAGP in this study viewed their role as more than a physician, more like family or a trusted advocate. Participants were found to be committed to serving their African American patients in a manner that resulted in a familial experience for those patients. In sharing their experience, they felt that many of their patients viewed them as part of their family. Doctor F. said, “It is like family. It's like they see you as part of them, you know… My patients think that I’m like part of their

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family.” This fostered a familial trust and enhanced the AAGP’ commitment to helping their African American patients with depression. AAGP valued their patients’ perception of them and, with great honor, were committed to serving. Doctor A shared this after being told she was part of the family: You know, that's important that they see me not just as a physician... because they see me as part of the family, they trust me more, I think. And I have to make sure I can live up to that kind of trust.

Familial Trust.

The importance of gaining their African American patients’ trust was shared by all participants as an essential part of treating depression in their African American patients. AAGP’s valued the level of comfort and trust they were able to establish in the doctor-patient relationship to foster a safe space and a sense of connection. Trust is an important part of healthy relationships and is often present in familial relationships. It sends the message of security and comfort between one’s self and others. Participants shared stories about feeling trusted by their African American patients in a familial manner. This level of trust and confidence was present in multiple stories and revered by the AAGP in this study. Doctor F shared this after a story of a patient who shared intimate details of his marital struggles. He valued this patient’s trust in the doctor-patient relationship and viewed it as a privilege: So, that shows the level of trust, the level of confidence and the level of relationship, you know, how they really feel like it was a psychological safety area, for them to, to share even that intimate part of their life with their doctor,

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you know. So that's kind of... (pause) it’s a privilege to kind of be in that position of (pause) or for someone to be able to share such things with you.

Doctor C reflected on the level of trust established in the doctor-patient relationship and values her role as a trusted advocate. This sometimes causes her patients to be less receptive to a referral to a behavioral health professional and more comfortable about opening up in the exam room: ...some people might say, you know what (pause) I don't want to talk to anyone else but you. I only feel comfortable opening up with you...It's like this understanding that I have with them that they have an advocate, you know... So, I think leaving feeling like “I have a true advocate for me�; that trust they need in their provider.

As discussed in the literature review, AA are more likely to trust providers of the same race (Conner, 2010) as those who will confirm their belief system (Van Voorhees et al., 2003) and are able to understand the AA experience (Lindsey, 2006). These key criteria for establishing trust in providers are also criteria one would imagine are found between members of the same family.

According to Jordan and Harting (2010), all people yearn for connection, and connection has to occur for people to change or to develop growth-fostering relationships. Relational Cultural Theory places particular emphasis on examining differences informed by imbalances in power and privilege in relationships.

Disconnection in relationships occurs when dominance and privilege is present, resulting in suppressed authenticity and mutuality (Jordan & Hartling, 2010). The power differential in the doctor-patient relationship places physicians in a position of power.

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This perceived power can cause disconnection in the doctor-patient relationship.

According to RCT, if managed effectively, disconnections can foster a space where individuals feel safe (Hammer et al., 2016). AAGP have managed this disconnection effectively, resulting in an increased sense of safety and security in doctor-patient relationship. This level of safety and security results in a familial trust through meaningful connections. This level of trust comes from the physicians’ perspective; thus, this study reveals the physicians’ awareness of that trust, as well as feelings in themselves to honor that trust and relate to their African American patients within the experience and value the trust the patient has projected into the relationship.

Unwavering commitment to serve.

Several AAGP shared their unwavering commitment to serve through various adjustments they have made to enhance their ability to serve their depressed patients.

Participants have explored additional learning opportunities and utilized their personal self-care strategies to assure they are available and able to continue helping their African American patients. The data reveals the participants’ experience of unwavering commitment to serving this population as one would commit to helping and supporting family. Doctor E shared personal strategies to restoring his energy and commitment by turning to spirituality and reading medical literature on primary care. He also acknowledged a sense of personal responsibility to serve “willingly and unselfishly”: You pour, continuously pour into yourself. So, you have to (pause) you have to have a well that you draw from just like people are using us as a well that they draw from, you know... If I'm getting low on what I can give, then I'm not good

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for you or anyone else. [If] I’m getting exhausted, and I need to pull back and refuel, and re-energize myself so I can come back and be better and give them more.

So, I utilize my faith and I like to listen to certain pastors that feed my spirit. So, I do that, and I read a lot of medical literature...I'm constantly pouring into myself. And I find that everything that I pour into me is pour out. I'm going to do what I do for as long as I can and serve as willingly and unselfishly as, you know, as I can. I believe in that saying to much is given much more is provided, you know, required. And so, I will continue to do my best to meet the mark, so to speak.

Doctor A shared the importance of learning how to prescribe psychotropic medications in an effort to enhance the support of African American patients and to protect them from other professionals who may not understand them. This reveals a greater level of commitment to serving African American patients with depression: I've had to learn, over the years, how to use [psychotropics] because, you know, [the black psychiatrist] would leave town‌ not all the time did I feel that my other colleagues in the field would understand my patients, you know‌ I'm talking about some of my white colleagues or those that may not understand them.

In summary, all participants valued the level of trust they were able to establish in the doctor-patient relationship. These trusting relationships provided a level of comfort that fostered a safe atmosphere which allowed patients to have conversations about their struggles. The AAGP recognized the level of trust and purposely provided a safe atmosphere for the doctor-patient relationship to develop, which allowed African

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American patients to feel accepted like family and free to be vulnerable with their providers.

Psychodynamic theory stresses the identification of transference and counter transference. Applying these conceptualizations into this clinical realm, the patient brings feelings into their relationship with their physician that is a transference.

Specifically, interpreting this experience from the self-psychology lens, Kohut (1968) defined a twinship transference as “the [patient’s assumption] that the analyst is like him or that the analyst's psychological makeup is similar to his…” (p. 96). The patient’s transference here reveals a sense of sameness or twinship that fosters a feeling of trust in the doctor-patient relationship. This twinship transference defines the patient’s need to be understood and valued by the AAGP. AAGP in this study defined their reaction to their African American patients’ feelings or the twinship transference, which is a counter transference. Their counter transference fostered a family-like responsibility or commitment to their African American patients. This defines the doctor-patient relationship AAGP have with their African American patients with depression, providing insight into the first two research questions. AAGP in this study viewed themselves and their role in the lives of their African American patients with depression as more than a physician.

Sub-Ordinate Theme II: Culture into Practice This study found that AAGP valued their similar cultural experiences they shared with the AA patient population. These shared experiences enhance AAGP’ understanding of the patients’ inner world. This section highlights two specific areas of significance in

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explaining how AA culture becomes part of AAGP’ practice of treating depression in the primary care setting. Communication and spirituality were specific areas of culture that AAGP found to be useful in their work with their African American patients with depression.

Relational theory is a two-person approach to treatment where both doctor and patient participate in the unfolding of the patient’s experience, thereby, making the doctor’s participation a key factor in the treatment process. In this two-person approach, doctors are fully engaged, taking into account his/her own feelings, thoughts, and behaviors in addition to the patient’s feelings, thoughts, and behaviors. This allows the doctor to operate within the context of social and cultural awareness when treating patients.

Communication.

As noted in Chapter 4, participants revealed their challenges with sharing a diagnosis of depression with their African American patients, particularly the impact of stigma and the importance of finding the best words. AAGP understand the stigma in the AA community and shared it in similar ways. Doctor A spoke of the stigma with the word depression and shared her approach to communicating depression to her African American patients by choosing her words carefully. This is an example of a type of relational responsiveness that utilizes anticipatory empathy: I think [the word depression] means that there is something very much wrong with them and they are not ready to hear that. And they may have had experiences in the past where somebody who was depressed, or they have gotten the message

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from someone in their immediate family or, you know, surroundings that that's not a good thing. So, you know, you don't use that word, you know. You got to use a code word because if you use the word depression, they're gonna shut down on you, so you say you got melancholy or something like that. You got to come up with a different word depending on who you're talking to--know what word you got to use with them.

Doctor B shared his experience of the stigma of depression in his communication with African American patients. He noted, “Now, for our population, there's still this stigma of, I don't want to be labeled as depressed, because then I'm labeled as crazy and it's not one and the same.” Doctor F explained how patients minimize their experience to avoid the word depression: Some people feel that word depression, it has a stigma and they don't want to be associated with it. They say, no I'm not depressed. I'm just going through life, you know. It's going to be alright…When I have money it will be okay or when I get this job, I’m gonna get better.

Doctor D spoke about denial in the community around a diagnosis of depression, resulting in an under diagnosis of depression: I think there is a lot of under diagnosis in terms of patients coming in and not realizing, not wanting to accept the part of their problem is depression. So, I think there's a lot of denial in our community about depression.

Doctor C identified with African American patients who chose to express depression differently and explained her perspective of why African American patients are more likely to manage their burdens on their own:

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We might express [depression] a bit differently, [we] may be more hesitant to put our burden on other people, but the pain is still the same…I would say the African American culture takes on more stress and burden before they ask for help. So, before you really get to that kind of help, they would shoe you away. If you ask them “well how [are] you managing?” You know, “girl, I’m fine, just stressed.

It is well documented in research that there is a stigma attached to a diagnosis of depression, especially in the AA community. When it relates to AA and depression, research highlights communication and stigma as challenging areas in the delivery of depression care in primary care settings (Ghods et al., 2008; Connor, 2010). According to Ghods et al. (2008), AA communicated less depression related statements than whites during PCP office visits and even when depression communication occurred, a lower percentage of AA than white patients were considered by their PCP to have significant emotional distress. The study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. According to Connor et al. (2010), AA view depression as a stigma in addition to their status as a minority race, particularly more stigmatized than any other race. Additionally, AA reported being stigmatized and stereotyped by members of their own race (Connor et al., 2010). With consideration of cultural and social components, RCT is best understood through the process of moving toward connections, through disconnections, and back to newly transformed or enhanced connections (Comstock et al., 2008). Being inside the AA culture allows knowledge of language and a connection with less potential for insult. African American patients see their AAGP as same race (connection), but different (disconnection). However,

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connections are restored through effective relational responsiveness or anticipatory empathy.

Spirituality.

All six participants identified as being a Christian at some point in the interview process. Spirituality was viewed as both, helpful and at times a hindrance to adequate depression care. Many AAGP in this study reported various ways in which spirituality was used to help in the doctor-patient relationship. AAGP reported their African American patients view them as part of the family and felt comfortable in sharing their symptoms of depression. The belief that one should only speak openly to family makes AAGP a safe and trusting other for their African American patients. This transference in the room offers a projection of needs that ultimately paves the foundation to establish a sense of trust in the doctor-patient relationship. This similarity enhances AAGP’ level of empathy in the doctor-patient relationship. Each participant shared the value in using their own spirituality as a way to navigate through the conversations with their African American patients with depression. Doctor F explained the use of prayer as a tool to enhance conversations with African American patients with depression and the overall importance of acknowledging spirituality and religion in conversations with African American patients: I mean, I’ve prayed for my patients in the room. We've talked about, you know, anytime you want to reach out for something, you can also reach out to the Bible.

So, we do that, and I think it helps to actually have those conversations, even if you don’t believe them. But having those conversations help.

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Doctor E shared the use of spirituality through self-disclosure as a tool to enhance the doctor-patient relationship with African American patients: Like I said, most African Americans have been involved in church related activities in the past. So then once they're stable, you can easily introduce [spirituality]. I've, I've shared different ministers that I listened to, with patients.

And they've come back in and they’ve listened to this person. And [patients say] man, I listened to him every morning now. Oh, my gosh! I say, All right, that's all right. So yeah, so they gain that inspiration and motivation to move on and keep doing what they're trying to accomplish whatever they feel is their assignment.

Doctor A shared her practice of addressing patients’ spirituality while encouraging them to accept help for depression: Well, I think spirituality is important to a lot of us... [I] just try to gauge and you don't always get it right, but, you know, a lot of times what people say you can tell how important spirituality is to their life. But if it is, it is something I freely share with them, you know, where I come from also. I try to go with, you know, like "God helps those who help themselves‌and God has put these people here on Earth, they can help you and I don't believe He just put these people here, you know, if He doesn't want you not to use these people to help you get better...I see it as, as almost as my mission and almost as my...I look at it as part of the way I also worship God, you know, as I take care of my patients, and make sure they are taken care of properly and make sure that they know that they are valuable and honored... So, I look at it, It's more than just a practice. It's almost a calling in a sense for me.

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Doctor D explained his use of spirituality in conversations with his African American patients as an additional tool to treating depression. He also emphasizes the importance of counselors to have some spiritual awareness when helping African American patients: I've talked to [patients] about prayer, I talked to them about having a worship [or] being part of the worship community.”...What I think the best way to try to pursue [spirituality] is to, when I talk to patients about talking to someone about psychological counseling, is that they have some sense that the counselor is going to have some faith awareness, as part of their efforts to help people it's not just medications and in whatever other tools that are recommended, for, you know, counseling, then it’s also some, some prayer effort involved in some awareness of the need for spirituality and patients, so that they don't just get pushed off into the non-spiritual field without any references to that...I think it's just not helpful for patients to ignore the need for some spiritual awareness in order to deal with all the health issues. They have to accept that the problem is bigger than they are.

They’re gonna have to really pray about it and seek higher help than what they can get from medicines and doctors and other professionals.

Doctor F referred to his role as “a calling” from God and uses his “calling” to encourage a trusting relationship where his patients feel comfortable: Some people do this job as a job, you know. As, “I'm just working to make, to earn money.” Some people, and that is what I believe, do it as a calling. Like, this is what I'm meant to do. So regardless of how bad I'm feeling, or how my day is, when I get to see my patient at the bedside, it is, all of my personal things are gone, it is all about the patient. So, I think that puts my patient in a position of

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comfort and position where they can actually trust. So, what I'm trying to say is like it is [an] individualized practice.

Doctor B uses his own faith to serve as an extension of God’s knowledge. He shared this perspective with his patients to build their trust: [I tell patients], Well, you know, me‌ myself that I'm, I'm also a Christian and I believe in God, I believe in Christ as our Savior, that I believe that I'm also given the knowledge [from] Him as well. And therefore, you come in to see me and allow me to try to pass that knowledge on to you as well." So, it’s a matter of being able to just find that connection, like... that builds the trust, for them to try to start to have some confidence and whatever approach we're trying to go with.

Doctor C referred to her work with patients as an extension of God and delivered the message to her patients as a way to help them feel more comfortable with accepting her guidance: I may have had a patient or two [who says] ...maybe I'm just gonna leave that up to the Lord. And then I have to bring my spirituality into it or my view of it, as I see myself as doing the work of the Lord. And what I do. And I'm asking you, to be open to this is what God is sending to you. You know, and once I present it like that, you know, then we're having a conversation, we're having about it...So, if I come up to the spirituality process, in other words, they're like, I'm just going to put it all in God's hands. I will acknowledge that. That is fine that they have their religion play into it. But I think there are other things that can be done as well.

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Though many participants view spirituality as a useful tool with their AA depressed patients, some AAGP also viewed it as a hindrance and a source of resistance at times.

Doctor E shared it this way: A lot of my patients have strong faith or were raised in the church. So, they would, they would sometimes prefer to see their pastor than a psychologist or psychiatrist. And I think that the pastor can play a role, but they cannot replace the psychiatrist or psychologist.

Doctor B shared that some patients feel their symptoms can only be managed through prayer and the religious activities. This creates a hindrance to getting African American patients to accept treatment for depression: For some of our population, they're very ingrained in the church. And that can be a help, but sometimes it can be a hindrance. Because it's depending on their church and with their philosophy on mental health and it may be that they feel that they can only be taken care of through prayer or through continuing to do activities related to their religion in order to get better.

Despite the increase in acceptability she sees, Doctor A shared that some of her patients continue to resist depression care due to believing they can just pray away their symptoms. She noted, “So, I think [depression is] much more acceptable than it used to be, but I still have people come in and tell me that, you know, they've been told to pray it away and all of that, you know.�

As noted in Chapter 2, AA were more likely to turn to religious faith to deal with feelings; practices like prayer, reading their bible, and talking to their minister or other church members were utilized (Cadigan & Skinner, 2015). AA viewed prayer as their

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front line of defense against depression and their way of turning “mental health problems over to God” (Conner et al., 2010, p. 980); this endorses the belief that one should not speak openly about mental health problems, but keep them in the family as part of African American culture.

In summary, the theme “Culture in Practice” reveals the impact that the AA culture has on AAGP’s practice with their African American patients. Their counter transference and use of self through self-disclosure exposes AAGP’ willingness to accept patients’ idealizing transference as a way of offering African American patients the comfort and support that is required to meet their emotional needs. This provided more insight into AAGP’ role in their African American patients’ lives; they cultivate a uniqueness in the doctor-patient relationship that non-African American physicians may or may not be able to cultivate. This study found that participants were well aware of their AA patient’s views on depression and this awareness informed their responses to African American patients, resulting in a modified treatment process that pulls from culture similarities.

Sub-Ordinate Theme III: I Was Trying to Help Participants’ most frequently shared barrier to treating depression in African American patients included time restrictions and a lack of resources. In sharing their experiences with treating depression in African American patients, AAGP echoed similar challenges that impact their ability to help and their feelings as a result of such challenges. Below I will share AAGP’ experiences with barriers to care like time constraints and lack of resources to support their work with African American patients

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with depression. AAGP’s also shared various feelings around failures to successfully help their AA patients with depression.

Barriers to Care.

Time constraints.

The average primary care appointment times were said to average 15-20 minutes per patient visit. As noted below, this allotted time is not enough for AAGP to feel they have adequately served their African American patients with depression. Doctor F viewed his patients with depression as more difficult to manage than patients who may present with physical healthcare needs, particularly due to the pressure he feels from time constraints. He finds it difficult to be present and attuned to the patient’s needs if he is worrying about getting to the next patient: It is tougher [treating patients with depression] because you cannot leave the patient in the room, when they're sharing this type of story. If you're, if you're in a relationship with your patient, you have to be able to listen to them, regardless of the pressure and I know the pressure is on… So, you just have to balance it. So, I think that is one of the issues, you know, understanding the fact of everything that goes on with that patient...it’s not only about you, because if you, if you're thinking about your time in the room, you are thinking about your pressure, you're thinking about the next patient, you are thinking about how to close your chart.

Thinking about all the people and what you’re going to do ...you're not really going to be in, in that room with that patients, you know.

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Doctor D has a privately-owned primary care practice. Despite having some control around his time, he also feels that he does not always have the time required to adequately attend to the needs of his African American patients with depression: I think sometimes you can spend an hour with the patient, and they're frustrated, because they're, they want even more than an hour. Then uh…then you just have to kind of let them know you have to, you know, draw the line someplace...People perceive that you're paying more attention to the clock, then you are to their conversation.

Like other participants in the study, Doctor C acknowledged the challenge around time restrictions and shared an approach that works for her: Initially starting off, I found that having quicker follow up visits to kind of massage out all the underlying stuff, because it's just not enough time for people to tell you everything that's going on that's bothering them. So, you might get a couple of the layers. I usually try to have once a week follow up. So, we kind of establish what's going on. So, the time limitation really becomes a factor with it, or they make a connection and once you see them, they want me to see them as my regular patient when I have to say I'm not taking regular patients, you know.

So, it's almost like seeing this really good thing and making this connection, then I'm “poof…on to the next one.

Lack of Resources.

A lack of resources was another reason AAGP in this study found it challenging to adequately help their African American patients with depression. AAGP expressed a

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need for education and awareness for the AA community and professionals and a need for more behavioral health professionals, particularly of professionals of color. Doctor F expressed the need for education and awareness for everyone: I just think we need more education and awareness for our people and probably things like this will help. Research like this will help kind of bringing awareness to our population and to the professionals. Probably not for only physicians, but all healthcare professionals...How do you respond to somebody talking to his child that just died, you know. What are you going to say? And we are not trained to say things like that, you know. We are not a psychiatrist and we are not a counselor.

Doctor D would like to integrate a behavioral health professional into his primary care practice but has not been successful in finding anyone. He noted, “We haven't been able to find anything that works for behavioral health in this office, would be nice…” Doctor C shared her perspective on the shortage of behavioral health professionals. She explained her process for meeting the patients’ needs despite having limited access to behavioral health professionals and insurance limitations: It's just a backlog of providers, you know. So, you might have people who have been waiting for months to get in to see a psychiatrist or therapist [or] their insurance might not pay for therapy. So, then the psychiatrist and their primary care doctor kind of have to tag team, whereas the primary care physician will serve in that therapist role.

Doctor A echoed the need for additional behavioral health professionals along with concerns around limited financial resources for her African American patients. These

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limitations impact which medications she can prescribe and the overall outcome of treatment: Some of the challenges are that we may not have all of the resources we need, you know, or that sometimes we can't get some of the medications I need to give...I need to get them in to see the psychiatrist and the waitlist to get them in to see him is just too much. And it's just so sad, you know, that that person is suffering, you know (pause) that period of time.

Failures.

Time constraints and a lack of resources have posed a challenge to these AAGP who want to help their African American patients with depression. There are times when AAGP may have felt a sense of failure when trying to help some patients, particularly patients who are resistant to care. Many of the AAGP’s in this study shared their feelings about not being able to help some patients. These physicians feel a pull to do more and offer more to their patients. Due to limitations, they sit with a feeling of failure. When asked about patients who do not seem to accept treatment or get better from treatment, Dr F replied, “It is heartbreaking. Um… It is one of the areas I feel that we’ve failed as physicians or as healthcare providers, generally.” Doctor F shared a story of a suicidal patient whom he referred to the emergency room for emergency evaluation and treatment. The patient said he felt betrayed and that Doctor F had breached his trust.

Doctor F shared his feelings about the encounter and stated, “So, you know, that was kind of heartbroken because I was trying to help [him].” Doctor F also spoke about the shift that occurs in the doctor-patient relationship once he introduces the idea of seeing a

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behavioral health professional. He fears that some patients view the referral as if he is dismissing them or pushing them away: When you bring it up that they need to see somebody, it's like "oh!" Once you bring that up it takes that conversation to a different level of "Is it, is it that bad?"

If you give them the message like "Oh, I'm gonna send you to [a] psychiatrist"... now you're dismissing them or you're pushing their care to someone who may or may not care. If they think you already care about them. You have just broken that trust, you know.

Doctor D admits to feeling frustrated when trying to treat depression in African American patients who resist treatment options or just do not get better. He described the process as draining his battery and elaborated on that comment here: It's frustrating, because it takes more energy to work with [depressed] patients‌So, patients with depression tend to take a lot more energy more, a lot more battery drainage than taking care of people who were looking for, you know, physical reasons for their problem. So, it can be real frustrating.

Doctor B spoke to his experience of African American patients who are not responsive to his treatment options when trying to help with depressive symptoms: It's a struggle, because you really, you know, if once you develop that, uh- if you remember, I call them my family...you know all the patients are part of the family and the team as you're taking care of them. You want them to try to feel better and do better as well‌ I believe that depression is one of those things that's contributing to your, your overall health.

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Doctor A commented on her experience with trying to get her African American patients to accept treatment for depression and stated, “It’s like an ice pick, you know, you keep hitting it and hitting it and sometimes you can crack it and sometimes you don't, you know.”

In this section, I highlighted AAGP experiences and feelings around not being able to help due to various barriers to care like time limitations, a lack of resources, and African American patients’ resistance to treatment options. AAGP feel the responsibility that care lies in the hands of the physician. As mentioned in Chapter 4, Doctor E said, “Whatever [the patient] needs, [I] should be able to provide as his primary care provider… in the scheme of what I'm able to do as a primary care provider.”

As a result of limited resources to for their African American patients, AAGP may have to act as a therapist and help their patients with their limited knowledge of the field. Disruption in the doctor- patient relationship can occur if a referral is ordered. This disruption in the familial dynamic may leave physicians feeling like they are failing their African American patients, ultimately having a negative impact on their sense of self.

General practitioners are tasked with providing an overall assessment of patients’ healthcare needs and are often frontline assessors of depression in the primary care setting (Wang et al., 2002). The primary care setting comes with limitations that can result in depression being under diagnosed or inadequately managed. According to Das et al. (2006), “African Americans who have depression may be frequently underdiagnosed and inadequately managed in primary care as a result of patient, physician and treatmentsetting factors” (p. 30). This study revealed similar outcomes with the management of depression in primary care.

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Conclusion AAGP in this study opened up about their unique experience of treating depression in their African American patients. As a result, the three subordinate themes emerged: “More than a physician,” “Culture into Practice,” and “I was trying to help.” As a part of the AA culture and part of the field of medicine, AAGP have provided significant insight into understanding this phenomenon. With regard to the guiding research questions, the following conclusions were made: 

How do they view themselves as African American physicians? AAGP in this study view themselves as more than a physician. Viewed as part of their African American patients’ family, AAGP value the familial trust and comfort they have established with their African American patients.



How do they understand their role with African American patients with depression? AAGP play a significant role in improving the mental health disparity for African American patients with depression. As more than a physician, AAGP understand their role to be a trusted advocate who guides patients through the treatment process by providing a comfortable and supportive atmosphere. This unique doctor-patient relationship provides AAGP the opportunities for patients to feel vulnerable and share symptoms of depression for proper treatment. In return, AAGP feel a sense of commitment to serve this cultural group in a manner that identifies with their cultural experience.

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AAGP explained various ways that the AA culture impacted their practice when interacting with their African American patients with depression. Evident in the theme “Culture into Practice,” they are utilizing culturally sensitive communication and spirituality with their African American patients, which enhance the doctor-patient relationship. 

How does the patient-provider relationship impact AAGP’ sense of self?

Patients’ resistance to a behavioral health referral could result in a positive or a negative impact of the AAGP’ sense of self. A positive impact may result in more validation of the physician’s value in the patient’s life, as evident in Dr. C’s earlier report of a patient’s comment, “I only feel comfortable talking to you.” In contrast, a patient’s resistance to a referral to a behavioral health professional could negatively impact the physician’s sense of self by sending the message that they have failed the patient in their attempt to help.



What attitudes and belief do AAGP have about behavioral health and their role in working with therapist, like social workers, to ensure their patients get treatment for depression? AAGP’s valued the role of behavioral health professionals like Clinical Social Workers but expressed the need for more AA professionals of color and those who can support African American patients’ faith-based beliefs. Their unwavering commitment to their African American patients may result in fewer referrals to outpatient behavioral health professionals like Clinical Social Workers, due to

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multiple factors. AAGP are protective of their patients’ familial bonds which may make it difficult for AAGP to make successful referrals to behavioral health professionals. This is due to fear of dismissing the patient for fear of transferring them to someone who may not understand them. 

What are the feelings, thoughts, and behaviors that depressed African American patients evoke in AAGP and how do these feelings, thoughts, and behaviors on the part of AAGP affect the treatment process of their patients? As evident in the third subordinate theme, “I was trying to help”, this study reveals thoughts, feelings, and behaviors that African American patients evoke in AAGP and how the treatment process is impacted by such thoughts, feelings, and behaviors. AAGP elaborated on their limitations to helping this population resulting in AAGP feeling frustrated and heartbroken. Limitations include time restrictions and a lack of resources. Physicians’ feelings, thoughts, and behavior impact the treatment process in various ways. At times, AAGP need to collaborate with behavioral health professionals like Clinical Social Workers, but this need for collaboration and support comes at the risk of losing their patients’ trust during the referral process. A referral may be perceived by the patient as dismissive and rejecting, therefore, resulting in the patient’s resistance.

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The patient’s projection of familial dynamics is felt as a need to care for this patient differently or to be more than physician. AAGP in this study weaved their shared culture into practice with African American patients. They use spirituality and culturally effective communication in a relatable manner to encourage African American patients to consider treatment of depression.

Validity and Limitations of the Study This study utilized IPA as the preferred methodology of qualitative research.

According to IPA (Smith et al., 2009), assessing for validity and quality of the research is an essential component in effective qualitative research and is comprised of four principles: sensitivity to content, commitment and rigor, transparency and coherence, and impact and importance. I adhered to the principle of sensitivity to content by showing empathy and providing a sense of ease for each participant during the interview process.

During the interviews, I referred to participants as the experts in their field in an attempt to reduce anxiety and avoid any fear of being psychoanalyzed by the therapist.

Commitment and rigor were demonstrated in each in-depth interview by remaining attentive and engaged in the participant’s story and helping it to unfold in the confines of a safe space. Five out of six interviews were conducted in the AAGP’s office, a familiarly space. The other interview was conducted in a reserved meeting room at a local restaurant chosen by the participant. Participants were carefully chosen to meet the needs of the research question.

Transparency was achieved through step by step details of the stages of research outlined in Chapter 3. Impact and importance of the study is discussed in the next section

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titled “Implications for Social Work Practice.” Validity of the study was also tested through member checking with each participant for accuracy.

Limitations to the study include geographical location and lack of transferability (or generalization) to the general public. The study was conducted in a small region in the state of North Carolina, a state that has significant AA history around the Civil War era.

A similar study conducted in other regions may yield different results. This study was also limited to two specialties of medicine: Internal Medicine and Family Medicine.

Other specialties like Pediatrics and Gynecology may also serve as primary care providers for their patients.

Implications for Clinical Social Work Practice As the field of behavioral health and primary care collaborate, social workers are experiencing more encounters with primary care physicians for the purpose of behavioral health support of their patients. This study provides social workers with insight into the AAGP’s perspective on their role in treating depression in their African American patients. According to Kathol et al. (2015), “… three-fourths of patients with behavioral health disorders are seen in the medical setting but are largely untreated because few medical patients choose to access the behavioral health sector” (p.95). Through enhanced understanding and awareness, clinical social workers are more equipped to work alongside AAGP for the delivery of behavioral health services for African American patients. As they are associates with the AAGP, clinical social workers’ awareness of the experiences defined in these findings can provide opportunities to educate and support AAGP by helping them understand their feelings working with African

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American patients. These results indicate a need to raise physician awareness, an objective that clinical social workers may pursue in their health care communities.

This study has identified cultural challenges AAGP experience in the delivery of depression care services and can allow social workers the opportunity to meet the needs of AAGP in addressing such challenges to managing depression in African American patients. More specifically, this study reiterates the need for education with AAGP and African American patients to reduce the gap between medical and behavioral health services. This study highlights the need for education to reduce the stigma attached to seeking and receiving depression care and education for providers on the impact of conversations around spirituality when treating African American patients with depression.

Suggestions for Future Research Some suggestions for further research include a larger sample size and exploring the experiences of different genders. There is value in exploring the experience of AAGP from a broader geographic region beyond the southeastern state of North Carolina.

Various geographical locations could yield different results. Another suggestion for further research is to explore other specialties of medicine that may treat depression in African American patients. Other specialties, like Pediatrics and Gynecology, may serve as primary care providers for their patients. One participant in this study spoke candidly about the experience of the AA male as a unique experience in the field of healthcare and particularly around mental health needs; therefore, gaining insight into this topic from a

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gender specific standpoint could also add value to the phenomenon of AAGP who treating depression in African American patients.

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Appendix A Research Flyer

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Appendix B Telephone Interview Script

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Telephone Interview Script “Thank you for your interest and support in my research study. I am a psychotherapist and doctoral student at the Institute for Clinical Social Work in Chicago. I am currently conducting a qualitative study to explore the experience of African American general practitioners who treat depression in African American patients. The study will consider issues like cultural attitudes and belief about depression, professional benefits and challenges in the doctor-patient relationship, and treatment decisions in depression care.

The study will include five to eight African American general practitioners, whose names will remain anonymous. For the purpose of the research topic, there will be personal questions asked. You will have the option of declining to answer any question, stopping the interview, or withdrawing from the study at any time.

Individual audio recorded interviews will last approximately 60 minutes and can be conducted at your place of choice (office, home, public setting, etc.). The study will require you to participate in one to two in-person interviews and one to two follow-up phone conversations lasting no more than 30 min. Audio recordings from each interview will be transcribed and analyzed for the purpose of data analysis. Do you have any questions?

Is it okay to ask you a few inclusion questions before moving forward in our work together?

1.

2.

3.

4.

5.

6.

Do you identify yourself as an African American physician?

In your practice, do you treat depression in African Americans patient?

Do you hold a certification from the American Board of Family Medicine or the American Board of Internal Medicine?

Do you have at least five years of post-certification experience?

Will you agree to 1-2 audio taped interviews and 1-2 follow-up call for the purpose of data analysis?

What is the best way to reach you for scheduling an interview?”

**For individuals who do not meet the study criteria the following statement will be made.

“Thank you for your interest in this study. I am currently looking for participants who meet other specific criteria, but I appreciate you taking the time to speak with me.”

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Appendix C Formal Consent Document

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Individual Consent for Participation in Research INSTITUTE FOR CLINICAL SOCIAL WORK

I, ________________________, acting for myself, agree to take part in the research entitled: The Experience of African American General Practitioners who Treat Depression in African American patients. I understand that this research will serve as part of the requirements for fulfilling the Ph.D. program at The Institute for Clinical Social Work, Chicago, Illinois.

This work will be carried out by Latasha Ellis, LCSW under the supervision of Denise Duval- Tsioles, PhD, LCSW. This work is conducted under the auspices of The Institute For Clinical Social Work at Robert Morris Center; 401 South State Street, suite 822, Chicago, IL 60605; 312-935-4232.

PURPOSE The purpose of this study is to gain an understanding of African American Primary Care Physicians’ experience with treating depression in African American patients. The results of this study will be useful in the development of programs and services that offer a comprehensive approach to treating depression in African Americans.

PROCEDURES USED IN THE STUDY AND THE DURATION This study will include five to eight African American Primary Care Physicians’ (Internal Medicine and Family Medicine) experience with treating African American patients with depression. Your experience will be captured during two, 60-minute, audio recorded interviews. Interviews will be conducted by the researcher. One interview will be face to face and conducted in a natural setting. The other will be conducted by phone.

Participation in this study is voluntary. You may decline to answer any question asked or stop the interview at any time.

BENEFITS You will benefit from the opportunity to enhance mental health care in African Americans. Participation in this study can offer you the opportunity to improve depression care and expand the base of knowledge around coordination of care for African Americans. Additionally, your participation can aid in guiding the development of new approaches to de-stigmatizing depression and improve the quality of life African Americans living with mental illness.

COSTS There are no monetary costs to you for participating in this research. Participants will receive a $50 gas card as compensation for participating in the study.

POSSIBLE RISKS AND/OR SIDE EFFECTS

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During the interviews, you may be asked about sensitive issues. In this case, you are encouraged to proceed at your own discretion. I will take any measure necessary to minimize participants discomfort. You may decline to answer any question or stop the interview at any time.

There are no other known or predicted risks to you, as long as confidentiality is maintained. If you have any questions about the research project, you may call me at 704-999-7378.

PRIVACY AND CONFIDENTIALITY Information you provide will remain confidential. Your identity and the identity of any person to whom you refer during the interview will not appear or be used in this research project. However, your phrases and/or sentences may be used anonymously as data in this project. By agreeing to participate in this research project, you are giving consent to have this data published.

Transcripts and study information will be kept on the Principle Investigator’s private computer with locked password. Recorded interviews will be deleted upon transcription.

All research materials will be kept in a locked filing in the researcher’s office for five years post-graduation.

SUBJECT ASSURANCES By signing this consent form, I agree to take part in this study. I have not given up any of my rights or release this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of The Institute for Clinical Social Work (ICSW) will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact LCSW at 704-999-7378.

Latasha Ellis,

If I have any questions about my rights as a research subject, I may contact John Ridings, Chair of the Institutional Review Board; ICSW at Robert Morris Center; 401 South State Street, suite 822, Chicago, IL 60605; 312-935-4232.

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SIGNATURES I have read this consent form and I agree to take part in this study as it is explained in this consent form. ___________________________________ Signature of Participant

______ _ Date

and believe that he/she understands and that he/she has agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

I certify that I have explained the research to

_____________________________________ Signature of Researcher

___________________ Date

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Appendix D Sample Interview Questions

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Sample Interview Questions 1. What has been your experience as an AA in the field of general medicine? 

Tell me about how you came to be a physician? Your inspiration?



What does it mean to be an AAGP in the era of integrated healthcare?



How do you view your overall success in the field at this point in your career?

2. What does it mean to be an AAGP to African American patients? 

Tell me how race and culture impact your role as a physician?



What are the challenges, if any, to being an African American physician to your African American patients? Are there benefits to your African American patients?



What message do you receive from your African Americans patients about your role in their lives?

3. What are your earlier experiences/exposures with depression as part of African American culture? 

Tell me how you think depression is viewed in the African American culture? (earlier experience with family, friends, self, etc.)



How was depression managed?

4. When it comes to African American patients with depression, what has been your experience? 

Which type of depression care treatment do you consider for African American patients?



How receptive are your African American patients to various depression care treatment?

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

Tell me what it is like for you to have an African American patient who does not respond favorably to treatment?



Please share your thoughts and feelings related to working with and referring African American patients to mental health therapists.



What factors play a role in your choice of treatment for depression in African American patients’ patient?

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Bailey, R. K., Patel, M., Barker, N. C., Ali, S., & Jabeen, S. (2011). Major depressive disorder in African American population. Journal of the National Medical Association, 103(7), 548-557.

Baker, H. S., & Baker, M. N. (1987). Heinz Kohut Self Psychology: An Overview. The American Journal of Psychiatry, 144(1), 1-9.

Balady, G. J., Williams, M. A., Ades, P. A., Bittner, V., Comoss, P., Foody, J. M., Franklin, B., Sanderson, B., & Southard, D. (2007). Core components of cardiac rehabilitation/ secondary prevention programs: 2007 Update. Circulation American Heart Association, 115 (20), 2675-2682.

Borden, W. (2000). The relational paradigm in contemporary psychoanalysis: Toward a psychodynamically informed social work perspective. Social Service Review, (September), 352-379.

Bowlby, J. (1988). A secure base. Basic Books.

Cadigan, R. J. & Skinner, D. (2015). Symptoms of depression and their management among low-income African American and White mothers in the rural south.

Journal of Ethnicity and Health, 20(3), 293-308.

139

Chen, F. M., Fryer, G. J., Phillips, R. J., Wilson, E., & Pathman, D. E. (2005). Patients’ beliefs about racism, preferences for physician race, and satisfaction with care.

Annals of Family Medicine, 3(2), 138-143.

Collins, E. G., Bauldoff, G., Carlin, B., Crouch, R., Emery, C. F., Garvey, C., Hilling, L., Limberg, T., ZuWallack, R. & Nici, L. (2014). Clinical competency guidelines for pulmonary rehabilitation professionals. Journal of Cardiopulmonary Rehabilitation and Prevention. 34(5), 291-302.

Commission on Cancer. (2015) Cancer program standards: Ensuring patient-centered care (2016 Ed). American College of Surgeons.

Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., and Salazar II, G. (2008, Summer) Relational-Cultural Theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86, 279-287.

Conner, K. O., Copeland, V. C., Grote, N. K., Rosen, D., Albert, S., McMurray, M. L., Reynold, C. F., Brown, C., & Koeske, G. (2010). Barriers to treatment and culturally endorsed coping strategies among depressed African American older adults. Journal of Aging and Mental Health. 14(8), 971-983.

Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Hong Thi, V., Powe, N. R., Nelson, C., & Ford, D. E. (1999). Race, gender, and partnership in the patient-physician relationship. JAMA: Journal of the American Medical Association, 282(6), 583-589.

Creswell, J. W. (2007). Qualitative inquiry & research design. Sage Publications.

140

Croghan, T. W., & Brown, J. D. (2010) Integrating mental health treatment into the patient centered medical home. Agency for Healthcare Research and Quality (AHRQ) Publication, No. 0-0084-EF. Das, A. K., Ofson, M., McCurtis, H. L., & Weissman, M. M. (2006). Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice, 55(1).

Department of Health and Human Services. (2012, March 27). Screening for depression in Adults. https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork- MLN/MLNMattersArticles/downloads/MM7637.pdf Gardner, J. (1999). Using self-psychology in brief treatment: Comparative approaches in brief dynamic psychotherapy. Haworth.

Ghods, B. K., Roter, D. L., Ford, D. E., Larson, S., Arbelaez, J. J., and Cooper, L. A. (2008). Patient-Physician communication in the primary care visits of African American and whites with depression. Journal of General Internal Medicine, 23(5), 600-606.

Hammer, T. R., Crethar, H. C., and Cannon, K. (2016). Convergence of identities through the lens of relational-cultural theory. Journal of Creativity in Mental Health, 11(2), 126-140.

Holloway, I., & Galvin, K. (2017). Qualitative research in nursing and healthcare (4th ed). Blackwell Publishing, Ltd. Jordan, J. V. & Hartling, L. & Baker, J. (2008). The development of Relational-Cultural Theory. https://www. researchgate.net/publication/247836552

141

Kathol, R. G., Patel, K., Sacks, L., Sargent, S., & Melek, S. P. (2015). The role of behavioral health services in accountable care organizations. American Journal of Managed Care, 21(2), 95–98.

Kohut, H. (1968). The psychoanalytic treatment of Narcissistic Personality Disorder: Outline of a systematic approach. Psychoanalytic Study of the Child, 23, 86-113.

Lindsey, M. A., Korr, W.S., Broitman, M., Bone, L., Green, A., & Leaf, P. (2006).

Help-seeking behaviors and depression among African American Adolescents Boys. Social Work, 51(1), 49-58.

Malat, J., & Hamilton, M. A. (2006). Preferences for same-race health care providers and perceptions of interpersonal discrimination in health care. Journal of Health & Social Behavior, 47(2), 173-187.

McDonald K. M., Sundaram V., & Bravata, D. M., et al. (2007, June). Closing the quality gap: A Critical analysis of quality improvement strategies. Agency for Healthcare Research and Quality (US), 7. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK44012/ McKinlay, J. B., Lin T., Freund, K., & Moskowitz, M. (2002). The unexpected influence of physician attributes in clinical decisions: results of an experiment. Journal of Health and Social Behavior, 43, 92-106.

Miranda, J., & Cooper, L. A. (2004). Disparities in care for depression among primary care patients. Journal of General Internal Medicine, 19(2), 120-6.

Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration.

Harvard University Press.

142

Center for Disease Control. (2015). National Ambulatory Medical Care Survey: 2015 State and National Summary Tables. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2015_namcs_web_tables.p df Nicolaidis, C., Timmons, V., Thomas, M. J, Waters, A. S., Wahab, S., Mejia, A., & Mitchell, S. R. (2010). “You don’t go tell white people nothing”: AfricanAmerican women’s perspectives on the influence of violence and race on depression and depression care. American Journal of Public Health, 100(8), 1470-1476.

Olfson, M. (2016). The rise of primary care physicians in the provision of U.S. mental health care. Journal of Health Politics, Policy and Law, 41(4).

Overstreet, K. M., Moore, D. E., Kristofco, R. E., & Like, R. C. (2007). Addressing disparities in diagnosing and treating depression: A promising role for continuing medical education. Journal of Continuing Education in Health Professions, 27, 5-8.

Pirraglia, P. A., Murthy, V., & Weilburg, J. (2006). Primary care doctor attributions for why patients did not receive adequate antidepressant treatment. Journal of Evaluation in Clinical Practice, 13, 473-475.

Richards, J. C., Ryan, P., McCabe, M. P., Groom, G. & Hickie, I. B. (2004). Barriers to the effective management of depression in general practice. Australian & New Zealand Journal of Psychiatry, 38(10), 795-803.

Rubin, A., & Babbie, E. R. (2001). Research methods for social work. Australia: Wadsworth/Thomson Learning.

143

SAMHSA. (n.d.). What is integrated care? https://www.integration.samhsa.gov/about-us/what-is-integrated-care Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis.

Sage Publications.

Snowden, L., & Pingitore, D. (2002). Frequency and scope of mental health service delivery to African Americans in primary care. Mental Health Services Research, 4(3), 123-130.

Specialists. (2017). Harvard University https://www.health.harvard.edu/staying-healthy/specialists.

Streubert, H. J. & Carpenter, D. R. (2011). Qualitative research in nursing. Lippincott, Williams & Wilkins.

Van Voorhees, B. W., Cooper, L. A., Rost, K. M., Nutting, P., Rubenstein, L.V., Meredith, L., Wang, N., & Ford, D. (2003). Primary care patients with depression are less accepting of treatment than those seen by mental health specialist.

Journal of Internal Medicine, 18(12), 991-1000.

Waite, R. & Killian, P. (2008). Health beliefs about depression among African American women. Perspectives in Psychiatric Care, 44(3).

Wang, P. S., Olga D., & Kessler, R. C. (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health, 92(1), 92-98.

Westheimer, J. M., Steinley-Bumgarner, M., & Brownson, C. (2008). Primary care providers’ perceptions of and experiences with an integrated healthcare model.

Journal of American College of Health, 57, 101-108.

144

Whaley, A. (2001). Cultural mistrust and mental health services for African Americans: A review and meta-analysis. The Counseling Psychologist, 29(4), 513-531.

Wittink, M. A., Givens, J. L., Knott, K. A., Coyne, J. C., & Barg, F. K. (2011, October).

Negotiating depression treatment with older adults: Primary care providers’ perspectives. Journal of Mental Health, 20(5), 429-437.