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Dr. Fred Dyer-Emerging Adults

We are happy to announce that Dr. Fred Dyer, a national expert on clinical practice with Emerging adults will author this exhibit on African American Emerging Adults with Substance Use Disorders. Emerging Adults are between the Ages of 18 to 25. Their development and clinical needs are different from adolescents and most report not feeling completely adult. Dr Dyer's content will range from blog posts, articles, thoughtful quotes and clinical tips. Scroll below to read his posts. Dr. Dyer can be reached at 773 322-8425,, and

Addressing Microaggressions, Micro-insults, and Micro-invalidations in working with African -American Emerging Adults with Substance Use Disorders: Counselor Implications Part III

by Fred Dyer, PH.D, CADC

This is the final part of a series of posts on Microaggressions, Micro-insults, and Microaggressions related to working with African American Emerging Adults with substance use disorders. This particular post will focus on the clinical relationship. The subject of clients of color and in particular African American Emerging Adults with substance use disorders experiencing microaggressions, micro-insults, or micro-invalidations is not new. Dr, David Satcher (former Surgeon General of the United States 1998-2002) headed up an impressive list of scholars, practitioners, researchers, and executive directors, and wrote a report in 2002 entitled Culture, Race, and Ethnicity. It is this writer’s belief that professionals who are serious about serving African American Emerging Adults should read that report. Additionally, in an article by Gina C. Torina entitled How Racism, and microaggressions lead to worse health (Center for Health Journalism, and the University of Southern California, 2017).She reminds us that in her section titled Overt racial discrimination and health, that there is a lot of evidence that suggests that overt racism, and discrimination lead to worse health outcomes for people of color. Researchers at Columbia University have found that the experiences of racism can result in traumatic stress. Furthermore this stress is linked to negative mental health outcomes, such as depression, anger, physical reactions, Avoidance, intrusion, hypervigilance, low self esteem, high levels of stress hormones, and wear and tear on the body.

An article entitled, Young Adults Reasons for Dropout From Residential Substance Use Disorder Treatment, (Oslo university hospital, 2016), provides four reasons emerging adults drop out of substance use treatment including: drug craving, negative emotions, personal contact, and activity. I would like to focus on personal contact as it pertains to the impact of racial microaggressions , micro-insults, and micro -invalidations on the counseling relationship with Afrian American Emerging Adults with substance use disorders.  The therapeutic alliance is the SINE QUA NON of any work taking place and in order for counselors to develop an effective relationship with clients of color, counselors need to acknowledge  that these clients have experienced racial microaggressions, microinvalidations and micro-insults throughout their lives. First, being aware being aware that there is indeed a link between all  the aforementioned micro's and using substances to cope. Perhaps the important goal of a counselor is to validate the experiences of African American emerging adult, and other marginalized groups, and help them to cope  successfully with microaggressions, micro-insults , and micro-invalidations as they occur. Counselors can also assist in addressing the three micro's by validating their experiences thru what Holder[2008} describes as a "sanity check" {p.332} in which the victims of any of the micro's often turn to others, who either have witnessed the interaction or can help them process  their cognitive  emotional reactions.

Finally, culturally competent counselors and other practitioners must be aware that intersectional  identities may affect clients experiences with the three  micro's, which in turn may have an impact on a client using substances or impact their mental health.. Because intersectional identities including: race, gender, age, sexual orientation, disabilities etc. or some combination are such  crucial aspects of an individuals development and sense of self, that it may be beneficial for counselors  to initiate conversations about potential microarressions, micro-insults, and micro-in-validations so that clients can thoroughly process  their  feelings about them, while preparing them to cope with future micro-aggressions, insults , and in-validations. For those of us who continue to want to get better in this important work with emerging adults, we take the time to develop our skills , we honestly address our biases, and prejudices (conscious, or unconscious) and strive to believe  that  a Change in Fact will Come as predicted by the late, great singer Sam Cooke (Summer 1963). A change is coming for African American Emerging Adults seeking recovery. Clink on the link below to hear the song.


African American Emerging Adults, Substance use Disorders, and Racial Microaggressions. Part 2

 by Fred Dyer, PH.D, CADC

Picking up from where we left off last time, and remembering that emerging adulthood is not just the sorting out of new developmental assignments, but for the African American emerging adult, it is the sorting it out in the midst of frequent, if not daily exposure to racial microaggressions, micro-insults, and,

micro-invalidations. Before going any further it is very refreshing to observe in the literature the plethora of attention to such an important subject, as opposed to believing, or behaving as if life is just one great big "love -in" (a 1960's reference). Or, pretending that these issues do not matter or no longer exist. 

 There are many studies and articles which have caught my attention in the preparation of the writing of this post, however, several articles in particular seem to really hit the nail on the head in discussing this subject. The first article  is called " Racial Micoaggressions in Everyday Life": Implications for Clinical Practice. In the May-June 2007-issue American Psychologist, and the second article is, "The What, the Why, and the How: A Review of Racial Microaggressios  Research in Psychology, by G. Wong, et al 2013, and lastly, I would be remiss if I did not mentioned this last article, "The Impact of Racial Microaggressions on Mental Health: Counseling Implications for Clients of Color, by Kevin l. Nadal, Journal of Counseling and Development, January 2014. 

It is necessary to define the terms used in this post. There are three types of  Racial Microaggressions. The first one is called, Microassaults, which is an explicit racial derogation characterized primarily by a nonverbal attack meant to hurt the intended victim through name-calling, avoidant behavior, or purposeful discriminatory actions (i.e.: calling someone colored or Oriental) using racial epithets, discouraging inter-racial interactions. 

The second term is microinsult. A  microinsult is characterized by communications that convey rudeness and insensitivity and demean a person's racial heritage or identity. Microinsults represent subtle snubs, frequently unknown to the perpetrator, but clearly convey a hidden  insulting message to the recipient of color. 

The last term Microinvalidation. Microinvalidations are  characterized by communications that exclude, negate or nullify the psychological thoughts, feelings or experiential reality of a person of color. When Asians are told they speak good English, or asked repeatedly where were you born, the effect is to negate their U.S. American heritage, or when African are told "I don’t see color" or we are all human beings, and according to (Helms, 1992). it is an attempt knowingly or unknowingly to negate  their experiences as racial/cultural beings. 

Regarding the connection between microaggressions, and discrimination, and substance use for African American Emerging Adults there is consensus among researchers  that there are two primary paths of influence from perceived discrimination to health for  African American Emerging Adults. The first is direct: The stress produced by discrimination is associated with a variety of health  markers, and outcomes, both acute (e.g., blood pressure elevation) and chronic (inflammation, metabolic syndrome), (Lewis, Aiello,Leaurgans, Kelly, & Barnes). 

The second pathway is indirect, through behaviors  such as heavy  substance use , which is an attempt to ameliorate the stress reaction but in the process, increase health risk (Clark, 2014: Gibbons et al., 2004:Pascoe & Smart Richman, 2009). 

It is necessary for those working with African American Emerging Adult clients in the context

of the unique development period , that we remain ever vigilant regarding the everyday microaggressions which these clients encounter. Maybe it is important for all of us who are committed to the mission of providing services to this cohort that we take heed to the song by Harold Melvin and the Blue Notes, from the summer of 1975, called 'Wake-Up. Click on the like below to hear the song.


 African American Emerging Adults, Substance Use Disorders Treatment and Racial Microaggressions Part 1

 by Fred Dyer, PH.D, CADC

 Upon beginning to cogitate on the writing of this subject, as well as examining the research and reflecting on my own experience, especially in the area of Microaggressions, I believe that there is no systematic way to begin, other than just to begin. In the theory of emerging adulthood, it has been proposed that identity explorations are one of the most important and distinctive features of this period (Arnett, 2000, 2004: Schawartz, Cole& Arnett, 2005). Identity formation was formerly believed to be central to development in adolescence, based on Erikson"s (1950) lifespan theory. We now know that since Erikson's fifty year old theory, that much has changed, as well as evolved, i.e., widespread post-secondary education, later ages of entering into marriage, and parenthood, and that identity exploration now continues into the twenties, and for some until their late twenties to make those enduring choices  in love and work.

African American Substance using Emerging Adults face many of the same challenges of identity explorations as other emerging adults. The salient challenge for the African American Emerging Adult is that their identity exploration can be complicated by the fact that it takes place within a society and context which  they perceive as possessing negative  assumptions about them (Way,Santos, Niwa,&Kim-Gervey,2008). These negative assumptions, which can be manifested in speech or interactions with African American Substance using Emerging Adults, and does impact on the therapeutic relationship, and can impact on his/her compliance and retention to treatment.

The subject of Microaggressions , Micro-invalidations, and Micro-insults were terms which were first introduced to me as  graduate student at the Illinois school of Professional Psychology and the again in my Doctoral program. Addressing Microaggressions in treatment can be and is hard work, and it means therapists/counselors have to allow themselves to examine their assumptions, acknowledge their assumptions, confront their assumptions, and go on and do good work with their clients. I referenced graduate school, because it was in graduate school where I first saw the documentary "The Color of Fear", which can now be watched on youtube. It was also where I read the book Black Families in Therapy, by Nancy-Boyd-Frankin, PH.D, LCSW.

Studies remind us of many reasons why clients may not stay in treatment, including, drug craving, negative emotions, personal contact, and activity. It is  important that we begin to examine the impact of microaggressions on our ability to develop a therapeutic alliance with African American Emerging Adults with Substance use disorders. Microaggressions can be defined as intentional or unintentional insults or slights. They serve as a barrier to not only the development of the alliance , but of any future work with the client. Let's be clear, racial microaggressions impact clients, staff and serve  as an impairment to any agencies mission to providing culturally competent treatment.

The spinners in the summer of 1973 recorded a song  called Ghetto Child, and upon listening to the song today, it still has meaning, and is relevant in helping us understand the challenges faced by African American Emerging Adults. As we continue in the work of providing culturally competent/age-appropriate, gender -response- treatment for African-American Substance using Emerging Adults. Click on the link below to hear the song.


Treatment Needs of Emerging Adult African American LGBTQ Clients with Substance Use Disorders

by Fred Dyer, PH.D, CADC

 A document issued by the American Psychological Association, January, 2012 which appeared in the journal the "American Psychologist", titled Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients, can help those providing culturally specific substance use disorders and mental health services for African American LGBTQ Emerging Adults.  Guideline 11 it notes that 'psychologists should  strive  to recognize the challenges related  to multiple  and often  conflicting norms , values, and beliefs faced  by lesbian , gay and bi-sexual members of racial and ethnic minority groups. The rational for this guideline is that African American LGBTQ individuals who are members  of racial , ethnic and cultural minority groups  must negotiate the norms , values, and beliefs regarding their sexual identity of both mainstream and minority cultures (Chen,1992 1995: Greene, 1994).

It is important for individuals working with African substance using LGBTQ Emerging Adults to understand the different ways in which multiple minority statuses may complicate and exacerbate the difficulties their clients experience. For example it is important for those providing treatment services to consider or examine how clients may be affected by their culture of origin views and may stigmatize individuals who are LGBTQ (Gock, 2001, Greene, 1994), as well as the effects of racism within mainstream LGBTQ communities (Gock, 2001: Greene, 1994a:, Morales, 1996: Rust, 1996a).

As a plan going forward  it is essential  to help clients recognize effective  coping mechanisms and utilize other protective factors that their LGBTQ  clients  from racial , ethnic , and cultural minority backgrounds have developed as a result of generations of marginalized experiences, such as support groups, identifying those supportive family members, as well as supportive communities. In closing African-American LGBTQ substance using emerging adults are in fact individuals who like everyone else deserve respect, and are entitled to be treated with dignity, because African American LGBTQ substance using clients are just what Sly and the Family Stone said way back in the spring of 1969 are 'Everyday People." Click on the link below to hear the song.


Relapse Prevention for African American Substance using Emerging Adults

by Fred Dyer, PH.D, CADC

 When counseling African American Emerging Adults with substance use disorders it is important to view relapse from a micro-systemic perspective. Areas of focus includes: 1. Brain development at this age, 2. Changes in support network, 3. Increases in psychosocial stress, 4. "Feeling in Between" i.e., not feeling like an adolescent yet, not fully embracing or achieving the full responsibilities of adulthood, 5. Addiction, and relapse. Both must be viewed as being impacted by the day to day systemic interactions that clients have with the systems of interface and how these systems influence the client’s behavior.

While abstinence is often the goal, harm reduction continues to be an effective approach with emerging adults despite its continued criticism from the "total abstinence community." Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors (Marlatt, 1998). Most frequently associated with substance use, harm reduction also applies to any decisions that have negative consequences associated with them. At its core, harm reduction supports any steps in the right direction. Harm reduction is based upon the belief that an act of self care anywhere can lead to self care everywhere. Many African American emerging adults are not ready for total abstinence. Harm reduction approaches such as: not sharing needles; not mixing illicit drugs; not mixing any drugs with alcohol; use narcan; not getting high with or getting in cars with strangers etc., can not only eventually lead to abstinence and recovery, it can also save their life.  It is always important to remember that recovery and the practice of relapse prevention are both a process, and that each client needs different things from treatment, but it is necessary to respect the clients decision to change or not to change.

In my work with African American Emerging Adults I have found that cognitive behavioral therapy is an effective relapse prevention tool. With each client we create an individualized relapse prevention plan. This involves the client identifying their top five relapse triggers (in their own words) and identifying strategies to deal with each trigger. Clients also select strategies to deal with cravings. Other cognitive strategies include: 

  1.  Address Fear. Fearful thoughts are common and a basic fear young adults experience is that they are not capable of recovery. Cognitive therapy helps client see that recovery is based on developing coping skills and relapse prevention strategies even in the midst of fear.

  2.  Redefining Fun. Many of the African American Emerging Adults I work with reveal that almost all of their fun revolves around drug use. One of the important tasks of therapy is to help individuals redefine fun utilizing Expectancy theory, which means that if a client expects to have fun, even without drugs, he or she will. 

  3.  Becoming Comfortable with being Uncomfortable. This is an affective /cognitive challenge which if addressed can help clients refrain from returning to using alcohol and drugs, and view this uncomfortability as an opportunity for growth. Lastly, there are five basic rules of recovery which can be applied to relapse prevention therapy.

     1.    Change your life (one day at a time, one decision at a time, one situation at a time).

    2.    Be Completely Honest (with yourself and others),

     3.    Ask for Help.

     4.    Practice daily acts of self care.

     5.    View relapse as a temporary setback and a learning experience. Carter G. Woodson said, "If you learn the lessons from history, you are less likely to repeat that history." One lesson from history is African American resilience. Ultimately, you're unstoppable! I end this post with the song from Mcfadden and Whitehead, Ain't No Stopping Us Now. Click on the link below to hear the song. 


Helping African American Emerging Adults Recover: A Focus on Treatment Planning and Relapse Prevention

 by Fred Dyer, PH.D, CADC

 Harlem Renaissance writer James Baldwin  said “Until it is faced nothing will change, and nothing will change until it is faced.” Baldwin made that statement over 50 years ago and yet it is as poignant today as it was when first spoken. It definitely has relevance to African American Emerging Adults who are seeking recovery. In the formulation of a treatment plan with this population, it is not only important to examine their readiness for change, it is also important to examine their current stressors. It is also necessary to gauge where they are developmentally. This is important because many African American Emerging adults with substance use disorders enter treatment having experienced trauma. It is clear from trauma studies that trauma interferes with development. We do not want to create a treatment plan which is impossible for the client to complete because of current stress or because the treatment plan does not match where they are at developmentally.

It is important to communicate to African American Emerging Adults that recovery not only includes abstinence, it also includes creating a new way of life which decreases the attractiveness of drug use. One addictions program that works with Emerging adults is affiliated with a trade school. Persons seeking recovery in that program report that they would not want their marijuana use to impact their ability to earn $30.00 per hour as an electrician as a result of a positive drug test. 

A simple and easy to grasp relapse prevention tool to introduce to African American Emerging Adults seeking recovery  the acronym HALT  which stands for hungry, angry, lonely, and tired. I often ask emerging adults if they are more likely to relapse if they are hungry (not just food hunger this can include desperately wanting anything), angry, lonely or tired? I help them develop a relapse prevention strategy based upon their response. We also want to help them to understand that recovery is not about one big change. It is about lots of little changes, and avoiding high risk situations can help create a new way of life  where gradually they find themselves in fewer high risk situations. It is recommended that clients make a list of high risk situations and keep the list with them to refer back to when they feel they are in a high risk situation. Learning to relax without alcohol and drugs is essential. Relaxation is not an optional part of recovery, it is an essential and necessary part of recovery

Lastly, McGovern et al. (2005) offers the following key ingredients  for substance use relapse prevention {1} reducing exposure to substances, {2} fostering motivation for abstinence, {3} self-monitoring, recognizing and coping with cravings and negative  effect, {4} identifying thought processes with relapse potential, and [5} deploying if necessary a crisis plan. Additionally avoiding toxic people ,places , and things, and participating in meaningful recovery activities i.e.,12-step AA, or NA meetings, sober parties, mentoring programs, volunteer programs, going back to school, or just taking a class, or just finding something that gives life meaning. African American Emerging Adults need to remember that recovery is a journey, and that relapse does not mean failure! The key is  a made -up mind,  with help from the higher power and a willingness to "Keep on Pushing" in their recovery. I occasionally end groups with emerging adults with an old school song "keep On Pushing" by Curtis Mayfield and the Impressions. Click on the link below to hear the song. 


 What is Recovery for African American Emerging Adults?


 As I began to write this post I found myself pondering the question, what does Recovery from alcohol and drugs really mean to 18-25 year old African American Emerging Adults? What we have learned from our work with adolescents and emerging adults from a public health perspective is that substance use for emerging adults is multi factorial, and multi-determined.  While Abstinence is an important aspect of recovery a broader definition is needed for African American Emerging Adults, with aspects of the definition which includes their entire life and psycho-social needs in recovery.

Drs. Alexandre Laudet, and David Best provide a definition of recovery which in my mind can be used as a framework to address the myriad of issues African American emerging adult faces in recovery. " The essence of recovery is a lived  experience of improved life quality and a sense of empowerment, that  the principles of recovery focus on the central ideas of hope ,choice, freedom and aspiration that are experienced rather than diagnosed and occur in real life settings rather than in the rare field atmosphere of clinical settings. Recovery is a process rather than an end state, with the goal being an ongoing quest for a better life". Addictions counselors reading this post should know that many of the components listed in Laudet and Best's definition of recovery are important for African Emerging adults seeking recovery. Particularly: empowerment; hope; choice; freedom and aspirations (for the future). Having a voice in the treatment plan, speaks to the need for choice and freedom. Counselor enthusiasm and hopefulness can go a long way towards sending the message to African American Emerging adults he or she can lead a self directed, successful life in recovery.

Many African American Emerging Adults seeking recovery are more likely to achieve lasting recovery if they build recovery capital. Recovery capital is defined as internal and external assets that a person can bring to bear on their recovery. Research indicates that as recovery capital increases the risk of relapse decreases. Many African Americans have "fallen behind" because of active addiction. It is important in recovery to help them increase, educational, vocational and occupational recovery capital. Addictions programs should have affiliations with GED, Community colleges, vocational schools and Universities. Linkages with mutual Aide groups (AA, NA, CA, Celebrate Recovery etc) which are African American Emerging Adult Friendly can go a long way toward helping clients develop social and community recovery capital which are important to recovery. Lastly, Recovery Capital can be instrumental in helping African Emerging adults renew their belief that life is not over, and that dreams do come true and instill the belief that " I'm in recovery that I'm a winner!" I occasionally end therapy groups with Emerging Adults with the song We're A Winner by Curtis Mayfield. Click on the link below to hear the song.


 African American Emerging Adults, Substance Use, Romantic Relationships, and Marriage.


 Catalano et al (2012) postulates that Marriage or a committed relationship is a protective factor for developing and reducing the risk of substance use. Sher and Gotham (1999) suggest that marriage is protective and conversely, divorce imparts risk of developing a substance use disorder. However, it seems that associations between marriage and substance involvement may be more complex. Studies show that marriage  is capable of both moderating the risk of other variables in relation to substance use outcomes, and is also itself subject to moderation by other variables. In relationship to marriage and dating among African American Emerging Adults it must be kept in mind that the achievement of intimacy in a romantic relationship is considered to be one of the critical developmental tasks, marking one’s entry into adulthood (Conger. Cui, Bryant, &Elder, 2000). Failure to establish and sustain a committed intimate relationship during this time is thought to not only hinder development (Erikson, 1968) but have serious negative implications for well-being across the lifespan (Kiecolt-Glaser%Newton, 2001).

Marriage is often thought of as the ultimate consummation of a relationship. Marriage traditionally signifies commitment, monogamy, stability, trust, and security. Studies indicate that in the African -American community the marriage rate is low and is consistently declining (Mcadoo, 2007). The answer to this assessment is complex as well as interesting. Some African American Emerging Adults have shifted from the traditional desire to form committed long-term monogamous relationships to wanting more casual relationships and "hooking up" (Owen&Fincham,2011). Although casual relationships and hook ups have been used interchangeably in the literature there are some distinctions that should be made. Casual relationships can be long term or short term (Simpson&Gangestad, 1991), with strangers, and may eventually lead to a committed relationship. The issue of the scarcity of African American Emerging Adult men being available for marriage or for a committed relationship is not to be relegated to just the pat answer that (they are all locked up), although incarceration rates for African American Emerging Adult men is a topic for another blog/discussion. There are additional issues such as sexual decision making and behavior, the using of alcohol and drugs by either person, past relationships which carry over into the new  relationship, intimacy, which means or refers to expectations and requirements, power and decision making. Lastly the individuals seeking to form a committed relationship with each other, should first asked themselves have they taken the time to have one with themselves. The consummate song in my mind which explains or personifies love and commitment is by Peaches and Herb from the awesome summer of 1967 called 'United" Click on the link below to enjoy the song.


 Racial and Gender Identity Development for African American Substance Using Emerging Adult Women

From the above title it is quite clear that this subject is worthy of becoming a book, thesis, or a dissertation. Nonetheless this topic is crucial and is definitely connected to a myriad of treatment issues for African American Substance using Emerging Adult women. The motivation for this blog stems from a song from 1969 titled "Black Pearl" by the group" Sony Charles and the Checkmates". Who can forget 1969, yes, the Vietnam war, Bobby Kennedy, and Dr. King assassinated. There were movements and protests occurring all around the country and the world. In the United States Africans Americans were exhibiting both an inward and outward expression of pride. For women they related to each other as" sister" or" sisters" and there was a collective expression of pride of being an African American women weather you were young or older. If you were an adolescent young woman it was important for you to know that going forward  there were women, mothers, grandmothers, and aunts, who paid dues for you to go forward, and that you did not have to be or feel ashamed of who you were.

Ethnic and Racial identity refers  to an aspect of self-concept and social identity that derives from an individual’s knowledge of their  ethnic or racial group membership and the significance and meaning they attach  to that group membership (Phinney, 1992: Tajfel,1981). Racial Identity is associated with lower psychological stress, distress, and well-being (Sellers, Caldwell, Martin, &Lewis, 2006). Self- identification as a group, a sense of belonging, pride in one’s group, and involvement in the activities of the group are all key aspects of racial identification (Phinney, 1990). Because of their unique minority status, racial identity is a central aspect of self -concept for young African Americans and may have important implications for their health, especially in the context of racial discrimination (e.g., Greene et al., 2006: D.R. Williams, Spencer & Jackson, 1999).

An understanding of gender role beliefs among African American women is imperative to comprehending her behavior. Gender roles are developed through socialization and because individuals are able to assume a variety of roles, context is better than gender (Eagly, 1987). This theory does not undermine the importance of gender roles but helps one understand that these roles are complex and can be influenced by social situations people find themselves in. Culturally competent treatment must not only address the addiction, but also encourage, and empower the African American emerging adult woman to empower herself to believe that she can recover, go on to raise  a family, be her own person, believe that her dreams are not over, and that she can begin again right where she is. Because others have done it, so why not you?

Click on the video below. Black Pearl by Sonny Charles and The Checkmates and view the images of successful young African American Women in the video.


Ethnic and Racial Identity as a protective Buffer against Alcohol and Drug use for African American Substance Using Emerging Adults

The motivation for the writing of this blog post stems from a song which was written in 1973 (45 years ago). At that time, Richard Nixon was President of the United States, the nation was still dealing with Vietnam, it was 5 years after Martin Luther King was assassinated, eight years after the death of Malcom X, Jimi Hendrix, and Janis Joplin were gone as well. College students were marching to address  women's rights and civil rights. But during those aforementioned months there was a song on the radio, that people were listening to on their eight track players at Historically Black Colleges, community centers, urban and rural African American Communities. This song became an anthem for African American Adolescents, and African American Emerging Adults. A 40 year old women from Tryon, North Carolina, named Eunice Kathleen Waymon ( aka NINA SIMONE) wrote the song from a play by Lorraine Hansbury called "To Be Young Gifted and Black."  The song was and  instilled a sense of pride, promoting a healthy Ethnic and Racial Identity.

Much  of what we know about ethnic identity, within the context of substance use literature was gleaned from mono-racial youth populations. Strong ethnic identity has been found to protect African American youth and young adults from heavy alcohol use (Nasim, Belgrave, Jagers, Wilson, and Owens, 2007). Ethnic and racial identity are multidimensional concepts (Burlew, Bellow, and Lovett, 2000: Cross, 1991:Phinney, 1990). There are several core components for ethnic and racial identity which help buffer African American Emerging Adults against using alcohol and drugs. The core components include emotional  and behavioral aspects, as well as cultural values and behaviors. An emotional dimension of ethnic identity pertains  to the individuals’ attachment and feelings of belonging to his/her ethnic or racial group (Cheung, 1993: Phinney, 1992). Related to this dimension of belonging is the individual's perceived likeness to and identification with close members  of his/her ethnic group (Brook, Balka, et al 1998). A more behavioral aspect of this form of ethnic identification is the affiliation with the same-ethnic  peers, in this case other African-American Emerging Adults.

I would be remissed if I did not mention the importance of the African -American church which provides  a strong sense and source  spiritual and political support (Morris,2001). The strength  of the African American community continues to lie  in its churches  and extended families (Morris, 2001, p. 11). It has been 45 years  since Nina Simone blessed us with a song that is timeless, relevant, and communicates to today's African American substance using emerging adult to hold your head up, and that there is a whole world waiting for you because you are "Young, Gifted, and Black, and SOBER.

Clink below to hear Nina Simone discuss her inspiration for the song followed by her performance of the song in front of a live audience.


 African American Substance Using Emerging Adults and The Ongoing Work of Establishing, Maintaining, and Improving Substance Use Disorder Treatment Engagement, Compliance, and Retention

Upon reflecting on last week’s blog, and along with observing time and time again from my own clinical work with this population, I felt the need to continue this all important topic of engagement because there are still too many African-American Emerging Adults who wind up in treatment but do not finish, or who are homeless, or who are struggling with being separated from their families, or who are in jail. Young African American women with children who may not have the skill set or familial supports in place to help buffer the daily hassles and stressors of life. Emerging Adult has been designated as “The Age of Feeling In-Between “ (Arnett 2000). It is during this period that the African American Substance using Emerging Adult enters into treatment with not just "Feeling In-Between," but also thinking and or believing "these folks can’t help me, because they don't know anything about me, or my problems". Regardless if the therapist/counselor is of the same race, or ethnicity, or from a different cultural group, issues of diversity must be taken into consideration in the treatment process if treatment is going to successful.

If client engagement and compliance is to be successful, then the continued working on the developing of the therapeutic alliance which has empathy as a necessary component to attaining a successful therapeutic alliance is a must (A.J. Clark,2010:. Researchers  have referred to empathy as a theoretical framework, a conceptual construct (Kohl,2006: Lux, 2010: Moyers & Miller, 2013) Regardless of the  label it is a necessary factor in the process of building a therapeutic alliance with clients.

Therapeutic alliance between African -American Emerging Adults and non- African American Emerging Adult counselors can be strained and lead to early termination of treatment if the therapeutic relationship is not cultivated.  Empathy, a component of therapeutic alliance is key when it comes to cultivating a therapeutic relationship and attempting to see the world from the client’s perspective (Carr &West, 2013) A lack of empathy can lead to ruptures  in therapeutic alliance and can cause African American Emerging adults  to feel  that they have not been heard , understood or supported (Owens et.,2012).

It is therefore necessary for therapists/counselors to engage in daily/ weekly Check-ins, with clients by simply asking them "How do you think we are doing" or "Do you feel or believe that you are being heard and understood" Remember, it is like in everyday life, everyone wants to be asked and believe that they are appreciated.

Engagement the Vehicle which Drives Treatment Compliance and Retention Among African American Substance Using Emerging Adults

It is clear from the word engagement that many key words or concepts emerge. Including, therapeutic alliance, and empathy which has been described as belonging to the vehicle of engagement is a destination which is observed from clinical practice and studies that is never arrived at , but rather is continuously driven or worked at. The issue of engaging African American substance using emerging adults in treatment starts with what I term as the utilization of the Therapeutic use of self. which begins with the principle of Liking and understanding African American substance using emerging adults. I am not talking about or condoning any self-destructive behaviors, or the violation of the rights and rules of others, but rather where those of us who are committed to working with this population, and who have not given up on them want to see them sober, running businesses, raising families, and being leaders in their communities. The question can be asked, how or what do I need to do to engage him or her in treatment?

 It all starts with the ongoing development of the therapeutic alliance which in Latin is the (sine qua non) or essential component. Meaning that without it nothing else gets accomplished. The process of engagement starts with talking with the emerging adult to get to know him or her. Not in an intrusive, prosecutorial manner, but in a manner which seeks to understand their world, their struggles, their losses, their dreams, their hopes, and their regrets, keeping in mind that all of this is in the context of their substance use whether it is before or after the losses, or regrets. The salient quality which will go a long way in understanding the world of the African American substance using emerging adult is Empathy. Now let’s be clear it is not the only factor but it goes a long way in developing the therapeutic alliance.

Empathy is a concept from Rogers’s  person-centered therapy (Rogers, 1959,1975) The empathy concept model centers on (a)genuineness or realness: (b) unconditional positive regard, which creates a climate for change and acceptance: and (c) empathetic understanding (Rogers,1959,1975). Remember, therapeutic alliance is also based on these factors, which from clinical practice not only promotes improved therapeutic alliance with African American emerging adults but also improved therapy outcome(Crenshaw& Kenney-Noziska, 2014) It is necessary to remember that the utilization and practice of empathy with clients must operate with deliberate practice.

Feedback Informed Treatment: Pursuing Clinical Excellence in Working with African American Substance using Emerging Adults

Most theories of counseling and evidence based practices were not developed with Africans in mind. Feedback Informed treatment is one evidence based approach which allows the clinician to tailor counseling to the unique needs of clients served. To that end, this approach can be culturally specific. It is the opposite of a one size fits all approach, which is a challenge of many evidence based practices. Feedback informed treatment calls for the therapist to get feedback at the end of each session and makes changes to the approach based upon that feedback.

As mentioned in previous posts, African American Emerging Adults with Substance Use Disorders often present with unique challenges which if not addressed can lead to premature termination from addictions treatment. These challenges include: poverty, mis-education, community violence, easy access to drugs and high rates of felony arrests. In spite of these challenges it is the alliance between the counselor and client that keeps clients engaged in treatment. Feedback informed treatment has been found to facilitate engagement. While having a voice is important to all emerging adults it is particularly important for African Americans who have often experienced discrimination and ostracism. Feedback informed treatment is empowering as it honors the clients need for autonomy and power to make decisions regarding the direction of his/her life.

Using the following three principles from (Miller,et al 2017) Feedback Informed Treatment, clinicians can engage in clinical excellence with African American substance using emerging adults, and observe better outcomes by: 1. Know your baseline. In other words is what you are doing with the client valid, reliable, and feasible?  2. Constantly engage in formal ongoing feedback. The question here is will the clinician formally seek and use feedback to guide service delivery?  3. Deliberate Practice, which refers to intentionally making changes in the approach based upon client feedback.

Finally, utilizing FIT results in the following benefits for the African American Emerging Adult and for the clinician.

Improves outcomes one client at a time.

Identifies areas where clinicians can improve their performance, generally and with specific cases.

Identifies cases at risk for getting worse or dropping out.

 At an agency level, helps reduce variability in performance between clinicians.

We owe it ourselves to continually strive to pursue excellence in practice, but much more important, we owe it to the client

Implementing Cultural Competence in a Trauma Informed Setting for African-American Emerging Adults with Co-occurring Disorders

The aforementioned title of this post reminds those of us who are working with African American Emerging Adults with Co-occurring Disorders, and/or those who desire to, that due to the early exposure of Adverse Childhood Experiences (ACE'S) and their impact psychiactrically, behaviorally and developmentally, when working with African Emerging adults it is necessary to be able to respond to the trauma in their lives in a culturally competent/sensitive manner.

 Laura Brown{2008} reminds us of the importance of cultural competence  in trauma informed care by stating that "Healthcare delivery of services for emerging adults  cannot be all inclusive without embracing, the need  for cultural competence/sensitivity, and even the best practices lack efficacy when culture is not incorporated as a trauma-informed solution. Additionally failure to bring cultural competence to the table can lead to missteps in genuinely helping African American emerging Adult trauma survivors or worse can result in deepening the wounds of trauma, creating secondary and tertiary traumas that are more painful than the original because they are appraised by victims and survivors as unnecessary wounds.

 As with other important topics time nor space affords the appropriate amount of time to discuss. However any discussion/treatment of trauma must and should include: Historical trauma and culturally competent/ sensitive practice parameters for healing historical trauma.

The following are a few principles for implementing culturally competent/sensitive trauma informed -care with African- American emerging adults with co-occurring disorders. 1. connect clients with resources they trust including types of professionals and traditional healers, 2. help clients to restore a sense of safety, 3. connect clients with elders who lived thru traumatic events and who managed trauma, discrimination, and setbacks, 4. remember it is important to ask clients "what the event means to them. It is clear that addressing cultural competency and utilizing cultural sensitivity in a trauma -informed setting with African - American emerging adults with co-occurring disorders is no longer an exception, but rather an expectation.

Biracial Emerging Adults and Substance Use Disorders

The topic of this post brings to mind a verse by the late singer Marvin Gaye in his song entitled What’s Going On, ”Come talk to me so you can see what's going on". These few words can reflect not only questions for the biracial emerging adult, but also the journey they may be on to figuring out who I am, where do I belong, where do I fit in, and can I be okay in my own skin. In this journey of discovery substance use continues to be an ever present challenge among all racial and ethnic groups, including biracial emerging adults (SAMHSA2010). Moreover, studies indicate that consequences of drug use vary by race and ethnicity such that minorities are more likely to experience adverse drug-related health and social consequences compared with whites. Despite the nation's growing demographic diversity (Marcera, Armstead&Anderson 2001) the prevalence and consequences of drug use among multiracial and ethnic groups are poorly understood.

Hispanics, are projected to be the U.S. majority population by 2050, obtaining national estimates of the prevalence of drug use among monoracial/ethnic and biracial/ethnic individuals is warranted. Multiracial individuals have unique experiences and challenges that continue to be unaddressed (Center for the Study of Biracial Children 2011). Multiracial young adults  often face unique conflicts related  to racial/ethnic identity, including, social marginality, educational, and occupational aspirations, defense mechanisms and coping strategies that are likely due to membership in more  than one racial or ethnic group (Gibbs &Huang 1998). The literature further  suggests that because of struggles with identity formation, which leads to low self-esteem and social isolation, multiracial  individuals may be at high risk of emotional, and behavioral health challenges including substance use disorders.

 An important  step in addressing alcohol and drug use among this  underserved, and often unacknowledged group is to utilize the  assessment phase of treatment and person centered individualized therapy to build rapport with clients and to help him/her understand contributing psycho-social factors to their substance use disorder. Treatment and recovery provides additional opportunities for the client to answer the questions, who am I, where do I belong and where do I fit in?

African American Emerging Adults with Co-occurring Substance Use and Psychiatric Disorders

Over two decades ago psychiatrist Kenneth Minkoff, MD coined the phrase, "dual Diagnosis is no longer an exception, but rather an expectation." This simple, yet profound statement is true today for clinicians who work with African American Emerging adults with co-occurring substance use and psychiatric disorders. According to research, emerging adults are particularly at risk for psychiatric disorder, and in a given year, over 40% of U.S. 18 to 29 year-olds meets criteria for psychiatric disorder. This is a higher rate than all other adult age groups.  Substance use even at levels that are non-diagnosable can result in a plethora of negative consequences for African Emerging adults, including: unwanted sexual experiences; poor school performance; weight gain; accidents; increased risk for certain cancers; and suicide. Additionally Corrigan, McCracken, and McNeilly (2005) provides eight negative impacts of dual diagnosis on individuals which include but are not limited to 1. More frequent/sever/psychiatric symptoms 2. More frequent hospitalizations 3. Less able to participate in treatment 4. Worse work history 5. More likely to be homeless 6. Greater rates of violence 7. Greater rates of incarceration 8. More frequent infections

Time nor space allows for a complete analysis, or discussion of such an important topic, However Bell and McBride (2010) offer guidance for moving forward with treatment as well as with prevention for African American Emerging adults with co-occurring substance use and psychiatric disorders. On the prevention side: 1. Understanding the exacerbations of mental illness, 2. Social pressures within drug-using networks, 3.lack of meaningful activities and social supports  for recovery, 4.Independent housing in high risk neighborhoods, and 5. A lack of Integrated dual disorders treatment. Some additional essentials  for treatment as well as relapse include: 1,Providing healthy and protective environments that support for recovery, 2. Helping African emerging adults formulate life  makeovers, i.e., obtaining satisfying employment, having friends who are not using drugs, developing support networks of others in recovery, finding a sense of meaning  and purpose, and providing specific and individualized integrated treatments for African American Emerging Adults with Co-occurring substance use and Psychiatric Disorders. 

 African American Substance Using Emerging Adults and the Five Features of Emerging Adulthood

The developmental theory of emerging adulthood postulates that there are five features which mark this unique developmental period. Arnett (2015) lists and delineates the following features: 1. Identity exploration: answering the question "who am I" and trying out various life options, especially in love and work; 2. Instability, in love, work, and place of residence; 3. Self-focus, as obligations to others reach a life-span low; 4. Feeling in- between, in transition, neither adolescent nor adult; and 5. Possibilities/optimism, when hopes flourish and people have an unparalleled to transform their lives. For African American substance using emerging adults, there are interesting question to ask, "For whom, and whose experiences fall under the rubric of emerging adulthood and its five pillars, and how might race and ethnicity impact the developmental period of emerging adulthood?”

Given the challenges that many African American substance using emerging adults face including: violence prone neighborhoods; lack of parental validation;  dropping out of school early; early pregnancy, running away from home; premature entry into adulthood; the absence of adult mentors, or pro-social  activities, substance use treatment should address the five features of emerging adulthood  but never forget that because of different cultural contexts and the myriad of experiences that African American emerging adults with substance use disorders have, additional struggles may need to be addressed in treatment.

Research reminds us that there are three motivations for substance use. 1. The drug experience motive, 2. The peer motive, and 3. The coping motive (Lecce & Watts, 1993). In summation African American Substance using emerging adults thru various modalities can learn to use their struggles and challenges to build resilience and become more motivated to live productive lives filled with purpose in recovery.

African Americans Emerging Adults with Substance Use Disorders and 12 Step Affiliations

There continues to be discussions, even debates concerning the relevance, importance and effectiveness of AA, and NA in general and for African American Emerging Adults specifically. Some of the questions raised by African American Emerging Adults include:  Why should I go to a meeting where I don't know anyone? Why should I attend meetings where no one looks like me?  Can anyone at those meetings understand what I have been through and what I'm currently going through?

In writing this blog I am reflecting on a phrase from the 60"s and early 70"s, "don't trust anyone over 25". The majority of the members of 12 step groups are over age twenty five. In my clinical practice with African American Emerging Adults I have found it helpful to provide a thorough education about how 12 step groups work. I educate them about the 3 parts to working a successful 12 step program: Attend meetings, Seeking sponsorship and working the 12 steps. I encourage them to attend 6 different meetings before they decide whether or not the program has value for them. They are encouraged to search for meetings where they feel most comfortable with some indicated that they would like to attend meetings with members of similar age and who share their ethnicity and drug of choice. 

There is also a value in introducing African American Emerging Adults to other pathways of recovery besides AA and NA. Letting them know that there are many paths, one destiny, recovery!

Addressing Substance  Use Among African American Emerging Adults In the Criminal Justice System

 When discussing African American Emerging Adult substance use, and the criminal justice system several salient factors should be considered. In the United States millions  of young adults have some contact with the justice  system, and that frequent and continued contact should give pause to ask the questions: Where is the emphasis on prevention and for those African American emerging adults who are arrested and convicted of drug related crimes? Where are the services to not only address those criminogenic factors, but also to address those substance use risk factors.? Since both interface and are interrelated, it appears that the focus continues to be incarceration. It is clear from studies  that disproportionate rates of incarceration of African American substance using emerging Adults leads to socioeconomic problems, mental health, and behavioral disorders, and continued substance use.

 Addiction is a complex yet treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. It is essential for those of us working with African American emerging adults with substance use challenges  find ways to decrease the high  rates of incarceration by focusing on modifiable risk factors, and see that spending money  on prevention, and intervention via substance  use treatment  will yield better  results than spending money on correctional facilities. With effective treatment of substance use disorders and alternatives to incarceration, African American emerging adults can go on to enjoy life, be productive, and raise families.

Developing Resilience in African American Emerging Adults Who Are At Risk for Substance Use Disorders: A Focus On Meaning and Purpose

 Given the multiple risk factors for heavy substance use which impacts many African America Emerging Adults, ranging from easy access to drugs, poorly performing schools, father hunger, the presence of gangs within communities,early criminal justice involvement and discrimination, how  can those of us who are committed to working with this population assist them in living  a drug free life? The answer is to help African American Emerging adults at risk for a substance use disorder develop resilience. There are many definitions of resilience.  Garbarino (1999) says that resilience is more than outside success, more than graduating from high school, staying out of jail, or holding a job. It also means developing a positive sense of self, a capacity for intimacy, and a feeling that life is meaningful. According to Walsh (2016) resilience can be defined as the capacity to rebound from adversity, strengthened and more resourceful. It is an active process of endurance, and growth in response to crises and challenges.

 There is a Japanese belief that everyone has the DNA, the trait and the cells to be resilient, and that resiliency must be practiced, developed and controlled (Bell and Suggs, 1998). Wolin and Wolin (1996) lists 12 characteristics of resilience. From their list the one which I believe encapsulates the remaining 11 is having a goal to live for which gives life meaning and purpose. Helping African Emerging Adults identify Meaning/purpose is a protective factor from developing a substance use disorder. Even with the presence of risk factors including poverty, discrimination, family alcohol and drug use etc., purpose can help them to thrive in the midst of risk. To help African American emerging adult clients tap into purpose I ask them a range of questions. How did you survive that? How have you been able to endure so much? What are your previous life challenges preparing you to do with the rest of your life? Does the challenges you have faced help create a mission for you? What is your life purpose? What are some steps you are willing to take today towards that purpose?


 Bell, C., Suggs, H., (1998). Using Sports to Strengthen Resilience in Children: Training Heart. Child and Adolescent Psychiatric Clinics of North America. Volume 7, Issue 4, October 1998, Pages 859-865

 Garbarino, J., (1999). Lost Boys: Why our Sons Turn Violent and How We Can Save Them. Anchor Books. New York, NY.

 Walsh, F., (2016). Strengthening Family Resilience. Guilford Press. New York, NY.

 Wolin, S., Wolin, S., (1996). The Resilient Self: How Survivors of Troubled Families Rise Above Adversity. Random House. New York, NY.

Risk Factors for Substance Using African American Emerging Adults: Early Use of a Substance in Adolescence                                                            Leads to Abuse of the Substance in Emerging Adulthood

Often times substance use among African American Emerging is not considered within the context or background of adolescent development, and or peer group affiliations. The risk factor of adolescent substance use and expectancies which can impact on African American emerging adult use must be considered in prevention, treatment, family engagement as well as relapse prevention strategies. Consistent evidence suggests that those who use a given substance during adolescence are more likely to use and have problems with the use of the same substance as young adults. This is supported  by research on alcohol use{Floy, Lynam, Leukefield, and Clayton, 2004}.In a study  examining early adolescent substance use in relation to subsequent young adult substance use disorders, Gil et al. 2004} found that young adult  substance users began  using substances in early adolescence. Adolescents with alcohol -using peers  may be more  likely to belong to an early drinking trajectory into young adulthood, which in turn can lead to increased dependence. The important part here for those who have a passion and commitment to working effectively with African American Substance using Emerging Adults is to remember that before they entered into the journey of emerging adulthood many may not have completed the ongoing struggles of adolescence.


One could spend hours upon hours listing and debating risk factors for substance use among African American Emerging Adults. For the purposes of this blog the writer will cite just a few. The first risk factor for substance use is Race/ethnicity. A number of studies support an association between race/ethnicity and young adult substance use outcomes. One of the most commonly observed associations is an increased risk of alcohol use or problem use among White young adults {Arria et al., 2008: Gil et al., 2004. In addition to finding increased risk for Caucasians, Gil, Wagner, and Tubman[2004 also found increased risk of experiencing a variety of substance  use disorders in young adults for other race/ethnicity groups, particularly if they transition from abstaining in early adolescence  to regular use in young adulthood.

Another risk factor for substance use among African American emerging adults is poverty. Interesting poverty is sometimes {non-intentionally} left out of the conversation, when in this writers mind poverty should always be discussed. Regardless of the terms used. Whether it’s SES, or the Working poor, or abject poverty, poverty is a risk factor for alcohol and drug use, for violence and for mental health problems. The work of Bell and Jenkins, 1992 reminds us of the significance of poverty when discussing adolescent violence. Poverty interferes with an individual’s self concept and self esteem.  Family substance use history is also a risk factor for use as well. There is substantial  evidence that individuals  who are children of alcoholics are at an increased  risk  of heavy alcohol use, binge  drinking{Chassin et al.,2002,2004} or having an alcohol use disorder during their young adult years{Alati et al., 2005: King & Chassin, 2007} Siblings of young adults may also play a role  influencing young adult alcohol use behaviors. Research has found that alcohol use in young adulthood {mean age 25} was predicted by an older siblings use when they were in emerging adulthood. This was found to be true when the siblings were close in age.

Understanding Risk and Protective Factors for African American Substance Using Emerging Adults. {A Series}

In the understanding and developing of treatment planning , and for relapse prevention, it is imperative that those working with this population have some basic , but important tools/information in their tool box. At the outset it is necessary to remember the essential work of Urie Brofenbrenner who in the 70's introduced us to looking at and examining  behavior thru a systems lens, and which social workers had long since practiced. The African American emerging adult must navigate themselves through a macrosystem, an exosystem, a mesosystem, and a microsystem, and it is important to keep in mind that each system can and does impact on them and influences their risk for using, treatment compliance, as well as retention. This series will look at prevention Science as it relates to African American Emerging Adults, as well as the risk and protective  factors African American substance using emerging adults. 

There is a question which some may ask, and the question is a fair one. Which is, why review or focus on risk and protective factors for African  American Adults? The answer is that, not only is Emerging Adulthood an important developmental characteristic {which is considered the ages of 18-26} but it is also an important development characterized by peak  prevalence of substance  use problems, and problems related to use, which can set the stage for later  adult development. Lastly the Four top causes of death for Emerging adults are 1. Accidents, 2. Homicides, 3. Poisons/suicides, and 4. Substance Use. Consider the causes of death, then consider the lost of all that potential.  

The Importance of Identity Issues for African American Emerging Adults

In an article  by Jeffrey Arnett and Gene Brody titled  A Fraught Passage : The Identity Challenges of African American Emerging Adults. The aforementioned authors offer a much needed discussion regarding the identity challenges of African Emerging Adults, and how they face many of the same challenges of identity explorations as other emerging adults do. However  for African American emerging adults their identity explorations are complicated by the fact that these explorations are taking place within a society they perceive as possessing negative assumptions about them{Way,Santos,Niwa,& Kim-Gervey 2008}. Accoording to Erikson{1950} forming  a stable identity takes  place through assessing one's abilities and interests, reflecting on the persons one has admired in the  course of earlier development, and then trying  to find a match between one"s desires and goals  and the opportunities offered by society. But what if the range of opportunities is restricted due to racial prejudice. For  African American emerging adults, the challenge  is not just to sort out their own assessments of who and what they wish to be but to reject and overcome the negative stereotypes that others hold of them.

Emerging adulthood is the key period  for confronting these issues, not only because this is  when most people begin to move toward making enduring choices in love and work, but because this is the period when most move  further beyond the immediate social social world of family, friends, and neighborhood and into the larger society{Phinney,2006}.

African American Emerging Adults and Mental Illness

Mental illness affects 25-30% of adults ages 18 years and older in the United Sates in a given year {Kessler,Chiu,Demler,et,al2005}. Of those individuals , about 41% fail to utilize mental health services{Natioanl Institute of Mental Health, 2006} Studies show that factors such as race [being Afican American} and age and being between the ages of 18-29 or an emerging adult are associated with decreased  rates of mental health service utilization when compared to Caucasian emerging adults .

Additionally studies show when diagnosed with mental illness. African American adults 18 and older utilize outpatient mental service at only half the rate of their Caucasian counterparts{Davis&Ford,2004, Snowden&Yamada, 2005}.