This paper reviews recent empirical studies (N = 13) that focused on two cultural resources (spirituality and racial identity) utilized by African-Americans to cope with stress in an attempt to: 1) Provide some explanations why the minority status hypothesis is unfounded in most epidemiologic community surveys; and 2) Develop a theoretical framework that explicates this phenomenon. The review shows that both spirituality and racial identity reduced the negative impact of life stressors while producing positive effects on African-Americans' well-being whereby affecting their mental health status. The findings allow the authors to build upon the existing life stress paradigm to produce a theoretical framework, The Cultural Resilience Life Stress Paradigm, which illustrates the life stress-distress pathway to mental health status revealed by the literature. This theoretical framework intends to increase understanding about cultural resources as a basic premise for improving and enhancing mental health promoting programs' policies and practices.
African-Americans are observed within the minority construct, which is usually linked with inferiority and powerlessness [1]. Within this perspective, minorities are viewed as occupying disadvantaged positions in society, and the chronic social stressors associated with these positions (inequity and alienation) produce psychological distress [2]. Consequently, the minority status hypothesis predicts much higher rates of mental disorders for African-Americans than for Whites at all levels of socioeconomic status, as a result of African-Americans' greater stress exposure [3,4]. This is mainly due to the correlation between African-Americans' mental health status and poor health status [5]; poor economic status [6]; and exposure to [7]. While these correlations should work to substantiate a minority status hypothesis, findings from five epidemiologic community surveys-the National Institute of Mental Health Epidemiologic Catchment Area Study [8]; the National Comorbidity Survey [9]; the National Survey of American Life [10]; the National Epidemiologic Survey of Alcohol and Related Conditions, 2001-2002 [11] and the 2008 National Health Interview Survey [12] present the minority mental health status dilemma. These five national studies indicate that the mental health status of African-Americans is comparable to, and possibly better than, those of Whites. Further, independent of the relative health of African Americans, this racial group's mental health status is better than might be expected based on the prevalence of stressors alone. The disproportionate rate of stress and the lower than expected rates of mental disorders among African-Americans has raised a number of questions regarding the cultural factors related to their mental health.
Culture influences mental health status and seems to play a role in how people cope with stressors [13]. Although African-Americans are exposed to more stressors than Whites, they take an active role in dealing with stressors rather than avoiding them [14]. African Americans appraise stressful situations as changeable more frequently than Whites [15] and are more likely than Whites to engage in healthy coping skills [16]. In an attempt at identifying the coping capacity of African-Americans, Edwards [17] conducted a qualitative study to examine the self-defined components of psychological health for African-Americans and found that two identified cultural resources (spirituality and racial identity) may help shed some light on the minority mental health status dilemma.
Spirituality is recognized as a cultural resource utilized by African-Americans when coping with life stressors [18,19] and as a way of understanding and giving meaning to stress and adversity [20]. Racial identity has also been identified as a cultural coping strategy among the African-American population [21,22] and has been associated with the psychological health and well-being of African-Americans [23,24].
The mental health-disorder continuum proposes that individuals with positive mental health have a successful performance of mental functioning of thoughts, moods and behavior. As they are faced with a stressor and become unable to cope with the stress, they begin to deteriorate in their mental functioning and become psychologically distressed. If this deterioration continues, a significant distortion of thoughts, moods and behaviors follows and begins the onset of a mental disorder [25]. In an attempt to understand the relationship between life stressors and mental disorders, researchers in the mental health field have focused their scientific investigations around the life stress paradigm.
The life stress paradigm attempts to explain the stress-contribution in the etiology of mental disorders and provides a theoretical understanding of the cultural factors surrounding psychosocial resources such as spirituality and racial identity within the context of African-American coping processes. The studies that were conducted utilizing the life stress paradigm usually identified the negative effects of various stressors on mental health status and specified the moderating effects of social and psychological resources in the relationships [26]. In a popular study on the life stress paradigm and psychological distress, Ensel and Lin [27] examined the role of stressors and psychosocial resources in the life stress process as they influenced psychological distress outcomes. The analyses in this study found that stressors and psychosocial resources had a direct impact on depressive symptoms, and that psychosocial stressors affected psychological distress.
Stress and coping theory proposed that when individuals are confronted with a life stressor, they resort to a wide range of coping strategies to help alleviate the stress [28]. The life stress process as conceptualized by Pearlin, et al. [26] identified three core components: stressors, moderators (social and psychological resources), and outcomes (psychological distress). According to Pearlin [29], stressors refer to: "problems, hardships, or threats that challenge the adaptive capacities of people; moderators are the social and personal resources that people can mobilize to contain, regulate, or otherwise ameliorate the effects of the stressors; and outcomes refer to the effects of the stressors that are observed after the moderating resources are taken into account" (p. 3).
According to Pearlin, et al. [26], each component of the life stress process is interrelated. For instance, they state that stress can be operationalized as the combined relationship of stressors and the individual's response to the stressors. Stressors, which are the sources of stress, are events that present a threat or a challenge to people. Stress responses are the ways that an individual reacts to the stressors; psychologically, physiologically, and behaviorally (e.g., depression).
This paper builds upon the existing life stress paradigm to produce a theoretical framework, The Cultural Resilience Life Stress Paradigm. This theoretical framework provides some information on the reasons that the minority status hypothesis, which predicts much higher rates of mental disorders for African-Americans than for Whites, as a result of greater stress exposure, is not evident in most epidemiologic community surveys. This paper can also enhance the understanding of the strategies utilized by African-Americans to cope with stress, which can in turn inform local and state public health practitioners who provide clinical and community services to the African-American population. Understanding spirituality and racial identity as coping strategies has implications for the promotion of positive mental health.
The current review utilized to develop The Cultural Resilience Life Stress Paradigm summarizes the more representative studies investigating the African-American coping strategies in reference to spirituality and racial identity and their relationship with life stressors and psychological distress. Relevant studies conducted from year 2000 to present were searched and collected through a number of databases, including the PubMed, the EBSCOhost Online Research, the Social Sciences Citation Index, the Medline, the PsyInfo, and Soci Index, using keywords like 'African-Americans, spirituality, coping and mental health', 'African-Americans, racial identity, coping and mental health'. After relevant research articles were identified, further efforts were made to scan through the references of these articles to locate other relevant research articles for the review. Among all the studies that were identified, those with standard quality and representation in terms of design, method and African-American sampling were included in the review.
Although a substantial number of empirical studies investigating the African-American coping strategies in reference to spirituality and racial identity respectively and their relationship with life stressors and psychological distress were identified through the aforementioned databases, most of the studies did not fulfill the purpose for review. The quantitative studies which are excluded are those that recruited students (elementary, middle, high school, college) in a non-longitudinal manner, as their targeted populations; those which do not treat spirituality (religiosity, religious coping, religiousness) or racial identity as a predictor variable; or those which apparently do not control for confounders and other covariates. In addition, empirical research articles adopted for this review were defined as quantitative studies that included in their methods and findings with at least the application of one inferential or correlation statistics to investigate the association between spirituality and racial identity respectively and their relationship with life stressors and psychological distress. All identified articles must include one or more measures of religiousness or religion-related spirituality and racial identity respectively as predictors and one or more psychological distress measures as outcome variables. Among these, those which only used descriptive statistics, percentages or frequencies, or those which did not treat spirituality or racial identity as a predictor variable were excluded. Consequently, not all pertinent studies would be addressed in this review for the reasons that they were either not highly relevant, or were to our knowledge questionable in design, or simply a result of our negligence of them. The final sample for this review consists of 11 quantitative studies and 2 qualitative studies across the years from 2001 to 2010.
Several studies have examined the role of spirituality in the life stress process and a review of the research conducted on the use of spirituality coping mechanisms by African-Americans, when confronted with a life stressor, was explored and evaluated in a chronological manner, oldest to most current, demonstrating the development over time.
Ellison, et al. [30] conducted a study that examined the relationship among aspects of religious involvement and mental health. They utilized data from the 1995 Detroit Area Study, which conducted multistage area probability sampling of adult respondents 18 years of age and older and who resided in Wayne, Oakland, and Macomb counties in Michigan; including African-Americans who were oversampled. The Psychological distress was measured by a six-item index of depression and anxiety. Religious involvement was measured by church attendance (organizational religiosity), prayer (non-organizational religiosity), and belief in eternal life (religious belief). Stressors were measured by analyzing five measures of stress: health problems, health impairment, work problems, financial problems, and family problems.
The researchers found that attending church frequently produced a positive association with well-being and a negative association with psychological distress. However, the frequency of prayer produced a slight negative association with well-being, but a weak positive association with psychological distress. More importantly, it was found that being at risk for social stressors or having access to other social or psychological resources did not mediate the total effects of frequency of church attendance and prayer. Measures of church-based social support were not found to be associated with psychological distress or well-being. Finally, frequency of prayer and frequency of church attendance did not buffer the effects of stressors on psychological distress and there was no evidence that support the notion that religious involvement exacerbates stress.
Jang and Johnson [31] conducted a study utilizing a sociological theory that attempted to explain the constructive effects of religion. The researchers utilized data from the last of four waves of the National Survey of Black Americans (NSBA), which conducted multistage area probability sampling of African-Americans 18 years of age and older. They constructed two measurement models of distress naming them situational and state distress. Sense of control was measured by examining the extent of each respondent's confidence that his or her own life would work out as he or she plans or expects. They developed three indicators of sense of control: your own fault, life plans, and life prospect. Sense of control was conceptualized as an internal locus of control or mastery that is on the opposite end of powerlessness thereby reducing psychological distress.
Social support was developed using three indicators: religious, family, and friend support. Social support was conceptualized as the potential, perceived, and actual support one uses when faced with a life stressor. Social support in this context included having intimate personal relationships with others not just merely being cared for by others. The authors used eight items of religious involvement to construct three dimensions: organizational, nonorganizational, and subjective religiosity. The researchers measured stressors by constructing an index of life problems through the calculation of the mean of the nine items asking about the degree to which the life problem was upsetting to the respondent. They also used three indicators to measure the poor health construct: health problems, dissatisfaction with health, and self-rated health.
Using a latent-variable structural equation modeling approach, the researchers found that African-Americans who were more religiously committed tend to report lower levels of physiological distress than those who were not, and it seemed to be explained by sense of control and social support. Simply put, religiosity has a positive effect on sense of control and social support, which in turn has a negative effect on distress. They also found that religiously committed African-Americans reported higher levels of support from their family members and friends than do their less religious counterparts. They reported that social support from family and friends as well as from other religious people caused the indirect effects of religiosity. More importantly, they found that African-Americans who are more religiously committed tended to experience lower levels of psychological and physiological distress partially through their sense of control (religious effect decreased in size but remained significant) but fully through social support (religious effect became nonsignificant). Simply put, African-Americans' reduced distress was due to being more religiously committed, exhibiting higher levels of sense of control and social support.
Eliassen, Taylor, and Lloyd [32] conducted a study from data from 1,785 young adults (including 434 African-Americans) who were interviewed between 1997 and 2000 in the Transitions study. The purpose of the study was to examine the relationship of subjective religiosity (operationalized as religious self-perception and religious coping), depression (measured by the 20-item Center for Epidemiology Studies Depression Scale), social support (measured by 8-item index of perceived family support and friends' support), and stress exposure (measured by utilizing four dimensions of stressful experience: recent life events, chronic stress, traumatic events, perceived discrimination). The authors found that African-Americans were, on average, more depressed and more religious as compared to the non-Hispanic white counterparts. This study utilized ordinary least squares multiple regression models and found that subjective religious practice is significantly positively associated with depressive symptoms among respondents who are less religious, but predict lower levels of depressive symptoms among respondents who score higher in religiosity. The authors also found that social support accounted for a significant amount of the influence on the predicted levels of depressive symptoms and reduced the effect of the relationship between religiosity and depression.
Holt and McClure [33] conducted 33 interviews with African-American church members from seven predominantly African-American churches to examine the perceptions of the religion-health connection. The researchers utilized semi-structured interviews to stimulate answers about religion-health connection; religion-health processes identified in the literature; and perceptions of illness based on their religiosity. One area of focus during the interviews was health locus of control which solicited participants' perceptions of the level of control they had over their lives and how much control they had over their health. Another area of attention was religion and health which solicited participants' perception of the connection between religion or faith and health. The data was analyzed using an inductive approach from readings from of the verbatim transcripts; allowing for the development of an open coding scheme based on the themes and patterns that emerged from the readings. The authors found that participants identified in their own words that God works with them to teach important lessons during their times of sickness. They found that participants reported that their church family helps them to cope with the deleterious effects of their health issues by providing supportive processes. They also found that participants, in their study, dealt with their health issues by actively putting forth their own effort to cognitively reframe the meaning attributed to their health issues. They found that the participants reported after exhausting all of their own efforts of cognitively reframing the meaning attributed to their health issues, they then "put it in God's hands" which allowed them to respond to their life stressors more positively.
Ellison, Musick, and Henderson [34] conducted a study using data from the National Survey of Black Americans (NSBA) panel study, which conducted multistage area probability sampling of African-Americans 18 years of age and older, to examine the relationship between racism, religious involvement, and psychological distress. Psychological distress was measured by the 10-item index of depression and anxiety from the RAND Mental Health Inventory. Racism was measured by the extent of the respondents' experiences with racism. Three dimensions of religious involvement were measured by assessing religious attendance, religious guidance, and church-based social support. Self-esteem, personal mastery, family support, functional impairment, and sociodemographic variables were included as covariates. This study utilized ordinary least squares multiple regression models and found that religious guidance and church-based social support are inversely related with psychological distress. Although religious attendance was positively related to psychological distress, those who attend church services once per week reported less psychological distress than those who attend a few times per month and those who attend a few times a year or never attend. They also found that although church-based support did not buffer the relationship between recent racist encounters and psychological distress religious guidance did.
Chatters, et al. [35] conducted a study using data from the National Survey of American Life (NSAL) to examine the extent of religious-coping strategies (collaboration with God and importance of prayer when dealing with stressful situations) across African-Americans, Afro-Caribbeans, and non-Hispanic Whites. The multivariate analyses utilized ordered logit regression and found that African-Americans were more likely than non-Hispanic whites to endorse the importance of prayer when dealing and coping with stressful situations. They also found that African-Americans were significantly more likely than non-Hispanic Whites to identify that they look to God for strength, support, and guidance. The authors contend that the differences in religious coping are quite significant enough to provide substantial support of the importance of religious coping and religious participation among African Americans. One of the noteworthy findings indicated by these researchers is that African-Americans identified religious resources and religious behaviors as being very important when coping with life stressors.
Archibald [36] conducted a study using data from the National Survey of American Life (NSAL) to determine if spirituality moderated the relationship between life stress and depressive symptoms. The sample included N = 3.570 African-American United States citizens 18 years or older. A multivariate linear regression approach was used to analyze the data. The findings did not support the hypothesis that spirituality moderates the relationship between depressive symptoms and stress although a direct relationship between spirituality and depressive symptoms was found. One of the notable results was that higher levels of spirituality, on average, tended to reduce the effects of life stressors on depressive symptoms therefore reducing levels of depressive symptoms. However, this effect of spirituality became non-significant when sense of control and social support were added to model. This indicated that the effects of spirituality that reduced the impact of life stressors on depressive symptoms thereby reducing levels of depressive symptoms were confounded by sense of control and social support being possible mediators of the relationship.
Table 1 provides a summary of the trend in these studies which showed that spirituality played a role in the coping processes of African-American participants when faced with life stressors.
Table 1: Summary of Key Findings of Spirituality-Coping Studies. View Table 1
The study of African-Americans has shown that their self-concept is engrained within their culture and that culture promotes coping mechanisms and adaptive reactions to stressors within the context of a mixture of values and practices. Several studies have examined the role of racial identity in the life stress process of African-Americans and a review of the research completed on the use of African-Americans' racial identity coping mechanisms when confronted with a life stressor will now be explored and evaluated in a chronological manner, oldest to most current, demonstrating the development over time.
Johnson [37] conducted a qualitative study with eight African-Americans from a metropolitan city in Georgia to explore racial identity through focus group sessions. Focus groups were used to gather the data and content analysis using NUDIST NVivo 1.0 was utilized to analyze the data. The initial coding of the transcribed audiotapes identified 165 codes which were then reduced to 12 categories and collapsed into three themes: 1) Racial Identity When Growing Up; 2) Becoming Aware of Racial Differences; and 3) Present Racial Identity. They found that participants identified that there were many African-American people in their lives that contributed to their positive racial identity development. The author found that participants described their racial identity on a continuum with "being guarded" on one end and "being accepting" on the opposite end. The results of this study seem to validate that there are multiple processes of racial identity that occur in varying degrees based on conscious or unconscious efforts of individuals to immerse themselves in the African-American culture.
Sellers, et al. [38] conducted a prospective study to examine the relationship between racial identity attitudes and psychological distress. The authors extracted 555 African-American students (who participated in the fourth and fifth waves of the study) from a larger longitudinal study of 850 students who were academically at risk in an urban school environment in Michigan. Two racial identity scales (centrality and public regard) from the MIBI were used to measure racial identity. Perceived racial discrimination was measured by asking participants to rate the frequency to which they experienced 20 hassles within the past year. Perceived stress was measured by using a shortened version of the Perceived Stress Scale. The Brief Symptom Inventory, which assesses depression and anxiety symptomatology, was used to measure psychological distress. The researchers found that individuals for whom race was more central reported lower levels of subsequent psychological distress. On the other hand, public regard did not significantly predict psychological distress. They also found that high racial centrality seemed to buffer the impact of racial discrimination and perceived stress.
Sellers and Shelton [39] conducted a longitudinal study of 267 African-American first year college students recruited from three predominantly White universities. This study examined the relationship of racial identity and perceived discrimination among African-Americans within a stress and coping framework. Multidimensional Inventory of Black Identity (MIBI) was used to measure racial identity. The Daily Life Experience subscale from the Racism and Life Experience scale was used to measure the frequency and impact of hassles due to race. The CES–D was used to measure the presence and frequency of depressive symptomatology. The Perceived Stress Scale was used to measure the degree to which participants appraised situations as being stressful. The Spielberger State-Trait Anxiety inventory was used to measure anxiety symptomatology. The measure for psychological distress was developed by the average of the z-scores for the three mental health scales.
The authors found that racial centrality seemed to buffer the negative mental health consequences of perceived discrimination. The researchers also found that racial ideology and public regard moderated the positive relationship between perceived discrimination and psychological distress. The participants who believed that other groups perceived African-Americans negatively were buffered from the negative impact of perceived discrimination when looking at the global indicator of psychological distress. The authors argued that these findings supported the theory that suggests that individual differences protect minorities from the negative impact of racism. They go on to state that the buffering mechanism of racial identity was not just based on the result of group identification but also on the meaning that one places on what it is to be a member of that group.
Franklin-Jackson and Carter [23] conducted a study of 255 African-American adults participating in community organizations in Maryland, District of Columbia, and New York City and who participated in a national mail survey. This study examined the relationship between race-related stressors (measured from results of the 22-item multidimensional Index of Race Related Stress-Brief Version) racial identity (measured from results of the 50-item Black Racial Identity Attitude Scale-Long Form), and mental health (measured from results of the 38-item Mental Health Inventory). The authors conducted hierarchical multiple regression analyses and found that African-Americans who reported higher levels of Internalization status attitudes also reported lower levels of psychological distress and reported higher levels of psychological well-being. The authors report that this study indicates the need for consideration of racial identity status attitudes when examining the mental health outcomes of race-related stressors among African-Americans.
Pieterse and Carter [24] conducted a study of 340 African-American adults who resided in New York or District of Columbia. This study examined the relationship of racial identity (measured from results of the 50-item Black Racial Identity Attitude Scale-long Form), perceived racism (measured from results of the 18-item Schedule of Racist Events-Modified), psychological stress (measured from results of the 14-item Perceived Stress Scale), and mental health (measured from results of the 38-item Mental Health Inventory). The authors conducted hierarchical multiple regression analyses and found that racial identity did not moderate the relationship between perceived racism and psychological distress. However, the results suggested that racial identity attitudes significantly predicted psychological well-being when controlling for life stressors and perceived racism. The authors also conducted profile analyses of racial identity and found that African-Americans with a higher internalization-dominant profile reported more positive psychological functioning that was represented by lower levels of perceived stress and psychological distress, and higher levels of psychological well-being.
Archibald [36] conducted a study using data from the National Survey of American Life (NSAL) to determine if spirituality moderated the relationship between life stressors and depressive symptoms. The sample included N = 3.570 African-American United States citizens 18 years or older. A multivariate linear regression approach was used to analyze the data. The findings did support the hypothesis that racial identity moderates the relationship between life stressors and depressive symptoms with a weaker link between stress and depressive symptoms for those with higher scores on the racial identity index even in the presence of social support and sense of control.
Archibald [36] conducted a study using data from the National Survey of American Life (NSAL) to determine if spirituality moderated the relationship between life stressors and depressive symptoms. The sample included N = 3.570 African-American United States citizens 18 years or older. A multivariate linear regression approach was used to analyze the data. The findings did support the hypothesis that racial identity moderates the relationship between life stressors and depressive symptoms with a weaker link between stress and depressive symptoms for those with higher scores on the racial identity index even in the presence of social support and sense of control.
Table 2 provides a summary of the trend in these studies which showed that racial identity played a role in the coping processes of African-American participants when faced with life stressors.
Table 2: Summary of Key Findings of Racial Identity-Coping Studies. View Table 2
The role of coping is affected by risk factors such as inequity, poverty, poor health, violence, and discrimination; it is also affected by protective factors such as spirituality and racial identity. The interaction of these modifiable risk and protective factors manifesting through complex interactions contribute greatly to mental health. The results from reviewing the literature on African-American spirituality-coping and racial identity-coping (refer to Table 1 and Table 2) can help explain the complex interactions of modifiable risk and protective factors by utilizing a theoretical framework, called "the cultural resilience life stress paradigm," that was developed from the thirteen studies reviewed. Figure 1 shows the proposed pathway of "the culture resilience life stress paradigm" developed from the findings of this analysis. This theoretical framework was built upon the life stress model and attempted to provide some information on the reasons that the minority status hypothesis, which predicts much higher rates of mental disorders for African-Americans than for Whites, as a result of greater stress exposure, is not realized in most epidemiologic community surveys. It attempted to assist with this societal dilemma by providing theoretical mechanisms of the African-American coping capacity in their life stress process.
Figure 1: Cultural resilience life stress paradigm.
View Figure 1
The "cultural resilience life stress paradigm" in this context attempts to explain the capacity to which a cultural group capitalizes on its resources to reduce psychological distress in the presence of life stressors. As identified by Johnson [37], the evidence of capacity (conscious or unconscious) to mitigate the effects of life stressors on psychological distress serves as a protective factor for African-Americans. This process includes such culture-resilient resources as spirituality and racial identity that help restrict the scope and intensity of life stressors and help protect African-Americans, who follow the "cultural norm" of the racial group, from the depressive effects of life stressors.
The spirituality-coping process, theoretically based on the findings from the literature review, can be interpreted as follows. Mattis [40] asserted that African-Americans oftentimes interpret the world, appraise their life stressors, and cope with those stressors through the lens of a varied spirituality that is expressed primarily through the vehicle of the "Black church" and is shaped from historical African religions and slavery. This culture of African-American spirituality incorporates a mechanism for both sense of control and social support to be revealed [41].
The literature review revealed a direct and significant positive relationship between spirituality and sense of control [31,36]. Hence, participants high in spirituality may perhaps have had an increased feeling of autonomy in reference to their level of mastery and understanding of perceived constraints and available resources which in turn possibly affected how they re-appraised their life stressors. When African-Americans are initially exposed to life stressors, and it has been identified that their available resources are low, they may assume a low sense of control [42]. However, during the re-appraisal phase of the life stress process, it is plausible that this low external view of sense of control activates a high internal view of sense of control through spirituality. Schieman, Pudrovska, and Milkie [43] developed a conceptual framework termed personal empowerment, asserting that as individuals identify that they are unable to adequately control or change the outcome of certain life's problems, they engage in a collaborative relationship with God in an attempt to solve these problems. This collaborative relationship enhances their feelings of personal effectiveness and reduces uncertainties [44,45]. Individuals who embrace this collaborative relationship now attach new meaning to life problems based on what is expected of them from God, which in turn, provides more favorable outcomes of their sense of control and affects their mental health status [33,35,46]. Simply put, as African-Americans are confronted with a life stressor, they resort to spirituality strategies to help interpret, comprehend, and alleviate the stress which in turn activates their sense of control. These spirituality strategies include engaging in high religious cognition and commitment, subjective religious practice, religious guidance, attending church, praying, or looking to God for strength, guidance and support [30-36]. This sense of control activation counteracts feelings of powerlessness which allows them to restrict the scope and intensity of life stressors and help protect them from the depressive effects.
The literature review also revealed a direct and significant positive relationship between spirituality and social support [31-34,36]. Social support related to spirituality accounted for a significant amount of the influence on the predicted levels of depressive symptoms and reduced the effect of the positive relationship between life stressors and depression. It has been shown that the African-American culture places great value on relationships and connection with others [33,34]. Windle [47] reported that how an individual perceives their level of acceptance and value in their interpersonal environment increases their esteem, confidence, and efficacy which reduce the impact of depression. Social support seems to cause the effect of spirituality that produces an increased feeling of being cared for and valued by others and an increased feeling of self-confidence and self-efficacy, which in turn possibly affects how life stressors is re-appraised. Hence, when African-Americans are confronted with a life stressor, they may possibly resort to spirituality strategies which in turn possibly promotes their level of social support and may counteract their feelings of low self-confidence, low self-esteem, and low self-efficacy which may help alleviate the deleterious effects of stress.
The relationship pathway between spirituality and sense of control and spirituality and social support possibly may allow participants to respond to a stressful event more positively which could have prevented the development of symptoms of psychological distress thereby affecting the expected results. According to Lazarus and Folkman [28], how a stressor is appraised influences the extent to which stress responses follow it. After a stressor has been appraised, the next step, if necessary, is coping. It is possible that when African-Americans appraise life stressors as threatening, they resort to spiritual strategies that may promote their sense of control and social support which might reduce the chance that they will develop symptoms of psychological distress and can provide for a more favorable mental health status.
The racial identity-coping process, theoretically based on the findings from the literature review, can be interpreted as follows. It is probable that at the point that African-Americans appraise life stressors as stressful, an expectancy frame is developed that may transform the initial appraisal causing a re-appraisal of the life stress event, which lowers the negative response. Specifically, the moderating effect of racial identity between the relationship of life stressors and psychological distress was supported because the highest levels of psychological distress were observed in the group with the lowest levels of racial identity in the majority of the studies reviewed [23,24,36,38,39]. More importantly, Archibald [36] provided evidence that the moderating effect of racial identity on psychological distress was present even after controlling for social support, sense of control, and demographic factors. For instance, although samples of African-Americans who had higher levels of racial identity tended to have higher levels of social support and sense of control, this did not explain the moderating effects.
Hence it is probable that during the re-appraisal phase of the life stress process, African-Americans activate their active coping skills through their racial identity by accessing their beliefs, opinions, and attitudes with respect to the way they feel they should act along with their evaluative judgment of their race, as identified by Sellers and Shelton [39]. This seems to moderate the relationship between life stressors and psychological distress and reduce the chance that they will develop symptoms of psychological distress and provides for a more favorable mental health status. Even further, at the point that African-Americans begin the re-appraisal phase, they opt for racial identity resources by identifying such things as their closeness to other African-Americans; identifying positive traits of African-Americans; and identifying the relevance of being African-American.
Azibo [48] suggests that the self-concept of African-Americans seems to be engrained within their culture and their racial identity. This is perceived as being necessary for their optimal functioning and any deviation from this core self-concept may lead to more pathology among African-Americans. Consequently, this self-concept seems to activate African-Americans' active coping skills by allowing them to regulate the emotions related to the life stressors and also by allowing them to actively participate in activities that reduce or eliminate the impact of the life stressors. These active coping skills activated by their level of racial identity moderates the relationship between life stressors and psychological distress and reduce the chance that they will develop symptoms of psychological distress and provides for a more favorable mental health status.
Through this review and analysis of the related literature, it is hoped to illustrate by the development of the "Cultural Resilience Life Stress Paradigm", some suggested explanations of the minority status hypothesis dilemma. The strategies utilized by African-Americans to cope with stress seem to become actualized into a set of cultural, spiritual, racial, cognitive, psychological and social resources, which mutually interact and reinforce one another through several chain responses. Through this process of mutual interaction and reinforcement, spirituality and racial identity are considered hypothetically to contribute to the mental health status of African-Americans. Although the "Cultural Resilience Life Stress Paradigm" serves as a theoretical explanation of the "minority status hypothesis", it was tested hypothetically at this present stage by reviewing the relevant literature. Future research should be conducted to test the validity of this framework by examining the relationship between spirituality and sense of control and spirituality and social support to determine how they predict each other over time and their synergistic role on the relationship between life stressors and psychological distress. Future research should examine further any mediating factors that may be contributing to the identified moderation of racial identity between life stressors and psychological distress. Finally, future research should incorporate both qualitative and quantitative methodology to obtain a greater understanding of the factors associated with coping amongst persons with high spirituality and high racial identity. Utilizing both methodology types may provide further insight into the mental health promoting practices of African-Americans who identify with high spirituality and high racial identity which can in turn steer mental health program development in the direction of assisting African-Americans in becoming mentally healthy.
Healthy People 2020, the nation's strategic health plan, identified that mental health plays an important aspect of overall health and well-being and asserted that it is important to understand the determinants and pathways for mental health in order to appropriately prevent and treat mental disorders. The "cultural resilience life stress paradigm" can serve as a guideline for facilitating discussions of culture and providing practical strategies for integrating the realities of risk and protective factors in the mental health-disorder continuum dialogue. The results of this present review can help to increase understanding about cultural resources as a basic premise for improving and enhancing mental health promoting programs' policies and practices. When the cultural resources of African-Americans are ignored, the interpretation and application of policies and procedures influence and contribute to the ongoing misinterpretation of the determinants and pathways for African-Americans' mental health status.
Additionally, "the cultural resilience life stress paradigm" may shed some light on the shortcomings of the current societal mental health promoting interventions for African-Americans. In order to produce culturally relevant and competent mental health promoting interventions for African-Americans dealing with life stressors, programs must integrate a spirituality and racial identity orientation, taking into consideration within-race differences. Mental health promoting programs need to broaden their understanding of the complexities of spirituality and racial identity when addressing the depression symptomatology caused by life stressors; when facilitating interventions with African-American clients for whom spirituality and racial identity serve as the lens through which they interpret interpersonal and intrapersonal relationships.
Understanding these complexities may help address the psychological consequences to African-Americans who are socialized in a society in which a person may or may not have access to adequate comprehensive and competent mental health services based on his/her racial or economic classification. This is crucial because spirituality and racial identity seems to guide African-Americans' thoughts, feelings, perceptions, behaviors, and level of investment in improving their mental health status. Thus, when providing mental health services to African-Americans, the domains of spirituality and racial identity should be explored in order to gain greater insight into their cultural active coping process which seems to be expressed internally and externally. This may install a new set of programmatic competencies around African-Americans' resilience, inner strengths and cultural resources that enhances their mental health status by creating activities that promote mental health. It may even encourage African-Americans to engage mental health promotion programs with less apprehension and mistrust.