Hyperarousal PTSD and Alcohol Abuse: Inequitable Treatment and Impact of Substance Use Among African American Women

Throughout history Black women have consistently been underrepresented in almost every aspect of society. This article examines the intersection of race, class, gender, and social systems as they relate to hyperarousal post-traumatic stress disorder (PTSD) and alcohol abuse. Although there is an abundance of literature regarding substance abuse in America, it has been reiterated in previous research that substance abuse in the African American community is severely understudied, with special regard to the misunderstanding of substance use among Black women. Drawing on the Angry Black Woman (ABW) archetype, I analyze historical and current social structures that render Black women especially susceptible to an underdeveloped window of tolerance for stress. The aim of this article is not only to contribute to the lacking body of research for this group, but also to suggest that hyperarousal PTSD serves as a direct determinant for alcohol abuse in African American women.


Introduction
Black women in America have consistently been marginalized and underrepresented in most aspects of society, which has fostered conditions to misuse alcohol as a coping mechanism.This is a preliminary study intended to expose systemic inequalities that contribute to alcohol abuse among Black women who are socio-economically disadvantaged.Systemic inequality has been contributing to hyperarousal post-traumatic stress by hindering the ability to control emotional responses which allude to alcohol and substance abuse.Hyperarousal PTSD occurs when there is a low threshold window of tolerance, resulting in an over-reactive state of being.
There is a strong emphasis on the need to address these inequalities in order for substance abuse treatment to be positively impactful.
I begin with an introduction to hyperarousal PTSD, it's psychological and physiological traits, and a summary of the importance of the window of tolerance followed by methodology.I then discuss the connection of hyperarousal PTSD and social systems which introduce: the "angry black woman" stereotype, systemic barriers and gender expectations, underinvestment in neighborhoods, cultural subjectivity, financial insecurity, and trust issues in health care.Next, I break down the impact of intergroup dynamics exploring cultural beliefs, family, intimate partnership, and the concepts of embarrassment and shame.I conclude with a suggestion that argues the importance of compassion and humility, which could potentially impact the current state of public health equity for Black women suffering with substance misuse.

Hyperarousal PTSD
Hyperarousal Post Traumatic Stress Disorder (PTSD) is referred to in the DSM-IV as persistent symptoms of increased arousal such as sleep problems, hypervigilance, exaggerated startle response, irritability or anger outbursts, and concentration difficulties (Florez et. al., 2022, p. 187).The symptoms that fall under the category of hyperarousal are panic, fear, worry, irritation, anger, frustration, impulsivity, high energy, stress, aggression, anxiety, and reckless behavior.The physiological traits are fast heart rate, shallow and quick breathing, high blood pressure, high cortisol and adrenaline, and muscle tension.
Within the concept of PTSD, there is an element that separates hyperarousal from hypoarousal.This element is referred to as the window of tolerance, which is considered a "zone where intense emotions and stress can be adapted to and processed in healthy ways."(Neff, 2023).Persistent exposure to stressors can create a strain on an individual's ability to process emotions in a healthy way.According to previous research, environment plays a key role in developing a window of tolerance: "People who grew up in traumatic homes where they were constantly bombarded with trauma often do not have the opportunity to develop a window of tolerance" (Neff, 2023).Although a person may be able to develop a small window of tolerance, remembrance of trauma or the experience of triggers "may cause them to be pushed out of their window of tolerance" (nicabm.com, 2023), which is critical in examining traumatic cycles in relation to hyperarousal.

Methods
The electronic databases psychINFO, psychARTICLES, and Google Scholar were used to carry out the retrieval of information using the following keywords and phrases: hyperarousal PTSD, African American women, alcohol abuse, socioeconomically disadvantaged, stigma, gender, Black women, substance abuse, and low-income.Articles maintained relevance by adjusting publication time frames from years 2000-2023.
The basis of this preliminary study stems from a scoping literature review which was completed to gain a clear understanding on the current state of alcohol misuse among women in the Black community.The review further breaks down gender roles and expectations, stigma, socioeconomic disadvantages, insight on interpersonal relations, historic oppressors, the health system, the concept of shame and the illusion of self-blame, and areas of intervention.

Hyperarousal PTSD and Social Systems
For decades there has been a running archetype of the "angry Black woman" (ABW) who has been judged for her response to her immediate outside world.Upon examining alcohol abuse in the severely understudied group of African American women, special attention has been paid to the concrete effects of systemic inequalities in relation to mental health -particularly Post Traumatic Stress Disorder (PTSD).There are many causes for developing hyperarousal PTSD and the underdevelopment of the window of tolerance, all of which are examined in this review.The "angry Black woman" is often called upon to be strong in the face of adversity without any allowance of grace.
The pressure to be resilient serves as a risk to her mental and physical health.The Self-Medication Hypothesis (SMH) maintains that suffering -not pleasure seeking -is at the heart of addictive disorders (Khantzian, 2017), and posits that individuals with PTSD use alcohol to relieve their trauma-related symptoms and may explain why avoidant coping serves as a risk factor for alcohol misuse (Florez et al., 2022, p. 188).Additionally, Black women who face adversity on a regular basis often operate at a baseline of primary emotions (animalistic instinct), which feeds into the belief that Black people are more animal-like and less humanthus contributing directly to hyperarousal.Fuchshuber et al. ( 2019) found that those who report greater frequency of experiencing anger and fear-primary emotions-were at increased risk of substance abuse and reported more anxiety and depression symptoms (McCleary-Gaddy and James, 2022, p. 3).Systemic barriers seated in the form of gender expectations have proven to have negative effects on Black women.Black men have historically been targeted for being criminals and face harsher consequences for minor offenses than their white counterparts.When the legal system incarcerates the "head of the household", the Black woman is left to not only take care of family, but also find a means to financially support her household, further adding to the hyperarousal state that her trauma and socio-economic status has invoked.Derived from the American slavery system to justify White enslavers' abuse of enslaved Black women, a core concept of the "strong Black woman" (SBW) is the pursuit of immense strength and resilience (McCleary-Gaddy and James, 2022, p. 2).This "immense strength and resilience" implies that a Black woman cannot have compassion or grace towards herself because she's expected to always remain strong not only for herself, but for her family.Her strength inevitably puts her last in priority: "While several women were in contact with their partners' families, these relationships were focused on the partner's well-being rather than that of the participant" (Cooper et al., 2014, p. 181) (regarding partner incarceration).
The Black woman struggling with alcohol abuse, let alone any other substance issues, suffers the most under the pretense that she has immense strength and resilience.This serves as a reason why Black women don't come forward when seeking help in dealing with their addiction.Coming forward would mean threat of incarceration, which is accompanied by the risk of losing her children to child welfare services with slim odds of being reunited.
These punitive CWS policies have a negative effect on mothers struggling to cope after losing their children to the system, and rather than decrease maternal drug use, may contribute to an increase in these behaviors, thus reducing a mother's chances of being rehabilitated and reunited with her children (Harp and Bunting, 2020, p. 269).General Strain Theory (GST) stemming from crime and delinquency supports this issue by highlighting the focus on negative treatment from others, and the role that negative emotions plays in the etiology of offending.(Brezina, 2017).
Perhaps the most critical element in the construct of gender is the comparison between man and woman regarding how substance use is viewed.Women have a harder time accepting themselves, let alone their own usage.Women suffer direr health-related consequences from their substance use while carrying greater social stigma or guilt because of drug and alcohol use compared to men (Green, 2006;McHugh et al., 2018).According to the World Health Organization (2008) [WHO], mental health issues disproportionately affect women compared to men.(Redmond et al., 2020, p. 3).Comparison strips away self-security thus blinding the woman from her own essence, causing her to harden herself for protection against judgment.
Underinvestment in urban neighborhoods leaves the inhabitants without access to critical resources such as reliable transportation, better quality food, and safe, affordable housing.It's been reported that resources to address social and economic needs are limited.Interviewees commonly described the lack of affordable housing, public transportation, and economic opportunities in communities of color as primary challenges for people in treatment and recovery (Bui et al., 2022, p. 7).The lack of ability to physically get to treatment centers provokes a feeling of hopelessness due to help being unattainable.The stress of being "trapped" in an undesirable environment contributes to the overall irritability and frustration of a Black woman struggling with alcohol addiction.Furthermore, Black women statistically earn less wages than White women, and women in general earn less than their male counterparts.This wage gap creates susceptibility to higher risks: Women tend to have greater gender specific risk factors such as poverty, as more women tend to live in poverty, earn lower wages and have lower employment, and experience relationship violence.(Redmond et al., 2020, p. 3).Additionally, the lack of affordable and safe housing is a serious issue for low-income women who are getting out of recovery and having to return to their previous environments (Redmond et al., 2020, p. 8).
Neighborhood segregation is another key factor in the over consumption of alcohol as a coping mechanism.Neighborhood segregation is extended to licensing of alcohol outlets, frequently restricting them to communities of color instead of White neighborhoods likely due to the association of alcohol outlets with crime and other unwanted behavior (Otiniano Verissimo et al., 2023, p. 2).With helpful resources being kept at more than an arm's length away and substances being readily available, those searching for relief from their grievances are left to the mercy of those substances.In a recent systematic review, Collins concluded that although groups with greater socioeconomic advantages (income, education, and other indicators at the individual, family, or neighborhood levels) had similar or greater levels of alcohol consumption than those with fewer advantages, the groups with fewer socioeconomic advantages were at greater risk for alcohol-related problems (Mulia, 2020, p. 5).With a lack of tools for basic survival, insecurity runs high.This insecurity not only affects the women, but their children too.Several studies found that the largest predictor of whether an infant will experience drugor alcohol-related birth defects is socioeconomic status (Harp and Bunting, 2020, p. 264).Evidently, socioeconomic status has a hold on the family, but even more profound are the roadblocks that being disadvantaged has on Black women who want better for themselves.According to research on adolescence and early adulthood, when traditional pathways to success are impeded or perceived to be blocked, people will seek other ways to find meaning and purpose in their lives (Montemayor, 2019).
Historical oppression contributes to the development of hyperarousal PTSD by way of cultural subjectivity.It's recognized that people who have unhealthy substance use and are from communities with a history of systemic racism or other institutionalized barriers often have faced or are facing traumatic experiences which might involve abuse, neighborhood violence, criminal justice involvement, racism and discrimination, and intergenerational trauma (Bui et al., 2022, p. 6).This cultural subjectivity adds to the lack of funding in healthcare services.It's been viewed that the lack of stable funding to address behavioral health and social service needs in communities of color as being part of historical racism and structural oppression (Bui et al., 2022, p. 8).It has also been emphasized that there is a lack of knowledge and relatability in health care settings designed for recovery.Structural inequities not only make it difficult to enter treatment but make it less desirable to stay in treatment due to lack of preparedness from their providers.Women felt the treatment centers were not equipped to help them deal with the trauma and other psychological issues in their lives, such as post-traumatic stress disorder (Redmond et al., 2020, p. 9).
Adding to structural inequities, the lack of availability in facilities poses another barrier to getting professional help.Per 10,000 adults in the Los Angeles County population, there are just 3.8 beds for detox services and 7.0 beds for residential treatment (Dekin, 2022).
Financial insecurity poses as a triggering occurrence and adds to the distrust that the Black community has for the health care system.Funding contributes to treatment readiness, so the lack of funding strips away the opportunity to be properly treated.Considering intervention or improving service utilization for African American women with substance use issues, it's important to further explore the role treatment readiness plays in the lack of help-seeking within this population and how it might contribute directly to unmet service needs (Redmond et al., 2020, p. 11).Also, the importance of relatability in treatment providers is high, as traditionally not many mental health professionals shared the same intersecting identities.This creates difficulty in connecting.Difficulty arises in trying to find a therapist that has the qualifications needed to help this population.Jones et al. found African American women had a preference for the same race, same gender therapist when possible (Redmond et al., 2020, p. 6).Although ideas for improvement have been proposed, "organizations must be built intentionally to provide culturally effective care, including the staffing, policies, and organizational culture" (Bui et al., 2022, p. 4), the need for cultural competency and cultural humility is crucial for successful rehabilitation.
Being that hyperarousal causes irritability and aggression, maintaining defensiveness from a patients' perspective makes it even more difficult to have breakthroughs in treatment when discussing (or not discussing) past trauma.This persistent state of fight-or-flight could account for the number of times relapse occurs.Early unresolved trauma may be associated with more severe and persistent drug use, thus frustrating attempts at recovery and leading to more frequent relapse (Marcenko et al., 2000, p. 323).Failed attempts at recovery fuels the idea of learned helplessness, which is described by the American Psychological Association (APA) as a phenomenon where repeated exposure to uncontrollable stressors causes individuals to fail at utilizing any other control options that may become available later.This phenomenon alludes to an ominous sense of shame.

Hyperarousal PTSD and Intergroup Dynamics
A key cultural belief in the Black community is that seeking psychological help for mental illness or addictions is a sign of weakness.There are cultural/community factors which may impact their belief or ability to seek treatment such as family responsibility or cultural beliefs about treatment (Redmond et al., 2020, p. 3).
Not only is this cultural belief a hindrance to the overall mental health of the entire community, but this internal stigma prevents struggling Black women from acknowledging their own avoidance and reactions to stressors.With the burden of stigma comes hesitance in seeking help, and this hesitance is part of the driving force for women having to selfheal.Regarding acknowledgement, what has been culturally acceptable in the Black community for decades is to downplay or ignore symptoms as being catastrophic to overall health, especially mental health.This inability to come forward with true emotions in seeking help for trauma is what inevitably keeps black women emotionally enslaved, thus leading to risky coping mechanisms.African Americans are less likely to report or categorize traumatic experiences as trauma or seek treatment when symptoms occur; therapy and the use of medications to treat mental illness and substance use disorders are often unmentionable in the Black community…consequently, these communities may be at higher risk of using substances as a maladaptive method to cope with stressors and to suppress thoughts and feelings associated with trauma (Shah, Monteiro 2020).
The family plays an important role in alcohol/substance abuse, and this factor has been shown to affect females more than males.Family discipline in childhood and family cohesion and parental rule setting during adolescence seem to be key factors in predicting later substance use for females (Doherty et al., 2008, p. 250).Abuse experienced in childhood in relation to the development of PTSD is important when considering treatment strategies.For our Black women to either bypass or overcome their substance usage, acknowledgement and psychological treatment of childhood abuse must be made available during formative years.Statistical results indicate that African American women who reported being abused as children may be at increased risk for substance use in adulthood if they develop post-traumatic stress symptoms (PTSS) that are severe, particularly if the symptoms associated with hyperarousal and/or avoidance are severe in nature (Florez et al., 2022, p. 186).Whether the abuse is emotional, physical, or verbal, Black women are more susceptible to severe symptoms of alcohol abuse resulting from unacknowledged and untreated hyperarousal PTSD.PTSS severity mediated the association between each type of childhood abuse and later alcohol misuse…this suggests that symptom severity is critically linked to increased risk for alcohol misuse in African American women, regardless of the type of childhood abuse experienced (Florez et al., 2022, p. 187).
The Black family also tends to be less supportive of a woman enduring alcohol abuse due to her own "choices."This lack of support is another deterrent for seeking help.Some women discussed losing family support over the course of their lives (including economic support) because family members disapproved of their substance misuse or choice of partners (Cooper et al., 2014, p. 178).What's most interesting about this lack of support from the family is that it leaks into the larger social system, turning our attention to the lack of overall compassion for the Black woman.She's forced to turn inward and seek spiritual support over physical support because of the absence of compassion from her community.When asked about their main source of support during this period, all women discussed their strong relationship with God (Cooper et al., 2014, p. 181).This reinforces the fact that Black women must "stay strong" for their own sake, removing their essence of femininity.Furthermore, substance abusing women tend to conform to their partners' usage, which poses a major threat to the mental health of a Black woman because she continues to relinquish what little control she has over her own wellbeing.Women's partners can reinforce their drug use and women may calibrate their use, so it is in sync with that of their partners (Cooper et al., 2014, p. 177).The duality in attachment styles developed in childhood, be it anxious/avoidant, codependent/interdependent, play a direct role in the type of relationship these women have with men (or women).The majority ( 70)) of heterosexual drug using women form relationships with drug using men (Cooper et al., 2014, p. 177).Black women with hyperarousal PTSD are most likely avoidant in daily life tasks and anxious in relationships.This anxiousness creates fear of the partner leaving, therefore keeping her in her state of abuse out of the need for love and approval from her partner.Since relationships play such a significant role in women's lives, women living with a substance-using partner may be deterred from seeking treatment because they fear the loss of the relationship ("Substance abuse treatment and care for women: case studies and lessons learned", 2005, p. 23).The established hyperarousal PTSD also acts as a catalyst for codependent behavior (further fueling alcohol abuse) in women who were not anxiously attached to their partners."Other women had weaker emotional bonds with their partner.Their relationships were often longer lasting than those described above and were characterized by frequent conflict, break ups, or violence."(Cooper et al., 2014, p. 180).
Deeply rooted embarrassment that weighs on the consciousness of Black women results in denial, ultimately hindering their mental health and contributing to their ongoing hyperarousal.Regarding mental health, interpersonal and direct experiences with discrimination can lead to heightened vigilance, challenge one's beliefs about fairness and justice, create internalized stigma towards oneself, and exacerbate physiological and psychological stress, all of which contribute to poorer mental health outcomes (Vu et al., 2019, p. 2).A pretentious sense of pride and self-blame acts as a barrier to connecting with the true self.Among African American women, SBW schema endorsement is associated with greater negative attitudes toward seeking professional psychological help (ATSPPH) and poorer mental health (McCleary-Gaddy and James, 2022, p. 1).With pride and embarrassment comes the fear of punishment and creates instability.For Black women -especially mothers, this combination is catastrophic when seeking treatment because it eliminates the desire to be treated.The penal system has historically been used to reframe unaccepted behavior which ends up becoming a real threat to the family."Prison and foster care function together to discipline and control poor and lowincome Black women by keeping them under intense state supervision and blaming them for the hardships their families face as a result of social inequalities" (Harp and Bunting, 2020, p. 269).The overflow of pride, embarrassment, and fear of punishment contributes to the avoidance that keeps Black women out of sight and uninvolved in their own treatment.This is concerning since African Americans compared to other racial/ethnic groups have a longer duration of substance use and tend to seek help once the problem is severe (Redmond et al., 2020, p. 2).

Conclusion
Hyperarousal PTSD stemming from, and combined with, social inequalities -the intersection of gender, race, and class, stigma, oppressors, relationships, the health system, and a false sense of self -fosters the unhealthy, unloving, and unsupportive livelihood of a Black woman struggling with alcohol abuse.Interventions proposed by industry professionals provide insight on where to start regarding treatment, "Meaning, intervening on the issue of stigma, guilt, and shame on levels directly addressing family, culture, community and environment."(Redmond et al., 2020, p. 7), however for there to be real change in the way this group is helped there would need to be a deep cultural understanding in the helping fields of psychology, social services, medicine, and criminal justice.Attentiveness in all helping fields for rehabilitation is not only necessary, but vital in breaking down structured inequality and reducing harm to Black women.