An estimated 58.7% of people aged 12 or older in the U.S. indicated substance use (i.e., tobacco, alcohol, or illicit drugs), and notably, 6.9% of African Americans aged 18 or older meet the criteria for a substance use disorder (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Despite the prevalence of substance misuse in the U.S. and robust options for effective treatment (Rieckmann, 2012; Verissimo-Otiniano & Grella, 2017), participation in treatment is low. Indeed, experts estimated that 1.4% of people who met eligibility for a concern received substance use treatment in the past year (SAMHSA, 2021). Formal treatment is offered by trained professionals who provide a professional approach that is believed to be more effective than informal practices (American Addiction Centers, 2020). In substance use treatment, the stages of change, as outlined by The Transtheoretical Model (TTM), are often central to understanding clients’ readiness for change in clinical services (Prochaska et al., 2008). However, Lappan et al. (2020) found that African American clients demonstrated higher attrition rates in substance use treatment, situated in the context of systemic oppression and racism, criminalization of substance use, mistrust of the medical system, and disparities in health care coverage and culturally informed treatments (Farahmand et al., 2020; Garfield et al., 2016; Jordan et al., 2021). Researchers have noted lower rates of treatment accessibility among African American women (Acevedo et al., 2012; Mennis & Stahler, 2016). Therefore, the current study aimed to explore how African American women experienced their recovery process without the use of formalized substance use treatment, known as natural recovery, to determine how, if at all, counselors may increase responsiveness to the lived experiences of this population.

Stages of Change and Natural Recovery

TTM encompasses the process of how humans change behavior across time (Prochaska et al., 2008). Prochaska and colleagues (2008) developed the model with their research associated with smoking cessation, and over time, addiction counselors have relied on the model to conceptualize clients’ readiness for change in treatment. The six stages of change represent cyclical movement between no desire to change (pre-contemplation), initial intentions to change (contemplation), initial steps toward change (preparation), active observable change (action), sustained change (maintenance), and no desire to revert behaviors (termination). In addiction treatment, the sixth stage of termination may not be congruent with the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5; American Psychiatric Association [APA], 2013), which revised substance use disorder criteria to reflect craving as an acceptable symptom in sustained recovery. Similarly, in the developers’ most recent TMM research, they describe only the first five stages (Krebs et al., 2018), which is the structure used in the current study.

Within the stages of change, Prochaska et al. (2008) described processes of change in which individuals actively engage, both apparent and concealed, in behaviors moving them through the cycle. Although these processes of change are largely rooted in traditional theories of counseling (e.g., Freud, Skinner, Rogers; Prochaska et al., 2008) centered on Whiteness, researchers noted generalizability across demographics, presenting concerns, and treatment settings (Prochaska et al., 1992). For example, a meta-analysis of TTM research revealed similar treatment outcomes across age, gender, race, and ethnicity (Krebs et al., 2018). However, among the 76 studies in the review, only six (7.89%) demonstrated samples with majority African American participants. Researchers suggested taking a critical lens to the disparities in addiction treatment, given the historical criminalization embedded in drug policy and inequitable treatment practices for individuals with marginalized racial and ethnic identities (Jackson et al., 2022).

Researchers postulated several reasons that African Americans are less engaged in formal treatment including medical mistrust and anticipated racism (Hall et al., 2022), stigma (Jordan et al., 2020), and non-culturally responsive approaches (James & Jordan, 2018). Structural racism remains at the core of disproportionate healthcare access, with the most recent opioid epidemic as a glaring example. Several researchers described the criminalization and stigmatization of opioid use among persons of color for decades, with more recent shifts to prevention after misuse rates overtook White communities (Chatterjee et al., 2022; Hughes et al., 2022). Decreased treatment initiation for substance misuse is pronounced among African Americans (Jordan et al., 2021; Priester et al., 2016), with significantly lower rates of treatment retention for African American women (Acevedo et al., 2012; Mennis & Stahler, 2016). Thus, African Americans experiencing substance use concerns may seek support from informal avenues.

Natural recovery, a nearly 200-year-old practice, is defined as “the resolution of alcohol and drug addiction without formal treatment” (Granfield & Cloud, 1999, p. 7). Researchers have framed natural recovery as accessing resources (i.e., physical, human, cultural, and social) that aid in one’s recovery process, known as recovery capital (Cloud & Granfield, 2008). Examples of resources tapped into during natural recovery might include peer support (O’Sullivan et al., 2021) found that engagement in the church community was a significant resource attributed to sustained recovery, as well as other recovery capital resources.

Purpose of the Study

As the counseling profession grapples with how to address addiction treatment disparities among marginalized racial and ethnic clients (Entress, 2021; Jordan et al., 2020), increasing counselors’ understanding of how minoritized individuals navigate their recovery process may illuminate culturally responsive care. Although formal treatment frameworks, such as TTM, demonstrated positive therapeutic outcomes across a variety of demographic identities and presented addiction concerns (Krebs et al., 2018), access to treatment disparities remain a concern, particularly among African American women (Acevedo et al., 2012; Mennis & Stahler, 2016). Emergent in the research are informal treatments, such as natural recovery, as a plausible pathway to recovery for individuals not accessing formal treatment services (Blount et al., 2021; Mellor et al., 2021). Thus, we guided the current research study with the following question: How do African American women in sustained natural recovery describe their process of change?

Method

The current study was derived as a secondary analysis of a transcendental qualitative phenomenological study that explored the recovery capital of eight African American women in sustained natural recovery (Blount et al., 2021). Upon the completion of data analysis, participant narratives included more depth of data not associated with the original phenomenon of recovery capital. Aligned with the values of qualitative research, team members reflected upon the data that seemed distinct from the original scope of the study. The narratives seemed to have substantial information regarding how participants in sustained recovery describe their process of change. We determined that a secondary analysis was needed to unpack the narratives further.

Heaton (2008) described the appropriate use of secondary analysis when new or additional research questions are considered, which aligns with informed consent procedures that advise participants that data may be disseminated in many formats. Furthermore, Wasterfors et al., (2014, p. 467) postulated that secondary analysis can be applied to allow researchers to “frame data in a new way”. In this case, it seemed participants may be describing their recovery through the lens of the Transtheoretical Model of Change (TTM), which became part of the conceptual framework of the study. In order to elevate the voices of African American women and their experiences of sustained recovery, this study applied a philosophical foundation guided by the seminal work of Collins (2009), Black Feminist Thought. Within this study, Black Feminist Thought demonstrates agency that resonates among African American women who have had to rely on their inner strength to combat systemic forms of oppression that seem to engulf them given the impact of race, class, and gender. By achieving long-term recovery, this theory demonstrates how African American women have become active agents within the construction of their social worlds and personal lives instead of remaining victims of circumstances (Blount, 2017). Furthermore, the transcendental qualitative phenomenological tradition allowed for meaning making of recovery experiences to remain the focus of the study (Moustakas, 1994). Indeed, lived experience methods are congruent to counseling research, given the interconnectedness and complexity of humans (Prosek & Gibson, 2021), and in this study, humans change behaviors.

Research Team Reflexivity

The research team consisted of three members, including the first author. The first author is of African American descent and has extensive experience counseling individuals from underserved backgrounds. The second research team member is a European American white male counselor educator with formal training in qualitative and quantitative methodology. The third research team member is a European American white male counselor with extensive clinical experience in the field of substance use and recovery. The research team’s reflexivity process included the cultivation of epoche in which we acknowledged and described our connectivity to the research topic, African American women, and substance use treatment (see Blount et al., 2021).

Participants

With Institutional Review Board approval, the first author employed purposive sampling to identify participants who initiated and maintained their sobriety from substance use without receiving formal treatment. Purposive sampling allowed researchers to create the specific eligibility for participation, including (a) self-identified as an African American woman, (b) at least 26 years of age, (c) acknowledged history of a substance use disorder meeting DSM-5 (APA, 2013) criteria, (d) self-reported recovery time of 5 or more years, (e) not currently using a 12-step model to maintain recovery, and (f) ability and interest to participate. Prosek & Gibson (2021) noted the potential arbitrary sample size minimums associated with lived experience methods, suggesting depth of experience as a key indicator. In the current study, eight participants were sufficient for the depth and meaningful data that resulted in the original interviews.

The eight African American women (N = 8) reported ages ranged from 52 to 65 (M = 61). In relation to marital status, five of the participants were divorced, two participants were single, and one participant was married. Three of the eight participants reported a previous unsuccessful recovery attempt using formal substance use treatment (e.g., residential and outpatient services lasting between 30 days and 6 months). Participants self-reported substances of choice as marijuana, crack, cocaine, heroin, prescription medication, and acid, noting 5–30 years (M = 19) since last use.

Procedure

Participants were recruited from the southeastern United States. The first author posted flyers within the local area (i.e., churches, community organizations, shelters, and non-profit organizations) and shared them with community leaders in the field of addiction. The first author screened potential participants with a telephone screening to determine if they met the inclusion criteria. During this screening call, the first author provided an overview of the study (e.g., length of the interview, purpose of the screening) and information about her clinical experience. Upon completion of the telephone screening protocol, the first author notified participants whether or not they were eligible to continue. All eight screened met the inclusion criteria for the study and expressed interest in continuing. The first author scheduled interviews on the day and time most convenient for participants, at a mutually agreed upon location. Before the interview, participants received the informed consent document. Interviews averaged 60–90 min.

Data Sources

Demographic Background Questionnaire

The demographic questionnaire included the following items: (a) name, (b) gender, (c) marital status, (d) the highest level of educational attainment, (e) current employment status, (f) occupation, (g) household income, and (h) religious/spiritual affiliation. The questionnaire also gathered answers to more in-depth questions, including (a) What were your previous drugs of choice? (b) Did you ever seek treatment for substance use? If so, what type? (c) What was your experience with utilizing treatment? (d) Did you experience barriers to treatment (i.e., childcare, health insurance)? (e) What is your current level of support used to abstain from substances? and (f) When were you first introduced to spirituality/religion? The background questions were derived from current literature related to substance use, religion, spirituality, and treatment.

Individual Interview Protocol

The first author developed a semi-structured interview protocol, which provides a guide in the interview process and allows for individualized flexibility for each participant (Hays & Singh, 2023). The interview protocol included open-ended questions and probes derived from existing literature. Interview questions associated with the current secondary data analysis include (a) How would you describe and define your recovery process experience? (b) How were you able to redefine your life through the recovery process? (c) How have you been able to integrate change into your lifestyle in order to maintain a commitment to recovery?

Field Notes, Memos, and Journals

The first author utilized field notes and memos as records to describe and analyze findings as they developed throughout the study (Hays & Singh, 2023). These field notes were maintained in a notebook that consisted of the title of the study, the date of the interview, the beginning time and ending time of the interview, and the location. Additionally, the first author kept notes pertaining to participant responses. For example, in one field note, the first author recorded that family is important to participants as evidenced by family photos. In a similar vein, the first author recorded participant responses to questions including non-verbal behavior. Another source of this data was reflexive journaling to document feelings that arose during interviews. The first author documented within journal entries the overall feelings of completing each interview. This practice allowed for the documentation of personal responses to the research process and its impact on her as a researcher (Hays & Singh, 2023). Other research team members accessed these documents to cultivate connectivity with the data during analysis.

Data Analysis

The first author transcribed the eight recorded interviews and distributed them to research participants for accuracy confirmation member checking before data analysis began. Two participants provided clarity to the transcripts (e.g., the statement that the participant lived with her boyfriend was inaccurate as she lived alone). The research team then analyzed data following Moustakas’ (1994) transcendental phenomenology approach that outlines three overarching steps: phenomenological reduction, imagination variation, and essence. During phenomenological reduction, we listed all relevant expressions (i.e., horizontalization) assigning equal value to all statements. Additionally, we removed repetitive or overlap** statements (i.e., reduction). The team identified invariant horizons or meaning units, as a method of arriving at participants’ core themes (Moustakas, 1994). Through imaginative variation, textural descriptions were converted to structural descriptions for each participant (Moustakas, 1994). For example, the research team considered participants’ meanings from various perspectives in order to develop a full, well-rounded understanding of both the individual and composite structural descriptions. Finally, team members synthesized the textural and structural descriptions into themes that captured the essence of the experiences (Moustakas, 1994). We conducted this secondary data analysis through the lens of the TTM, as a framework for understanding the experiences of the participants who adhered to a natural recovery process.

Strategies for Trustworthiness

We intentionally implemented several trustworthiness strategies to demonstrate the rigor of the study (Hays & Singh, 2023). Credibility was supported by member checking and the use of an external auditor, accounting for the accuracy of the findings. We implemented triangulation of researchers and data sources, which informed the confirmability and transferability of the study (Hays et al., 2016). The thick description of the design allows for transferability. Finally, the researcher’s reflexivity practices of journaling, field notes, and memos allowed research team members the ability to discuss their relationships with the data, topic, and participants, all of which address credibility, dependability, and confirmability (Hays et al., 2016).

Findings

We identified eight emergent themes from the data that reflected how African American women in sustained natural recovery described their process of change: (a) focused on the drug; (b) engagement in risky behavior; (c) desire to be free; (d) Damascus Road experience; (e) plea to higher power; (f) geographical cure; (g) self-liberation in commitment; and (h) develo** abilities to help others through new associations. We maximized narrative descriptions of each theme with supportive participant quotes and developed a figure to overlay their lived experience of change in the recovery process with TTM (see Fig. 1).

Fig. 1
figure 1

Natural recovery stories through the lens of the transtheoretical model

Full size image

Focused on the Drug

In the theme, focused on the drug, participants chronicled their preoccupation with acquiring, using, and recovering from substances, as well as the socializing activities rooted in their use experiences. They described the connectivity between increasing instability in their lives and the diminished desire to refrain from substances. For many participants, the instabilities felt drastic as their addictions exponentially became more severe and all-consuming, immersed in drug-scene culture. For example, Mercy described a binge experience:

I remember staying up for like three or four days. I learned to smoke by myself because I would have more and I would take my time and smoke because I would be tweaking. I was hearing and seeing something from somebody.

She further described a night in which her high left her out of touch with reality, experiencing a euphoria:

I remember we liked this courtyard that we used to sit in and get high. I had some crack and the guy put some dope on it and I hit that, they called that chase the dragon. I was so high that I was walking in the middle of the street with my stem. They said, “Put the stem out before the cops come.” I'm like, forget the cops, I'm looking at the stem and that was a high that I will not forget.

The euphoria could not be separated from the growing instabilities that made drug use all-consuming, and participants described times when the consequences of use were disregarded. Tracey relayed her loss of control:

It changed my life so quickly. The life I lived wasn’t a thing that I liked to do, it was nothing I had ever done, you know? It took me away from myself and I had no control…I would just get up at 4:00 in the morning and sit in the car waiting for the man to bring me drugs that could have killed me.

This participant’s comments highlight both the great lengths she went to in order to acquire substances and the unpleasant experience of lacking the agency to direct her life.

With respect to drug culture and the social environment, Scorpio declared, “And once I started doing it then I liked it. You know? I just got hooked on it. Because they [friends] had to do it every day and I was right there with them every day.” Her misuse seemed to be sustained by her network of friends and absorbed much of her attention. Patricia initially called herself a “weekend junkie,” but as her habit began to escalate, she described, “And that’s the worst thing in the world to have as a habit on heroin. You dream about the drug day and night.” Thus, preoccupation with the substance takes on an extreme form, where other life activities suffer and a person feels powerless.

Engagement in Risky Behavior

Connected to the heightened focus on drugs, participants described the normalization of various risk-taking behaviors within their substance use lifestyle. Participants’ lived experiences reflected how the risky behavior supported their access to drugs. Lorraine recounted, “I felt powerless over the drug, and I just sat there using, shoplifting, doing everything I could do to support my habit.” Three participants described engaging in prostitution and dating drug dealers to support their habits. Mercy shared, “I was doing drugs and sometimes tricking for them drugs.” Saundra stated, “So you get caught up in that life and you start doing things you normally wouldn’t do and you would even sleep with people that had the drugs. That’s how life went.” Furthermore, Edna recounted her experience of dating a drug dealer, “I left the relationship with my baby’s father only to enter another unhealthy relationship with a big-time drug dealer because I thought, he can supply me with more drugs to support my habit.” In these examples, access to drugs was a major driver in decision-making, sometimes with clear tradeoffs to safety and security. Saundra recalled how she was introduced to selling drugs by her boyfriend; when her weekly drug habit began to escalate, she then started selling drugs:

Because the guy I was seeing, that’s what he did and I was telling him about how I didn’t have. I needed money, I need to make extra money or whatever, and he said, “if you do this, take this, sell it, and what you make from it, this is what I expect you to give me every week.” So, I took and I sold it and I gave him what I made and so I did it every week. People would come to my house and get it [the drugs]. I never got big time, I kept enough selling so that I could support my habit.

Participants looked back on these behaviors as straightforward and born of necessity and also expressed some self-judgment and regret in their recollections.

Desire to be Free

All eight participants shared their initial desires to leave the lifestyle of addiction; many rooted in the unsustainability of the risks required to maintain their habits. Several participants described how it was vital to “first admit that you need help and that you have a desire to change.” Lorraine acknowledged that although she attempted inpatient and outpatient substance use treatment and Narcotics Anonymous (NA) meetings, she did not have a sustained desire to change:

At one time, even though I kind of thought I would have wanted to be free from the addiction, I really wasn’t, I really wasn’t ready. I tried treatment, inpatient a couple of times, it did not help, and so I still continued just to use, use, and use.

Among the lived experiences, participants noted that their early desires to be different were intertwined with struggles and relapse. For example, Scorpio expressed that she started to take small steps toward “straightening up” her life. However, she continued to struggle and acknowledged that she “prayed on it and when I first prayed on it, it didn’t work.” In this quote, the participant acknowledged how desire is an important precursor to change but not sufficient. As the desire to recover increased and the addiction continued, she experienced disappointment that her spirituality did not immediately transform her life situation.

Damascus Road Experiences

Nearly all participants described how initial desires to change did not sustain a recovery lifestyle, and that a significant life event dramatically led to a more sustainable road to recovery. For the participants, this significant moment was often inseparable from their spiritual beliefs; therefore, researchers named the theme Damascus Road experiences. The theme is inspired by the story of Saul in the Bible in which he lives a persecutory life until a life-changing spiritual experience on route to Damascus shifts his lifestyle to that of serving God as the Apostle Paul (King James Version Bible, 2022, Acts 9:3). Participants vividly described their Damascus Road encounters including death threats, interactions with police, prison, near-death experiences, and diagnosis of cancer. For example, Edna stated:

I owed him so much money, I found out that he started scheming and plotting a hit on me. At that time, violence was terrible around DC. We had shootings 5-6 times a day, people were being found dead in the hood and near wooded areas for owing people money for drugs. I was afraid for my life. I had owed this guy a lot of money and I mean a lot, the habit was so bad that I couldn’t even afford the $20.00 rent that I had to pay.

Tracey reported her Damascus experience occurred on Valentine’s Day when a drug dealer gave her a bag of methamphetamine, acid, and THC. She owed the “wake-up” experience to the Lord:

All of a sudden, my body felt like it was on fire. I looked at that man and he looked like Satan and I looked at the walls, you know how they have in a hotel, they have the wall, the light on the wall, it looked like it was a fire torch and the bed looked like hell. I was burning up, I got so sick, he had to take me and put me in cold water. He took me home and I did not look back…I felt the Lord was telling me to wake up, wake up, wake up.

For the participants in the current study, the powerful Damascus Road experiences required them to surrender within their call to live in Christ. Participants indicated that if it were not for these experiences, they probably would have continued to misuse substances.

Plea to Higher Power

As participants embarked on their natural recovery processes, they described their lives as chaotic, unpredictable, and destructive. Because spirituality played a significant role in the lives of participants, all eight acknowledged making a plea to their higher power to help “set them free” from their addiction. All eight participants reported histories of involvement in a church community as children; however, they steered away from religious practice in adulthood. In this theme, participants described their reconnection with God in their early recovery processes. For example, Edna strikingly recounted her experience of communicating with God:

I will never forget that night. I was walking the streets high as a kite, and I prayed to God and told him that if he would save my life I promise that I would serve him and nobody else. I remember staying in bed for a few days because I was depressed, and I needed to find a way out.

Moreover, Lorraine highlighted her plea:

I began to get tired and this was close to the twelfth year [of using crack/cocaine]. So, I just, you know, I prayed and I told the Lord that I was ready to give up the cocaine usage because my daughter would be the last one that would go into the system.

Similarly, Saundra awoke from a binge thinking “I can’t do this no more. I'm awake and jittery and you say, “Lord, if my heart just slows down, I won’t do it no more.” Calling on God in these early moments of change seemed to assist participants in taking the next step in their recovery. In other words, the reconnection to their spirituality became an important resource as they began to envision a new lifestyle for themselves.

Geographical Cure

In the theme, geographical cure, participants described how physical relocations to new communities were necessary for their recovery process. For example, Scorpio expressed that she moved from a “drug-infested” neighborhood and relocated with her sister where the drugs were not as prominent in the community. For several participants, the geographical cure also put physical distance between them and individuals who engaged in substance use. Emma expressed how she left a small country town and moved to an urban area:

I didn’t allow myself to be around people that use that stuff. I was around people and had to ask myself, “Do I want to stay in this little country town, small town and be caught up with everything or move on?”

Mercy recounted moving to New York City, after being released from prison in a southern state, where she began dating a “knucklehead” and relapsed, describing herself this time as a “responsible addict.” In this case, the geographical cure ended with social isolation, not benefiting her recovery.

As participants’ narratives illustrated, substances were concentrated within their living environment. Within their stories, it was evident they found it difficult to escape the issues that plagued family members and friends. Participants described how disconnecting from those who were using substances became essential in their recovery. In addition, participants shared the importance of relocating from their neighborhoods that were immersed in drug culture.

Self-Liberation in Commitment

Within this theme, participants described embracing their self-liberation and conscious decision to remain committed to their recovery lifestyle. For example, Scorpio explained how she continually decides each day, “not [to surround] myself in that environment. Staying away from people you know that would bring that.” Her sobriety is connected to her self-liberation from people, places, and triggers. The Damascus Road experiences remain influential in their continued commitment to live in recovery with several participants noting their involvement in church ministry. For example, Tracey further recounted how the Damascus Road encounter was symbolic and revelatory for her to “get in place.” She conveyed that God got her attention and took the craving away and that she did not have to complete NA meetings. She said, “But I thank God and I didn’t have to do the steps, I was step** to the cross.” Further, all eight participants acknowledged the unyielding relationship between their hope in a higher power and their long-term recovery. Based on participants’ narratives, having a committed lifestyle and being socially liberated were essential in their change process.

New Associations

For our participants, the geographical cure, although useful in the initial change process, was not sufficient for sustainable recovery. Participants described that long-term recovery blossomed from new associations and relationships cultivated in their new communities. For instance, Lorraine acknowledged: “I just changed, met new people, stopped hanging out in the clubs and the streets, started going to church, and staying home being a mom.” Participants described develo** healthy friendships, establishing new associations with biological family members, and building relationships with a church family. For example, Edna described re-establishing family bonds, “We lived with my uncle and his wife for about one year until I was able to get on my feet.” Participants recalled reunification with parents and children, a part of their lives that had been disrupted while addicted to substances.

In particular, participants expressed how engaging in relationships with the intention to help others plays a meaningful role in their recovery sustainability. For instance, Saundra acknowledged, “When I realized that I was ready to change, I moved in with my grandmother. Two of my oldest children moved with their father and my youngest child stayed with me and my grandmother and I got rid of the boyfriend.” Saundra shared, as a result of no longer being involved in the drug scene, she began to find refuge in her family as evidenced by establishing new associations with family members, specifically her grandmother.

Discussion

Although the participants in the current study used a natural recovery process, their narratives expressed alignment with TTM, an approach often employed to conceptualize clients’ recovery in formal treatment. Consistent with existing literature (Williamson & Hood, 2013), findings from the present study affirmed that TTM is applicable to those individuals who have decided to use natural pathways to recovery. The participants in our study described their experiences from pre-contemplation through maintenance, following the human behavior change model (Prochaska et al., 2008). For example, aligned with previous research, they described internal and external crises that motivated change (Moxley & Washington, 2016) and cultivated new identities that required modifying old behaviors related to substance use (Coleman et al., 2021). New and additive to the literature from our study is empirical support that movement through the stages of change may not require formal treatment. Situating the results of the current study with TTM highlights catalysts for change among African American women, such as the Damascus Road experience, which while specific to the women in our study, aligns with previous research on recovery that crises serve as an impetus for change (Moxley & Washington, 2016) and the significance of religion and spirituality for recovery among African American women (DiReda & Gonsalvez, 2016). These moments represented powerful, pivotal timepoints in which they experienced a deep reckoning with themselves (i.e., the Damascus Road experience) and a desire to be free from drug abuse.

Also additive to the literature from our study is the description of how faith interacted in the change cycle, deeply embedded from early stages through maintenance (e.g., desire to be free, Damascus Road experience, plea to higher power, new associations), which is consistent with previous research noting the importance of spirituality and religion in the recovery process of African American women (Blakey, 2016). Indeed, in our study, participants anchored their higher power across contemplation, preparation, action, and maintenance stages of change, illuminating the reliance on faith in natural recovery. Sustaining their own recovery required sharing of themselves in their church communities. Counseling researchers have noted the neglect of religion and spirituality in diversity discussions (Mintert et al., 2020), which may play a contributing role in the attrition of African American women in formal substance use treatment. Researchers noted anticipated racism in care (Hall et al., 2022), overlooked social influences of misuse (Farahmand et al., 2020), and perceived self-stigma (Avent Harris et al., 2021) as barriers in the African American community to access and remain in formal treatment. The natural recovery process and recovery capital components associated with faith communities may be central to sustained recovery (Blount et al., 2021). In the current sample of participants, clinical treatment was not what led to their long-term recovery; thus, counselors may need to use this data to reimagine their role in the substance use recovery of African American women.

Implications for Counselors

Researchers have established lower rates of substance use treatment initiation among African Americans (Jordan et al., 2021; Priester et al., 2016); particularly, high treatment attrition rates among African American women (Acevedo et al., 2012; Mennis & Stahler, 2016). The women in this study did not have sustained recovery gains in clinical treatments offered by counselors; however, their perspectives on their change process in natural recovery provide useful information for the profession. Specifically, this data may help guide how counselors may need to reflect upon their positionality in upholding the status quo in substance use treatment among African American women. Lee and Haskins (2021, p. 105) stated that “critical consciousness involves a cycle of reflection and action, as true reflection leads to action”. In the framework of the current study, counselors may need to embrace other professional identity roles beyond individual counseling to reach African American women seeking recovery support, such as community outreach. In counseling literature, the construct of community-engaged counselor is often associated with research–practice partnerships (Barrio Minton et al., 2020; Hays et al., 2019); however, practicing counselors also have a responsibility to remain connected to their communities, which informs best practices in care, specifically, among marginalized populations. Experts in the medical community suggested the importance of responding to disparities in addiction treatment outside of the clinical setting (Jackson et al., 2022). Counselors need to first be immersed in the community before assuming culturally responsive treatment practices for African American women in recovery.

Although the goal of qualitative studies is not intended to be generalizable, current findings may inspire a few ways in which counselors can engage in their communities to support the natural recovery processes of African American women. Aligned with the American Counseling Association Advocacy Competencies (Toporek & Daniels, 2018), counselors may collaborate with community members, viewing them as experts in their recovery process, actively listening to hear the strengths of African American women seeking recovery, as well as the barriers to care, which may alter how counselors provide treatment in the future. Additionally, counselors may need to shift the perspective that care is only provided within formal treatment and recognize how care can operate within the structure of a community that experiences racism, oppression, and generational trauma (Blount et al., 2021).

The results of the current study remain consistent with previous work noting the significance of religion and spirituality for recovery among African American women (DiReda & Gonsalvez, 2016); therefore, community-engaged counselors could cultivate relationships with church communities. When trust is fostered in the relationship and understanding of the community is develo**, counselors may offer psychoeducation to church leaders to increase awareness of and the ability to identify potential substance use concerns among their congregates. For example, counselors can equip leadership (e.g., pastors, elders, Bible study leaders) with educational information on TTM. Such outreach aligns with the Multicultural and Social Justice Counseling Competencies (MSJCC), in which counselors engage at the institutional and community level as advocates with and on behalf of community members (Ratts et al., 2016). Researchers emphasized that churches in African American communities are trusted institutions that have a responsibility to promote mental health and wellness (Campbell & Littleton, 2018), and counselors may be able to support such efforts with outreach efforts. Finally, the community-engaged counselor who has cultivated trusting relationships within the African American church community may be able to connect clients who do enter treatment with the natural recovery resources, or recovery capital. African American women in sustained natural recovery highlighted the importance of the church community (Blount et al., 2021). In particular, the findings of this study indicated the role of the church within its maintenance stage of change. Therefore, having church community partners as an adjunct service may offer community-based recovery support, increasing recovery capital and demonstrating the cultural responsiveness of counselors working with African American women seeking substance use treatment.

Limitations and Future Research

The findings of the current study should be considered within the context of the study’s limitations. Participants represent one geographical location in the U.S., in which religion is more prevalent (Pew Research Center, 2014). The interpretation of the data represents the meaning and understanding of the current research team; another team of researchers may have a different interpretation of the data. Additionally, we conducted a secondary analysis, which has drawn some criticism (Heaton, 2008). We did not have prolonged exposure with participants, which is a limitation in qualitative research (Hays et al., 2016). Moreover, another limitation of the study can be attributed to the data analysis team. The positionality of two white men on the data analysis team needed additional attention, given the systemic oppression of African American women in the U.S. to the advantage of white, male privilege. Finally, the complexity of analysis could be improved in future research studies, perhaps with multiple interviews across participants, or expanding the sample to include church leaders. Researchers may expand upon the current findings by designing studies that interrogate substance use treatment practices in an effort to develop culturally responsive interventions for African American women.

Conclusion

Our findings affirm that natural recovery is indeed occurring within communities, specifically illustrated by the narratives of African American women in sustained recovery, who described their change process. As the counseling profession continues to raise critical consciousness on the embedded oppression in formal substance use treatment interventions, the results of the current study in which African American women made meaning of their sustained recovery experience may offer suggestions for how counselors may participate in outreach as a culturally responsive practice.