Black women have been disproportionately affected by anxiety disorders, yet they are often underrepresented in research and clinical settings. The intersectionality of race and gender brings unique challenges and stressors that contribute to the high prevalence of anxiety in this population. Additionally, systemic barriers to mental health care further exacerbate the situation for black women, leading to under-diagnosis and under treatment of anxiety disorders. Anxiety adversely affects members of the African Diaspora. 

Black women have been disproportionately affected by anxiety disorders, yet they are often underrepresented in research and clinical settings. The intersectionality of race and gender brings unique challenges and stressors that contribute to the high prevalence of anxiety in this population. Additionally, systemic barriers to mental health care further exacerbate the situation for black women, leading to under-diagnosis and under treatment of anxiety disorders. Anxiety adversely affects members of the African Diaspora. “Anxiety is the most common mental health disorder in the United States and impacts African Americans at a higher rate than any other group, especially African American women” (Simon, 2018). “Anxiety is an emotion marked by tension and perceived threat or apprehension that often consists of physiological responses, such as increased heart rate and perspiration” (Gordon, Steiner, & Teachman, 2015). While anxiety affects Black and African Americans at higher rates, more literature and culturally appropriate treatment are needed. According to Williams, Beckmann-Mendez, & Turkheimer (2013), found “anxiety disorders are understudied, under-diagnosed, and under-treated in Black and African Americans. Anxiety is a complex mental health condition that can include the following symptoms “feeling nervous, restless or tense, having a sense of impending danger, panic or doom, having an increased heart rate, breathing rapidly (hyperventilation), sweating, trembling, feeling weak or tired, trouble concentrating or thinking about anything other than the present worry, having trouble sleeping, experiencing gastrointestinal (GI) problems, having difficulty controlling worry, and having the urge to avoid things that trigger anxiety” (Mayo Clinic, n.d.). 

The Diagnostic Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-V-TR) is the book many clinicians use to diagnose clients with mental health and substance use disorders. The DSM-V-TR lists the following types of anxiety disorders: Agoraphobia, Anxiety disorder due to a medical condition, Generalized anxiety disorder, Panic disorder, Selective mutism, Separation anxiety disorder, Social anxiety disorder, Specific phobias, Substance-induced anxiety disorder, and Other specified anxiety disorder and unspecified anxiety disorder. According to the Anxiety & Depression Association of America (ADAA) (2020), "Nearly 45 million people in the U.S. identify as Black, with at least 3.1 million identifying as a combination of Black and another race. More than 7 million Black and African American individuals in the U.S. are living with mental health conditions. While we have some stats on African American and Black mental health, the statistics on anxiety disorders within this group vary. "Both depression and anxiety are often misdiagnosed and mistreated in Black communities. Because Black communities have historically experienced extreme adversities, it is easy for the community to normalize symptoms of depression and anxiety disorders" (ADAA, 2020). When reviewing the complexity of anxiety in the Black Community, we must understand prevalence, triggers & causes of anxiety, Anti-Black Racism in clinical diagnosis, barriers to anxiety treatment, and African Centered treatment modalities for African American and Black clients. Moving forward, it is imperative for mental health services to be more accessible and responsive to the needs of black women. This includes advocating for policy changes, increasing the diversity of mental health professionals, and fostering collaborations between community organizations and healthcare providers to create more comprehensive and culturally competent support systems for black women dealing with anxiety. Understanding the intersectional challenges faced by black women in dealing with anxiety is crucial for developing effective support systems. Research suggests that traditional therapeutic frameworks may not fully address the specific needs of this demographic. Therefore, it is essential to integrate culturally sensitive and trauma-informed approaches into mental health care for black women. It is evident that creating a more inclusive and empowering mental health landscape for black women dealing with anxiety requires an intersectional approach that considers the unique experiences and needs of this demographic. As we strive to prioritize the voices and experiences of black women, it is essential to recognize the intersectional challenges they face, including those related to race, gender, and socio-economic status. One crucial aspect of addressing anxiety in black women is the need to integrate culturally sensitive and trauma-informed approaches into mental health care. Traditional therapeutic frameworks may not fully address the specific needs of this demographic, making it imperative for mental health interventions to be tailored to the cultural and historical context of black women. "NTU psychotherapy is based on the core principles of ancient African and Afrocentric world view, nurtured through African American culture, and augmented by Western psychology concepts and techniques. NTU psychotherapy is spiritually based and aims to assist people and systems in becoming authentic and balanced within shared energy and essence aligned with the natural order. Furthermore, NTU therapy utilizes the principles of Nguzo Saba as guidelines for harmonious living. Basic principles of NTU therapy include Harmony; Balance; Interconnectedness; Cultural Awareness; and Authenticity" (Phillips, 1990). This paper will review NTU Psychotherapy's use to treat anxiety symptoms in Black women effectively.

Search Methodology 

Searches for journal articles and dissertations used ERIC, PsycINFO, PubMed, Science Direct, Cochrane Collaboration, Campbell Collaboration, ProQuest, Dissertation and Theses, and Google Scholar databases. Search terms included Anxiety, Anxiety Disorders, African American Women, Black Women, and NTU Psychotherapy. Articles had to be written in English and published in a peer-reviewed journal to meet the criteria for being part of this review. A review of titles, abstracts, and keywords determined inclusion. Collectively, more than 1,600 articles were produced. Any materials lacking empirical results or involving treatment approaches other than an NTU Psychotherapy context to treat anxiety symptoms or anxiety disorders in African Americans or Black clients were excluded. Articles appearing on multiple databases were also eliminated. Six articles initially met inclusion criteria and were selected for this literature review. The reference section of each article was scanned for additional relevant citations. No additional articles were identified and added to the literature review. A total of six peer-reviewed journal articles are included in this literature review that discusses anxiety, African Americans, and NTU Psychotherapy. 

Anxiety and African American Women

The involvement of black women in the design and implementation of mental health programs is crucial for ensuring that these initiatives are tailored to their specific needs and experiences. By actively involving black women in decision-making processes and program development, mental health interventions can become more effective and relevant to the community they aim to support. Moreover, promoting education and awareness about the intersection of race, gender, and mental health is essential in dismantling existing stigmas and biases that may prevent black women from seeking help. This can be achieved through public campaigns, workshops, and educational resources that emphasize the importance of culturally competent care and the validation of black women's mental health experiences. Anxiety disorders are a severe problem, with a lifetime prevalence in the general population1 of 28.8%, but there have been conflicting reports in prevalence rates for US ethnic/racial minorities” (Williams, Beckmann-Mendez, & Turkheimer, 2013). More data is needed on the prevalence of anxiety disorders in African Americans. Himble, Baser, Taylor, Campbell, & Jackson (2009) performed a study to review the age of onset, severity, and prevalence of anxiety disorders in African Americans, Blacks of Caribbean descent, and non-Hispanic whites in the United States. These researchers found that “Whites were at elevated risk for generalized anxiety disorder, panic disorder, and social anxiety compared to Caribbean Blacks and African Americans. However, When African American and Caribbean Black respondents met the criteria for an anxiety disorder, they experienced higher levels of overall mental illness severity and functional impairment compared to white” (Himble, Baser, Taylor, Campbell, & Jackson, 2009) clients. Villines & Legg (2020) state, “Anxiety is a complex mental health issue, with many triggers. Some common causes across racial groups include early trauma or abuse, family history, genetics, early environment, shy or inhibited temperament, and certain medical conditions. “Black Americans face several risk factors for anxiety including, racial trauma, exposure to racism and racist abuse, the effects of racism, such as fewer our-outlines and less safe communities, and higher rates of trauma including sexual assault and police” (Villines & Legg, 2020). Despite this finding, it is imperative to continue to build on the research regarding Black and African Americans who have anxiety symptoms or meet the criteria of an anxiety disorder. Despite meeting diagnostic criteria, Black and African Americans are often underdiagnosed with anxiety symptoms. Black clients may interact with clinicians who exhibit Anti-Black racism or implicit bias when assessing and diagnosing their anxiety symptoms. Some clinicians are unaware of anxiety triggers or symptoms in members of the Black community and its effects on anxiety symptoms. Racism and microaggressions contribute to symptoms of Anxiety in Black and African Americans. It is also clear that more research is needed on the relationship between exposure to racism, trauma, and Anxiety in African Americans. 

Racial Bias in Diagnosis 

African Americans and Black clients often experience racial bias regarding mental health diagnoses even amongst other Black or African American clinicians. "Anxiety disorders are understudied, under-diagnosed, and under-treated in African Americans. The research focused on the phenomenology, etiology, and treatment of anxiety in African Americans has been hampered by lack of inclusion of this population in clinical research studies" (Williams, Beckmann-Mendez, & Turkheimer). As it relates to clinician bias in "2003, the surgeon general's report and various studies documented racial and ethnic disparities in mental health care, including gaps in access, questionable diagnostic practices, and limited provision of optimum treatments. Bias is a little-studied but viable explanation for these disparities" (Snowden, 2003). African Americans are often misdiagnosed and mistreated due to clinician bias. According to Gara et al. (2019), "Rates of diagnoses of schizophrenia among African Americans are elevated compared with rates for other racial and ethnic groups in U.S. clinical settings... Specifically, previous investigations have consistently suggested that African Americans with mood disorders are much more likely than other groups to be misdiagnosed with schizophrenia". An African American person misdiagnosed and mistreated for a mood disorder instead of an anxiety disorder can be detrimental to their client's health. This can lead to a client receiving the wrong evidence-based practice, incorrect treatment level, and even inaccurate and ineffective medication. Moreover, it could also result in the client not receiving culturally aware or relevant treatment options. African Americans are often "offered medication or therapy at lower rates than the general population" (American Psychiatric Association, 2017). Often, an African American client's culture may not be fully considered during their assessment, diagnosis, and treatment phases. A clinician's bias can deter a client's ability to receive the correct mental health treatment and the proper assistance. African Americans' historical and current life adversities contribute to the mental health symptoms, assessment, incorrect assessment, diagnosis, misdiagnosis, treatment, and mistreatment. 

Cultural Mistrust 

Cultural mistrust also leads to a lack of accurate anxiety diagnosis in Black and African American clients. According to Mental Health America (MHA)(n.d.), "Historical adversity, which includes slavery, sharecropping, and race-based exclusion from health, educational, social, and economic resources, translates into socioeconomic disparities experienced by Black and African American people today. Socioeconomic status, in turn, is linked to mental health: people who are impoverished, homeless, incarcerated, or have substance use problems are at higher risk for poor mental health. Despite progress made over the years, racism continues to impact the mental health of Black and African American people. Negative stereotypes and attitudes of rejection have decreased but continue to occur with measurable, adverse consequences. Historical and contemporary instances of negative treatment have led to a distrust of authorities, many of whom did not have the best interests of Black and African Americans." Scharff, Mathew's, Jackson, Hoffsuemmer, Martin, & Edwards (2010) found "mistrust stems from historical events including the Tuskegee syphilis study and is reinforced by health system issues and discriminatory events that continue to this day. Mistrust was an important barrier expressed across all groups regardless of prior research participation or socioeconomic status. Researchers should incorporate strategies to reduce mistrust and increase African Americans' participation". If social scientists do not continue to advocate for Black and African American clients, we will continue not to be correctly diagnosed and will not receive culturally appropriate treatment. 

African Americans & Trauma Exposure

African Americans and individuals who identify as Black frequently experience mental health symptoms due to traumatic exposure. "Research suggests that African Americans have a higher risk of developing PTSD than the general population (Alim, Graves, & Mellman, 2006; Himle, Baser, Taylor, Campbell, & Jackson, 2009; Janssen, n.d.). Complex, Simple, Historical, and Intergenerational trauma can cause symptoms of Post Traumatic Stress Disorder and Anxiety in individuals of African descent. Simple trauma is "a single, circumscribed traumatic event" (Franco, 2021). Car accidents, house fires, natural disasters, and assaults are all examples of simple traumas. Complex Trauma "occurs when a person experiences a series of repeated traumatic events or when new, unique traumatic incidents occur. Complex trauma may involve entire families in incidents of violence, addiction, or poverty." (Franco, 2021). Anyone who experiences a traumatic event either experiences a complex or simple trauma. These forms of trauma are different than historical and intergenerational traumas. Historical and Intergenerational traumas align with a person's racial and ethnic identity. "Historical trauma refers to traumatic experiences or events shared by a group of people within a society, or even by an entire community, ethnic, or national group. Historical trauma meets three criteria: widespread effects, collective suffering, and malicious intent. Historical Trauma Response (HTR) can manifest as substance abuse, suicidal thoughts, depression, Anxiety, low self-esteem, anger, violence, and difficulty in emotional regulation (Franco, 2021). African Americans as a group experience historical traumas. "Most African Americans are aware of historical patterns of violence and oppression. African Americans have been "systematically brutalized, mutilated, murdered, abused, controlled, raped, objectified, and demonized by guns, whips, chains, and manacles; by shootings, lynchings, and rape; laws, policies, social norms, and codes of behavior; and by images and concepts. For centuries, trauma upon trauma compounded" (Janssen, n.d.). Historical trauma differs from Intergenerational trauma. "Intergenerational trauma is trauma that gets passed down from those who directly experience an incident to subsequent generations. Intergenerational trauma may begin with a traumatic event affecting an individual, traumatic events affecting multiple family members, or collective trauma affecting the larger community, cultural, racial, ethnic, or other groups/populations (historical trauma)" (Franco, 2021). African Americans also meet the criteria for Intergenerational trauma as they experience events that affect mail-let family members or collective trauma. "For Black Americans who descended from enslaved people, the trauma experienced by ancestors has been passed down through each generation" (Asare, 2021). Intergenerational trauma affects not only a person's self-esteem, response to internalized oppression, and health outcomes but also their mental health. Self-esteem can be a direct result of Intergenerational trauma. "One of the aftereffects of slavery observed is vacant self-esteem, which can include feelings of hopelessness and depression. The negative racial stereotypes applied to Black people throughout history may have been internalized and passed down from generation to generation. (Asare, 2021). Health outcomes can also be affected by Intergenerational Trauma. Racism is associated with many adverse health outcomes. One 2010 study found that Black women experienced accelerated biological aging due to prolonged stressors. Research indicates that racism is associated with higher stress levels, increasing the risk of high blood pressure. Hypertension is a condition afflicts a higher percentage of Black people compared to other racial and ethnic groups; racism could be one of the contributing factors. Racial differences are found in sleep patterns, with Black people getting less sleep than their counterparts on average. Young adults aged 18-28 who experienced discrimination were more likely to "experience psychological distress, to be diagnosed with a mental illness or to report excessive drug use." There is a cornucopia of evidence outlining the health implications of racism. To complicate matters, disparities in healthcare access, food deserts, and environmental racism exacerbate these issues even further. Within the Black community, this can show up in several different ways. "Colorism, texturism, and featurism are built around the oppressive belief that physical attributes closer to white are more acceptable, presentable, and beautiful. Internalized oppression can also show respectability politics—the belief that behaving in a certain way makes a person more valuable and deserving of respect and dignity. There is a pervasive and false belief that aligning with whiteness will shield you from racial harm" (Asare, 2021). More information is needed on the correlation between exposure to trauma, African Americans, anxiety, and post-traumatic stress symptoms.

Anxiety and Racism 

African Americans and people from the African Diaspora receive the majority of implicit and explicit experiences that involve racism, prejudice, discrimination, micro-aggressions, and stereotyping. According to Clark et al. (1999, p. 805) racism are the "beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation." Traditionally, researchers have divided racial discrimination into two main types: major discriminatory events and day-to-day discrimination events (Soto, Dawson-Andoh, & BeLue, 2011). The former can entail such instances as being unfairly treated by police, being denied a bank loan, or being fired because of membership in a racial group (Soto, Dawson-Andoh, & BeLue, 2011). Countless studies have documented the elevated experience of racial discrimination among ethnic minority groups in the United States, especially African Americans, relative to European Americans (Soto, Dawson-Andoh, & BeLue, 2011). Research has shown that perceived discrimination—subjectively believing one did not receive a promotion at work due to their ethnicity—can be just as damaging as being the victim of objective discrimination" (Soto, Dawson-Andoh, & BeLue, 2011). African Americans experience both forms of racial discrimination, resulting in increased mental health symptoms. For example, findings from the National Survey of Black Americans showed that participants' reports of racial mistreatment were prospectively linked to higher levels of psychological distress as defined by symptoms of depression (Jackson et al. 1996). Similarly, other studies have found that perceived racial discrimination was linked to higher levels of depression and anxiety symptoms among African Americans, as well as increased somatization (Broman, Mavaddat & Hsu, 2000; Landrine & Klonoff, 1996). Recent longitudinal research suggests that the frequent experience of perceived racial discrimination can be causally related to psychological distress (Sellers & Shelton, 2003; Soto, Dawson-Andoh, & BeLue, 2011). African Americans experience racial battle fatigue as a result of racial mistreatment. Rival battle fatigue often can lead to symptoms of Generalized Anxiety Disorder. "Smith et al.'s (2007) define racial battle fatigue in African Americans as "the result of constant physiological, psychological, cultural, and emotional coping with racial microaggressions in less-than-ideal and racially hostile or unsupportive environments" (p. 555; Dawson-Andoh, & BeLue, 2011).). Racial microaggressions refer to subtle attacks or invalidations against an individual because of their race or ethnic group membership (Sue et al., 2007; Dawson-Andoh, & BeLue, 2011). Other researchers have posited a similar framework for understanding the result of chronic exposure to racism (Clark et al., 1999; Franklin, 1993; Lantz, House, Mero, & Williams, 2005; Dawson-Andoh, & BeLue, 2011). African Americans who experience racial battle fatigue can experience symptoms of Generalized Anxiety Disorder, Major Depressive Disorder, and Post Traumatic Stress Disorder. Generalized Anxiety Disorder might be uniquely associated with racial battle fatigue and thus with the chronic experience of perceived racial discrimination. Racial battle fatigue connotes a depletion of psychological and physiological resources due to African Americans' coping with chronic discrimination that may set the stage for the subsequent onset of GAD (Dawson-Andoh, & BeLue, 2011). These researchers found that in African Americans and those who may identify as Black, assessing and reviewing symptoms of worry and depletion of resources is essential. According to these researchers, The repeated response of worry and tension to chronic discrimination may strengthen worry as the response of choice to various other stressors. Alternatively, individuals who have experienced chronic discrimination may have little personal resources left to cope with other stressors. First, the notion that the repeated experience of chronic worry may facilitate GAD suggests that examining the frequency of experiencing discrimination (i.e., number of incidents) should be more informative than simply looking at the presence or absence of these experiences. Second, the depletion of resources to deal with anxiety may promote GAD, suggests that we need to consider the accumulation of discrimination over the lifetime as coping abilities can be continually depleted over the lifespan under conditions of chronic stress (Dawson-Andoh, & BeLue, 2011). It is clear that African Americans, and those of the Diaspora, can experience symptoms of anxiety disorders not just due to biology or environment but also due to implicit bias in mental health diagnosis, cultural mistrust, and due to experience of racism. Despite all of the reasons why African Americans experience anxiety symptoms, there is more information on how to treat anxiety in this population. 

Anxiety Treatment

Anxiety treatment should be as complex as the symptoms of each disorder. "The two main treatments for anxiety disorders are psychotherapy and medications. Some clients may benefit most from a combination of the two" (Mayo Clinic, 2018). However, this paper will focus on psychotherapy as a treatment modality. One of the most widely used psychotherapy evidence-based practices to treat Anxiety is Cognitive Behavior Therapy (CBT). "CBT is the most effective form of psychotherapy for anxiety disorders. Generally, a short-term treatment, CBT focuses on teaching clients' specific skills to improve their symptoms and gradually return to the activities they avoided because of anxiety" (Mayo Clinic, 2018). While CBT is used for clients who have symptoms of Anxiety, it is essential to know if this evidenced based practice is effective in treating African Americans with symptoms of Anxiety. "Horrell's (2008) review focused broadly on cognitive-behavioral therapy (CBT) for ethnic minority adults and summarized four RCTs addressing outcomes specifically for African Americans. Those four trials support that CBT is effective for African Americans with depression, PTSD, panic disorder with agorapho­bia, and substance abuse" (Frisby & Donahue, 2018). Some researchers had found that CBT was more effective for African Americans when the clinician was also African American. There have not been enough studies to review the effectiveness of CBT when treating African Americans with anxiety disorder symptoms. It is also unclear if CBT is effective with anxiety disorders due to trauma or racism. "The scant literature on treating African Americans with anxiety disorders has typically shown at least comparable therapeutic benefit (compared to European Americans) from traditional treatment approaches.Nonetheless, much can be done to more fully examine the treatment of Anxiety among African Americans" (Carter, Mitchell, & Sbrocco, 2012, p. 7). We still need to understand the complexity of what effectiveness means with CBT and African Americans. Cater, Sbrocco, Gore, Marin, & Lewis (2003) found CBT effective with African Americans when "an African American therapist used treatment tailored to prompt discussion of cultural issues, and the sample was mid- to upper Socio-Economic Status and well educated."a Other researchers feel that evidenced-based practices can become more effective when culturally adapted. Culturally adapted treatments/interventions (CAT/I) refers to any modification to evidence-based mental health treatments to include a particular population's cultural beliefs, attitudes, and behaviors (Whaley & Davis, 2007). "Mental health interventions targeted to a specific cultural group were four times more effective than interventions provided to culturally diverse groups of clients (Griner & Smith, 2006). Culturally adapted treatment may be more efficacious when adaptations are specific to a particular racial or ethnic group" (Griner & Smith, 2006). Being "people of African descents, thrush any treatment modality which is to benefit African people must have its theoretical underpinnings in an African Perspective" (Harvey, 2018). Some African Americans may require Afrocentric Mental Health practices such as NTU Psychotherapy. 

NTU Psychotherapy

NTU Psychotherapy is African Centented psychotherapy evidence-based practice tailored to African Americans and those of the African Diaspora. "NTU is a root word from the Bantu tribe of Central Africa. NTU Psychotherapy refers to the natural healing force, the force that is oriented toward harmony, balance, and health (Phillips, 1990, pg. 13). "The goals of NTU therapy are to assist people and systems in becoming harmonious, balanced, and authentic within a shared energy and essence that is in alignment with the natural order (Phillips, 1990, pg. 13). Natural order implies that there is a unity of mind, body, and spirit throughout life and that the relationships within and between life are purposeful and orderly and, at the base, spiritual (Phillips, 1990, pg. 13). Natural order infers that our lives and relationships have a purpose and direction; consequently, it is our ongoing task in life to be in tune with the natural order. Furthermore, good mental health springs from being in tune with the natural order, and healing is, therefore, a "natural" process" (Phillips, 1990, pg. 1). "The basic principles of NTU therapy include Harmony, Balance; Interconnectedness; Cultural Awareness; and Authenticity. The role of the NTU therapist is based on a spiritual relationship with the client system since NTU therapy recognizes that the healing process is a natural process in which the therapist assists the client system in rediscovering natural alignment. The five phases of NTU psychotherapy are Harmony, Awareness, Alignment, Actualize, and Synthesis" (Phillips, 1990). When reviewing each of the phases of NTU, it is clear how it can align as a treatment for Anxiety in African Americans. Let us discuss the first phase of NTU Harmony. Harmony is defined as living life and not controlling or fighting life (Phillips, 1990). "From an NTU therapeutic perspective, the overriding focus of life and, indeed, the goal of the mentally healthy person is to be in harmony with the forces of life. When we are in harmony with our mind, body, and spirit, we are experiencing confluence or the act of aligning ourselves from within (immanent) and from without (transcendent) (Asante, 1986). When we are harmonious, we are "at peace" whether or not the external forces surrounding us are fragmented. Being in harmony depends more on our abilities to adapt through a clear process of organizing the disparate parts into a meaningful whole. When we are in harmony, we are NTU" (Phillips, 1990, p. 3). An NTU psychotherapist can assist their client in defining what it means to be in harmony with the force of life and assist the client. In identifying ways to be "at peace." The second phase of NTU is Balance. While Balance and Harmony have some overlapping, there is a distinct difference between the two. Balance is the "life as a dynamic process of energy fields and forces, and therefore our life task is to balance these seemingly competitive forces in a manner that brings about a unified whole" (Capra, 1983; Davies, 1983, Phillips 1990). "All systems continuously utilize energy to achieve balance, whether at a cellular level or at a family level. We must, for instance, continuously balance our material and spiritual selves. Problems or symptoms occur when there are blocks to the fluid exchange of energy that encumber the normal process of healthy balance and dynamic equilibrium" (Phillips, 1990, p. 3). The NTU psychotherapist will assist clients in understanding and identifying what healthy balance and dynamic equilibrium may be in their life. They may also be able to use balance techniques to decrease some symptoms of anxiety. The third phase of NTU psychotherapy is interconnectedness. "NTU psychotherapy is inclusively oriented as the bonding is primary. Thus, the concept of general systems thinking and the later development of family systems' orientations are easily understood within the context of interconnectedness. In addition, the ideas of balanced ecology and being at one with the environment are different expressions of this ancient concept" (Phillips, 1990, p.4). "When the therapist maintains a systems focus, which is a central component of NTU psychotherapy, then he/she/they can view any person or family as both composed of subsystems and a subsystem of a larger organization. All systems share common properties, and the intrinsic desire for system harmony, internally and externally, is a major system characteristic (Davies, 1983; Dossey, 1982). Therefore, the term "client system" used throughout this paper indicates systems thinking in that the NTU principles equally apply to the various systems that are the focal point of our attention at any particular moment. System thinking has been a living truth within Afrocentric thought" (Phillips, 1990, p.4). According to Harvey (2017), "Many African people do not recognize how we participate in our self-destruction through t process of alienation. Alienation is being out of harmony with one's self, community, and environment" (p.16). Interconnectedness will allow the therapist to see how connected the client is to their family, friends, and other social supports. Alienation can exacerbate anxiety symptoms in African Americans, making interconnectedness a critical aspect of treatment. The fourth phase of NTU Psychotherapy is Affective Epistemology. "Epistemology relates to the nature and basis of knowledge, and effective refers to the quality of one's feeling or emotional being. Affective epistemology refers to the process and belief system of a people discovering knowledge and truth, i.e., awareness through feeling or emotion. This feeling orientation to knowledge is highly representative of African people and is recently experiencing a reawakening among many progressive Western thinkers and health professionals (Davies, 1983; Capra, 1983; Myers, 1988; Phillips, 1990). In NTU Psychotherapy, Affective Epistemology is the view that "African people come to awareness and process reality through an integration of both feeling experience, and verbal cognitive interaction. Therefore, NTU psychotherapy is spiritually-intuitive and rationally scientific and aims to help people integrate both aspects of themselves. The feeling experience integrates the knowledge and brings the information into reality. Therapeutically, we can access awareness, belief, and truth through the feeling component of the person and do not rely on just "talking." We are directed to have people become active participants in the therapy process; therefore, NTU therapy is an active, participatory therapy" (Phillips, 1990). When dealing with trauma or racial trauma, it will be necessary for both the client and therapist to understand and utilize Affective Epsitomleolgoy.  The fifth phase of NTU Psychotherapy is Authenticity. "Within the Afrocentric world view, the highest value lies in the interpersonal relationship between human beings. This priority on the value of the relationship places a premium on the person's authenticity. The relationships we build within the larger family/community of people. It is our connectedness with the essence (NTU) of others that brings fulfillment" (Phillips, 1990). "The authenticity of any particular person is colloquially referred to as his or her or their "Realness." As a community, we ask that a person "Be for Real," and this authentic essence becomes the basis for effective and satisfying relationships (Phillips, 1990). Authenticity is going to be very important for the client and therapist dyad. The therapist and client need to exhibit "realness" to build rapport, trust one another in therapeutic exercises, and decrease anxiety symptoms. It is important to note that in NTU Psychotherapy, these five phases are not linear. "These phases of psychotherapy must be considered within the context of circular, not strictly linear, time so that the therapist perceives that all five phases can occur at one time or that the phases can occur "out of sequence." A technique can be utilized in one phase with equivalent meaning for the client in another" (Phillips, 1990). Phillips has now updated NTU Psychotherapy to include Personalism and Bodymind awareness. "NTU psychotherapy and healing are grounded on a traditional African philosophy of Personalism in which the essence of reality is the personhood of persons, objects, situations, and forces. A key construct of the term personalism is that it views life as composed of energy and forces which inhabit physical structures of various materials and configurations. Everything is energy, all energy has a consciousness, and all consciousness has a purpose" (Phillips, 2018, p. 3). "The clinical framework of NTU healing is anchored in four principles of a healthy body mind: Harmony, Balance, Interconnectedness, and Authenticity. These NTU principles are supported in neuroscience" (Phillips, 2018, p 3). This area of neuroscience can be very effective in treating African Americans with anxiety symptoms. "All approaches to healing and psychotherapy have a process or protocol of intervention which is more or less formalized (Philips, 2018, p. 17). The NTU approach to healing is alike in that, while there is a consistent framework of intervention which provides a clinical road map, there also is flexibility which allows for variations of techniques within each phase" (Phillips, 2018, p.18). "The NTU phases of healing and intervention are expansive and allow, even encourage a mix of interventions which are unique and appropriate for the therapist/healer and patient at any one time and in a particular space" (Phillips, 2018, p. 18). This research has provided NTU psychotherapists with NTU Phases of intervention for Harmony, Awareness, Alignment, Actualization, and Synthesis. Philiips (2018) states that the Harmony intervention objective includes "joining or connecting with a client and developing or nurturing a relationship between the therapist and client system. Methods include joining connected through social interaction, empathy, self-disclosure, ritual use, recognition of client energy, and accentuation of the positive. Moreover, the transition will occur in the session when tension subsides." The objectives, methods, and transition listed under the NTU Psycotherpay phase of harmony align with anxiety treatment for African Americans. The Awareness Intervention Phase includes "developing client awareness of physical, mental, emotional, and spiritual self. The client and therapist will also clarify challenges, problems, strengths, and treatment goals" (Phillips, 2018, p. 20). Methods for this phase include "assessment, relabeling, re-framing, visualizations, "I "statements, creative advice and solutions, awareness while, four-stage creative process, and attention to the truth of body" (Phillips, 2018, p. 20). Transitioning to the Awareness Intervention Phase includes self-awareness of unhealthy energy (Phillips, 2018, p. 20). Awareness of unhealthy energy can assist African American clients in identifying their symptoms and severity of anxiety. The Alignment Intervening Phase includes "the restructuring of experience, person, and people so that the healing force (NTU) can flow freely and optimally. During this phase, the client system overcomes fear, resilience, and discrepancies (cognitive, emotional, and behavioral) (Phillips, 2018, p. 21). Methods in this section include peeling the onion (fears), exposure of incongruence of self, four creative stage processes, exploration of worst fears, confrontation of thought process, feelings, behavior, and specialty, clarification of wants and needs, and focusing on energy (Phillips, 2018, p. 21). The transition for this intervention phase is "centeredness, positive, anchor, and reclaiming of internal strength and direction" (Phililps, 2018, p. 21). This entire phase would benefit African American clients with anxiety in understanding their symptoms or fears, processing their thoughts, feelings, and behaviors, and identifying their wants and needs. The Alignment Intervention Phase of NTU includes "The materialization of potential and the utilization of new attitudes and behavior in a client system and solidifies the problem-solving process" (Phillips, 2018, p. 22). The methods of this intervention phase include "practice of new attitudes and behavior, recording new behaviors, home assignments, the establishment of tasks and behavior, and feedback from environment (Phillips, 2018, p. 22). The transition for this intervention phase includes "acknowledgment and awareness of benefits and consequences of action" (Phillips, 2018, p. 22). This phase will allow the client to practice and change attitudes and behaviors related to anxiety symptoms. The Synthesis Intervention Phase of NTU includes "the client has incorporated a problem-solving process that is transferable and transportable" (Phillips, 2018, p. 23). The methods of this phase include asking the client, "What is different? How are you different? Are you clear about your plan and next steps? How do you understand your healing process? Discussion of NTU Principles. (Phillips, 2018, p. 23). The transition for this phase is the "internalization of the self-healing process" (Phillips, 2018, p. 23). This phase will be helpful to African Americans experiencing symptoms of anxiety. This phase is a strong example of the end phase of treatment. It allows the client to identify what went well, what could have improved, and differences in symptoms, behaviors, and emotions, as well as understand the following steps and understand and continue to apply the NTU principles.  It is clear that NTU Psychotherapy can effectively assist African Americans with anxiety symptoms due to exposure to trauma, racial trauma, and implicit bias, in addition to genetic and environmental factors. "NTU psychotherapy and healing is grounded on a traditional African philosophy of Personalism in which the essence of reality is the personhood of persons, objects, situations, and forces. The clinical framework of NTU healing is anchored in four principles of a healthy body-mind: Harmony, Balance, Interconnectedness, and Authenticity. The intervention process of NTU psychotherapy proceeds via the processes of Harmony, Awareness, Alignment, Actualization, and Synthesis. The primary focus of NTU healing is to stimulate the promotion and generation of inner healing energy and spirit" (Phillips, 2018, p. 30). 

Anxiety disorder symptoms in African Americans are very complex; therefore, assessment, diagnosis, and treatment need to address all the nuances of being African American with anxiety symptoms. Clinicians treating Anxiety in African Americans must include knowledge of trauma exposure, racism, and clinician bias implicit bias when diagnosing, assessing, and treating this population. There were several methodological strengths in this literature review. Several of these studies were meta-analyses examining CBT approaches to anxiety without discussing clinicians' racial trauma, discrimination, microaggressions, or unconscious bias. They also used small sample sizes to determine whether CBT was an effective practice for African Americans with symptoms of anxiety. The meta-analyses described the research's current state and suggested future research directions (Carey et al., 2007). Methodological weaknesses included NTU psychotherapy with African Americans with symptoms of anxiety disorders. The significant implication of this literature review is that the findings support the use of culturally adapted treatments/interventions (CAT/I) for diverse clients and African-centered treatments and interventions for African Americans. Therefore, "treatment approaches should focus on an appreciation of the person as an African who has the potential to live in harmony within the natural order of the universe, moving the individual away from individuals to creative communalism and spiritually harmony with the one universal truth" (Harvey, 2017, p. 18). More research utilizing African Centered treatment modalities with African Americans is needed. African Centered Psychotherapy models should be "self-supporting based upon the African concept of cooperative economics, be created by African Americans, administered by African Americans, for African Americans, define African American Mental Health from an African Perspective, view Anti-Black Racism as the most significant cause of mental illness in the African American Community, and have a goal of liberation for African Americans from their neo-colonial position in the United States" (Harvey, 2017). By prioritizing the intersection of race, gender, and mental health, we can strive to dismantle the barriers that have historically impeded black women from receiving adequate support for their anxiety. Ultimately, by centering the experiences and needs of black women, we can lay the groundwork for a more equitable and compassionate approach to mental health care. According to the sources, depression and anxiety are significant mental health issues that disproportionately affect urban, ethnically diverse, impoverished women. According to one study using community-based research and focus groups, Black women, along with Hispanic and White women, identified economic, family, cultural, and neighborhood issues as perceived determinants of their depression and anxiety. Furthermore, they also identified practical, psychosocial, and cultural barriers to seeking help for their mental health issues. One of the barriers identified in the sources is the lack of accessibility to mental health services for minority women, including black women. For example, a study focused on African American women with panic disorder found that they faced individual barriers such as fear of confiding in others about their symptoms, fear of social stigma, and a lack of information about panic disorder. Another barrier identified in the sources is the presence of stigmatizing attitudes towards mental illness within the social networks of African American women. These attitudinal barriers discourage African American women from seeking help and contribute to their experience of social isolation. The mental health needs of black women require a multi-faceted approach that encompasses community involvement, policy changes, and the elevation of black women's voices. By recognizing and actively addressing the intersecting factors that contribute to anxiety within this demographic, we can work towards creating a more equitable and supportive mental health landscape for black women. More research is also needed to establish the efficacy of African Centered and culturally adapted treatments/interventions (CAT/I) when treating African Americans with symptoms of an anxiety disorder. There is no "one size fits all" approach to treating anxiety in African Americans, and mental health clinicians' knowledge of African-centered Psychotherapy practices and culturally adapted treatments/interventions (CAT/I) is essential.