Abstract
Little research has focused on African American women’s sexual assault victimization and mental health seeking. A mixed methods study was conducted to explore African American women’s sexual assault in relationship to mental health seeking and experiences with mental health providers in a large community sample. Quantitative survey and qualitative interview data indicated unique correlates of immediate and longer term seeking of help from various mental health sources. Barriers and facilitators of African American women’s mental health seeking were identified and qualitative themes were uncovered relevant to this group of survivors. Implications for research and clinical practice with this population are provided.
Introduction
Rape prevalence is high in African American women. Recent data from the National Sexual Violence Survey (NISVS) show that 21.2% of African American women have a lifetime experience of sexual violence similar to 20.5% of White women (Breiding et al., 2014). A national telephone survey of community and college women showed that African American women in both samples had experienced twice the rate of lifetime forcible rape than non-Hispanic White and Hispanic women (Kilpatrick et al., 2007). Furthermore, African American women who are low income, HIV-positive, bisexual, or incarcerated are at an increased risk for sexual victimization (West & Johnson, 2013). Together, these studies highlight the high risk for and experience of sexual victimization among African American women.
Experiences of sexual assault (SA) can pose a myriad of physical and mental health consequences, but less is known about the nuances of these experiences by racial or ethnic group. In a nonrepresentative community sample of African American women showing high rates of sexual victimization, those with rape or coercion had much higher rates of posttraumatic stress disorder (PTSD) and depression than nonvictims. More than two-thirds (67%) had PTSD symptoms compared with 32% of nonvictims, and 74% had depression symptoms compared with 34% of nonvictims (Basile et al., 2016). The high prevalence and consequences of SA among African American women underscore the need to examine SA experiences among individual ethnic and racial groups, particularly African American survivors. Yet, this remains rather understudied. The present study uses qualitative and quantitative methods to examine African American SA survivors’ mental health care help-seeking and experiences in the aftermath of SA.
Mental Health Care Seeking
Despite the prevalence of negative mental health effects following SA, victims seek help from mental health sources at relatively low rates soon after the assault (see Ullman, 2007 for a review) and typically do not seek this help specifically for SA. For example, studies of lifetime help-seeking show that two thirds (60%) of women with a lifetime rape history from a representative community sample sought some form of formal assistance (Amstadter et al., 2008), with 54% seeking mental health care; whereas for college female rape victims, 52% ever sought help for emotional problems (Amstadter et al., 2010), mostly mental health care (93%), but this help-seeking was not necessarily connected to experiences of SA.
Various factors relate to SA survivors’ seeking help from mental health sources (Price et al., 2014; Ullman, 2007). Specifically, demographics of older age, nonheterosexual sexual orientation, and more education were each related to greater mental health–related treatment seeking (Amstadter et al., 2008, 2010; Starzynski et al., 2007). Specific assault characteristics may be important, with more violent assaults, stranger assaults, and those where victims perceived life threat (i.e., that they might be killed during the incident) being related to more mental health help-seeking (Starzynski et al., 2007). A national sample of rape victims (38% African American) showed that depressive symptoms, private insurance or Medicaid, alcohol abuse, and prior mental health care all predicted mental health care in the 6 months post assault (Price et al., 2014), indicating that mental health history and socioeconomic status may contribute to help-seeking. Postassault factors may also play a role as PTSD symptoms, tangible aid, telling more informal sources (e.g., family, friends, and romantic partners), and depression were also related to greater mental health help-seeking (Starzynski et al., 2007). Furthermore, other research shows that survivors receiving tangible support (odds ratio [OR] = 1.64) from informal sources had increased odds of seeking mental health treatment (Kirkner et al., 2018).
Research shows racial differences in mental health seeking. Specifically, Sexually Assaulted women seek mental health services less than White women, who are twice as likely to seek such help as minority women (Amstadter et al., 2008; Flicker et al., 2011; Starzynski et al., 2007; Weist et al., 2014). A study of a large sample of Sexually Assaulted women found that being White (OR = 2.04) increased the odds of survivors seeking mental health treatment (Kirkner et al., 2018). Sexually Assaulted survivors were also less likely to seek help from mental health services and rape crisis centers, including SA hotlines, in a regional convenience sample (Weist et al., 2014). The few studies of race differences in specific types of formal help-seeking in SA victims show such differences for Sexually Assaulted women.
African American Women and Help-Seeking
The historical context of slavery, including SA by slave owners, shapes African American women’s experiences of SA in the present through racist sexual stereotypes and institutional racism (White, 1985), which, in addition to other barriers, may further reduce their help-seeking postassault and worsen their help-seeking experiences. Stereotypes about African American women’s sexuality still remain intact today and may serve as a barrier to disclosure and help-seeking (Tillman et al., 2010) as may the “strong black woman” (SBW; Wyatt, 2008) persona. This SBW identity may not only empower African American women to survive but also make it difficult to admit that they need help coping with the trauma of SA (West & Johnson, 2013) and has also been associated with silencing (Tillman et al., 2010). Thus, the racial and gender-based socialization that helps them survive may also make them less able to acknowledge their own needs and more likely to delay help-seeking (Beauboeuf-Lafontant, 2007).
Cultural barriers to African American women’s help-seeking includes the norm of keeping one’s personal business “off the streets” and the SBW persona (Neville & Pugh, 1997; Washington, 2001). Some African American women show concern that their minority status would bring them greater stigma and unfair treatment by service providers, as well as concerns about protecting Black assailants and men more generally (Munroe, 2015; Washington, 2001; Williams, 2013). Some argue that lack of sexuality socialization in the African American community is a barrier to help-seeking as many women do not define the experience as rape or know the definitions of rape (Washington, 2001; Williams, 2013). Washington’s (2001) interviews showed that lack of and/or inadequate information about sex and sexuality based on stereotypes or rape myths were common among African American sexual abuse survivors and argued that cultural norms of loyalty to keep one’s business in the community combined with the myth of the SBW discouraged disclosure. All this may lead to greater help-seeking from informal supports than from formal sources among African American women survivors (Anyikwa, 2015).
Studies have identified several barriers to formal help-seeking in the African American community. Personal barriers include the survivor’s emotional states (e.g., shame, embarrassment, humiliation, guilt, and self-blame), fear of external exposure (e.g., not being believed, lack of confidentiality, and fear of the assailant), and lack of knowledge (e.g., not knowing what services were needed, where to get services, and how to pay for services; Krebs et al., 2011; Munroe, 2015; Weist et al., 2014; Williams, 2013). Research also cites environmental barriers to help-seeking, such as structural/organizational barriers (e.g., lack of availability, limited services, and White-dominated helping professions) and societal myths (e.g., perceptions of social stigma and belief that the assault was not serious enough to warrant services; Krebs et al., 2011; Munroe, 2015). A convenience sample showed that African American survivors had the lowest income and employment rates, but more past traumas than other ethnic groups, and yet engaged in the least free mental health services offered as part of the study (Alvidrez et al., 2011). Overall, these findings suggest societal or cultural barriers to help-seeking.
Women who are unable to receive mental health care may turn to religion to cope. Religiosity is frequently reported by African American women (Jang & Johnson, 2005), particularly among those with PTSD (Bryant-Davis et al., 2015) and has been linked to less illicit drug use and recovery from drug use following SA (Long & Ullman, 2016). However, it is unclear whether religious coping leads to better outcomes with or without traditional mental health help. Survivors with more social support have fewer symptoms of PTSD and depression (Bryant-Davis et al., 2015), which may also lead to lower mental health seeking. Yet, depression is common among African American survivors, especially in the weeks after assault (Rickert et al., 2000). Kubiak and Siefert (2008) found African American women with trauma exposure, PTSD, alcohol dependence, and a health condition preventing working had more depression.
Only a few studies examine help-seeking in African American only victim samples (Bryant-Davis et al., 2015; Long & Ullman, 2013; Tillman et al., 2010; West & Johnson, 2013), whereas most research to date compares the experiences of women from different ethnic groups (Amstadter et al., 2008; Starzynski et al., 2007; Weist et al., 2014; Zinzow et al., 2010) or statistically controls for race in multivariate analyses (Amstadter et al., 2008, 2010). Yet, it is clear from the limited extant knowledge that African American women seek help differently than women of other racial or ethnic groups, and largely reveals little use of formal services and significant barriers to them. Thus, little work has been done regarding the correlates of mental health care seeking specifically among African American survivors, leaving much to be learned in terms of the assault, demographic, and disclosure characteristics associated with their mental health care seeking. This research is needed as African American women may be in greater need of mental health care due to both victimization and the cumulative stress of race, class, and gender oppression (West & Johnson, 2013) that serve as both a need and a barrier to mental health care. This study aims to fill this gap by exploring African American survivors’ mental health seeking experiences in a community sample.
Current study rationale and hypotheses
African American SA survivors face significant barriers to formal help-seeking and, consequently, are unlikely to receive needed mental health support services. While extant research exposes this gap in postassault help-seeking among African American survivors, research is quite limited regarding help-seeking in solely African American samples. Much of the research thus far includes a subsample of African American survivors, compares the experiences of survivors from different ethnic groups, or statistically controls for race in multivariate analyses, leaving a lack of understanding of what assault and demographic characteristics are associated with mental health care seeking among African American survivors. In addition, these studies are largely quantitative in nature, highlighting a need for qualitative studies to explore help-seeking experiences in greater depth to give voice to this historically marginalized community of survivors. Given the gaps in knowledge on mental health care seeking of African American SA survivors, we explored mental health seeking practices in a mixed methods sample of African American SA survivors. The following sections present mixed qualitative/quantitative method, sample, and results from the same sample of African American SA survivors.
The present study included several hypotheses to be quantitatively tested. First, participants with specific demographic characteristics, including women of older age, with more education and income, and who identify as nonheterosexual are expected to engage in more mental health help-seeking. Second, history of more traumatic events, child sexual abuse (CSA), more violent SA, greater perceived life threat, stranger assailants, no preassault drinking, and earlier disclosure will be related to more mental health seeking. Third, greater PTSD and depressive symptoms, positive coping, telling informal sources, negative and mixed reactions, and tangible support will be related to mental health care seeking. The qualitative portion of this study uses interview data to explore African American survivors’ barriers and experiences of mental health care seeking following SA.
Method
Study Procedure
The present study used quantitative survey data and qualitative interview data to understand variables associated with African American survivors’ mental health care help-seeking and their experiences of seeking help. Mail survey data were collected over 1 year from a sample of African American women volunteers recruited from the community through advertisements (both online and print) and/or referrals from other participants. Fliers advertising the study were posted at community agencies serving women and survivors of violence, at local colleges and universities, and businesses catering to women (e.g., women’s bookstores and nail and hair salons). Women were screened for eligibility by phone using the following criteria: (a) they had an unwanted sexual experience at the age of 14 or older, (b) were aged 18 years or older at the time of participation, and (c) had told someone previously about their unwanted sexual experience. Even if they were not eligible to participate, women were sent a list of community resources. Eligible women who were interested were sent packets with the survey, an informed consent document, a list of community resources, and a stamped return envelope for the completed mail survey. Women were sent US$25 for completing surveys and an additional US$25 for interviews. The study response rate was 85%. The study was approved by the University of Illinois at Chicago’s Institutional Review Board. Participants completing the mail survey were then asked whether they would like to participate in a follow-up qualitative interview about their disclosure, help-seeking, and social support experiences. As such, we had a subsample of survey participants who also completed an in-person interview. Both data sources are used in the present study to triangulate African American survivors’ mental health help-seeking experiences.
Quantitative Sample
Participants were a volunteer sample of 836 African American women from the Chicago metropolitan area who had an unwanted sexual experience at the age of 14 or older. Women ranged in age from 18 to 71 at the time of the survey (M = 31.1, SD = 12.2). The sample was well educated (44.5% some college, 21.7% college graduate or beyond, and 19.9% high school or General Educational Development [GED], and 13.6% less than 12th grade). Almost one quarter of women were currently in school (23.4%). More than one-third of women were employed at the time of the study (33.6%). Few African American women were of Hispanic ethnicity (4.8%). Income was low with more than half making less than US$10,000 per year (52.7%); 17.5%, US$10,000–20,000; 11.6%, US$20,000–30,000; 7.5%, US$30,000–40,000; 4.9%. US$40,000–50,000; and 5.8%, over US$50,000. Sexual orientation was identified by women as only heterosexual for most (68%), mostly heterosexual (13.7%), bisexual (9.4%), other (3.5%), and mostly lesbian (.7%). More than two-thirds had children (70.8%) and more than half were single (56%).
Qualitative Sample
Survivors were entirely African American women, with six reporting also being of Hispanic or Latina ethnicity (19%). The average age of survivors was 44 (SD = 11.27, range = 21–59 years). Approximately 66% of participants (n = 21) reported having children. More than half had attended some college (n = 17, 53%), whereas five (16%) participants had graduated high school and four (12%) had graduated college or beyond. Five participants (16%) had less than a high school education. Seven (23%) were in school and seven (23%) were employed at the time of the study. Just under half had an income of US$10,000 or less (n = 14, 44%), followed by incomes of US$10,001–US$20,000 (n = 9, 28%), US$20,001–US$30,000 (n = 3, 9%), and over US$40,000 (n = 3, 9%). Three participants did not report their income. Compared with the quantitative sample of African American survivors, the interview sample was similar in terms of income, education, and having children, though slightly older in age. Almost all (n = 29, 91%) survivors experienced completed rape and three (9%) experienced sexual coercion. Half of assaults were perpetrated by strangers (n = 16, 50%), followed by nonromantic acquaintances (n = 8, 25%), casual or first dates (n = 3, 9%), romantic acquaintances (n = 2, 6%), a relative (n = 2, 6%), and a spouse (n = 1, 3%). Half of survivors (n = 16) were under the influence of drugs, alcohol, or both at the time of the assault. Thirteen survivors indicated having a CSA experience (n = 41%). Most survivors suffered with PTSD (n = 23, 72%). Survivors in the interview subsample had more completed rapes and assaults perpetrated by strangers compared with the survey sample.
Quantitative Measures
SA
Specific forms of sexual victimization in both childhood (prior to the age of 14 years) and adulthood (at the age of 14 years or older) were assessed using a revised version of the Sexual Experiences Survey (Testa et al., 2004) to compute highest SA severity in both life phases. Most women had a completed rape (80%), and 78.7% of women had a history of CSA.
Assault characteristics included relationship to the perpetrator (stranger, acquaintance/date, romantic partner/husband, other relative, or multiple perpetrator types), perceived life threat (feared life was in danger during assault), physical injuries (minor cuts, scratches, bruises, cuts, knife or gunshot wounds), and preassault drinking of alcohol (no/yes).
Coping strategies were assessed with the Brief COPE, a 28-item self-report scale of coping strategies (Carver, 1997) assessing strategies used in the past 12 months to cope with the assault with maladaptive coping (behavioral disengagement, denial, self-blame, and substance use; M = 16.35, SD = 5.78, α = .81) and positive coping, including individual (M = 29.19, SD = 7.81, α = .83) and social or interpersonal (M = 9.07, SD = 3.72, α = .87) coping.
Social reactions to assault disclosures were assessed with the Social Reactions Questionnaire (SRQ; Ullman, 2000), reporting how often they received 48 different social reactions from any support provider (SP) they told since the assault. Responses were averaged to create subscales assessing the frequency with which participants received positive reactions to assault disclosure (e.g., emotional support, aid, or information) and negative reactions (e.g., blaming or stigma). On average, women reported “rarely” receiving negative reactions (M = .96, SD = .80) and “sometimes” receiving positive reactions (M = 2.22, SD = .95). Mixed reactions (M = 1.25) and negative turning against reactions (M = .78) were both infrequent.
Psychological symptoms
PTSD symptoms were assessed with the Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995), a standardized 17-item instrument based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) criteria on which women rated how often each symptom (i.e., re-experiencing/intrusion, avoidance/numbing, or hyperarousal) bothered them in relation to the assault in the past 12 months. The 17 items were summed to assess extent of posttraumatic symptomatology (M = 20.75, SD = 12.76, α = .93 in this sample). Depressive symptoms were measured using a 7-item version of the Center of Epidemiologic Studies Depression Scale (CES-D-7) modified by Mirowsky and Ross (1990). Reliability (α = .86) was satisfactory and items were averaged (M = 2.01, SD = .75).
Traumatic life events
Traumatic event history was measured with the Stressful Life Events Screening Questionnaire (SLESQ-Revised; Green et al., 2006) to assess interpersonal trauma (e.g., stalking, child abuse, abuse by a romantic partner, abuse by someone else, or emotional abuse) and contextual trauma (e.g., military war zones, dangerous neighborhood, being threatened with a weapon, been in other frightening situations, force used against you in robbery, close friends died from homicide, or witnessed death). Descriptives included contextual traumas, M = 2.36, SD = 1.55, and interpersonal traumas, M = 2.98, SD = 1.50.
Qualitative Measures and Analysis
The interview protocol for survivors focused on disclosure of the unwanted sexual experience, social support provided/received, and appraisals of their relationships. Each social reaction in the interview was coded as positive, negative, or mixed in accordance with the social reactions literature and coded for the survivor’s appraisal of the reaction. In this study, we focused on one aspect of the interviews: formal support interactions with mental health professionals where mental health was defined as “Survivor’s interactions with mental health professionals post-assault.” This definition included the survivor’s disclosure of SA to formal sources providing mental health treatment (e.g., psychiatrists and therapists), social reactions and support received from them, and any treatment for drug/alcohol use, including rehab.
Interview transcripts were summarized to identify patterns and themes that were discussed among the research team in a process similar to that of thematic analysis (Braun & Clarke, 2006). Coding and analysis took place in Atlas.ti Version 7 qualitative analysis software. We identified codes that made the most analytic sense of the data (termed “focused” coding; Charmaz, 2006) and used them to code segments of the transcripts. Specifically, we selected codes that best represented what was happening in the text. We coded the data separately and compared our interpretations on an ongoing basis to achieve consensus (Eisikovits & Koren, 2010). Analysis took place using an iterative process in several stages after completion of coding. Individual survivor narratives regarding the themes and their surrounding context were examined. First, queries were conducted in Atlas.ti software to identify the number of times each interviewee endorsed a specific code related to SA disclosure, social reactions, and mental health help-seeking). Second, as in thematic analysis, research team members individually reviewed the quotes for each query in search of patterns and noteworthy findings (Braun & Clarke, 2006). Third, the team met several times to review identified themes and patterns and, in the final stage of thematic analysis, we named and described identified themes discussed in the following section.
Results
The following section provides the quantitative and qualitative results of African American survivors’ postassault mental health care seeking experiences. We first provide quantitative findings, including descriptive statistics and multivariate regression analyses from the quantitative sample. Following the quantitative results, we present the qualitative findings of survivors’ mental health care seeking experiences from the subsample of survivors who completed an interview after survey participation.
Descriptive Statistics and Contributing Factors to Mental Health Help-Seeking
Descriptive characteristics of assault, postassault experiences, and disclosure
Most assaults were by known perpetrators (77%) including acquaintances/dates (35.3%), romantic partners/husbands (17.6%), other relatives (13.5%), and multiple perpetrator types (1.9%), whereas 22.7% were by strangers. Highest severity of SA as assessed by the Sexual Experiences Survey showed that .5% reported none of the items (but had some other type of unwanted sexual experience); 3.3%, unwanted sexual contact; 8.0%, sexual coercion; 7.8%, attempted rape; and 80.4%, completed rape. Most women reported having a CSA (78.7%) history in addition to the adult SA. Most (70.3%) reported perceiving their life was in danger at the time of the assault. Women reported minor physical injuries (soreness 66.7%, bruises 46.5%, or cuts 12.1%) and few severe injuries (e.g., broken bones 2.3% or gunshot wounds 3.3%). Less than one-fifth of victims were drinking prior to the assault (19.1%).
In terms of the SA, most women delayed disclosing assault for anywhere from months to years after it occurred (53.7%), whereas 46.3% disclosed any time from immediately postassault up through weeks after the incident. Virtually all women (96.2%) told an informal support source (family, friend, or romantic partner/spouse). Women reported a moderate level of positive/adaptive coping. Women reported a relatively low level of tangible support reactions, as well as low negative social reactions of turning against the survivor (e.g., victim blame) and low levels of mixed (positive and negative) reactions. Women reported a low level of depressive symptoms and a moderate level of PTSD symptoms related to the assault. In terms of help-seeking, more women sought mental health care postassault (29.1%) at low rates. In response to our question, “Did you receive counseling or therapy for help with the feelings you had after this experience?” we found that again, few women sought mental health care after the assault (61.3% did not) and for the 29.1% who did, 9.6% planned to do so in the future but still had not done so; 8.5% sought counseling right after the assault; 6.2% did so within 1 year postassault; and 14.4% sought counseling over 1 year postassault. As expected, a higher percentage of women reported that they had ever told a mental health professional about the assault (36.7%) than those disclosing soon after assault.
Regression analyses
Analyses were conducted to examine whether demographics, assault characteristics and trauma history, and postassault psychosocial factors are related to mental health care seeking. Separate initial logistic regressions were run with three variable sets based on past theoretical and empirical research: (a) demographics, (b) assault/trauma history, and (c) postassault factors with significant predictors from each set then entered into final combined block-wise logistic regressions, predicting postassault counseling and ever told a mental health professional about the assault (Table 1).
Logistic Regressions Predicting Seeking Counseling Postassault and Ever Telling Mental Health Professionals.
Note. Block columns include significant predictors from each of three variable domains (demographic, assault, and postassault) significant in initial models and final columns show significance of all variables entered in final composite models. UA = unsupportive acknowledgment.
p < .10. *p < .05. **p < .01. ***p < .005.
These analyses show that certain factors are related to likelihood of seeking mental health care by African American SA survivors. In terms of demographics, we hypothesized that older age, higher income, higher education, White race, and heterosexuality would be associated with mental health care seeking. We found partial support for these hypotheses: older age was associated with more mental health care seeking. Hispanic ethnicity was related to more ever seeking mental health care for SA. Other demographics (e.g., education, income, and sexuality) were not.
Our second hypothesis concerned assault characteristics and mental health care seeking. We hypothesized that a history of traumatic events, a more violent SA, greater perceived life threat, a stranger assailant, no preassault drinking, and earlier disclosure would be related to mental health care seeking. We found that interpersonal traumas, but not CSA history, were related to mental health care seeking for SA both immediately following the assault and at any point, in support of Hypothesis 2. Violence and perceived life threat were not predictive of mental health care seeking. Survivors who drank prior to the assault were less likely to seek mental health care. Victims of assaults by strangers, not only known perpetrators, were more likely to seek mental health care both immediately postassault and ever.
Third, we hypothesized that PTSD and depressive symptoms, positive coping, informal disclosure, negative and mixed social reactions, and tangible support received would be associated with seeking mental health care. Social reactions predicted mental health care seeking in support of Hypothesis 3. Negative social reactions were related to more mental health care seeking ever but not immediately. Mixed social reactions (i.e., acknowledgment without support—distraction, egocentric, and some control) were related to less immediate mental health seeking. Greater tangible support/aid reactions from others told about SA were related to greater odds of seeking mental health care immediately and ever in life, in support of our hypothesis.
Survivors’ Perspectives on Mental Health Help-Seeking and Professionals
The following section provides qualitative results regarding survivors’ perspectives on mental health and physical health help-seeking in the aftermath of SA. Themes discovered during qualitative analysis are discussed, including evidentiary quotes. Eighteen survivors spoke about interactions with mental health professionals, mental health treatment, and/or psychiatric service systems.
Pathways to survivors’ mental health help-seeking
Survivors discussed what led them to seek help from mental health resources or prevented them from doing so. The pathways to help-seeking for these survivors followed three general patterns: cultural barriers, mistrust of mental health professionals, and stigma of needing mental health care.
Two survivors spoke about cultural barriers to utilizing mental health services. The first survivor spoke of a deeply rooted mistrust of mental health professionals, which unfortunately affected her experience seeking help postassault. This survivor had access to a therapist at an army base but did not perceive mental health professionals to be trustworthy and was subsequently reluctant to disclose to her therapist: I went to the therapist at the army, at the base, but only for like, didn’t want to talk to her either, not talked about it and after a few months. I didn’t trust.
This survivor also spoke about why she did not tell anyone, including her mother, in the past, noting that in the old days one could not talk about SA, therapy was not an option, and the church blamed women for SA: Back in the early 60s and 70s, therapy and letting stuff out was not an option. For some in society it wasn’t a big option, and then you had the church saying, oh you shouldn’t do this and that, you put yourself in that position.
This articulates the silencing influence of society and religion on nondisclosure of SA, which both clearly contribute to lack of help-seeking from informal and formal sources. The second survivor spoke about cultural barriers and how views of mental health services seeking have changed in the African American community, specifically alluding to the fact that therapy was not an option, but that seeking help at church could lead to victim blame.
As the survivor’s quote below indicates, it is now socially acceptable to go to a psychiatrist, as the old barrier of stigma regarding acknowledgment and seeking of mental health services has declined in the African American community: I was raised as African American back in those times it’s like we were almost raised to believe that getting psychiatric help was like a sign of weakness. We was just kind raised like you do what you have to do to survive. But times has changed so drastically. Going to see a psychiatrist is the norm it’s okay to do. But it was not 20 okay year ago. They think you crazy, but in my community, it was a sign of weakness. You know you don’t go see a psychiatrist you go to church, but it’s so much going on right now I could easily say I am going to see a psychiatrist tomorrow and people accept that it’s ok.
This survivor went on to receive counseling services and attend Alcoholics Anonymous, both of which she described as helpful.
The stigma of seeking mental health services may be abating in the African American community, but women may still be hesitant to seek services, despite encouragement from others. On the contrary, survivors may disclose to informal SPs to receive help in accessing mental health services. In one case, the survivor told her mother who took her to the hospital because she was suicidal after being attacked by her boyfriend’s friends: I eventually ended up telling my mother a couple months after, as by that time I was having a lot of mental issues and she ended up taking me to the hospital where they admitted me because I actually was trying to kill myself.
Another survivor not only spoke of the influence of family members on seeking counseling but also being labeled in negative ways regarding the impact of SA. This survivor had experienced multiple child and adult SA experiences, and had disclosed to her mother shortly after her first SA, which was perpetrated by a friend of her mother. She spoke about her mother labeling her “crazy” and taking her to counseling sessions. This survivor explained that even though she was in and out of counseling throughout her life, she never felt comfortable telling her counselor about her unwanted sexual experiences. As she explained, “I just couldn’t find myself to tell them what was actually going on with me.” This survivor’s mother also took her to the police, but she explained that she was faced with “five white men,” was scared, and ran away. It appears that despite her mother’s efforts to get her into formal services, this survivor was never comfortable disclosing to professionals.
In addition to SA, other stressful life experiences or health issues may prompt survivors to seek services. For example, mental health resources were available in hospitals for one survivor who was living in a crack house and had decided to get sober: (Hospital name) has housing for mentally ill people that don’t want to go back to where they were living. I was living in a crack house so I was not going back there and decided to turn my life around and get clean.
Similarly, one survivor had mental illness and saw a counselor. She came from a family with a history of schizophrenia, where the panic caused her family members to drink to cope with the symptoms. This fear of having schizophrenia sparked by the trauma and subsequent panic attacks following her assault led the survivor to seek counseling: I’m going to go see a psych doctor because I have a lot of panic attacks now. And I’m scared and my brother had schizophrenia and my father, I believe he had it. I don’t know if it passes on to females, I don’t think so. I don’t hear voices. I’m not paranoid, it’s just panic attacks. Now I realize why my father and my brother and my aunt drank.
As the survivor explained, after experiencing the panic attacks associated with her posttraumatic stress, she now understands her brother and aunt’s drinking to cope with the mental health issues.
One survivor explained that she was using angel dust (phencyclidine [PCP]) to self-medicate following her assault and had a mental breakdown. As she described, she simply remembers waking up in a mental hospital where she stayed for a week: I’ve been institutionalized cause I guess I just couldn’t take it no more. . . . And I had a nervous breakdown, I was going down the street screaming. I thought maybe it was the drugs, a bad reaction because I was on PCP. I guess I got tired of using drugs to medicate how I was feeling. So, I just ran down the street screaming. I woke up and I was in the mental hospital strapped down to the bed. And I stayed there about a week. But I guess it made me wanna come back, just cuz I know I had kids.
This survivor explained in her interview that she had multiple unwanted sexual experiences throughout her life, beginning with molestation by her uncle at the age of 4 years. She disclosed to her mother who instructed her to “stop trying to get attention” and was told “not to bring white people into our business.” From a young age, this survivor was discouraged from seeking formal help, particularly from White professionals, which may have been a factor leading her to cope via substance use. Her path led her to receiving mental health services.
Survivors’ experiences with mental health professionals
Survivors reported various positive mental health experiences. In some cases, experiences with receiving mental health services were long after the assault yet still very helpful to them. Survivors often reported both positive and negative experiences with mental health professionals, as they often had contact with more than one at different points of time in their lives. The following section provides examples of survivors’ responses from mental health professionals.
The survivor in the quotes below had mixed experiences in telling mental health professionals about her assault experience over time. She was a middle-aged African American Latina survivor with a history of multiple SAs by a prior husband and acquaintances as a teenager. She had a past drug problem for many years and a history of prostitution, during which she also was assaulted by various men and once by police.
Her first two mental health disclosures were at the age of 18 years and to her current therapist of 10 years and were very positive initially. An experience with a male therapist was quite negative, as he told her that she had to disclose her experience to someone else and she did not want to do so: The therapist was very understanding, always acknowledges my loss or pain. I: And you told her later also after these experiences usually. S: Oh yea I didn’t do it till later. That experience, that specific first experience I was 18, I’m 54 now. I go to therapy, I’ve been dealing with my therapist for like 10 years. She can’t get rid of me. She’s trying to (laughs). But she’s played an intricate part in me getting myself together. I thank the lord for (name), I really do.
Another survivor, a middle-aged African American woman had a history of multiple SAs by different perpetrators in her life. She disclosed SA with depression to medical sources in the context of thinking of doing a research study. This survivor went on to explain that she was put on antidepressants by her psychiatrist who then referred her to a psychologist: She rendered me as being depressed. And they put me on Z (type of anti-depressant), but I didn’t really see Z really doing anything for me, because like I told the primary care physician, I, she sent me to see a psychologist.
The survivor then encountered a barrier that she could not pay a bill she thought the hospital was covering for her as she had no income or employment at the time. She then had to stop seeing the psychologist as this financial barrier precluded her ability to continue treatment: I saw her for 4 months and I thought the hospital was taking care of that and then they started sending me a bill that I couldn’t pay it at that time cuz I didn’t have no money coming in. The only money I had comin in was my last unemployment and I moved in here and I didn’t have to pay no rent, because I didn’t have any income, so that helped me a great deal. But I couldn’t pay them, so I had to stop going to see her . . . I felt good talking to her. I saw her twice a week and it was very, very, helpful.
She clarified she would have kept going to her therapist as it was very helpful and was going because of her doctor’s advice, and that she was making progress. However, she could not continue and finish therapy because of unpaid medical bills, which led to her being pursued more aggressively by bill collectors. This is a problematic barrier that many survivors likely face who have serious psychological effects of complex trauma histories requiring professional help.
One survivor talked about both professional psychiatric help and a self-help program, Alcoholics Anonymous (AA), both of which helped her: I am glad I came into Alcoholics Anonymous because I got a chance to get it up outta me. I have well my therapist we’re through, but I have a psychiatrist.
She specifically pointed to positive social reactions from her psychiatrist who told her it wasn’t her fault, which was the first time anyone told her that and she was in middle age: I remember are he told me it was not my fault, he [the offender] didn’t have the right. That was the first time in 54 years I had heard it wasn’t my fault.
Another woman had been in therapy since the age of 10 years and learned that letting men violate her was not normal, a common belief for women sexually abused in childhood: I thought it was normal to let a guy have sex with you, that’s just what you do for them to like you but then I realized after five years. I got that sober—now I’m five and a half years sober, I’m addressing these things because it wasn’t until I got a therapist that she just dug in deep, so I didn’t know that my sexual dilemmas was not normal.
She couldn’t deal with it until she got sober, when her therapist helped her learn to protect herself and set healthy boundaries: My therapist gave me three huge books I read on being sexually abused. I didn’t want to think it’s my duty so she would ask me to refrain from being with men and assuming it has to be sexual. If it’s going to be sexual, tell myself it is only sex. My therapist said I have to protect the little girl, cause nobody protected her.
This survivor’s story shows how being violated when young may be something that limits women’s ability to later set boundaries in relationships, including appropriate sexual boundaries with men. She also talked about being in counseling currently but says that it’s not working and doesn’t help to look at her past regarding her father [who abused her in childhood] or knowing past causes of her current problems. She is tired of talking about it, so she lashed out at her therapist, but then also mentioned needing to deal with her feelings and supposes it helps to talk about it: I got pissed with her and I’m like look [to the therapist], “I’m tired of talking about this shit,” you know, because they make you go all the way back to your father and I’m like “he fucking abandoned me, okay? So what? Am I supposed to live my life from that perspective?” . . . I had to acknowledge, because you just have to deal with this kind of shit or whatever and I’m like let’s deal with it, so I’m dealing with it, and I was like “I can’t believe you chose this as a career.” And she seems very therapist, very stoic like nothing could ever bother her. I guess it’s good for me to talk about this shit . . .
This survivor also talked about resisting medication as it harmed her by bringing up things that upset her. She also spoke about not blaming other people and her therapist saying she took too much responsibility, though these are not necessarily the only two choices—blaming oneself or blaming others. The survivor talks about taking responsibility for her own actions, which is typically regarded as a healthy coping strategy if it doesn’t involve blaming oneself: I don’t like blaming other people for shit but . . . my therapist was like you really tend to be over responsible for shit, over accountable for shit, but that’s just how I see it and that’s just how I’m made so it’s hard for me to blame other people for whatever action that I took in whatever situation so I had to kind of come to peace with that.
Overall, the survivor acknowledged needing therapy for depression but being frustrated at being labeled bipolar, which she insists she is not. She is angry at the stigma of being labeled and emphasizes that she is not “just these experiences”: Now it took a lot of faith, took a lot of spiritual practice, took a lot of therapy, took a lot of work, for real, work to be able to communicate this shit.
Another survivor had both multiple SAs where friends took advantage of her sexually and she became pregnant twice. These were experiences which, in combination with a persisting mental illness, led to drinking binges, financial stress, and time in a mental institution. One survivor was receiving mental health services after attempting suicide. After being admitted to the hospital, she had a negative mental health experience as her therapist blamed her by asking what she was wearing before the assault: Even if it’s not like a lot that I had a therapist, I was talking to them, and they were asking, “well, what were you wearing” and I just like look, it doesn’t matter, I coulda been wearing a spacesuit. You know that doesn’t really help to justify the situation.
The survivor also had her trust violated by the doctor who told her mother “her business,” thereby undermining her control over her experience: I was mad that the doctor told her cuz that’s like my business. Why you telling her [survivor’s mother] my business, but I mean I knew I would eventually have to tell her, but I didn’t want the doctor telling her. I’m glad the doctor told her, but it was just like, dude, that’s my business! Certain stuff I told the doctor, but I wasn’t telling the doctor anything that should have gotten back to my mom basically.
The survivor did understand why the doctor told her mother because she needed to know about the assault. The survivor was crying and couldn’t tell her, but eventually did. It was very hard to tell her mother because she felt she disappointed her.
In a common pattern, a survivor saw a psychiatrist who wanted to put her on medications: Just totally try to block it out, because, when I was going to my psychiatrist, she wanted to give me medicine. I didn’t believe I need no medicine for it to stop feeling that it was my fault. I just had to stop believing that it was my fault.
Some survivors also expressed preferences in the demographic characteristics of their mental health professionals. This is known to be a facilitating factor that can be important to survivors’ comfort with a therapist. One survivor mentioned that the demographics of the therapist were key to her being comfortable with him, so it would not be similar to the perpetrator: One day I pretended that to my therapist and he said lets work at one thing at a time, let’s go back, and he’s a young man, 24, light skinned, at first I told him you know, “I’m glad you young,” I said, “because if you was older man I wouldn’t talk with you,” but he made me very comfortable and we did, we went back as far as I could remember. I didn’t have to apologize to my uncle, godfather. I just wrote down how they made me felt.
Another survivor discussed her preference for seeing a female mental health professional: They try to change my mental health therapist to a man and I’m telling them no, I don’t want a man as my mental health therapist. I have to share too much. I told them I don’t like men! “We need to work on that, we need to talk to somebody about that.” I don’t care who you talk to, I don’t want no man doctor. No.
Similarly, another survivor thought she would be questioned for not wanting a male therapist because she is a lesbian: So [the therapist] think I’m probably crazy or something. I ain’t crazy, haven’t shared anything with them. They know I’m a lesbian so they kind of figured. I’m a lesbian, I don’t like men. They haven’t came to it, but the question going to come pretty soon. What’s wrong, you don’t like having men for your counselor?
Despite seeing a therapist, this survivor told the interviewer that she has not told her about the rape or explained that she does not like men only because she was raped multiple times by them. She has trouble talking about her SAs that is complicated by their knowing that she is a lesbian and doesn’t like men, which reflects double stigma of SA and sexual orientation disclosure: They feel like maybe she [survivor] don’t like men because she’s a lesbian. I’m pretty sure they’re going to put it together. Because they’re therapists and know when a lady don’t like a man, you can tell the lady is a lesbian so she likes ladies. She don’t like men. My mental health therapist, I haven’t even told her about the incident. The things that’s been going on right now in my life, it’s all I’ve been talking to her about. I don’t talk about why I don’t like men. I never talk to her about men raping me because it did happen more than once.
Discussion
The present study used quantitative and qualitative methods to examine mental health care seeking among African American SA survivors. Quantitative analyses show that some demographics, preassault characteristics, other traumas and assault characteristics, disclosure timing, and social reactions of tangible aid are associated with immediate and ever seeking of mental health care. Most women had incomes under US$20,000 per year and fewer than half had health insurance at the time of the survey (49%), but that variable was not statistically significant in preliminary analyses and does not necessarily reflect insurance status at the time of the assault or, therefore, its impact on postassault help-seeking. Future research is needed on correlates of help-seeking for women with and without insurance at the time of the assault, especially as past research on victims generally shows that lack of insurance can also affect the quality of care, not just access to care, leading to revictimizing experiences (Starzynski et al., 2017).
Hispanic ethnicity was related to ever seeking mental health care, a finding that should be replicated and may be a proxy for other factors, but a finding supporting our contention that looking within racial/ethnic groups is important for understanding formal help-seeking. The finding that victims who drank prior to assault sought less mental health care is concerning, given that drinking is associated with greater self-blame in SA victims (Lorenz & Ullman, 2016), which is associated with greater PTSD and depression in rape victims (Branscombe et al., 2003; Koss et al., 2002; Mokma et al., 2016). Stranger assault was associated with greater mental health care seeking both immediately and ever, which is not surprising given the greater legitimation of stranger rape in society and increased likelihood of women labeling it as rape. Greater tangible support/aid reactions from those told about the assault were related to seeking greater mental health care and may reflect receipt of help from such sources, which is common, and/or that social reactions were assessed from all possible informal and formal sources. Mixed social reactions were related to less immediate mental health care seeking, which may reflect distinct sets of support sources women told postassault, yielding combinations of social reactions that gave them needed support precluding them from seeking mental health care. Turning against social reactions were related to more mental health care seeking ever but not immediately postassault, which may reflect survivors receiving harmful reactions when telling those around them and then later needing mental health help for self-blame and psychological symptoms that persisted postassault. These findings regarding social reactions are limited by not being separated by support source, which is needed in future work, but critically important in light of other data showing that the impact of negative social reactions on PTSD symptoms may be greater for African American survivors than for White survivors (Hakimi et al., 2018).
Qualitative data revealed barriers to mental health care. Some survivors had barriers to mental health treatment related to money. Unpaid medical bills caused one survivor to be unable to finish therapy that was helping her. For others, therapy interrupted due to unpaid medical bills was a problem, suggesting that the medical system can interfere with building ongoing therapeutic relationships crucial to survivors’ recovery. This lack of continuity and insurance barriers, also found in past research (Starzynski et al., 2017), are likely to be similar for those seeking therapy via insurance. This is a problematic barrier that likely many survivors face who have serious psychological effects of complex trauma histories requiring professional help. Munroe (2015) discussed financial barriers as common in the African American community and Starzynski et al. (2017) found that both low income and lack of insurance contributed to SA survivors’ negative mental health seeking experiences. As such, financial barriers may not be something unique to African American survivors, but most prevalent in this community (Alvidrez et al., 2011; Bryant-Davis et al., 2010).
While barriers and negative responses related to mental health care seeking occur, qualitative data showed that positive social reactions are also uniquely helpful. In our study, a survivor pointed to simply being told her rape was not her fault and how important that was for her to hear in middle age as it was the first time anyone ever said that to her, even though this was years after her victimization. Given the authority and expertise of professionals, their belief and validation may be especially healing for survivors harboring feelings of self-blame and/or responsibility for their assaults. Even if survivors do not blame themselves, society’s myths that victims are blameworthy and at least somewhat responsible for SA are very important to counter, given that is the dominant narrative regarding this form of victimization. Similarly, our findings support earlier researchers asserting the value of racially diverse mental health professionals (Krebs et al., 2011; Munroe, 2015) as survivors felt more comfortable seeking services from someone in their racial/ethnic group and perhaps are more likely to internalize validation by mental health professionals who share their demographic characteristics.
We did not find any evidence to support the “strong black woman” stereotype as a barrier to help-seeking. However, we did find evidence that there are unique barriers to mental health care seeking related to the African American community, including the racial composition of service providers, religion, and the stigma of utilizing mental health care services, in support of extant research (Jang & Johnson, 2005; Munroe, 2015). Qualitative findings also revealed drug use as a pathway to mental health care seeking among some survivors, a relationship that should be explored further to better understand the relationship between mental health, coping, and help-seeking among African American survivors.
Results also revealed help-seeking experiences that are not unique to African American survivors, including self-blame, fear of not being believed, and fear of reprisal from the perpetrator (Krebs et al., 2011; Munroe, 2015; Weist et al., 2014; Williams, 2013). Furthermore, findings reveal that like many survivors, African American survivors respond to encouragement from informal support sources to seek help. In our study, when survivors were supported, provided tangible aid, or encouraged by informal supporters to seek mental health care, they were more apt to do so, as in previous research (Kirkner et al., 2018). This suggests the importance and value of positive informal support, including a need for interventions targeting informal support.
Our qualitative data suggest that African American survivors use other forms of coping outside of social support and formal support, including 12-step groups, therapy, and religion/spirituality. In addition, those with early sexual abuse by close trusted family members may have difficulty setting boundaries in later relationships, especially sexual boundaries with men, which may lead them to not know that this is abnormal or wrong, not disclose to others, be targeted for further victimization, and to struggle with shame and feelings of stigma regarding their sexuality. This supports past research on lack of sexuality socialization of children in the Black community that may be a barrier to SA disclosure and help-seeking (Tillman et al., 2010).
Survivors had mixed experiences with mental health professionals, consistent with past studies (Campbell et al., 1999; Starzynski et al., 2017). Some appraised therapists positively and valued their role in their recovery for validating that they were not to blame and affording them the chance to talk about their experiences openly, whereas others were blamed by professionals or misdiagnosed or labeled in ways they felt were incorrect and/or stigmatizing. Being put in mental hospitals and/or medicated can also be traumatic. Similarly, survivors sometimes resisted medication as the effects led to too much flooding of memories that were too traumatic to deal with. Learning to take responsibility is adaptive, consistent with research showing that blaming self or others for trauma leads to worse symptoms (Littleton et al., 2007; Tennen & Affleck, 1990). In some cases, mental health effects of multiple assaults led survivors to drink and develop substance abuse problems that then led to legal problems, which in turn led to being institutionalized or mandated to treatment.
Limitations
The present study has several limitations. The sample of African American survivors was a small, convenience, volunteer sample. Future qualitative studies could benefit from obtaining a wider diversity of views of African American survivors, which are needed to ensure that saturation of themes is achieved. This study is also limited by the retrospective design. The period between when the assault occurred and when the study took place may have affected the quality and accuracy of the information received from survivors. Memory bias could have influenced accounts of help-seeking processes and experiences with mental health care providers. However, the retrospective design may have allowed survivors to gain perspective on their postassault experiences, which may have allowed them to provide greater details during their interview. Regarding the qualitative data, interviews were geared toward disclosure to informal sources, so did not explicitly inquire about experiences with mental health care help-seeking. Data obtained regarding survivors’ experiences with mental health care providers were unprompted and obtained only when survivors volunteered this information when discussing help-seeking or social support. Thus, more survivors may have engaged in mental health care help-seeking but did not talk about it during interviews. Still, 56% (N = 18) of survivors discussed mental health care seeking during interviews. Future studies that solicit information regarding mental health care in the aftermath of SA among African American survivors should obtain a broader range of information, from more survivors, and in greater depth. Despite these limitations, this study provides needed data on mental health care help-seeking in African American SA survivors, adds to the help-seeking literature, and has implications for practice and future research.
Implications
The present study has important implications for research and practice focusing on African American survivors’ mental health care seeking experiences. First, outreach is needed for sociodemographic groups (e.g., younger and less educated) who are less likely to seek mental health care. Furthermore, stranger and life-threatening assaults lead to more formal treatment seeking, whereas acquaintance and partner assaults result in fewer services soon after assault. This suggests the need to study individual ethnic/racial groups to detect differences in assault and postassault experiences among survivors of other marginalized communities as specific assaults may affect help-seeking distinctly for different survivors.
Our data suggest that Alcoholics Anonymous and the church are valued as sources of support, in addition to therapy/psychiatric help, suggesting that multiple support sources are sought and may be helpful to African American survivors recovering from SA-related psychological and substance abuse issues. Some survivors were sent to other formal sources such as police when they really needed counseling or confidantes in treatment systems to help talk about their experiences. Therapists need to help survivors, especially with CSA histories, learn to set boundaries, attain sobriety, and engage in adaptive coping. Inadequate sexuality socialization is also a target for education of young girls who otherwise may be silenced following assault.
Survivors spoke of being cautious when seeking mental health services due to being unsure of whether they could trust their therapist. Some formal providers told survivors’ parents or others without their permission, a violation of trust and confidentiality that is appraised negatively in past research on SA (Ullman, 2010) and may be particularly problematic for African American survivors, who already have a culturally rooted distrust of helping professionals (Williams, 2013). The core experience of loss of control experienced in SA makes it critical for professionals to avoid any responses, advice, or treatment that takes more control away from survivors. Matching of therapist–client characteristics (e.g., gender, race, and sexual orientation) is vital to improve survivors’ trust and rapport crucial to building a relationship and recovering. Fears that therapists saw them as “crazy” show it is important to normalize reactions to abuse and trauma and avoid pathologizing survivors. Lesbian survivors may receive more negative reactions from therapists, if some do not realize their sexual identity is not the problem and/or due to assault, and instead due to double stigma of disclosing assault and sexual minority status.
Qualitative data revealed unique barriers and experiences perhaps specific to African American women, so more work is needed about how survivors come to disclose (or not) to mental health professionals, experiences they have, and how they feel about them, including barriers and facilitators to recovery outcomes. The role of other support sources in conjunction with formal treatment should also be explored, including informal support sources and other groups or institutions (e.g., 12-step groups and church). Finally, mental health professionals should screen women for SA and provide referrals to other formal and informal support resources that may be helpful as single and/or supplemental sources of support and recovery.
Footnotes
Acknowledgements
We thank Mark Relyea, Rannveig Sigurvinsdottir, Liana Peter-Hagene, Meghna Bhat, Cynthia Najdowski, Saloni Shah, Susan Zimmerman, Rene Bayley, Farnaz Mohammad-Ali, Shana Dubinsky, Diana Acosta, Brittany Tolar, and Gabriela Lopez for assistance with data collection.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA No. 17429) to Sarah E. Ullman, Principal Investigator.
