Correlates of perceived helpfulness of mental health professionals following disclosure of sexual assault.

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research-article2014

VAWXXX10.1177/1077801213520575Violence Against WomenStarzynski and Ullman

Article

Correlates of Perceived Helpfulness of Mental Health Professionals Following Disclosure of Sexual Assault

Violence Against Women 2014, Vol. 20(1) 74–94 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801213520575 vaw.sagepub.com

Laura L. Starzynski1 and Sarah E. Ullman2

Abstract A diverse sample of more than 365 adult sexual assault survivors, recruited from college and community sources, was surveyed about sexual assault experiences, post-assault factors, and perceived helpfulness of and satisfaction with mental health professionals. Regression analyses were conducted to identify factors associated with perceived helpfulness of and satisfaction with mental health professionals. Older age, higher posttraumatic stress disorder (PTSD), greater control over recovery, and more emotional support reactions were associated with positive perceptions of mental health professionals. Stranger offenders, greater resistance during assault, high victim post-assault upset, and blaming social reactions from others were associated with negative perceptions of mental health professionals. Keywords mental health professional, perceived helpfulness, sexual assault survivor Survivors of sexual assault often experience increased psychological symptoms, including anxiety, posttraumatic stress disorder (PTSD), depression, low self-esteem, and social adjustment difficulties as a result of the attack (Resick, 1993). For some victims, these psychological sequelae can last for months or even years after the assault (Burnam et al., 1988; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). 1Wayne

State University, Detroit, MI, USA of Illinois at Chicago, USA

2University

Corresponding Author: Laura L. Starzynski, Department of Criminal Justice, Wayne State University, 3281 FAB, Detroit, MI 48202, USA. Email: [email protected]

Downloaded from vaw.sagepub.com at UCSF LIBRARY & CKM on April 13, 2015

Starzynski and Ullman

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Following sexual assault, many women turn to mental health professionals for help in dealing with psychological symptoms (Foa & Riggs, 1995; Golding, Siegel, Sorenson, & Stein, 1989). Some data suggest that receipt of sustained mental health support may decrease psychological symptomology (Campbell et al., 1999). However, no research has been done on what factors are related to women’s perceived satisfaction with mental health professionals after disclosing sexual assault (Campbell, Dworkin, & Cabral, 2009). The purpose of this study was to examine women’s experiences disclosing sexual assault to mental health professionals. Individual, assault, other trauma, and post-assault variables were analyzed to identify factors related to women’s perceptions of helpfulness and satisfaction with mental health professionals. Several researchers have argued that one must take a variety of factors, including demographic, assault, and post-assault variables, into consideration to understand women’s recovery from sexual assault trauma and help-seeking decisions. Such data can enhance understanding of the different ways individuals affect, and are affected by, different social support sources as they recover from sexual assault (Campbell et al., 2009; Harvey, 1996; Neville & Heppner, 1999; Schreiber, Renneberg, & Maercker, 2009). Specifically, Campbell et al. (2009) showed that interactions between individual-level factors (e.g., demographic variables), assault characteristics, microsystem factors (e.g., informal support from friends and family), meso/exosystem factors (e.g., formal support from police or rape crisis centers), macrosystem factors (e.g., societal rape myth acceptance), and chronosystem factors (e.g., sexual revictimization and other traumas) all need consideration when evaluating women’s experiences with disclosing sexual assault to mental health professionals. Each level of the system interacts in ways that can affect women’s experiences with help seeking after sexual assault. For example, Liang, Goodman, Tummala-Nara, and Weintraub (2005) studied women’s intimate partner help seeking in response to intimate partner violence and showed that individual demographic characteristics interacted with interpersonal influences and sociocultural influences to affect whether people seek the help and what type of help is sought. Furthermore, research has shown that interpersonal interactions between mental health professionals and those seeking help are influenced by individual, interpersonal, and sociocultural variables and can have a very real impact on perceived helpfulness of and satisfaction with mental health providers (Campbell & Raja, 1999).

Present Study This study examined women’s disclosure of sexual assault to mental health professionals and perceived helpfulness of mental health professionals upon disclosure. In previous analyses of these data, we found demographic (race, sexual orientation, and age) and post-assault factors (PTSD symptom severity, number of informal support sources told, and receipt of tangible aid/information support) all predicted assault disclosure to mental health professionals (Starzynski, Ullman, Townsend, Long, & Long, 2007). The present research was an exploratory study done to expand on previous results to determine which factors are associated with women perceiving mental health


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Violence Against Women 20(1)

professionals as helpful and satisfactory. It was expected that a grounded theory approach to this topic would help contribute to help-seeking literature to inform a larger theory. Based on the previous studies, demographic, assault, other traumarelated variables, and post-assault variables, as used in previous studies with these data (Starzynski et al., 2007), will affect women’s perceived satisfaction with and helpfulness of mental health professionals.

Demographics Individual-level demographic factors influence processes of help seeking, including problem recognition and definition, decision to seek help, who is told, and reactions from social support sources (Campbell et al., 2009; Liang et al., 2005). However, most current research shows no significant relationship between demographics and satisfaction with mental health professionals (Carlson, Shaul, Eisen, & Cleary, 2002; Garland, Aarons, Saltzman, & Kruse, 2000; Lebow, 1982). Thus, demographics (e.g., age, race, sexual orientation, education, income, marital status, employment, children) will be included as control variables, with no hypotheses made regarding their effects.

Assault Characteristics Based on past research showing that more stereotypical assaults result in more disclosure to social support sources and more negative social reactions (Ahrens, Campbell, Teneir-Thames, Wasco, & Sefl, 2007; Ullman & Filipas, 2001a), we expected that women with stereotypical assaults will report less perceived helpfulness of and satisfaction with mental health professionals upon assault disclosure. Specifically, stereotypical assaults (e.g., stranger offenders, weapons, physical force, victim injury, non-drinking victims, high victim resistance, and perceived life threat; Burt, 1980; Burt & Albin, 1981; Estrich, 1987; Schwartz & Nogrady, 1996) were expected to be associated with less perceived helpfulness of and satisfaction with mental health professionals. Other assault characteristics (e.g., age at assault, number of offenders, offender intoxication) were included as control variables because few studies have examined these variables and they may affect the dependent variables.

Trauma History It is also possible that multiple life stressors may have led women to seek mental health help in the past, which could affect their perception of mental health professionals as they disclose sexual assault. No studies have examined trauma histories in relation to women’s perceptions of mental health professionals, but some research shows that women who experience multiple traumas, especially childhood sexual abuse (CSA), are less likely to disclose their experiences to others (Hlavka, Kruttschnitt, & Carbone-López, 2007). Multiple traumas like CSA and other stressful life events can compound women’s psychological symptomatology (Dennis et al., 2009; Kubiak,



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2005). Furthermore, research shows that women with more severe psychological symptoms (e.g., PTSD) receive more negative reactions from social support sources (Ullman & Filipas, 2001b). Therefore, it was hypothesized that women who experienced CSA and multiple stressful life events would report greater perceived unhelpfulness of and less satisfaction with mental health professionals.

Post-Assault Factors Post-assault variables (e.g., timing of disclosure, time since assault, perceptions of control over recovery, characterological and behavioral self-blame, level of upset after assault, depression, PTSD, problem drinking, and social reactions) could have an important impact on women’s experiences with mental health professionals after sexual assault disclosure (Campbell et al., 2009). Campbell, Wasco, Ahrens, Sefl, and Barnes (2001) found that women who disclosed sexual assault right away were more distressed and more likely to have contact with more social systems like mental health services. Research also shows that women who disclose to more social support sources receive more negative social reactions (Ullman & Filipas, 2001b). Therefore, faster disclosure of sexual assault to others was expected to be significantly related to women’s perceptions of greater unhelpfulness of and less satisfaction with mental health professionals. Because the amount of time since the assault may affect memory of assault, years since assault was included as a control variable. As perceived control over recovery was associated with less psychological distress in rape victims (Frazier, Mortensen, & Steward, 2005), we expected it to be related to greater perceived helpfulness of and satisfaction with mental health professionals. Although no research has investigated how self-blame attributions relate to women’s perceptions of mental health professionals upon disclosure of sexual assault, research has shown that characterological and behavioral self-blame are related to poorer psychological adjustment after sexual assault (Frazier, 1990; Frazier & Schauben, 1994). As increased psychological symptomatology is related to women receiving more negative social reactions upon disclosure of sexual assault (Ullman & Filipas, 2001b), it was hypothesized that increased characterological and behavioral self-blame would be associated with less helpfulness and lower satisfaction with mental health professionals after disclosing sexual assault. Women’s use of avoidance coping after sexual assault has not been studied in relation to perceptions of mental health professionals. If women’s preferred method of dealing with sexual assault trauma is to avoid thoughts of the assault, they might not perceive therapy after assault as a positive, helpful experience. Thus, it was hypothesized that avoidance coping would be related to less helpfulness and lower satisfaction with mental health help after disclosing sexual assault. Women who are more distressed after assault may be treated more negatively by mental health professionals, many of whom do not have training about sexual assault. Thus, victim post-assault upset was expected to be related to less helpfulness and dissatisfaction with mental health professionals. Research has shown that sexual assault victims who experience some kind of mental disorder are more likely to seek help


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(Amstadter, McCauley, Ruggiero, Resnick, & Kilpatrick, 2008). Therefore, women who have a diagnosable disorder like PTSD or depression may seek more satisfactory help and may be treated better by mental health professionals. Therefore, women with depression and PTSD were expected to find mental health professionals more helpful and be more satisfied with them. Women with problem drinking experience more negative social reactions post-assault (Ullman & Brecklin, 2003), thus we expected that women’s problem drinking would be associated with less perceived helpfulness and lower satisfaction with mental health professionals. Social reactions from others such as friends and family members may not only influence the likelihood of seeking mental health help, but also affect women’s perceptions of the helpfulness of and satisfaction with mental health professionals based on whether or not those sources are encouraging or discouraging of victims in recovery from sexual assault. Given that negative social reactions are related to greater PTSD (Ullman & Filipas, 2001b), we expected that negative social reactions would be related to less helpfulness and satisfaction with mental health professionals, whereas positive reactions from others would be related to more helpfulness and satisfaction with mental health help (Ahrens, 2002; Ahrens et al., 2007). Specifically, positive reactions of emotional support and tangible aid to disclosures of assault were expected to be related to more perceived helpfulness of and satisfaction with mental health professionals, whereas negative reactions (e.g., blame, egocentric responses, distraction, treat differently, controlling reactions) would be expected to be related to lower perceived helpfulness of and satisfaction with mental health professionals.

Method Sample A diverse sample of women in Chicago and the surrounding metropolitan area was recruited to participate in a mail survey using various methods. Fliers were posted at a large urban university in academic buildings, bookstores, college dormitories, and other places women congregate to recruit college students and community members. In addition, to include the experiences of help-seeking survivors, fliers were sent to mental health agencies and rape crisis centers. Finally, to target potential participants from the city and surrounding suburbs, advertisements were placed in various local newspapers. Fliers and newspaper ads invited women aged 18 or older with unwanted sexual experiences since age 14 to participate in a mail survey. Potential participants were informed of the purpose of the study when they called the project office. Interested women were sent a packet containing a cover letter, a referral list of community resources, an information sheet explaining the study purpose, and a 20-page mail survey. Participants were sent US$20 after returning the survey. In this study, 1,084 participants returned completed surveys, a 90% response rate. Within this sample of women, 365 women (34%) said that they had discussed sexual assault experiences with a mental health professional and all results reported in this study are from this subsample of women.



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Measures Demographic information. Personal information collected in the mail survey included current age; education (less than 12th grade, high school graduate, some college, and graduate school or beyond); sexual orientation (heterosexual, lesbian, bisexual, not sure); marital status (single, cohabitating, married, divorced, widowed); race (White, Black, Hispanic, Asian or Pacific Islander, American Indian or Alaskan Native, Other); and annual household income (six ordinal categories ranging from US$10,000 or less to US$50,001 or more). Assault characteristics. Koss’s Sexual Experiences Survey (SES; Koss & Gidycz, 1985) was used to identify completed and attempted rape victims and women who had experiences of unwanted sexual contact and sexual coercion. The questions assessed adult sexual victimization from age 14 on, the age criteria used in the SES. The SES is a behaviorally specific questionnaire that asks whether or not women have experienced events against their will that correspond to sexual assault statutes in most states (Koss & Gidycz, 1985). The SES questions can also be coded as a measure of sexual assault severity from less severe attempted assault to completed sex acts (Koss, Gidycz, & Wisniewski, 1987). Respondents were also asked for details about their assault or, if they had multiple assaults, about details of what they considered their “most serious” unwanted sexual experience. Characteristics included age at the time of assault (in years); relationship with the offender (stranger, non-romantic acquaintance, first or casual date, romantic partner or husband, or some other family member); number of offenders; victim and offender pre-assault substance use (alcohol, drugs, both, or none); physical injuries (ranging from mild soreness and bruises to knife or gunshot wounds); coercive tactics used by the perpetrator (e.g., threats of force, physical force, weapons); resistance strategies used by the victim (e.g., nonforceful and forceful verbal and physical resistance strategies); and perceived life threat during the assault (no or yes). Trauma history. Two variables assessing trauma exposure—child sexual abuse and number of additional traumatic life events—were analyzed. Following Koss et al. (1987), women answered each SES question with respect to whether they had each experience before age 14 to assess CSA. Highest severity of child sexual victimization was coded continuously according to Koss et al.’s (1987) guidelines (e.g., none, sexual contact, sexual coercion, attempted rape, completed rape). Goodman, Corcoran, Turner, Yuan, and Green’s (1998) Stressful Life Events Screening Questionnaire (SLESQ) was used to assess lifetime history of traumatic events. The SLESQ is a brief, self-report measure of 10 behaviorally specific screening items assessing a variety of traumatic events of an interpersonal nature (e.g., “Was physical force or a weapon ever used against you in a robbery or mugging?”). This measure was scored as the summed number of events experienced by each participant (excluding childhood and adult sexual assault measured by the SES). Respondents were asked if they reported the same incident on more than one item. If so, it was


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counted as one event. Psychometric data for the SLESQ are excellent with good test– retest reliability (median κ = .73), adequate convergent validity (with a lengthier interview) with a median Kappa of .64, and good discrimination between Criterion A and non-Criterion A events. Prevalence rates for specific events were similar to those reported by Norris (1992) and Kessler, Sonnega, Bromet, Hughes, and Nelson (1995) in two large probability samples. Post-assault factors: Assault-specific social support measures. Women were asked if they had ever told anyone about the assault (no or yes) and whether they had ever talked with each of several informal and formal sources. Informal support sources included parents, family, romantic partners, or friends. Disclosure to a psychiatrist or other mental health counselor (no or yes) was the only formal support source analyzed in this study. Once women answered “yes” to disclosing to a particular social support source, they were asked whether they were helpful (no or yes). The number of informal support sources told was computed by summing the affirmative responses to each of these questions. Women were asked how long after the experience it took them to first tell someone else about the assault (immediately, days after, weeks after, a year after, more than 1 year after). Women were asked about the timing of disclosure to mental health professionals (never, immediately after, within year after, or more than a year after). Finally, to determine the amount of time since the assault, a new variable was created that subtracted the age of participants at the time of assault from the age at the time of the survey. Post-assault factors: Attributions of blame. Frazier’s (2003) Rape Attribution Questionnaire (RAQ), a valid and reliable self-report measure of attributions, was used to measure attributions made by sexual assault victims about why the assault occurred. Five 5-point Likert-type scales assessed attributions made in the past 30 days, including behavioral self-blame (e.g., I made a bad decision) and characterological self-blame (e.g., I am just the victim type). In the present study, the mean ratings of characterological self-blame and behavioral self-blame were analyzed. The RAQ was found to be valid and reliable using female emergency room victims and sexual assault survivors identified by a random telephone survey with subscale alpha coefficients ranging from .77 to .89 and test– retest reliability coefficients that ranged from .68 to .80 (Frazier, 2002, 2003). Post-assault factors: Avoidance coping strategies. Coping strategies used in the past 30 days were assessed using the Brief COPE, a 28-item self-report scale, that assessed a variety of approach and avoidance coping strategies (Carver, Scheier, & Weintraub, 1989) to cope with a specific stressful event (in this case, sexual assault). Respondents indicated the extent to which they used each coping strategy, from “I didn’t do this at all” (1) to “I did this a lot” (4). Each coping strategy was computed as the unweighted sum of responses to two items comprising each subscale. The COPE has been widely used and has good internal consistency reliability (all subscales had alphas of .60 or greater except for one) and test–retest reliability (correlations of .46-.86). In this study, a composite avoidance coping scale was computed by



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summing the items assessing behavioral disengagement, denial, and self-distraction forms of coping. Post-assault factors: Present control over recovery process. Frazier’s (2003) perceived control items assessed women’s perceptions of control in the last 30 days over the recovery process from their sexual assault experience. Frazier (2003) reported an alpha of .81 for the present control over recovery from assault. Post-assault factors: Depression. Depressive symptoms were measured using the CESD10 (Andresen, Malmgren, Carter, & Patrick, 1994), a short version of the Center of Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). The 10 items on the shortened version are each rated on 4-point scales (range = 0-3) to indicate respondents’ symptoms during the past week. The total score is the sum of items after reversing the two positive mood items. Higher scores indicate a higher level of depressive symptoms. In this study, we used the mean of the item scores to indicate the average frequency with which respondents experienced depressive symptoms. Cronbach’s alpha of the CES-D was found to be .85 in the general population and .90 for patients. The measure’s content, concurrent, and discriminant validity have been supported (Radloff, 1977). The CESD10 is strongly correlated (r = .97) with the 20-item scale (Andresen et al., 1994). Post-assault factors: PTSD. PTSD symptom severity was measured with the Posttraumatic Stress Diagnostic Scale (PDS), which has been shown to be a valid and reliable self-report measure of PTSD (Foa, 1995). The PDS is a brief self-report instrument used to provide a reliable diagnosis of PTSD and a measure of the severity of PTSD symptoms based on Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria. The 17-item scale has been shown to have good internal consistency (α = .92) and validity with a 79.4% agreement between the PDS and the Structured Clinical Interview for the DSMIV Axis I disorders (severe combined immunodeficiency [SCID]) PTSD module (PTSD diagnoses of κ = .59). Instructions were modified for this survey to refer to women’s unwanted sexual experiences. Respondents indicated how often each symptom had bothered them in the past month with responses rated on a 4-point scale from not at all (0) to almost always (3). Total PTSD symptom severity was computed by summing response weights to all items corresponding to numbing/avoidance, reexperiencing/intrusion, and arousal symptoms. Overall symptom severity scores across the three criteria symptoms ranged from mild (6.3%), moderate (33.1%), moderate-tosevere (46.3%), to severe PTSD (14.3%). Post-assault factors: Drinking problems. The Michigan Alcoholism Screening Test (MAST; Selzer, 1971) was used to assess past-year drinking problems. The MAST is a 25-item widely used, standardized self-report screening instrument for alcohol abuse and dependence. The number of alcohol problems in the past year endorsed was coded as a continuous measure of total past-year drinking problems. This measure was dichotomized to differentiate those with a drinking problem from those without a


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drinking problem in the past year. Those endorsing five or more items on the MAST were classified as having a drinking problem, in accordance with Selzer (1971). Social reactions to assault disclosure were assessed with the Social Reactions Questionnaire (SRQ), a valid and reliable instrument of positive and negative social responses to sexual assault disclosure (Ullman, 2000). Women were asked how often they received 48 different reactions from anyone they told about the assault. Participants indicated the frequency of positive and negative social reactions received since the assault on Likert-type scales ranging from never (0) to always (4). The SRQ assesses positive reactions (emotional support and tangible aid support) and negative reactions (treat differently, take control, victim blame, egocentric responses, and distraction; Ullman, 2000). The mean scores on each subscale for participants were computed for analyses. For example, the emotional support subscale was computed by summing all Likert-type items associated with emotional support according to Ullman’s (2000) study, then dividing by the number of emotional support items. This computation was done for all SRQ subscales. Perceived helpfulness of and satisfaction with mental health professionals. Two dependent variables were specifically examined to determine how women perceived their experiences with mental health professionals. The first question asked women whether or not they found mental health professionals helpful (no/yes) and the second question that asked women how much satisfied they were with those mental health professionals they disclosed to (5-point Likert-type scale from very unsatisfied to very satisfied).

Results Sample Within this sample of women (N = 1,084), 365 women (34%) said that they had discussed sexual assault experiences with a mental health professional. In this subsample, most women identified as White (47.2%). The rest identified as African American (36.4%), multiracial (8.1%), Latina (5.3%), and Asian (1.9%); fewer than 1% of women identified as Pacific Islander/Native Hawaiian, American Indian, or women of other ethnic backgrounds. This sample somewhat overrepresented African Americans and underrepresented Hispanic and Asian victims relative to their proportion in the Chicago metropolitan area according to the 2005 Census data that showed the figures of 45% Caucasian, 26% African American, 22% Hispanic, 6% Asian, 1% multiracial, and .05), showing that the logistic regression model accurately fits the data (Hosmer & Lemeshow, 1989).

Linear Regression Analysis of Women’s Satisfaction With Mental Health Professionals A linear regression analysis3 was run with independent variables that approached statistical significance (p ≤ .10) in relationship to satisfaction with mental health professionals measured on a 4-point ordinal Likert-type scale ranging from “very unsatisfied” to “very satisfied.” Table 2 presents the standardized beta coefficients for the regression analysis. Only cases without missing data were used, resulting in a sample of 299 women.



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A few variables were related to women’s satisfaction with mental health. As victim resistance increased, women’s satisfaction with mental health professionals decreased. As women received more emotional support reactions from social support sources, they were more satisfied with the help they received from mental health professionals. A few variables were related to the dependent variable at a level that approached statistical significance. Older women reported more satisfaction with mental health professionals at a level approaching statistical significance (p < .06). As women felt more in control over their recovery after sexual assault, they reported more satisfaction with mental health professionals. As women received more tangible aid from social support sources, they reported more satisfaction with mental health professionals. Victim–offender relationship, level of victim injury, timing of first disclosure, PTSD symptom severity, and negative social reactions of blame, treat differently, and control were all unrelated to satisfaction with mental health professionals.

Discussion The purpose of this study was to examine women’s experiences with mental health professionals to help discover what factors are related to women having helpful, more satisfactory mental health experiences. Quantitative analyses identified demographic, trauma history, assault-related, and post-assault variables significantly related to women’s perceived helpfulness of and satisfaction with mental health professionals. The multivariate logistic regression showed that of demographic variables, only older age was significantly related to women finding mental health professionals more helpful. Furthermore, increased age was related to being more satisfied with mental health professionals at a marginally significant level in the linear regression analysis. These findings are similar to those found previously (Carlson et al., 2002). Some research has shown that this may be because doctors in general tend to be more receptive to older patients (Hall & Dornan, 1990; Harris, Rich, & Crowson, 1985). However, due to the wording of the questions in the survey, it is impossible to know exactly when women disclosed to mental health professionals. Other research has also shown that older age of mental health patients could lead them to be more tolerant of mental health professionals, perhaps making them more accepting of mental health experts (Kalman, 1983; Rosenbeck, Wilson, & Meterko, 1997). The quantitative analyses showed that demographics (e.g., race, marital status, sexual orientation, income, employment, having children) were unrelated to the dependent variables as expected. It was important to examine women’s childhood sexual trauma and other stressful life experiences to determine if they affect women’s perceptions of mental health professionals. Even at the bivariate level, neither CSA nor the number of other traumatic life events was significantly related to the dependent variables of perceived helpfulness of and satisfaction with mental health professionals. Therefore, the hypotheses that increased CSA and stressful life events would be significantly related to women’s perceptions of increased helpfulness and satisfaction with mental health professionals were unsupported. The ways in which other assault variables affect women’s recovery


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from sexual assault are very complex, and more refined surveys and interviewing methods are needed to fully tease out how CSA and other stressful life events affect women’s experiences with mental health professionals. Several assault-related factors yielded significant results. At the multivariate level, stranger assaults were significantly related to finding mental health professionals unhelpful and more victim resistance was significantly related to less satisfaction with mental health professionals. These findings contribute to other research that has shown that stereotypical assaults (e.g., stranger offenders) are related to women receiving more negative reactions when disclosing sexual assault to mental health professionals, often because they disclose to more formal support sources such as police who are known to respond negatively to victims (Ahrens et al., 2007; Ullman & Filipas, 2001a). These findings also support the hypothesis that stereotypical sexual assaults would be significantly related to more negative experiences with mental health professionals and should be more carefully studied in future research. Other assault variables that showed statistical significance at the bivariate level were not significantly related to the dependent variables. In the multivariate logistic regression analysis, both PTSD and feeling in control of the recovery process maintained statistically significant relationships with women perceiving mental health professionals as helpful. These findings support the hypothesis and are consistent with and expand on previous research showing that when women feel in control, they are more likely to seek help (Campbell et al., 2009; Frazier et al., 2005; Liang et al. 2005; Schreiber et al., 2009), and probably more likely to seek help until they find someone they feel will help them through their recovery process. Also, women with PTSD who may be seen as more legitimate also tend to find mental health professionals more helpful. The multivariate logistic regression analyses showed that greater victim upset and more blaming reactions from social support sources were significantly related to finding mental health professionals more unhelpful. These findings also support the hypothesis that greater victim upset after sexual assault could negatively affect women’s experiences in help seeking from mental health professionals and prevent them from finding a helpful counselor or therapist after having any previous negative experiences with mental health care. Little research has investigated the effects of victim upset on women’s disclosure of sexual assault to social support sources, but this study shows that blaming reactions from social support sources are related to more unhelpful experiences with mental health professionals, as expected. Also, research shows that negative disclosure experiences (including blaming reactions) often have a silencing effect on women and prevent them from further disclosures (Ahrens, 2002; Ahrens et al., 2007). It is possible that negative social reactions (like blame) from support sources could prevent women who have had negative and unhelpful experiences with mental health professionals from seeking out another, more positive, counselor or therapist for help with their recovery. Within the multivariate linear regression analysis, PTSD symptom severity did not maintain its statistical significance, nor did the timing of first disclosure, or negative social reactions of blaming, taking control, and controlling behaviors from social



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support sources. Positive social reactions of emotional support were significantly related to finding mental health professionals more helpful, though we must concede that viewing mental health professionals positively may be related to positive appraisals of social support sources in general. Tangible aid social reactions and women’s control over recovery were related to finding counselors and therapists marginally more satisfactory. These findings support hypotheses that positive social reactions from support sources would be related to women’s greater satisfaction with mental health professionals. They also support research that shows that women’s feelings of greater control over the recovery process positively affect their help-seeking experiences (Frazier et al., 2005), consistent with research showing that positive reactions from others encourage women to continue to disclose and seek help until they find good mental health help (Ahrens, 2002; Ahrens et al., 2007). Characterological and behavioral self-blame, avoidance coping, depression, drinking, and some negative social reaction (e.g., egocentric, distraction) were not significantly related to the dependent variables, even at the bivariate level. This study was limited in using a nonrepresentative, cross-sectional, volunteer sample in a large metropolitan area that may not be representative of women in the general population or of women in suburban or rural areas. The cross-sectional nature of this study prevents us from making causal arguments because we cannot be sure of the sequencing of events. Another limitation of this study is the fact that “mental health professionals” was a definition we asked women to define for themselves and we were, therefore, not able to specifically describe mental health professionals, nor the circumstances under which women made contact with them. Some women did not fill out all parts of the survey, which left some information unknown for the participants.4 Women who had missing data for variables examined here were not included in the analyses. Missing data accounted for between 15 and 127 cases in the bivariate analyses. In the logistic regression and linear regression analyses, there were 122 and 66 missing cases, respectively. Also, the liberal p < .10 value used in the exploratory bivariate analyses to identify predictors of the dependent variables makes the multivariate findings vulnerable to Type I errors. It is possible that some of the variables included in the multivariate analyses were only included due to chance relationships with the dependent variable(s). Despite these limitations, this study identified correlates of women’s experiences with mental health professionals that can enhance efforts to improve the helpfulness of these professionals to victims seeking help after assault. There has been very little research done on this subject, and an understanding of women’s mental health help-seeking experiences after the trauma of sexual assault is an important aspect of their recovery process (Campbell et al., 2009). This was the first study that specifically analyzed sexual assault survivors’ appraisals of their mental health help-seeking experiences. The findings from this largely exploratory study can provide guidance for other research examining the mental health services experiences of sexual assault survivors. Overall, women’s mental health experiences were mixed, with some women indicating helpful and satisfactory mental health assistance and others reporting unhelpful


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or unsatisfactory experiences with mental health professionals. This study shows that all aspects of women’s lives, from their individual characteristics and assault experiences to the ways in which they interact with other social support sources, need to be considered when trying to understand how women experience mental health care. While this study addresses some of the existing gaps in the literature on women’s mental health experiences after sexual assault, it is important to address its limitations in future research to replicate the results in other samples of sexual assault victims. A few policy changes may improve responses to the mental health needs of survivors of sexual assault. Other support sources, such as rape crisis centers, could be involved in circulating recommendations to women who seek help. This information could include low-cost or free mental health centers that specialize in helping women who have experienced violence. Rape crisis centers could also encourage women to advocate for themselves as they seek mental health assistance, letting them know that it’s okay to leave therapists who are not helpful to them to find someone who might be more helpful. It may also be useful for mental health professionals to work more closely with rape crisis centers and be willing to send survivors to these crisis centers if they lack knowledge of the best ways to work with victims of sexual assault. Overall, services that help women recover from sexual assault could be better advertised to alert women to the fact that there is help available. The results of this study also show that poorer women should have more and better access to mental health services. Because this study was exploratory, more research is needed on women’s experiences of disclosing sexual assault to mental health professionals. Further qualitative analyses with women with more diverse backgrounds and experiences are needed to understand all of the patterns that might emerge as women disclose sexual assault to mental health professionals. Longitudinal studies of sexual assault survivors who have disclosed their experiences to mental therapists or counselors are needed to identify factors related to finding mental health professionals helpful and satisfactory. Future research should disaggregate the different types of mental health professionals and look into the ways in which those mental health professionals feel about working with sexual assault survivors, why they react the way they do to disclosures of sexual assault, and the ways in which they feel they are most helpful to women who seek their help post-assault. If researchers uncover why mental health professionals react positively or negatively to survivors of sexual assault, further policy changes might result in better training for mental health professionals to prepare them for helping women who have experienced sexual assault. Acknowledgments We thank Henrietta Filipas, Stephanie Townsend, and Kelly Kinnison for their 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.



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Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by NIAAA Grant AA13455 to Sarah E. Ullman.

Notes 1. Although race was dichotomized into non-White (0) or White (1), crosstab analyses were performed between subjects identifying as White, African American, Latina, and all other ethnicities with no difference in perceived helpfulness of or satisfaction with mental health professionals (p > .05). 2. A correlation matrix of the variables included in the multivariate analysis is available from the authors upon request. 3. A linear regression analysis was run to take advantage of the greater statistical power than a multivariate analysis that treated the outcome as categorical that showed the same findings. 4. Continuous missing variables were replaced at a primary level using mean substitution. Missing bivariate and dependent variables were not imputed. Crosstab analyses showed no significant differences (p < .05) between women who had missing data on the dependent variables and those who did not.

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Author Biographies Laura L. Starzynski is an full time lecturer in the Department of Criminal Justice at Wayne State University. She received her PhD from the Department of Criminology, Law, and Justice at the University of Illinois, Chicago, in 2010. She has researched sexual assault, recovery, disclosure, and social reactions as a part of Dr. Sarah Ullman’s Women’s Life Experiences project. Sarah E. Ullman is a professor of criminology, law, and justice at the University of Illinois, Chicago, and director of the Office of Social Science Research. She is a social psychologist whose research concerns the impact of sexual assault and traumatic life events on women’s health and substance abuse outcomes and rape avoidance/prevention. Her book, Talking About Sexual Assault: Society’s Response to Survivors, was published by American Psychological Association in 2010 and she is conducting a National Institute on Alcohol Abuse and Alcoholism (NIAAA) -funded longitudinal study of risk and protective factors in sexual assault survivors related to risk of revictimization, mental health, substance abuse, and posttraumatic growth outcomes.


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