Racial Disparities in Intimate Partner Violence and in Seeking Help With Mental Health.

555011 research-article2014

JIVXXX10.1177/0886260514555011Journal of Interpersonal ViolenceCheng and Lo

Article

Racial Disparities in Intimate Partner Violence and in Seeking Help With Mental Health

Journal of Interpersonal Violence 1–25 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514555011 jiv.sagepub.com

Tyrone C. Cheng, PhD1 and Celia C. Lo, PhD2

Abstract Applying Aday and Andersen’s health services utilization model, this examination of racial disparities in women’s experience of intimate partner violence also looked at racial disparities in mental disorders and in use of mental health professionals’ help. We conducted a secondary data analysis of 6,589 women completing the National Violence Against Women Survey. Per our linear regression results, minority women, versus White, tended proportionally to seek less help from mental health professionals. Help seeking by African American women was less likely if they were using illegal drugs; among Hispanic women, additional threats from partner curtailed help seeking from mental health professionals. “Other ethnic minority” women’s help seeking decreased with their use of stimulants. Implications for intervention are discussed. Keywords domestic violence, PTSD, stalking, mental health and violence

Introduction Well over a third of American women have been raped, physically abused, and/or stalked by an intimate partner: 43.7% of African American women, 37.1% of Hispanic women, and 34.6% of White women (Black et al., 2011). 1University 2Texas

of Alabama, Tuscaloosa, USA Woman’s University, Denton, USA

Corresponding Author: Tyrone C. Cheng, School of Social Work, University of Alabama, Room 118, Little Hall, Box 870314, Tuscaloosa, USA. Email: [email protected] Downloaded from jiv.sagepub.com at CAMBRIDGE UNIV LIBRARY on August 13, 2015

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Journal of Interpersonal Violence

Beyond physical violence and sexual violence, intimate partner violence (IPV) can include the threat of such violence as well as psychological or emotional violence (Centers for Disease Control and Prevention, 2010). Women subjected to IPV (committed by a current or former partner/spouse, heterosexual or same-sex) are 2.7 times more likely to be in poor physical health than women never experiencing IPV, and they are 3.1 times more likely to have poor mental health (Black et al., 2011). Moreover, for women subjected to IPV, violence often is ongoing (Office on Violence Against Women, 2012). One national study found that, although 72% of women experiencing IPV sought help, only 26% sought it from mental health services (Flicker et al., 2011). Others found that 31.0% to 45.5% of such women sought help from mental health professionals (Coker, Derrick, Lumpkin, Aldrich, & Oldendick, 2000; Nurius, Macy, Nwabuzor, & Holt, 2011). However, according to other research, minority women experiencing IPV tend not to seek help from mental health professionals, whatever the type or degree of violence suffered (Sabri et al., 2013; Yoshioka, Gilbert, El-Bassel, & Baig-Amin, 2003). This study questions whether there are racial disparities within dysfunctional intimate relationships, involving women and violent male partners, which are associated with obtaining mental health services to resolve IPV.

Literature Review Aday and Andersen’s behavior model of health services utilization (Aday, 1993; Aday & Andersen, 1974; Andersen, 1995) suggests that an individual’s access to or utilization of health services arises from the following individual indicators: need for treatment (e.g., illnesses, symptoms), social structural factors (e.g., ethnicity, education, employment), means to access (e.g., income, insurance coverage, geographic proximity to services), and demographic characteristics (e.g., age, gender, family size). This behavior model has been widely applied to mental health services utilization (Cheng & Robinson, 2013; Dhingra, Zack, Strine, Pearson, & Balluz, 2010; Gamache, Rosenheck, & Tessler, 2000; Lipsky, Caetano, & Roy-Byrne, 2011; Maulik, Mendelson, & Tandon, 2010; Nejtek et al., 2011; Schmidt, Tam, & Larson, 2012; Stockdale, Tang, Zhang, Belin, & Wells, 2007; Theriot, Segal, & Cowsert, 2003). The present study was derived from Aday and Andersen’s model and examined relationships between IPV-involved women’s help seeking from mental health professionals, and treatment need, enabling factors (e.g., financial resources, insurance coverage), and predisposing factors (e.g., social structural characteristics, social–demographic characteristics).

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Need for Mental Health Treatment Help-seeking behavior may be related to whether the experienced IPV involves abusive behavior or controlling behavior. Experiencing severe physical abuse from, or being stalked by, an intimate partner significantly increases the likelihood a woman has sought help from a mental health professional(s); there is no such association, though, between sexual or emotional abuse and consulting a mental health professional(s) (Flicker et al., 2011). A cycle of violence may exist, with the woman recurrently subjected, by turns, to abusive and controlling behaviors (Walker, 2000). Moreover, the literature shows that physical assault, rape, stalking (Miller, 2006), and emotional violence (Prospero, 2008) all are associated strongly with controlling behaviors. One study (McCloskey et al., 2007) found that women experiencing controlling IPV tended not to seek help from services, another (Cheng & Lo, 2014) that such women would indeed pursue mental health services if controlling behaviors crossed a certain threshold (here, three or more controlling behaviors). Among minority women, pursuing mental health services is an indicator of subjection to relatively high levels of controlling behaviors (Prospero & Kim, 2009). Among women with IPV experience, mental disorders increase the likelihood that help will be sought from mental health professionals (Cheng & Lo, 2014). Symptoms of depression and post-traumatic stress disorder (PTSD) alike have been significantly associated with abusive and controlling behaviors within intimate relationships (Coker et al., 2002; Johnson & Leone, 2005). Controlling behaviors, however, appear to have more impact on depression and PTSD than abusive behaviors have (Anderson, 2008). Moreover, for African American women experiencing IPV, neither depression nor PTSD symptoms seem to promote help seeking from mental health services (Sabri et al., 2013). Indeed, among women—of any ethnic origin— experiencing IPV, those exhibiting PTSD tend to develop avoidance coping (e.g., denial, wishful thinking; Krause, Kaltman, Goodman, & Dutton, 2008). The present study posits that minority women concurrently experiencing intimate partner controlling violence and either PTSD or depression will be unlikely to seek help from mental health professionals. At the same time, it is reasonable to suggest that many IPV-involved women may turn to mental health professionals on developing the somatic symptoms—frequent headache, chronic pain, sleep difficulties, irritable bowel—reported almost twice as often (1.8 times) by IPV victims than women with no IPV history (Black et al., 2011). Such symptoms tend to become more frequent when IPV persists over time (Gerber, Wittenberg, Ganz, Williams, & McCloskey, 2008). Research has found, unsurprisingly, a


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significant association between experience of IPV and self-perceived poor health among women (Carbone-Lopez, Kruttschnitt, & Macmillan, 2006; Coker et al., 2002). And yet, IPV-involved women may not seek help from mental health professionals—or from anyone. Instead, they may self-medicate their trauma, some consequently becoming substance abusers (Carbone-Lopez et al., 2006; Coker et al., 2002), perhaps eventually also demonstrating mental illness symptoms (McPherson, Delva, & Cranford, 2007; Oei et al., 2009) and even, ultimately, seeking treatment for substance abuse (Cheng & Lo, 2014; Greenfield & Wolf-Branigin, 2009; Petersen, Gazmararian, & Clark, 2001).

Enabling Factors A major deterrent to seeking help for IPV is financial resources. Financial dependence on their batterers reportedly bars many IPV-involved Hispanic women from seeking help (Rizo & Macy, 2011). A study of White and African American victims, however, failed to show their employment status or socioeconomic status to be significantly associated with their likelihood of seeking help from mental health professionals (Hutchison & Hirschel, 1998). A later study did show that women receiving Medicaid and also subjected to low levels of abusive IPV tended to seek mental health treatment, whereas for women with other health insurance, there was no significant association between such IPV and help seeking for mental health (Cheng & Lo, 2014). In addition to asking how finances affect help seeking, research has evaluated how education might be involved. At least two studies have shown that IPVinvolved women who are relatively better-educated are likely to seek help from mental health professionals (Flicker et al., 2011; Hutchison & Hirschel, 1998).

Predisposing Factors Although some researchers have found no significant differences among ethnic-minority women’s likelihood of experiencing physical violence from partners (Cho, 2012; Golden, Perreira, & Durrance, 2013), racial disparities distinguish minority women’s experiences of IPV from those of White women. For instance, White women are more likely to experience physical violence than Asian women are (Cho, 2012), and White women are more likely to experience emotional abuse than African American or Hispanic women are (Golden et al., 2013). In addition, among IPV-involved women, racial disparities also characterize help seeking from mental health professionals. As previously noted, African American women experiencing IPV are


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less likely than White counterparts to seek mental health services (Flicker et al., 2011; Hutchison & Hirschel, 1998). Among minority women generally, cultural stigmas and language barriers appear to pose major obstacles to seeking any kind of help from mental health professionals (Overstreet & Quinn, 2013; Rodriguez, Valentine, Son, & Muhammad, 2009; Simmons, Farrar, Frazer, & Thompson, 2011).

Hypotheses The literature makes clear that help seeking by women involved in IPV has generated much investigational interest. However, few studies have focused on racial disparities in the tendency to seek help from mental health professionals (Sabri et al., 2013; Yoshioka et al., 2003). A gap exists in the literature in this area, namely, the relationship by ethnic group between IPV and women’s help seeking from mental health professionals. The present study was intended to compare and contrast these relationships. It hypothesized that (a) IPV-involved women’s treatment needs, enabling factors, and predisposing factors would be associated with any help seeking from mental health professionals the women pursue, and (b) that the associations observed (between these types of factors and such help seeking) would exhibit racial differences.

Method Sample For this secondary data analysis, a sample was first extracted from the National Violence Against Women Survey (NVAWS), a public-use data set. During 1994-1996, NVAWS interviewed 8,000 women to gather information on IPV experience, seeking help, service utilization, and other responses to IPV (Tjaden & Thoennes, 1999). The present study excluded women aged 65 and above, and women with same-sex partners, generating a final sample numbering 6,589 (648 African American women, 569 Hispanic women, 293 other ethnic minority women, and 5,079 White women).

Variables The outcome variable, seeking help from mental health professionals, gave the proportion of all professionals contacted by respondents seeking help, who were specialized mental health professionals (psychologists, psychiatrists, mental health counselors, or similar). NVAWS had asked women


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whether they had talked to a professional about four types of “incident”: physical assault, forced sex, stalking, and threats. Seeking help from all professionals represented the total number of women contacting any professional (mental health professionals; law enforcement staff; physicians, nurses, or similar; social services staff; teachers; lawyers or other court officers) for help in the wake of an “incident” of any of the four types. Where the outcome variable’s measure was high (reflecting a relatively greater proportion of mental health professionals), strong tendency to seek help from mental health professionals is suggested. An outcome measure of 0% would indicate a woman never sought help from a mental health professional or never even felt a need to seek any professional help. Explanatory variables in the present study fell into three groups: treatment needs, enabling factors, and predisposing factors. Treatment needs included measures for the four types of “incidents,” per women’s reports to NVAWS about IPV. Number of incidents of physical assault was the total number of times a partner was physically violent toward a woman (throwing things at her, shoving, slapping, hitting, kicking, choking, using gun/knife, etc.). Number of incidents of forced sex was the total number of times a woman’s vagina, anus, or mouth was forcibly penetrated by penis, fingers, or objects. The dichotomous (yes/no) variable being stalked indicated whether a woman was ever serially followed or otherwise harassed by a partner (single occasions were excluded). Number of incidents of threat was the total number of times a woman received a threat of harm or death from a partner. Treatment needs also included measures for four types of IPV experience, per women’s reports to NVAWS. Controlling behaviors was the total number of controlling behaviors the current partner and/or all former partners exerted against the woman. A controlling behavior constituted any of 13 actions: rejecting the woman’s viewpoint, exhibiting jealousy/possessiveness, provoking argument, limiting woman’s contact with family/friends, insisting on knowing at all times who the woman is with, calling the woman names, demeaning the woman, frightening the woman, swearing at the woman, denying the woman access to family income, preventing the woman from working, and unwanted moving of the household. High scores for this controlling behaviors variable suggested experience of severe controlling behaviors. Physical assault was the total number of 12 possible violent physical actions that a woman’s current and/or former partner had directed at her. The 12 were throwing things at her, pushing/grabbing/shoving, pulling hair, slapping/hitting, kicking/biting, choking/drowning, hitting her with an object, beating her, threatening her with a gun, threatening her with a knife, using a gun against her, and using a knife against her. High scores for the physical assault variable implied experience of severe physical violence. Forced sex


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was the total number of occasions on which either of two behaviors—vaginal penetration, anal penetration—had been inflicted on the woman by the current partner and/or a former partner. High scores for this variable suggested experience of severe forcible sexual behaviors. Stalking behaviors was the total number of actions considered stalking, which numbered up to 8: following/spying on, sending unsolicited letters, leaving unwanted items, making unsolicited phone calls, making other unwanted communications, paying unwanted visits, standing outside home/school/workplace, and vandalizing personal property. These could have been exhibited by a current and/or a former partner. High scores for the stalking behaviors variable suggested an experience of severe stalking. Health and mental health were measured by several variables. Health gave a respondent’s self-reported health level, from 1 (poor) to 5 (excellent). Depression was the total score from a depression inventory (of eight 4-point items) administered during NVAWS (Cronbach’s α = .78). Examples of items are “How often in the past week did you feel downhearted and blue?”; “How often in the past week have you felt so down in the dumps that nothing could cheer you up?”; and “How often in the past week did you feel tired?” (NVAWS developed this inventory based on the SF-36 Health Survey acute version; Tjaden & Thoennes, 1999). Higher scores suggested worse depression. PTSD measured—with a 4-point scale—how many out of 21 specified symptoms attributable to a partner’s violence a respondent reported experiencing in the preceding 7 days; the scale’s Cronbach’s alpha was .99. Examples of the 21 are “I thought about it when I didn’t mean to”; “Pictures about it popped into my mind”; “I was jumpy and easily startled”; and “I found myself acting or feeling like I was back at that time.” Higher scores indicated relatively strongly the presence of PTSD. Beyond the study’s health and mental health measures, substance use was a possible indicator of treatment need. Alcohol use in past 12 months indicated how often (per self-reporting) a woman typically consumed beer, light beer, wine coolers, and/or liquor, during the specified period; responses ranged from 1 (never) to 7 (every day). Illicit drug use indicated (yes/no) whether (per self-reporting) a woman had used marijuana, cocaine, heroin, angel dust, and so on in the past month (excluding stimulants). Stimulant use (yes/no) indicated (per self-reporting) whether a woman had consumed uppers, speed, or amphetamines in the past month. The reference for the latter two variables was no drug use. Six variables in the study measured enabling factors. Personal income consisted of 10 levels, from less than $5,000 to more than $100,000. Education was one of seven schooling levels, ranging from 1 (no schooling) to 7 (postgraduate). Employed (yes/no) indicated whether a woman was


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employed (full-time or part-time). Medicaid/free-clinic coverage (yes/no) noted whether a woman was covered by Medicaid or used free/subsidized clinics for low-income people; private health insurance coverage (yes/no) indicated women having private health insurance; and other health coverage (yes/no) indicated women having military/veterans insurance, workman’s compensation, or disability coverage. The reference for the three insurance variables was uninsured. Four study variables constituted predisposing factors. Married (yes/no) indicated a woman had a legal spouse or lived as a couple with a male partner, its reference was single/divorced/separated/widowed. African American, Hispanic, other ethnic minority, and White (the reference) were the ethnicity variables in the study. Age (in years) and number of dependent children were used as demographic variables.

Limitations Focused as it was on seeking help from professionals, this study left out women’s help seeking through informal networks of relatives, friends, neighbors, and clergy, which is a limitation on the research. However, in estimating the outcome variable, this study did acknowledge that women who had sought help from mental health professionals might also have consulted other professionals (physicians, nurses, law enforcement staff). Quite commonly during interventions with victimized women, professionals from several disciplines coordinate and collaborate. In addition, the original NVAWS publicuse data set includes no information about respondent residence (e.g., urban versus rural) or transportation barriers (e.g., possessing a driver license and/ or an operational vehicle), posing a second limitation, because residence and transportation variables could suggest proximity’s impact on use of mental health services. A third limitation is the present study’s reliance on inventories of depression and PTSD that measured acute symptoms only. These inventories, then, do not represent respondents with chronic mental health conditions.

Data Analysis Linear regression within STATA was used for data analysis. No sampling weight was provided in the original data set; reportedly, NVAWS researchers found their study sample to closely resemble the general population, such that sampling weights would create negligible impact on victimization rates (Tjaden & Thoennes, 1999). Correlations (−.39 ≤ r ≤ .62) and tolerance statistics (≥.45) obtained during preliminary analysis suggested no problems


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related to multicollinearity. The first step was linear regression modeling with all explanatory variables. The second step was linear regression modeling conducted separately for each ethnic group. We intended to examine various ethnicity-based subsamples’ potentially differential outcome–explanatory variable associations, so to begin, these subsamples were coded as dummy variables (White as the reference). Next, interaction terms were created between each dummy variable and selected explanatory variables. We needed to offset potentially conservative results arising from the small size of our ethnicity-based subsamples, so a selected explanatory variable had to have shown, for two or more of these subsamples, a significant association with the outcome. Then, the three dummy variables, three interaction terms, and all other explanatory variables were included in a regression model for further analysis. Significant interactions in the model indicated that a dummy variable moderated the association between each selected explanatory variable and the outcome variable, when all explanatory variables other than the selected one were controlled.

Results Descriptive Statistics African Americans. For the subsample of 648 African American women, on average, the seeking help from mental health professionals was 7.7%, age was 37.7 years, number of dependent children was 1.3, and 45.4% were married (see Table 1). These women had experienced an average of 0.4 incidents of forced sex, 1.3 incidents of physical assault, and 0.1 threat behaviors; 0.8% had been stalked by a partner. On average, women in this subsample had experienced 2.71 controlling behaviors (of 26 possible), 0.91 physical assault behaviors (of 24 possible), 0.01 forced sex behaviors (of 4 possible), and 0.23 stalking behaviors (of 16 possible). Our African American respondents’ average health level was 3.5 (“good”); their average depression score was 16.2 (of 32 possible) and average PTSD score was 2.1 (of 84 possible). On average, these women consumed alcohol at a level of 1.8, indicating once monthly or less. Only 2.9% used illicit drugs, with 0.2% using stimulants. Average personal income in this subsample was 3.9, or $15,000 to $20,000, whereas average educational level was 4.6 (high school graduate) and 68.5% had employment. Furthermore, 10.3% of the African American women were Medicaid or free clinic users, 64.5% were privately insured, 8.2% were insured by other health coverage, and 17% were uninsured.


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Table 1. Descriptive Statistics of Variables.

Variables Seeking help from mental health professionals Number of incidents of physical assault Number of incidents of forced sex Being stalked Yes No Number of incidents of threat Controlling behaviors Physical assault Forced sex Stalking behaviors Health Depression Post-traumatic stress disorder Alcohol use Illicit drug use Stimulant use (No drug use) Personal income Education Employed Yes No Medicaid Private health insurance coverage Other health coverage (Uninsured) Married Yes No Age Number of dependent children

African American

Hispanic

%

%

M

M

Other Ethnic Minority %

M

White %

M

7.7

10.0

17.0

13.5

1.3

1.2

1.7

1.5

0.4

0.4

1.2

0.7

0.1

0.2

0.4

0.2

2.71 0.91 0.01 0.23 3.5 16.2 2.1

2.62 0.95 0.02 0.19 3.5 16.1 2.8

3.06 1.26 0.05 0.40 3.6 16.6 1.9

2.60 0.97 0.03 0.32 3.9 15.6 1.6

0.8 99.2

0.7 99.3

1.8 2.9 0.2 96.9

1.0 99.0

1.8 2.8 1.1 96.1

3.9 4.6

1.0 99.0

1.9 1.7 0.3 99.0

3.3 4.2

1.4 0.4 98.2 4.0 5.0

2.3 4.1 4.9

68.5 31.5 10.3 64.5

54.0 46.0 12.5 52.5

62.1 37.9 7.5 64.2

68.7 31.3 2.9 79.7

8.2 27.3

7.0 40.5

8.2 27.6

3.8 16.5

45.4 54.6

68.9 31.1

66.9 33.1

77.1 22.9

40.4 1.0

37.7 1.3

34.4 1.5

36.7 1.0


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Hispanics. For the subsample of 569 Hispanic women, on average, seeking help from mental health professionals was 10.0%, age was 34.4 years, and number of dependent children was 1.5; 68.9% were married. These women had experienced an average of 0.4 incidents of forced sex, 1.2 incidents of physical assault, and 0.2 threat behaviors; 0.7% had been stalked. On average, women in this subsample had experienced 2.62 controlling behaviors (of 26 possible), 0.95 physical assault behaviors (of 24 possible), 0.02 forced sex behaviors (of 4 possible), and 0.19 stalking behaviors (of 16 possible). Our Hispanic respondents’ average health level was 3.5 (“good”); their average depression score was 16.1 (of 32 possible) and average PTSD score was 2.8 (of 84 possible). On average, these women consumed alcohol at a level of 1.8, indicating once monthly or less. Only 2.8% used illicit drugs, with 1.1% using stimulants. Average personal income in this subsample was 3.3, or $10,000 to $15,000, whereas average educational level was 4.2 (high school graduate) and 54.0% had employment. Furthermore, 12.5% of Hispanic women were Medicaid or free clinic users, 52.5% were privately insured, 7.0%were insured by other health coverage, and 28.0% were uninsured. Other ethnic minority. For the subsample of 293 other ethnic minority women, on average, seeking help from mental health professionals was 17.0%, age was 36.7 years, and number of dependent children was 1.0; nearly 67% were married. These women had experienced an average of 1.2 incidents of forced sex, 1.7 incidents of physical assault, and 0.4 threat behaviors; 1.0% had been stalked by a partner. On average, women in this subsample had experienced 3.06 controlling behaviors (of 26 possible), 1.26 physical assault behaviors (of 24 possible), 0.05 forced sex behaviors (of 4 possible), and 0.40 stalking behaviors (of 16 possible). Our other ethnic minority respondents’ average health level was 3.6 (“good”); their average depression score was 16.6 (of 32 possible) and average PTSD score was 1.9 (of 84 possible). On average, these women consumed alcohol at a level of 1.9, indicating once monthly or less. Only 1.7% used illicit drugs, with 0.3% using stimulants. Average personal income in this subsample was 4.0 ($15,000-$20,000), whereas average educational level was 5.0 (some college completed) and 62.1% had employment. Furthermore, 7.5% of other ethnic minority women were Medicaid or free clinic users, 64.2% were privately insured, 8.2% were insured by other health coverage, and 20.1% were uninsured. Whites. For the subsample of 5,017 White women, on average, seeking help from mental health professionals was 13.5%, age was 40.4 years, number of


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dependent children was 1.0; 77.1% were married. These women had experienced an average of 0.7 incidents of forced sex, 1.5 incidents of physical assault, and 0.2 threat behaviors; 1.0% had been stalked by a partner. On average, women in this subsample had experienced 2.60 controlling behaviors (of 26 possible), 0.97 physical assault behaviors (of 24 possible), 0.03 forced sex behaviors (of 4 possible), and 0.32 stalking behaviors (of 16 possible). Our White respondents’ average health level was 3.9 (“very good”); their average depression score was 15.6 (of 32 possible) and average PTSD score was 1.6 (of 84 possible). On average, these women consumed alcohol at a level of 2.3, indicating once monthly or less. Only 1.4% used illicit drugs, with 0.4% using stimulants. Average personal income in this subsample was 4.1 ($15,000-$20,000), whereas average educational level was 4.9 (some college completed) and 68.7% had employment. Furthermore, nearly 3.0% of White women were Medicaid or free clinic users, 79.7% were privately insured, 3.8% were insured by other health coverage, and 13.5% were uninsured.

Multivariate Analyses All subsamples. The full model with all explanatory variables differed significantly from the null model (F = 58.42, p < .01; see Table 2). The R2 for the full model indicates that the model explains 18.8% of variance in the outcome variable. Significant positive associations with the outcome variable (seeking help from mental health professionals) were observed for each of the four types of incident. Moreover, all four types of IPV experience were associated positively with the outcome variable. Depression (b = .28, p < .01) and PTSD (b = .34, p < .01) had significant positive associations with the outcome variable, whereas health level and substance use variables lacked significant associations with the outcome. Educational level (b = 2.03, p < .01) and personal income (b = .55, p < .01) were associated positively with the outcome, although employment and health insurance showed no significant associations. Being married (b = −3.38, p < .01), age (b = −.13, p < .01), African American ethnicity (b = −6.59, p < .05), and Hispanic ethnicity (b = −3.02, p < .01) showed negative associations with the outcome variable; remaining predisposing factors (i.e., variables) lacked any significant association with the outcome variable. African Americans. Results for the African American subsample (see Table 3) indicated significant association of the outcome variable with incidents of physical assault (b = .93, p < .01) but not with the remaining incident types.


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Table 2. Linear Regression on Seeking Help From Mental Health Professionals of All Respondents. Variables

b

Number of incidents of physical assault Number of incidents of forced sex Being stalked (no) Number of incidents of threat Controlling behaviors Physical assault Forced sex Stalking behaviors Health Depression Post-traumatic stress disorder Alcohol use Illicit drug use (no drug use) Stimulant use (no drug use) Personal income Education Employed (no) Medicaid (uninsured) Private health insurance coverage (uninsured) Other health coverage (uninsured) Married African American Hispanic Other ethnic minority Age Number of dependent children Constant F R2 N

0.32** 0.77** 10.05** 0.35** 1.72** 1.29** 5.78** 1.19** −0.59 0.28** 0.34** 0.29 0.75 6.83 0.55** 2.03** −1.39 2.56 1.25 1.48 −3.38** −6.59** −3.02* 0.03 −0.13** −0.09 −1.77 58.42** .188 6,589

Note. Reference groups are in parentheses. *p < .05. **p < .01.

Although controlling behaviors (b = .75, p < .05) and forced sex (b = 32.89, p < .01) were associated positively with the outcome variable, physical assault and stalking showed no significant associations. And, although illicit drug


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Table 3. Linear Regressions on Seeking Help From Mental Health Professionals Among Four Ethnic Groups.

Variables Number of incidents of physical assault Number of incidents of forced sex Being stalked (no) Number of incidents of threat Controlling behaviors Physical assault Forced sex Stalking behaviors Health Depression Post-traumatic stress disorder Alcohol use Illicit drug use (no drug use) Stimulant use (no drug use) Personal income Education Employed (no) Medicaid (uninsured) Private health insurance coverage (uninsured) Other health coverage (uninsured) Married (no) Age Number of dependent children Constant F R2 N

African American

Hispanic

Other Ethnic Minority

White

b

b

B

B

0.93**

1.11**

1.51**

0.19**

0.28

0.78

1.05**

0.72**

−5.53 2.57

36.20** −1.49**

−30.36 0.69

12.40** 0.49**

0.75* 0.71 32.89** 0.15 0.86 0.20 −0.13

0.10 1.85** 14.93** −0.18 −0.24 0.22 0.44**

0.34 0.92 −11.37 2.32 −2.64 0.71 0.68**

2.22** 1.18** 5.51** 1.16** −0.59 0.26* 0.42**

1.66 −1.87 72.48* 0.30 −0.06 −1.62 9.29 1.54

0.41 3.60 6.07 0.48* 2.51** −1.26 2.66 0.80

−1.05 −11.69* −8.24 1.37* 0.95 −4.69* 8.25* 4.16

0.24 9.32 5.02 0.32 0.73 2.63 −5.27 2.36

4.95

8.89*

−4.81

0.73

−2.12 −0.13 −0.94

−5.02* −0.14 1.21

−2.98 0.02 −2.08

−2.98** −0.12** −0.01

−4.05 3.99** .128 648

1.07 6.75** .222 569

6.09 4.94** .297 293

−5.36 56.06** .205 5,017

Note. Reference groups are in parentheses. Figures in italics indicated significant (p < .05) interaction terms between variables and ethnic groups (White was the reference group). *p < .05. **p < .01.


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use (b = −11.69, p < .05) and employment (b = −4.69, p < .05) alike showed negative association with the outcome variable, personal income (b = 1.37, p < .05) and Medicaid/free-clinic coverage (b = 8.25, p < .05) showed positive association with it. Other variables showed no significant associations with the outcome variable. Hispanics. For the Hispanic subsample, incidents of physical assault (b = 1.11, p < .01) and stalking (b = 36.20, p < .01) were associated positively with the outcome variable; incidents of threat (b = −1.49, p < .01), however, were associated negatively with it. Moreover, forced sex (b = 14.93, p < .01) and physical assault (b = 1.85, p < .01) had positive associations with the outcome variable. Although PTSD (b = .44, p < .01) and other health coverage (b = 8.89, p < .05) were associated positively with the outcome variable, being married (b = −5.02, p < .05) was associated negatively with it. Other variables showed no significant associations with the outcome variable. Other ethnic minority. Results for the other ethnic minority subsample indicated that the outcome variable was significantly associated with four explanatory variables: incidents of forced sex (b = 1.05, p < .01), incidents of physical assault (b = 1.51, p < .01), PTSD (b = .68, p < .01), and stimulant use (b = 72.48, p < .05). Whites. For the subsample of White women, all four incidents and all four types of IPV experience showed positive associations with the outcome variable seeking help from mental health professionals. Both depression (b = .26, p < .05) and PTSD (b = .42, p < .01) also had positive associations with the outcome variable. Personal income (b = .48, p < .05) and educational level (b = 2.51, p < .01) were associated positively with the outcome variable as well; being married (b = −2.98, p < .01) and age (b = −.12, p < .01) were negatively associated with it. Other explanatory variables showed no significant associations.

Differences in Coefficients We created 30 interaction terms, but only 9 showed significant associations with the outcome (see Table 3). They were other ethnic minority’s incidents of assault (b = 1.04, p < .01); African Americans being stalked (b = −28.44, p < .05); Hispanics’ incidents of threat (b = −1.64, p < .01); controlling behaviors, for African Americans (b = −1.88, p < .01), Hispanics (b = −1.67, p < .01), and other ethnic minority (b = −1.04, p < .05); other ethnic minority’s forced sex (b = −13.25, p < .05); African Americans’ physical assaults (b = −2.03, p < .01); and African Americans’ PTSD (b = −.70, p < .01). Downloaded from jiv.sagepub.com at CAMBRIDGE UNIV LIBRARY on August 13, 2015

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Discussion The present results partially supported the first hypothesis, that treatment needs, enabling factors, and predisposing factors would be linked to a woman’s seeking help from mental health professionals. Such results tend to confirm one prior study (Flicker et al., 2011) in finding that all incidents and types of IPV violence studied were associated significantly (see Table 2) with the proportion of seeking help from mental health professionals. Our present results also support a prior study (Cheng & Lo, 2014) in observing an association between controlling behaviors and help seeking from mental health professionals. Although that study (Cheng & Lo, 2014) used a relatively small sample from within a single state of the United States, its results showed that women sought such help after experiencing three or more controlling behaviors (or 53% of those who reported some controlling behaviors). The present study, in turn, found that 53% of those respondents who had experienced controlling behaviors reported experiencing 5 or more of the 22 behaviors they were asked about. Examining our present findings suggests, moreover, that as the severity of controlling behaviors increased, women became more likely to seek help from mental health professionals. The present study also found that reporting having a mental health condition (in other words, demonstrating a treatment need) was associated positively with seeking help from mental health professionals. This is consistent with results of a prior study (Nurius et al., 2011). On the other hand—and contradicting earlier findings (Greenfield & Wolf-Branigin, 2009; Petersen et al., 2001)—our study did not find a significant association between any substance use variable and the outcome variable. Very few respondents indeed had ever self-medicated to relieve IPV-related trauma. The observed link, in the present study, between experiencing controlling behavior and an increased seeking help from a mental health professional probably indicates minimal perceived need for self-medicating. Initial findings from our study seemed to suggest that IPV increased help seeking from mental health professionals. Closer examination of analytical findings, however, established that the majority of our present sample (74.3%-96.8%) had never experienced forced sex, physical assault, or a threat from a partner. Compared with that in another national study (Black et al., 2011), the IPV reporting rate in our research was very low, but an explanation for the discrepancy readily presents itself. Data for NVAWS were collected in 1996, whereas the other national study was conducted in 2010. It is likely that public awareness of IPV increased dramatically over that decade and a half. Better IPV awareness in recent years probably has fostered women’s willingness to reveal any IPV experienced.


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As for the enabling factors we examined, personal income and educational level alike showed significant positive associations with seeking help from mental health professionals. This supports some prior findings (Flicker et al., 2011; Hutchison & Hirschel, 1998; Rizo & Macy, 2011). In contrast, our outcome variable showed only negative associations with the studied predisposing factors (age, being married). Consistent with prior studies (Flicker et al., 2011; Hutchison & Hirschel, 1998; Sabri et al., 2013; Yoshioka et al., 2003), the present study demonstrated that African American and Hispanic women were significantly less likely than White women to have sought help from mental health professionals, after controlling other explanatory variables (see Table 2). One plausible explanation is cultural bias and language barriers that may need to be overcome when mainstream mental health providers serve minority Americans (Overstreet & Quinn, 2013; Rodriguez et al., 2009; Simmons et al., 2011). Yet, however, in our study, minority women other than African Americans and Hispanics demonstrated a rate of help seeking from mental health professionals that did not differ significantly from White women’s rate. Additional studies with more specific tracking of ethnic groups may be warranted, given that in this research, the other ethnic minority subsample comprised all minorities beyond African American and Hispanic, despite the probable divergence of their various cultural beliefs. The present results also partially supported the second hypothesis, that racial differences would be observed in associations between seeking help from mental health professionals and the treatment needs, enabling, and predisposing variables. For each studied ethnic group, a distinct pattern of factors significant to the outcome variable was observed. Among the White women, there were significant, positive associations between the outcome variable and all IPV types/incidents presently studied. That is, for White women in our study, experiencing severe IPV or frequent IPV episodes generally promoted help seeking from mental health professionals. For African American women in our study, experiencing severe controlling behaviors, severe forced sex, or frequent physical assault promoted help seeking from mental health professionals. Like African American women in our study, our Hispanic respondents reporting relatively more incidents of physical assault or severe forced sex tended to seek mental health professionals’ help. However, Hispanic respondents differed from African American ones in tending to seek such help if a partner had stalked them or if they had experienced severe physical assault. Our Hispanic respondents also differed from other ethnic groups in that they were relatively unlikely to seek mental health professionals’ help after receiving more threats from a partner. Furthermore, among Hispanic women, a


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strong association was observed (b = 36.20, p < .01) between experienced stalking and the outcome variable, suggesting stalking was traumatic to them; similarly, among African American women in our study, experiences of severe forced sex seemed to promote help seeking from mental health professionals. Within our other ethnic minority subsample, in turn, incidents of physical assault and of forced sex were associated significantly with the outcome variable, results that suggest help seeking by women in this group was promoted by number of IPV incidents only, not by severity of IPV. In our study, White women with relatively worse depression or PTSD tended to increase help seeking from mental health professionals; whereas among African American respondents, no significant association was observed between the outcome and a given mental health condition. Such a result supports the results of at least one prior study (Sabri et al., 2013). For Hispanic women and other ethnic minority women in our study, in turn, significant association with outcome was observed solely for PTSD. Among White women and Hispanic women, substance use showed no significant association with seeking help from mental health professionals; whereas African American women who used drugs reduced seeking help from mental health professionals and other minority (non-Hispanic) women who used, specifically, stimulants increased such help seeking. These findings suggest that relatively many IPV-involved African American women pursue selfmedication instead of seeking help from mental health professionals and that relatively many women from other, non-Hispanic minorities develop symptoms in line with dual diagnosis of PTSD and stimulant use that require professional help. For this study’s White subsample, personal income and educational level showed positive associations with seeking help from mental health professionals; no significant associations were observed, however, for types of insurance coverage. For our African American subsample, in contrast, the outcome was associated positively with personal income and with Medicaid/ free-clinic coverage. We also noted, on examining respondents’ participation in Medicaid and free-clinic programs, that the rate of such participation among African Americans (χ2 = 88.41, p < .01) was significantly higher than that among Whites but did not differ significantly from rates of the other two subsamples. For the Hispanic subsample, other health coverage was the sole type of insurance associated significantly with the outcome. Implied by these findings is African Americans’ use of Medicaid and free clinics for access to affordable mental health services, as well as Hispanic women’s use of other health coverage for such access. For women in our other ethnic minority subsample, none of the specified enabling factors was significantly associated with the outcome. We also found, interestingly, that for African


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Americans in the study, employment reduced their seeking mental health professionals’ help. A plausible explanation is that these respondents’ on-the-job hours coincided with mental health services’ hours of operation, so that attending therapy might well mean losing pay. Among Whites and Hispanics in our study, seeking help from mental health professionals was less likely for those who were married; among African American and other, non-Hispanic minority respondents, marital status showed no significant association with the outcome. For the Hispanic and White women, apparently—although not for women in the other subsamples—emotional and social support from partners lessened perceived need for professional help. Moreover, although older White women tended not to seek help from mental health professionals, among women in our other ethnic minority subsample, age showed no association with seeking help. Despite the numerous between-ethnic group differences just outlined, certain similarities in the outcome’s associations with individual explanatory variables bridged the four subsamples. Across all four, for instance, experiencing a larger number of incidents of physical assault was significantly associated with seeking help from mental health professionals. Physical assault’s uniform effect on help seeking by women across ethnicities perhaps reflects the women’s familiarity with the accounts of beaten women reported by the mass media. At the same time, however, for women in our other ethnic minority subsample, the outcome’s association with physical assault was significantly stronger than it was for our White respondents. It appears that non-Hispanic, non-Black minority women in our study responded more strongly than White women did on experiencing repeated physical assaults by partners. The association between the outcome variable and experienced controlling behavior was weaker in all of our minority subsamples than in the White subsample. When subjected to comparable levels of controlling behaviors, then, the minority women tended to seek help from mental health professionals to a lesser degree than White women did. This may support the authors’ speculation about controlling behaviors’ capacity to affect minority women’s help seeking in negative ways. Among our African American respondents, we observed weaker associations between the outcome and being stalked, physical assault severity, and PTSD symptoms than we observed among Whites we studied. In addition, among Hispanic women as compared with White, we observed a stronger association between the outcome and partner’s threat. In addition, for women in our other ethnic minority subsample, the association of the outcome variable with severe forced sex tended to be stronger than the same association among White women. All of these findings suggest that a woman’s response to IPV—degree of seeking mental health professionals’ help—is shaped both


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by her ethnicity and by the type of violent behavior in which her partner engages. The findings imply that mental health professionals who would promote help seeking in given ethnic groups should focus on the specific IPV experiences involved.

Conclusion The present study successfully applied Aday and Andersen’s behavior model of mental health services utilization and demonstrated that women’s decisions to seek help from mental health professionals were significantly determined by variables representing treatment needs, enabling factors, and predisposing factors. The study observed, generally, that IPV experiences representing women’s need for treatment were associated with likely use of professional mental health services. Furthermore, women with mental health disorders (related or unrelated to their IPV experiences) showed relatively prone to seek mental health professionals’ help. It is thus important that mental health professionals explore whether women clients’ mental health symptoms might be related to IPV. Exploration of this kind appears particularly important in work with low-income or relatively uneducated clients. This study identified distinct patterns of factors associated with four ethnic groups’ likelihood of seeking help from mental health professionals. Knowledge of the patterns might help in tailoring IPV-related intervention to the particular needs of women of particular ethnicities. For example, for African American women in low-income families, mental health intervention might emphasize addressing women’s management of forced sexual behaviors involving a partner. Among low-income African American women as well, preventive intervention and substance abuse treatment might effectively counter IPV, given the potential link observed in this group between IPV and drug use. In working with Hispanic women who are involved in IPV and insured by military/veterans insurance, workman’s compensation, or disability insurance, mental health professionals could focus on the traumatizing experience of being stalked and threatened. Other minority women—of any income and educational level—who are experiencing IPV may need mental health professionals to intervene against a strong tendency to self-medicate with stimulant drugs. Special attention should be given to equipping women from ethnic minorities to recognize early signs of unhealthy controlling behavior and to encourage them to use mental health services if they experience IPV. White women experiencing IPV commonly report being comfortable seeking help from mental health professionals, but especially among those who are undereducated and low-income, seeking help following the first sign of IPV should be encouraged through public education efforts.


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Future researchers might survey women from specific minorities (e.g., Asian Americans, Native Americans) about their help seeking involving mental health professionals. Other important topics for additional research are co-occurring mental health/substance use disorder in minority women and its relation to IPV and the impact of controlling behavior on women’s help seeking from professionals outside mental health, such as police officers and physicians or nurses. 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) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Tyrone C. Cheng, PhD, received the MSW and PhD in social work from the University of Alabama in 1993. He had taught in Southern Illinois University at Carbondale (1993-1994) and University of Alabama at Birmingham (2002-2008). Since 2008, he has been an associate professor and the MSW program chair for the School of Social Work. He had been a social worker, child therapist, and community organizer in Hong Kong, Chicago, Michigan, and Ohio. His research areas include welfare policies, child welfare, substance abuse, and mental health. Recent publications include articles published in Journal of Social Policy, Journal of Health Care for the Poor and Underserved, Journal of Child and Adolescent Substance Abuse, Journal of Interpersonal Violence, Aggression and Violent Behavior, Families in Society—The Journal of Contemporary Social Services, Children and Youth Services


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Review, Substance Use & Misuse, American Journal on Addictions, Journal of Psychoactive Drugs, and Journal of Mental Health. Celia C. Lo, PhD, is a professor in the Department of Sociology and Social Work at Texas Woman’s University. Her research interests include the sociology of drugs and alcohol, disparities in health and in health-risk behaviors, and drugs and crime.


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