The mental health needs of Black women in the US population have been underserved and understudied. Historically, Black women have been underdiagnosed, misdiagnosed, and undertreated for mental health conditions often leading to health and healthcare disparities [1]. Furthermore, Black women experience higher levels of post-traumatic stress and when criteria are met for anxiety disorders, their symptoms are more acute and debilitating compared to their White counterparts [2]. Yet, Black women are less likely to seek or obtain professional mental health treatment [3]. Furthermore, once in treatment, Black women are more likely to be misdiagnosed [4,5,6] and prematurely withdraw from treatment leading to healthcare disparities [1]. While researchers have explored barriers to mental health service use, little is known about how psychological distress may inform help-seeking attitudes among Black women. Help-seeking for psychological distress is a process that is informed by attitudes and past experiences of mental health treatment [7] and is also contextualized by myriad factors (e.g., structural inequities, discrimination, distrust) that impact service use [4]. Given that help-seeking attitudes are a significant predictor of mental health service use [8,9,10], it is important to understand how the relationship between symptoms of psychological distress and attitudes toward seeking mental health services might differ among Black women by past mental health treatment. In this study, we investigated the relationship among symptoms of psychological distress (e.g., anxiety, depression, post-traumatic stress) and attitudes toward seeking professional psychological help (i.e., psychological openness, help-seeking propensity, and indifference to stigma) in a sample of Black women. We also examined if past mental health treatment exacerbated or mitigated these relationships.

Psychological Distress Among Black Women

National estimates have shown that Black people, in general, have a lower lifetime prevalence of mood and anxiety disorders compared to their White counterparts [11, 12]. Despite the lower lifetime prevalence of psychiatric disorders, researchers have found that generally Black people with psychological distress tend to have more persistent mental disorders and more negative attitudes towards professional mental health services [11]. Indeed, findings from previous studies with Black individuals have indicated that more psychological symptoms are associated with less favorable attitudes toward seeking mental health services, such as indifference to stigma [13, 14], which predicts future use of mental health services.

Psychological distress may be one factor associated with more favorable help-seeking attitudes [15]. In general, individuals who have experienced mental health disorders for longer periods tend to experience greater functional impairment, which in turn, may foster a willingness to seek mental health treatment [15]. Moreover, findings from several studies have indicated that psychological distress is associated with a greater likelihood of seeking treatment [15, 16]. Notably, findings from past research have suggested that Black women seek mental health treatment when symptoms are severe and functionally impairing [17]. Due to myriad, complex factors Black women may delay seeking voluntary treatment until they experience more acute mental health disorder symptoms [18, 19].

Help-Seeking Attitudes

While previous findings have enhanced our understanding of help-seeking attitudes among Black individuals [13, 14], it is important to examine help-seeking attitudes among Black women in particular. Black women experience unique stressors that are linked to interlocking systems of oppression and structural inequities, which may increase psychological distress [20,21,22] and influence help-seeking attitudes differently. Moreover, understanding how psychological distress (i.e., symptoms of anxiety, depression, and post-traumatic stress) is associated with mental health help-seeking attitudes (i.e., psychological openness, help-seeking propensity, and indifference to stigma) among Black women is worthy to investigate. For example, these associations may bring an understanding to which psychological symptoms are associated with mental help-seeking attitudes around psychological openness, help-seeking propensity, and indifference to stigma.

Several factors (e.g., cultural mistrust, discrimination, informal sources of support, lack of financial resources, stigma, religiosity/spirituality) have been suggested to account for differences in mental health treatment utilization among racial/ethnic minority groups including Black women [19, 23,24,25,26,27,28]. Furthermore, researchers have suggested that a shortage of affordable, accessible, and culturally competent mental health providers also hinders mental health treatment utilization [29]. As such, some Black women may circumvent mental health treatment to avoid negative experiences [30]. Indeed, researchers have found that some African Americans perceive mental health providers as unhelpful, insensitive, and in some cases harmful [29].

Concerning attitudes toward mental health treatment, findings from qualitative and quantitative research have found that Black women hold negative [19, 31, 32], favorable [33, 34], and nuanced attitudes [35, 36]. For example, Ward and colleagues investigated the attitudes toward mental health treatment and preferred coping behaviors in a sample of 272 African American women and men [19]. Findings demonstrated that African Americans reported low willingness to acknowledge psychological distress, high concerns about stigma, and limited openness to help-seeking. Overall, religious coping was preferred instead of professional mental health services. Furthermore, African American women were slightly more psychologically open and willing to seek mental health services compared to African American men. Researchers did not examine the impact of psychological distress on attitudes toward mental health. Similarly, Watson and Hunter [31] investigated the Strong Black Woman (SBW) Schema, which refers to expectations of strength, helping others, emotional restriction, and succeeding despite limited resources [22, 37, 38], and attitudes toward mental health treatment as a predictor of anxiety and depression symptoms in a sample of 95 African American women. The authors also investigated the interaction between the SBW Schema and help-seeking attitudes in predicting anxiety and depression. Findings revealed that African American women held less favorable attitudes toward professional help-seeking than previous non-African American samples in the domains of psychological openness, help-seeking propensity, and indifference to stigma [31]. Moreover, high indifference to stigma predicted lower levels of anxiety. Psychological openness and help-seeking propensity were not associated with anxiety or depression. Furthermore, help-seeking attitudes did not moderate the association between the SBW Schema and anxiety or depression, respectively.

The Moderating Influence of Past Mental Health Treatment

In general, seeking formal mental health services for psychological distress is not a common practice among racial and ethnic groups in the USA [39,40,41]. For example, in a recent study of help-seeking attitudes and mental health experiences among college students, Black college students were less likely to have pursued professional mental health treatment and reported that they knew fewer people who had psychological treatment or were diagnosed with mental health conditions compared to their White counterparts [39]. Moreover, in a previous research, Black college students have indicated a lower perceived need for mental health treatment when experiencing psychological distress and less confidence in the ability of clinicians to treat mental health conditions compared to their White counterparts [42, 43].

In the general population, previous research findings have also indicated that Black individuals’ experiences with formal mental health services have been mixed [29, 34]. For example, in one study, help-seeking attitudes worsened after receiving treatment than before treatment [34]. While Black women continue to underutilize formal mental health services [44], there has been increased visibility (e.g., Boris Lawson Henson Foundation, Therapy for Black Girls) on destigmatizing mental illness and promoting mental health treatment among Black women [45]. However, other studies have found that Black college students who experienced mental health treatment had more favorable help-seeking attitudes compared to those who had not been treated [42, 43]. Thus, it is plausible that past mental health treatment may moderate the relationship between psychological distress and attitudes toward seeking mental health services.

Current Study

Black women’s symptoms of psychological distress and factors which influence professional help-seeking warrant increased attention [4, 46, 47]. While previous research with White participants has shown that psychological distress is associated with help-seeking attitudes, little is known about this relationship with Black women. In prior studies, symptoms of depression, anxiety, post-traumatic stress, and previous mental health treatment have not been included as predictors of attitudes towards professional psychological help-seeking simultaneously. This is important because previous research has not explored these variables and there are mixed findings concerning the relationship between prior treatment and help-seeking attitudes [29, 34, 42]. To address this gap, we examined the relationship between symptoms of psychological distress (e.g., depression, anxiety, and post-traumatic stress) and attitudes towards seeking professional psychological services (i.e., psychological openness, help-seeking propensity, and indifference to stigma). We also examined if past mental health treatment (i.e., counseling or therapy) moderated the relationship between symptoms and help-seeking attitudes.

Method

Participants

The sample for the current study included 205 self-identified Black women. Participants were ages 18 to 70 and the mean age of the sample was 34.23 (SD = 11.43). The majority of the sample was heterosexual (88%) and 12% identified as lesbian, gay, or bisexual. Seventy-two percent of participants had a bachelor’s degree or higher. Participants’ annual household income ranged from less than $29,999 to more than $100,000. Nearly 55% of the sample reported an annual household income of over $50,000. Approximately 44% of the sample reported having received mental health treatment (i.e., counseling or therapy) for a mental health condition.

Measures

Anxiety

Symptoms of anxiety were measured by the Generalized Anxiety Disorder 7-item Scale (GAD-7; [48]). The GAD-7 consists of 7 items that assess self-reported symptoms and severity of anxiety over the last 2 weeks. Example items include “feeling nervous, anxious, or on edge” and “trouble relaxing.” Responses ranged from 0 = not at all to 3 = nearly every day. The GAD-7 total score for the seven items ranges from 0 to 21 with higher scores representing a greater endorsement of anxiety symptoms. The GAD-7 has been used with good consistency in previous research with African Americans [49]. The scale demonstrated excellent internal consistency for this sample (α = .91).

Depression

Symptoms of depression were measured by the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R; [50]). The CESD-R consists of 20 items that assess self-reported symptoms defined by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V) for a major depressive episode. Example items include “I could not shake off the blues” and “I felt depressed.” Responses ranged from 0 = not at all or less than one day to 4 = nearly every day for two weeks with higher scores representing a greater endorsement of depressive symptoms. Mean scores were used with higher scores representing a greater endorsement of depressive symptoms. The CESD-R is a reliable and valid measure of depressive symptoms among African Americans [51]. The scale demonstrated excellent internal consistency for this sample (α = .95).

Post-traumatic Stress

Symptoms of post-traumatic stress were measured using the PTSD Checklist for DSM-V (PCL-5; [52]). The PCL-5 is a 20-item measure that assesses self-reported symptoms of post-traumatic stress. Participants were asked to indicate how much they have been bothered by symptoms in response to a very stressful experience in the past month. Example items include “Feeling very upset when something reminded you of the stressful experience” and “Avoiding memories, thoughts, or feelings related to the stressful experience.” Responses ranged from 0 = not at all to 5 = extremely. Mean scores were used and higher scores represent greater symptoms of post-traumatic stress. The PCL-5 has been used in previous research with African Americans (e.g., [53]). The scale demonstrated excellent internal consistency for this sample (α = .95).

Attitudes Toward Seeking Mental Health Services

The Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS; [54]) was used to assess attitudes towards seeking mental health services. The IASMHS was adapted from The Attitudes Toward Seeking Professional Psychological Help (ATSPPH; [55]) scale and updated to reflect the gender-inclusive language and the extent to which aspects of help-seeking should occur or not occur [54]. The IASMHS is a 24-item measure with 3 subscales: psychological openness, help-seeking propensity, and indifference to stigma. The psychological openness subscale assessed the extent to which individuals were open to acknowledging psychological problems and the possibility of professional help-seeking for these problems. An example item included “People should work out their problems; getting professional help should be a last resort.” The help-seeking propensity subscale measured participants’ willingness to seek professional psychological help. One example item was “If I were to experience psychological problems, I could get professional help if I wanted to.” Finally, the indifference to stigma subscale assessed the extent to which participants perceived others might view their experiences of psychological distress and help-seeking. An example item included “I would be uncomfortable seeking professional help for psychological problems because people in my social or business circles might find out about it.” Responses ranged from 0 = disagree to 4 = agree. All negatively worded items were recorded so that higher scores represent more positive attitudes. The IASMHS has been used in previous research with African Americans [31]. The psychological openness (α = .78), indifference to stigma (α = .77), and help-seeking propensity (α = .79) subscales demonstrated good internal consistency for this sample (Table 1).

Table 1 Summary of means, standard deviations, correlations, and reliability for study variables
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Demographic Measures

Participants provided information regarding age, sexual orientation, annual household income, education levels, and experience with mental health treatment.

Procedure

Participants were recruited using convenience sampling of Black women from national professional, community, and civic organizations in the USA that focus on Black individuals. Participants were invited to take part in this study via email communication, which included a brief description of the study, the eligibility criteria (i.e., self-identification as a Black woman and 18 years of age or older) for inclusion in the research, contact information for the principal investigator, and the web address to complete an online survey. Participants were informed that the study requirements included the completion of several questionnaires about Black women’s mental health and perceptions of help-seeking. After providing informed consent and verifying eligibility, participants completed the online Qualtrics survey. All participants were entered into a raffle to receive one of ten $50.00 gift cards to be received via email. Data were collected as part of a larger study on Black women’s mental health, and only measures used in the current study are discussed. The university institutional review board approved this research.

Data Analysis Approach

We examined normality, skewness, and kurtosis for all variables of interest in this study. All variables were deemed fit for analyses. Next, we conducted several one-way analysis of variance (ANOVA) models to determine if there were statistically significant differences in attitudes toward seeking professional psychological services (i.e., psychological openness, indifference to stigma, and help-seeking propensity) by all demographic characteristics (e.g., annual household income, education). All significant differences in ANOVA models were explored using Tukey’s post hoc analyses and controlled for in subsequent analyses. We ran bivariate Pearson correlations to investigate the relationship between our variables of interests, including age, which was measured as a continuous variable. Finally, we conducted a series of nine separate moderation analyses, controlling for age and education, with psychological openness, indifference to stigma, and help-seeking propensity as the dependent variable and symptoms of psychological distress (i.e., anxiety, depression, and post-traumatic stress) as the independent variable. For all moderation analyses, we used 5000 bootstrap estimates. Interactions were probed if p < .05 with conditioning values of the predictor at 1 standard deviation above and below the mean. All statistical analyses were conducted in SPSS Version 26.0; moderation analyses, including syntax and data for probing and visualizing interactions, were generated in PROCESS Macro Version 3.1 in SPSS Version 26.0 [56, 57].

Results

Preliminary Analyses

Positive attitudes toward seeking mental health services (i.e., psychological openness, indifference to stigma, and help-seeking propensity) did not differ by income or sexual orientation. However, there were significantly lower levels of indifference to stigma among participants who reported having a high school diploma/GED or less (M = 18.88, SD = 8.15) compared to those with a bachelor’s degree (M = 24.00, SD = 5.84). Similarly, help-seeking propensity was lower among participants who reported having a high school diploma/GED or less (M = 19.88, SD = 6.76) compared to those with a Bachelor’s (M = 24.17, SD = 6.10) or graduate degree (M = 24.69, SD = 5.87) (Table 2). Furthermore, help-seeking propensity differed by past mental health treatment such that those who reported having past mental health treatment (M = 26.17, SD = 5.18) had higher help-seeking propensity compared to those who reported never having had past mental health treatment (M = 23.42, SD = 6.15).

Table 2 Psychological distress, past mental health treatment, and professional attitudes toward seeking professional psychological help
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Bivariate Pearson indicated significant inverse associations between depression and post-traumatic stress respectively and all positive attitudes toward seeking professional psychological services. Specifically, increased symptoms of depression (r = −.15, p = .038) and post-traumatic stress (r = −.24, p = .001) were associated with decreased psychological openness. Symptoms of depression (r = −.36, p ≤ .001) and post-traumatic stress (r = −.38, p ≤ .001) were negatively associated with indifference to stigma. Symptoms of depression (r = −.26, p ≤ .001) and anxiety (r = −.25, p ≤ .001) were also negatively associated with help-seeking propensity respectively. Anxiety symptoms were negatively associated with indifference to stigma (r = −.26, p ≤ .001) and help-seeking propensity (r = −.25, p ≤ .001) only. With regard to demographic characteristics, there were negative associations between age and all symptoms of psychological distress (i.e., anxiety, depression, and post-traumatic stress). Furthermore, age was positively associated with help-seeking propensity (r = 0.21, p =.004) and indifference to stigma (r = 0.18, p = .013).

Symptoms of Anxiety

Symptoms of anxiety were not associated with psychological openness while controlling for age and education. However, there was a significant relationship between anxiety and indifference to stigma (B = −0.44, p ≤ .001) and help-seeking propensity (B = −0.32, p = .002). Past mental health treatment did not moderate the relationship between anxiety and indifference to stigma or help-seeking propensity respectively.

Symptoms of Depression

Symptoms of depression were not associated with psychological openness when controlling for age and education. However, depression was negatively associated with both indifference to stigma (B = −0.21, p ≤ .001) and help-seeking propensity (B = −0.13, p ≤ .001). In addition, past mental health treatment moderated the relationship between depression and indifference to stigma (B = 0.12, p = .019) and help-seeking propensity (B = 0.10, p = .025) respectively. Probing the interactions for depression revealed a significant decline in favorable attitudes (i.e., indifference to stigma) at increased levels of depression for participants who did and did not report having had past mental health treatment. Furthermore, at high levels of depressive symptoms, participants who reported having had past mental health treatment had higher levels of indifference to stigma compared to participants who did not report having had past mental health treatment (see Fig. 1). With regard to help-seeking propensity, there was a significant decrease in this favorable attitude only for participants who reported not having had past mental health treatment. Specifically, when symptoms of depression were high, there were significantly lower levels of the help-seeking propensity among participants who had not reported having had past mental health treatment (see Fig. 2). There was no significant decline in help-seeking propensity among participants who reported having past mental health treatment.

Fig. 1
figure 1

Moderation of depression on indifference to stigma by past mental health treatment

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Fig. 2
figure 2

Moderation of depression on help-seeking propensity by past mental health treatment

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Symptoms of Post-traumatic Stress

Symptoms of post-traumatic stress were negatively associated with psychological openness (B = −0.13, p = .001), indifference to stigma (B = −0.21, p ≤ .001), and help-seeking propensity (B = −0.10, p = .007) when controlling for age and education. Past mental health treatment did not moderate the relationship between symptoms of post-traumatic stress and psychological openness or help-seeking propensity respectively. However, past mental health treatment did moderate the relationship between symptoms of post-traumatic stress and indifference to stigma (B = 0.13, p = .011). Probing the interaction between past mental health treatment and symptoms of post-traumatic stress revealed a significant decline in favorable attitudes (i.e., indifference to stigma) at increased levels of post-traumatic stress for participants who did and did not report having had past mental health treatment. However, at increased symptoms of post-traumatic stress, participants who reported having past mental health treatment had higher levels of favorable attitudes (i.e., indifference to stigma), compared to those who did not report having had past mental health treatment (see Fig. 3).

Fig. 3
figure 3

Moderation of post-traumatic stress on indifference to stigma by past mental health treatment

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Discussion

Overall, findings may highlight the reluctance (via less favorable attitudes towards professional psychological services) that exists around seeking care for symptoms of depression, anxiety, and post-traumatic stress in the Black community. The finding for this sample of Black women may also be consistent with the majority of previous research with Black communities, which has shown a general mistrust of mental health services wherein help-seeking is delayed until individuals experience acute mental health episodes. For example, in previous studies with Black college students, increased psychological distress was associated with less favorable help-seeking attitudes. Our findings support and extend this research by highlighting how a community sample of Black women may have similar views when experiencing symptoms of depression and post-traumatic stress, as it pertains specifically to psychological openness, help-seeking propensity, and indifference to stigma. Interestingly, anxiety was not associated with a decreased willingness to seek professional help. This may be due to the specific symptom profile that exists with post-traumatic stress and depression (e.g., negative alterations in mood/cognitions, dysphoria, guilt/shame) compared to anxiety [58]. These common symptoms of PTSD and depression such as dysphoria and negative cognition may be more likely to limit psychological openness and help-seeking compared to symptoms of anxiety.

Findings also highlight how past mental health treatment (i.e., counseling or therapy) mitigated the relationship between symptoms of depression and post-traumatic stress and attitudes towards professional psychological help. These findings contradict results from a previous national study where help-seeking attitudes among Black individuals worsened after receiving treatment [34]. Interestingly, our findings support results from a previous study with college students where help-seeking attitudes were more favorable compared to those who did not receive mental health treatment [42]. Similar to the sample of college students, this sample of primarily well-educated women may have access to better and more culturally responsive treatment. This is important as previous research has noted gaps in experiences of stigma and microaggressions based on socioeconomic status, type of insurance (e.g., public vs. private), and level of cultural responsiveness of clinicians [59,60,61]. This highlights that it may be how Black women are treated in therapy that predicts their subsequent treatment attitudes and the need for cultural responsiveness for all clients regardless of social status.

Overall, these findings contribute to the literature on the links among psychological distress, attitudes towards professional psychological help services, and mental health help-seeking behaviors. Whereas previous research suggests psychological distress is associated with increased help-seeking in the general community [18], the results of this study demonstrate that this association may not hold with this sample of Black women. This is an important consideration given the healthcare disparities and historical mistreatment of Black people in general and Black women in particular by mental health professionals. Notably, Black men experience state-sanctioned violence, healthcare disparities, and discrimination by the healthcare system. Yet, we focus on Black women, not to exclude or minimize Black men’s experiences but rather to focus on Black women’s experiences specifically. For example, it is well-documented that Black women face mental health stressors stemming from interlocking systems of oppression, including racism and sexism in society [15, 16]. However, Black women are less likely than their White counterparts to seek mental health help [3].

There are several implications from this literature. First, the results of this study demonstrate the need for greater outreach efforts to offer counseling and therapeutic services to Black women. Given that they are less likely to seek professional help when experiencing mental health symptoms, providers and community organizations need to increase prevention and outreach services in an effort to offer screenings, market their services, and help alleviate barriers to psychological care (i.e., lack of transportation, lack of insurance). Additionally, this research did demonstrate that past mental health treatment was correlated with an increased willingness to seek professional psychological services when experiencing psychological distress. Moreover, this may show that this sample of Black women is experiencing therapy as beneficial given their favorable attitudes toward help-seeking when under psychological distress. More research is necessary to determine what factors in therapy (e.g., cultural humility, empathy, decreases in symptoms) may be related to Black women’s attitudes toward help-seeking.

Altogether, Black women have been overlooked and mistreated by psychological professionals [1]. To help address this history, researchers and clinicians must do more to advocate for Black women and offer specialized services that meet their unique needs. Clinicians can become aware of the historical mistreatment of Black women and the stigma in the Black community, which Black women may hold as well, towards mental health. Clinicians can help address this stigma by utilizing culturally responsive models of treatment infused with a Black feminist/womanist perspective, which acknowledges systemic barriers and interlocking systems of oppression that Black women experience and seeks to empower Black women [62]. Additionally, clinicians and researchers alike can emphasize cultural humility, defined as an other-oriented professional stance that emphasizes openness, curiosity, and relationship building [63]. Future research should focus on examining the relationships between symptom severity and attitudes towards help-seeking with other mental health disorders (e.g., suicidality, psychosis, substance use). Lastly, researchers could examine other factors that may influence attitudes towards professional help such as peer norms and relationships.

Limitations and Strengths

There are several limitations to this investigation worth noting. First, this study includes a convenience sample of Black women. Thus, the ability to generalize findings to Black women in the general population is limited. Second, participants provided self-reported data, which might reflect either underreporting or overreporting on variables of interest (e.g., symptoms of anxiety depression, and post-traumatic stress). Third, participants were asked about lifetime and not current use of counseling or therapy to treat a mental health condition. Therefore, it is unclear how current symptoms of psychological distress and attitudes toward professional psychological services would be impacted by the current endorsement of mental health treatment (i.e., counseling or therapy). As data were cross-sectional, we neither make causal claims nor do we make any inferences about the directionality or longitudinal nature of these associations. Fourth, over 70% of Black women in this study had at least a college degree and over 50% reported annual incomes over $50,000. Thus, the findings in this investigation may not reflect the experiences of psychological distress, help-seeking attitudes, and mental health treatment utilization of Black women with less educational attainment and income.

Despite these limitations, this study has several strengths. First, the current study focuses on Black women’s current symptoms of psychological distress and attitudes toward professional psychological services and the impact of past mental health treatment. We deem this important as favorable attitudes toward seeking professional psychological services are a proxy and significant predictor for future service use [8, 9]. Second, this study included a diverse range of Black women concerning age, sexual orientation, and national origin (e.g., some participants identified as Black, which may not necessarily include African Americans). For example, in previous studies on help-seeking attitudes, many of the samples included aggregate data from college students, which is informative, but may not capture the unique experiences that Black women experience. Furthermore, researchers have found that Black sexual minority women are at increased risk for mental health conditions and have unique stressors and experiences at the intersection of racism, sexism, and heteronormativity. Future research should continue to explore mental health treatment utilization among Black women.

Conclusion

An increase in outreach efforts to reach Black women who may be reluctant to utilize mental health treatment (e.g., counseling or therapy) is of continued importance [29]. Further research is also needed to explain the underlying mechanisms of how symptom severity and attitudes influence Black women’s choices with regard to mental health treatment, and whether there are differences in treatment engagement based on specific symptoms or disorders. By understanding psychological antecedents and contextual factors associated with help-seeking for psychological distress among Black women, we may enhance efforts to reduce racial and ethnic healthcare disparities for Black women.