Sexual Assault Survivors’ Experiences with Mental Health Professionals: A Qualitative Study

Abstract

An interview study of 15 sexual assault survivors’ narratives examined positive and negative post-assault experiences with mental health professionals. Survivors who told one professional had more positive experiences than those who told multiple professionals. Qualitative analyses revealed how help seeking experiences were related to the context and nature of disclosures, survivors’ readiness to disclose, trust building, social reactions received from providers, type of therapy, perceived control over recovery, and mental health system factors impacting access and quality of care. Themes from survivor’s accounts illustrate how survivors perceived therapists, which can be used in training mental health professionals encountering survivors in clinical settings.

Survivors of sexual assault (SA) often experience increased psychological symptoms, including anxiety, posttraumatic stress disorder, depression, low self-esteem, and social adjustment difficulties as a result of the attack (Campbell, Dworkin, & Cabral, 2009). Following SA, less than 35% of women turn to mental health professionals for help in dealing with psychological symptoms (Coker, Derrick, Lumpkin, Aldrich, & Oldendick, 2000; Foa, & Riggs, 1995; George, Winfield, & Blazer, 1992; Golding, Siegel, Sorenson, Burnam, & Stein, 1989). Despite this low rate of mental health professional help-seeking, many women disclose SA to informal support sources (e.g., friends, family, partners), yet often delay doing so, in some cases for years (see Ullman, 2007 for a review). Researchers showed that previous experience with mental health help, availability of insurance, and depressive symptoms predict women’s mental health help seeking after SA (Price, Davidson, Ruggierio, Acierno, & Resnick, 2014). Some data suggested that receipt of sustained mental health support may decrease psychological symptomatology in rape survivors (Campbell, Sefl, Barnes, Ahrens, Wasco, & Zaragoza-Diesfield, 1999).

When applying ecological theory to the understanding of SA, one can observe the different ways that specific systems (individual, assault, micro-, meso-, and macrosystems, along with the chronosystem) all affect and are affected by each other (see Campbell, Dworkin, & Cabral, 2009 for review). For example, researchers showed certain factors correlate with perceived helpfulness and satisfaction with mental health professionals (microsystem factors) when seeking help for SA. Starzynski and Ullman’s (2014) multivariate analysis of data from 200 SA survivors showed that older age (individual factor), higher PTSD, greater control over recovery (all post-assault individual level factors), and receiving more emotionally supportive reactions to assault disclosure (microsystem factor) were associated with positive perceptions of mental health professionals (microsystem factor). On the other hand, stranger assailants, greater victim resistance during assault (assault factors), greater victim post-assault distress (post assault individual level factor), and receiving blaming social reactions (microsystem factor) in general were associated with negative perceptions of mental health professionals (microsystem factor).

More in depth research is needed to understand what happens when victims of SA encounter mental health professionals. Australian researchers found that mental health workers responding to survivors had not had adequate SA training and rarely referred women to mental health professionals specializing in SA recovery (McLindon & Harms, 2011). On the other hand, adolescent SA victims reported positive experiences with well-trained SA Nurse Examiners (SANEs) (Campbell, Greeson, & Fehler-Cabral, 2013). Although promising, research has yet to investigate women’s positive and negative experiences with mental health professionals after disclosing SA in their own words (Campbell, Dworkin, & Cabral, 2009).

Present Study

The purpose of this qualitative study was to examine women’s experiences disclosing SA to mental health professionals using ecological theory of SA (Campbell et al., 2009; Schreiber, Renneberg, & Maercker, 2009). Our goal was to identify possible patterns that might help to understand women’s experiences disclosing SA to mental health professionals, specifically (a) reactions they received, (b) how they felt about those reactions, and (c) effects on future disclosures and recovery. An ecological theoretical framework was used to examine interviews of women’s accounts of their experiences seeking help from mental health professionals (Campbell et al., 2009). Interview data was used from the Women’s Life Experiences study (Ullman, 2010) in which women described their experiences disclosing SA to various social support sources, including a specific focus on mental health professionals. These semi-structured interviews asked about the specific social reactions mental health professionals made to survivors’ disclosures and how women appraised those reactions in relationship to their recovery. Prior research has not delved into women’s experiences with mental health help post-assault, but this information is vital for therapists, given that training is often not adequate (Campbell & Raja, 1999).

Method

Sample and Procedure

Data were part of a larger convenience sample study of women’s unwanted sexual experiences in the Chicago metropolitan area. Fliers and advertisements were posted at universities, in the community, bookstores, at mental health agencies, and rape crisis centers. Fliers and newspaper ads invited women age 18 or older with unwanted sexual experiences since age 14 to participate in a paid mail survey. Women completing the survey (N = 1,084) were invited to participate in a follow-up in-depth tape-recorded interview at a convenient time and place, usually their homes. Interviews were 45 minutes to 2.5 hours and were transcribed.

Of the 33 women completing interviews, 15 women reported disclosing SA to mental health professionals, and only these interviews were analyzed in this study. It is important to note that when women were asked about “mental health professionals,” they answered the questions based on their understanding of what mental health professionals were; thus, this was participant-defined, and the definition of “mental health professional” could mean psychologists, psychiatrists, social workers, or other counselors.

Demographics

Women in the interview subsample were age 19 to 55 and were all assaulted in their teens or early 20s by known offenders. Nine were Caucasian, five African American, and one Latina. Nine women identified as heterosexual, one lesbian, four bisexual, and one unsure. Over half had a college degree or more education; three were still in school. Ten women had annual incomes of $20,000 or less.

Assault characteristics

All women described their SAs in some detail and were at least acquainted with the rapist at the time of assault. Nine women had multiple SA experiences.

Post-assault sequelae/help-seeking

Five women described being very depressed post-assault, and two said they had PTSD due to SA. Ten reported that they drank or used other substances to numb feelings associated with assault, and three had eating disorders due to SA. Of the 15, two saw only one mental health professional they told about SA, three saw multiple professionals, but only disclosed to one, as two weren’t ready to disclose initially and one had already dealt with the assault and was seeking help for other issues. The remaining 10 women disclosed SA to multiple mental health professionals with mixed results.

Semi-structured interviews began with researchers inviting women to discuss their SA experiences, if they felt comfortable doing so, followed by questions about women’s experiences disclosing SA to others (including specifically asking about mental health professionals). Participants were allowed to diverge from questions as they shared their experiences, an ethical approach for research on highly sensitive topics, so women were not just providing “raw data,” but were actively sharing their stories (DeVault, 1999). The validation strategy that was used was prolonged engagement of the interviewer during the interview process (Creswell, 2003).

Analysis Strategy

Qualitative analyses were conducted using deductive qualitative content analysis (Mayring, 2000) informed by ecological theory of SA (see Campbell et al., 2009; Schreiber et al., 2009). Survivors’ discussions of their lives, including (a) age, (b) race, (c) previous relationships with friends and family, and (d) preexisting mental health issues, were coded as individual factors. Discussion of the details of the assault (if the survivor wished to disclose them to the interviewer) was coded as assault factors. Survivors’ discussions of disclosure of SA to friends and family were coded as microsystem factors, whereas disclosure to formal support sources (police, medical doctors, etc.) were coded as macrosystem factors. Discussion of disclosure to mental health professionals was separated and analyzed independently from the other macrosystem factors. Finally, (a) post-assault events, (b) physical responses to assault, (c) psychological responses to assault, and (d) reactions from social support sources were coded as post-assault experiences.

The social reactions that survivors received from members of their support network were coded based on categories from the Social Reactions Questionnaire (Ullman, 2000). This was done to help categorize the social reaction as either positive (e.g., emotional support, tangible support) or negative (e.g., victim blaming, egocentric responses) and in what way. Women’s emotional responses to those reactions, coping strategies (i.e., adaptive, maladaptive), and psychological symptoms were also coded. Coding decisions for demographics, assault factors, disclosure, and social reactions were objectively coded based on information from the interviews. Coding decisions for emotional responses were subjectively based on the specific vocabulary used by women in self-reporting symptoms (e.g., if they mentioned being depressed or anxious).

Then, we drew on Glaser and Strauss (1967)’s constant comparison method of qualitative analysis in developing working categories to assess survivors’ overall satisfaction with mental health professionals. Two categories emerged: positive experiences with mental health professionals and negative experiences. Different ecological factors were examined in differentiating between positive and negative experiences. These factors included (a) individual (e.g. coping, mental health), (b) microsystem (e.g. help-seeking experiences including social reactions received), and (c) macrosystem (e.g. attitudes expressed by mental health professionals) factors. Satisfaction with survivors’ mental health help-seeking experiences were determined based on expressed feelings from the survivors.

Results

Analyses showed different patterns of experiences for women revealing whether they were a good match with their mental health professional or not. This pattern was exhibited by (a) disclosing to only one mental health professional and (b) for those telling multiple professionals; thus, results are presented for these groups separately. Names and identifying details were changed to protect confidentiality.

Women Disclosing to One Mental Health Professional

Two women had seen only one mental health professional since the SA and had very positive experiences. One woman described successfully finishing therapy years prior to the interview, and another woman was still actively involved in therapy with a counselor she liked and respected. Both women discussed feelings of depression and anger before therapy and how therapy helped them. Adrienne, a 23 year-old African American woman, sexually assaulted both at work and date raped by an acquaintance, said therapy has been the most helpful thing in her recovery process. She appreciated not just being medicated for her depression and having an understanding, helpful therapist. She felt that everyone involved in her care was working to help her so she could eventually move past therapy:

I would say having a therapist that sees wellness as being very multi-faceted and more than just giving you a pill. My therapist totally gets that I don’t want to just take this pill, that I need it to be a process. The goal is to get me to the next process. I don’t want this to be it…Or going to therapy for the rest of my life.

Adrienne felt her therapist was a good fit for her recovery because she was non-judgmental and understanding of her perspective and experience and challenged some of her maladaptive beliefs about her assault and everyday life damaging to her mental health. With therapy and depression medication, Adrienne was optimistic that she would move beyond needing therapy in the foreseeable future.

Like Adrienne, Caroline (Caucasian, 22 years old) experienced date rape by a boyfriend at age 14, but had a very positive experience with a mental health professional she saw soon after the assault. Caroline refused to disclose her experiences initially to anyone and even tried to persuade herself that she had not been sexually assaulted. Over time, her personality changed from a cheerful, happy person to being argumentative and disrespectful to her family. Although her parents wanted her to get help, Caroline initially refused, but then went to therapy at a women’s clinic because of mood and personality changes. Although reluctant to talk to the counselor at first, she eventually opened up.

I wouldn’t talk to the counselor for multiple sessions. I would just sit there for like half an hour, 45 minutes, and finally, I thought, ‘Okay, this lady may be able to help me get [recent ex-boyfriend] away from me.’ Even though that wasn’t the same person I needed help with, by trusting her with that situation, I was able to start talking about the rape. I could tell her that I did not really understand what happened to me. She told me I was okay, so I trusted her and think I saw her 4 or 5 times after that. She never questioned me or said, ‘Oh, you don’t remember, so that means you really don’t have anything wrong.’ She just believed me and seemed to understand what I was saying even though I did not really know what I was saying to her.

Through the counselor’s commitment and interest in her, Caroline was able to trust and understand the date rape was truly SA and she was justified in feeling angry and depressed. By having the therapist validate her experience, she was able to move on with her life. After counseling, Caroline said she was able to be a happier person and felt better because the counselor helped her see it was not her fault. She has not had any other kind of therapy since this positive experience and describes herself as recovered from the date rape largely due to this counselor from the women’s clinic.

Adrienne and Caroline have different ethnic backgrounds and SA experiences, but both were able to find mental health professionals who treated them with kindness, understanding, and without negative judgment. They both spoke in glowing terms about their counselors’ commitment to them and their SA recovery. Because they both experienced few negative reactions and felt that their therapists truly had their best interests at heart, a level of trust was built, which gave them confidence about the mental health care they received. By finding a good match in their mental health professional, they no longer had to continue to look for help. Like the women who saw and disclosed to one mental health professional, the three women who saw more than one mental health professional, but disclosed assault to only one, also described their experiences with mental health professionals as mostly positive.

Women Who Saw Multiple Mental Health Professionals, But Disclosed To Only One

Three women saw multiple professionals, but only told one about the assault. Beatrice, a 55 year-old African American woman sexually assaulted by an acquaintance at 15 and molested by siblings in childhood, described the first time she disclosed her assault to a counselor in prison several years later. She had been court-mandated to counseling for drug addiction and found the counselors very helpful. They told her that she needed to deal with the pain of the assault or she would never heal and would probably continue to use drugs to numb that pain. Beatrice stated: “She was there to help me. It was brought to my attention that I couldn’t get well, if, for instance, I had a cut and did not clean it with peroxide, then no healing would take place.” She appreciated that the counselor responded with compassion and was there to help her so she could trust what that counselor told her and accept that she was not a bad person and did not deserve the pain she experienced earlier in life. Beatrice felt this counselor opened her eyes to how she had been wronged. When seeking counseling later in life for other issues, she did not need to disclose SA because the first counselor had helped her recover.

On the other hand, some women were not yet ready to disclose the first time they sought mental health help. Like Caroline, Sylvia (Caucasian, 55 years old), who was sexually assaulted by an acquaintance in college, was taken to the YWCA shortly after the assault. Unlike Caroline, Sylvia refused to disclose initially or to return as she felt uncomfortable with the YWCA counselor and was not ready to open up. Sylvia stated: “I did not feel comfortable talking to her. I was just, you know, we did not click well. And my mom was sitting there with me, too.” Sylvia’s mother already knew about the SA, which had spurred her to take Sylvia to the counselor. Yet, Sylvia was not comfortable disclosing to the therapist with her mother in the room. Although most therapy is done privately and confidentially, Sylvia’s YWCA counselor allowed her mother to stay for the session, which likely prevented her from trusting her therapist to help her recover so she did not return for further counseling. Later that year, Sylvia and her family started family counseling because of an issue with one of her parents, and during one-on-one time with the therapist, she felt comfortable enough to disclose the SA. This counselor built a relationship so Sylvia felt she could trust him enough to disclose the assault. She considered his advice and counseling beneficial and continued seeing him for years for other issues as they arose. She said, “I’ve had other issues down the road and have come back to him for some peace.”

Olivia, a 42 year-old Caucasian woman who was assaulted by an acquaintance at a party, also did not feel ready to disclose SA to the first mental health professional she saw. After being raped, she developed anorexia that she described as an unconscious effort to “de-sex” her body and was hospitalized. Her parents asked her to see a psychiatrist friend, who she thought was unhelpful as he dealt with children and was too connected with her parents.

I think he was the wrong person for me, but my parents did not know what to do, so I went. Probably a lot of factors made me feel it was an unhelpful experience; also I wasn’t ready to deal with it.

Because she felt the eating disorder counselors could not help her, she did not trust them enough to take their advice and refused to disclose her SA to them. Later, Olivia decided she needed to discuss her SA and joined a YWCA survivors’ therapy group where she thrived, even taking on what she described as a leadership role during group therapy activities. She did not feel individual counseling was helpful as her ideas about SA differed from her counselor’s, and she did not appreciate being told she was “too smart” for the counselor to help. Olivia said, “I felt like she did not even have confidence in herself and couldn’t help me. I really don’t think that I had much confidence in her ability to help me, either.”

Fortunately, Olivia worked hard to make her YWCA experience positive by taking an active role in her recovery despite negative experiences with professionals. She was ready for therapy on her terms, which helped her move forward. Although individual therapy was part of her experience, she much preferred the feeling of community she got from group therapy.

Women Disclosing SA to Multiple Mental Health Professionals

Most women disclosing to only one mental health professional (n=5) had positive experiences; however, multiple disclosures led to more opportunities for negative reactions from different mental health professionals. We now present results from women disclosing to two or more mental health professionals (n=10). Two women had only positive disclosure experiences, and two had generally positive experiences compromised by the need to keep switching therapists because of health insurance requirements. Three others had overwhelmingly negative experiences with mental health professionals, and three more had mostly negative experiences, but kept looking until they found someone helpful.

Positive experiences disclosing to multiple mental health professionals

Zoe, a 27 year-old African American woman sexually assaulted the first time she tried prostitution, attempted suicide some years later. While in the hospital recovering, she talked to a very understanding counselor about various issues that led to her attempt, including the SA in detail, and the counselor responded with what Zoe felt was supportive advice. When asked what the counselor said, Zoe said:

Something about needing to change my lifestyle. He said not using drugs doesn’t guarantee that something like that wouldn’t happen again, but changing my lifestyle would be helpful so I wouldn’t have to go through that type of situation again.

Even though this was only one session with this counselor during a time of extreme crisis, Zoe felt he really understood and was trying to help her by letting her know that once she was able to quit drugs, she would have a different life where she would be less vulnerable to SA. She also disclosed in group therapy at a drug detox center and found that sharing her experiences with other women with similar experiences gave her a community of support. Zoe had positive experiences with both mental health professionals she told, both of whom showed support and understanding of her life and experiences. In addition, the women in group therapy were instrumental in helping her move past her self-blame for the assault.

Nicole (Caucasian, 46 years old), who was raped by her boyfriend, had generally positive experiences disclosing her SAs to various mental health professionals. Although she felt unwelcome by some groups or therapists, specifically when seeking help for domestic violence, Nicole was experienced enough to leave therapists she did not get along with.

It’s really amazing what therapists can do and how important they are to people. I’ve been in therapy for so long and know a good therapist in no time flat. I have two friends with bad experiences where the therapist just sat there not saying a thing. I told them don’t give up on therapy, that’s just a bad therapist.

Even though Nicole did not disclose assault to every therapist she saw because sometimes she felt they would not react positively, she found mental health professionals helpful to recovery. She needed a certain level of trust and to know therapists well enough to predict how they would react to SA and was very careful about what she said to different therapists to avoid personality conflicts and negative reactions that would harm her recovery. Overall, she believed women could greatly benefit from good therapy, and through her experiences, she learned what to look for in therapists and was savvy enough to know when to leave or to disregard therapists’ negative reactions.

Positive mental health seeking worsened by external forces

Two women discussed neutral or positive experiences with mental health professionals. However, constraints in the mental health system compromised their experiences as they either did not have enough time to even start discussing SA or had to change therapists and re-start building rapport and trust all over again, which wasted time in sessions, just to get back to the place they were with the previous therapist. Lack of adequate time and having to switch therapists were frustrating.

Laurel (Caucasian, 42 years old) had two separate acquaintance rapes and had seen many different therapists in life due to experiencing many traumas as a child and young adult (both parents died, drug addiction) so did not get a chance to discuss SA with her therapists.

This insurance system makes it harder, so is it really worth it? What happened with me was interesting because my therapist left because he was an intern but he was great and said it was important to hook me up with someone there to continue, but there’s a big long gap. Six weeks later someone else called saying they were ready to see me, but I said no and did not continue. So, there a lot of flaws in the system that might end up causing someone great pain.

Laurel discussed feeling disconnected from her body due to SAs and the other traumas and, as a result, often downplayed the extent to which the SAs actually affected her. When disclosing to others, she acted as if it were no big deal, which she said led others to also treat it as no big deal. However, Laurel felt that if given more time with each therapist, she might have talked more about being disconnected from her body and impact of the assaults. She said she might have been more open also if therapists pressed her on the subject more. Despite this, she appreciated most of her therapy experiences, just feeling she would have benefited much more from consistent, long-term therapy.

Penelope (African American, 45 years old) was assaulted numerous times by family members in her teens and had similar experiences with mental health professionals. She also experienced many traumas, including a murdered parent and friends’ unexpected deaths. Cumulative stress resulted in a breakdown and her being institutionalized for a time. After stabilizing, Penelope bounced from therapist to therapist for years, experiencing both good and bad therapists. She said, “The thing about therapy is that if you’re in a teaching system, you’re going to get a new therapist once a year. That did not help, either, because by the time you connect with somebody, you get somebody new.”

After having so many therapists, some of whom were very negative (e.g., asking if she preferred depression to feeling not depressed), she finally insisted on a permanent therapist.

She described the counselor she had at the time of the interview as validating, understanding, honest, and open. After her experiences, Penelope had very specific ideas of how mental health professionals should help women through SA recovery. She said, “They need to treat you like an individual. Basically, they have a routine they’ve been doing for years they think works, so they tend to treat everybody the same.”

Like Laurel, Penelope described the mental health system as deeply flawed, as one’s health insurance limits the number of sessions with psychiatrists and specific mental health professionals and places to get therapy. Without health insurance, many have to pay for therapy out of pocket which neither Laurel nor Penelope could afford, and they could not seek lower-cost, more consistent mental health care options (e.g., YWCA counseling). Financial and emotional vulnerability of these survivors resulted in negative mental health services experiences worsened by insurance limitations and lack of low-cost quality service options. Even though both were exposed to negative therapists, fortunately, each got help through some part of the recovery process. Unfortunately, some women had overwhelmingly negative experiences with numerous mental health professionals.

Women’s negative experiences with mental health professionals

Three women interviewed described their experiences as very negative, with unprofessional counselors and poorly conducted therapy sessions. They described therapists not giving them what they needed (e.g., safety, understanding) and not having adequate time to make progress in therapy, which thwarted their recovery.

Yvette, a 22 year-old Caucasian woman sexually assaulted at age 15 by a family member, had various mental health professionals after disclosing SAs to a parent who then initiated a civil lawsuit against the abusive family member against her wishes. Due to the lawsuit, Yvette was taken to numerous therapists who did nothing or ignored her needs in favor of her parents’ or other family members’ agendas.

I’ve probably seen 5 or 6 counselors. Once, the abusive family member insisted upon being in the room with me, which obviously did not help. The counselor said having him there was fine with her. Initially, we all had to go to an older family counselor. Then, Mom and the abusive family member would go in, then me and my sister would go in, and then my sister and I would each go in alone. That old man did not believe a word I said and did IQ tests on me to check if I was mentally capable. It was ridiculous and totally biased.

During the interview, Yvette made clear she felt like a pawn in the family fight. Little trust was built between Yvette and the mental health professionals supposed to help her in therapy because the counselors often believed others instead of her so lack of trust led Yvette to appraise them negatively. Yvette had subsequent negative therapists, including one who was negative and judgmental, who she refused to see again. Another therapist came on to her during the session by making sexual comments about her appearance and asking her for a date after the session. This inappropriate, unethical behavior came from therapists who should have been helping her with teen sexual abuse. Later in life, Yvette considered getting further counseling, but could not due to cost and lack of insurance. College counseling had limited sessions so the therapist recommended that they not discuss SA as they would not have enough time to fully work on it. Like others with negative experiences, Yvette was unable to find positive mental health care due to mental health system constraints and had negative, damaging experiences.

Other women are unable to build rapport with therapists, resulting in unsatisfying therapy experiences. Willa, a 26 year-old Caucasian woman with child sexual abuse (CSA) and adult rape by a coworker, said she was dissatisfied with her mental health seeking experiences, although they were not overtly negative. To be more specific, she was not satisfied with the pace of therapy.

I tried to go to a counselor, but felt they weren’t asking the right questions. I wanted to talk about the assault, but they started building a relationship asking a zillion other questions. At the time, I did not have the patience and wasn’t really getting to the problem at hand, and did not want to talk about family issues. It was pretty soon after the assault, so I did not want to talk about anything else and just stopped going.

Soon after this experience, Willa went back to college and started seeing a school counselor, but like before, did not feel a connection or like she was being listened to, concerns confirmed when the therapist left and she was switched to a new counselor. The new counselor could find no notes about Willa from the previous counselor who took none. Even after that negative experience, she still felt that she needed therapy to recover from SA. At the time of the interview, Willa was seeing another counselor, but again was dissatisfied with the slow pace of the therapy process. She had a specific idea of how she wanted her therapy to go with more prompting and in-depth questions delving into the SA. Willa liked her latest counselor, but still appraised her mental health experience as unsatisfactory.

Val, a 19 year-old Latina, sexually assaulted by two different family members at age 14 and then by a boyfriend, was unsatisfied with her mental health experiences, first telling the school guidance counselor when her grades fell after the SAs. Val described the school counselor as completely unhelpful, perceiving her as unintelligent and saying she “wouldn’t amount to anything.” When Val disclosed SA, the counselor gave her a pamphlet with a cartoon about the dangers of “accepting candy from strangers,” which was inappropriate given her assaults by family members. This counselor was probably not trained to deal with students disclosing SA so did not know how to respond, except by making disparaging remarks about Val’s intelligence, but this negative reaction could also reflect high rape myth acceptance or negative stereotyping of Latinas. Later in college, Val went to the university counseling center and was again disappointed by the therapist’s egocentric response to her disclosure.

It caught me off guard because when I started telling her my story, she kept going ‘Oh my goodness!’ Like, ‘Are you okay?’ I did not feel comfortable because she just made it so much of an issue and was trying to be there so much that it threw me for a loop, and I didn’t know how to respond or react to it.

She continued seeing this counselor, even after the counselor tried to get her to see a psychiatrist for medication that Val emphatically refused. She thought the counselor never gave her any real answers to help her deal with SA, so instead of relying on her, Val began to trust her own instincts about what was right for herself and stopped going to therapy. This experience motivated Val to turn to other sources, namely her own inner psychological resources, to recover from her SA experiences. Although she recommends mental health help to other women, she does not think it helped her very much.

In summary, these women all experienced negative, unsatisfactory mental health professionals, sometimes due to a mental health system that does not always provide quality, consistent care that survivors need. Most women felt mental health professionals were unhelpful when they could not build up enough trust and confidence to take their advice about how to recover from SA. Negative, blaming, unprofessional actions of therapists and counselors were damaging in many cases. Also, when the women’s ideas of what therapy should entail did not match their actual therapy experiences, they were dissatisfied, which often led to leaving the mental health professional to pursue different avenues of recovery.

Fortunately, some women had numerous negative mental health seeking experiences, followed by a final, positive experience. These women broke away from negative counselors and kept looking for help until they found ones who were actually able to help them make positive changes in their lives. The next section analyzes the experiences of these women.

Women who found positive mental health professionals after many negative experiences

Three women described disclosing SA to mental health professionals as a mixture of negative and positive experiences. They continued to seek counseling despite negative experiences, and when finding helpful therapists, they stuck with them and therapy.

Tanya (Caucasian, 30 years old) experienced multiple SAs throughout life and had negative therapy experiences initially, first with a psychiatrist after leaving school who was not at all helpful. He used medications in lieu of therapy, and she never felt he listened to her. According to Tanya, “He drugged me up and kept drugging me up. I never got a second opinion. Thank God, I survived it.” Tanya realized her trust was misplaced in the psychiatrist and felt he hurt her by drugging her to numb her feelings instead of helping her talk through the experience and presenting options for recovery. Like some other women interviewed, she disliked when medications were used as a first option instead of talking about the SAs.

Tanya saw other therapists, but didn’t go into detail about them during the interview, just saying they all neglected to go into the SA experiences she disclosed. Feeling the counselors had the authority during sessions, she didn’t insist on talking about SAs and instead left to find a professional that would do so. Tanya eventually found a therapist she got along with well and felt helped with recovery, stating that, “She was generally supportive as a therapist, supporting my actions and helping me evaluate my feelings and find a comfortable pace.” At the time of the interview, she was still seeing this therapist and looking for positive support sources, like women’s empowerment groups, to continue her recovery.

Rebecca (Caucasian, 36 years old) was assaulted by her boss for over a year at age 17 and also had mixed therapy experiences. Like many other women interviewed, she was not ready at first to discuss SA in detail, but sought help as she was experiencing depression because of continued assaults. Many therapists were supportive, suggesting she take better care of herself and telling her she was deserving of love and respect, but Rebecca had a hard time taking their advice to heart because of her self-blame. She often felt unsure about disclosing to mental health professionals because she thought they might blame her for the SAs.

Rebecca also had experience with blaming mental health professionals, but was able to quickly leave therapists who blamed her. Still, she suffered some negative responses from professionals who could not understand how her post-assault depression manifested in her life. She developed anorexia post-assault because she was suicidal, but eating disorder specialists were unhelpful in her recovery and did not believe her when she said she did not care how much she weighed or how she looked. Because her counselors did not believe her motives for starving herself, Rebecca did not trust them and later sought help from other psychologists she found helpful. She was currently in therapy at the time of the interview and described the therapeutic process as slower and more work than she expected, but ultimately beneficial over time. She even found a way to take what previous therapists recommended that she could not hear at the time and incorporate it into her recovery. Rebecca stated, “Most of the time it was just talking and listening and thinking, ‘Gee, I never thought about that.’ So there was no one answer or breakthrough.” In the end, Rebecca accepted therapy as it was and over the years learned to advocate for herself in therapy. Because of her intense depression, she knew she needed outside professional help to recover and continued therapy until she found a way to accept that she was not to blame for the SAs and deserved to feel better, after which she was able to make progress by creating positive changes in her life and her recovery process.

Mina (Caucasian, 38 years old) who was violently date-raped in college also had to struggle to find good mental health help in the years after her assault. Immediately after the assault, Mina experienced depression and her grades began to drop so she made an appointment with a college counselor. When she disclosed the assault and how depressed she was feeling, the counselor reacted with a singularly unhelpful response.

After the SA, I became very depressed and at my small college saw the female counselor who told me I was like Persephone from mythology, and was kidnapped and taken to Hades (hell) for six months of the year, and sent me on my way. When I look back on that, I described every symptom of depression, but that was her response.

Mina did not return to this counselor or seek help for another ten years. Subsequent therapists were also unhelpful, and she was shuffled around from therapist to therapist, often for only one session, before being told she wasn’t someone they felt they could help. Mina found this bouncing around negative and unhelpful. When she finally found a psychiatrist willing to work with her, she was unprofessional, taking a paternalistic attitude, so after months of feeling ill-treated, Mina stopped therapy. At the time of the interview, she had found a psychiatrist who was good at prescribing medication and talk therapy, which she found very helpful. Mina would still recommend other women seek therapy and keep looking until they find someone that is helpful. She said, “I managed to find a couple of people who were useless, but I think it could help as you come to understand things a little better.”

Like Tanya and Rebecca, Mina was able to access resources to find different mental health professionals until finding someone beneficial. By continuing to seek help, these women recovered further, benefiting by helpful therapists they eventually found.

Discussion

This study examined women’s mental health help-seeking experiences for SA through the lens of ecological theory. The main pattern that emerged during this qualitative analysis of women’s interviews about disclosure to mental health professionals was the relationship between the number of mental health professionals’ women told and their positive or negative experiences with them. Most women who only disclosed to one counselor or therapist described those professionals as positive, and all felt helped by the process. Except for one woman still in positive counseling at the time of the interview, none were pursuing further counseling to help recover from SA as those positive single therapy experiences helped enough not to need further help. Once complete, they were satisfied with their experiences. Similarly, these women with all positive experiences with multiple mental health professionals only pursued more therapy, if they were unable to continue seeing their original therapist or for counseling for other reasons tangentially related to their SAs.

On the other hand, of the women with negative mental health experiences, all had seen more than one counselor. Two women with only negative mental health experiences stopped going to counseling altogether, preferring to find a way to recover on their own rather than subject themselves to negative mental health professionals. This supports previous research that showed that women felt hindered by therapists who made them feel judged or negative about themselves (Glass & Arnkoff, 2000). Other women with multiple negative therapy experiences kept seeking mental health help until finding someone helpful, all of whom described having very debilitating psychological symptoms (either PTSD or depression) for which they knew they needed professional help. These findings support theory and research which showed that women who self-identified as needing mental health care were more likely to seek help until they found someone satisfactory (Liang et al., 2005; Price et al., 2014; Schreiber et al., 2009).

Furthermore, our data support research that showed negative reactions from social support sources can be quite harmful (Campbell & Raja, 1999; Glass & Arnkoff, 2000; Ullman & Filipas, 2001). All women who described their counselors as blaming them also described those reactions as damaging. On the other hand, women who received supportive reactions from mental health professionals stated that their outlook changed and they were able to find ways to lessen their self-blame. Therapists were able to add positive perspective related to other negative social reactions women received when disclosing SA to others. When therapists were able to show women that blaming reactions from others and themselves (e.g., self-blame) were wrong, women appraised them as extremely helpful in their recovery process.

Women often described building trust as a determining factor of whether or not they found specific mental health professionals helpful, feeling that when they were listened to and believed, they grew to trust their therapists and their advice. On the other hand, when women did not trust mental health professionals, it was either because they did not listen or responded with disbelief or negative judgments so they saw them as unhelpful. Even though women did not say explicitly they had control over the recovery process, some expressed a similar idea. When asked if other SA survivors should seek mental health help, many women stated that survivors needed to take control and find a “good” therapist and to leave all of the “bad ones” as soon as possible. It could be argued that these women definitely felt in control of their recovery in that they were prepared to drop therapists and counselors who they did not feel could help them. These qualitative findings also support research that showed women who felt more in control of their recoveries also had more positive mental health experiences (Frazier et al., 2005). The qualitative analyses did not elicit other patterns of post-assault factors related to women’s disclosure experiences in therapy.

Women’s interactions with informal and formal support sources while seeking help are important as those interactions affect help-seeking and disclosure experiences with mental health professionals (Campbell et al., 2009). Analyses showed that lower income and lack of insurance may negatively affect women’s mental health care experiences due to various constraints. Women with a lot of other traumas in their lives risk having the SA disclosure lost and not delved into as deeply in therapy as would be helpful. Multiple stressors and CSA sometimes led to unsatisfactory mental health experiences because some therapists ignored or skimmed too lightly over SA, not allowing for healing in that area of women’s lives.

A lack of diverse assault experiences in the women interviewed did not allow for any analyses of relationships between women’s assault characteristics and their experiences disclosing SA to mental health professionals. This study is limited in looking only at women’s experiences with mental health help after disclosing SA. Crime victims of either gender or females who have not specifically experienced SA may have different experiences with counselors and therapists. This was a preliminary study so more studies are needed to fully understand mental health care experiences of SA survivors. Results cannot be generalized to all women disclosing SA to mental health professionals or to the general population. Also, there was a lack of diversity in the interview sample as most women were Caucasian, a few were African American, but only one woman identified as Latina. Women of color often have negative views of mental health professionals and may seek help elsewhere (Heath, 2006; Pierce-Baker, 1998) so studies are needed to identify where they receive help after SA and their help seeking experiences.

Although the assaults lacked diversity since all women were raped by known offenders in their teens or early 20s, this is typical of sexual assault survivors, and they varied in other trauma histories. Even though women’s individual experiences were often quite different, interviews with a more diverse population are needed to achieve a fuller understanding of women’s experiences disclosing to mental health professionals. This was a qualitative study with no comparison group in order to focus on women’s descriptions of disclosing SA to mental health professionals so more research is needed about women who decide not to seek mental health help. Despite these limitations, this study uncovered rich information about women’s experiences seeking help for SA from mental health professionals that can serve to guide training therapists about what women find helpful and unhelpful in therapy and how to respond supportively to SA survivors in various counseling settings.

Although this study did not examine specific therapies or techniques that different mental health professionals could or should employ when dealing with disclosures of sexual assaults from survivors, it showed the absolute importance of trust building between mental health professionals and their clients and the importance of survivor’s ability to exert control over the recovery process. Furthermore, it showed the ways in which mental health insurance could be a potential barrier to recovery and the impact of cumulative trauma. Finally, it showed that there is not necessarily one single approach that is best for mental health professionals when dealing with sexual assault survivors. Each survivor has different needs; therefore, mental health professionals must be able to adjust their approach according to those needs in order to find the best fitting relationship where trust can be built and healing can begin.