Seeking Counseling Services: A Phenomenological Study of African American Women

African American women bear a mental health burden and are less likely to seek and receive appropriate services than their dominant culture peers. African Americans may underutilize professional counseling services due to factors such as stigma, healthy cultural mistrust, and cultural values. To date, researchers have paid limited attention to ways to break through barriers to mental health equity. This phenomenological study examined the lived experiences of ten African American women who sought service from licensed professional counselors. Participants sought help after failure of self-care and traditional supports, recognized barriers, and approached counseling as a last resort. Through counseling, they found new perspectives, surprise connections, and opportunities for growth. Findings inform communities about what counseling is (and is not) as well as different types of support that can be obtained from a professional counselor. Limitations and future research directions are discussed.


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Journal of African American Studies (2023) 27:251-267 of fear that their concerns will not be tolerated or accepted as valid within the family (Jones & Pritchett-Johnson, 2018;Zounlome et al., 2019).Similarly, "the church" is considered a constant and dependable source of support for many African Americans and has been named "the pulse" of the African American community (Adkinson-Bradley et al., 2005, p. 147).Although the church emerged as a primary support network across studies, relationships are complex; religious beliefs and community may also deter help-seeking (Harris et al., 2021;Nelson et al., 2020;Vaterlaus et al., 2015).
Research specific to African American women supports the importance of cultural values, family, and religious support in mental health concerns and help-seeking behaviors.Assuming that African American women may operate under cultural scripts related to providing strength and nurturance to family and community, researchers found that African American women reported greater levels of network stress than self-stress, and network stress was associated with mental health symptoms (Woods-Giscombe et al., 2015).Similarly, endorsement of the Strong Black Woman schema was associated with increased levels of depression; concerns related to stigma also predicted psychological distress (Watson & Hunter, 2015).In another study, sexual objectification, racist events, gendered racism, and internalization predicted depression among African American women who were seeking treatment; the impact of racist events on depression was influenced by internalized coping with oppressive experiences (Abrams et al., 2019).Together, it appears that life stress, including stress related to depression and cultural norms, plays a substantial role in mental health concerns among African American women (Nelson et al., 2020).
Although the literature speaks to reasons African Americans may not participate in mental health services, some samples of African American college students have indicated openness to counseling with key facilitating factors including family norms, previous experience with mental health services, and education level (Jones & Pritchett-Johnson, 2018;Jones & Sam, 2018;Szymanski & Lewis, 2016;).Still, little is known about how and why African American women choose to attend counseling.The purpose of this study was to explore African American women's experiences and decision-making when seeking counseling services.The following questions guided this inquiry: 1. How do African American women make meaning of their decision to seek mental health counseling services?2. What considerations are involved in decision-making with African American women who decide to seek mental health counseling services?

Method
Because our research questions were open, exploratory, and directed at understanding of decision-making processes, we utilized phenomenological analysis to explore how individuals make sense of their experiences and transform experiences into meaning (Williams, 2021).This section includes attention to participants, recruitment and interviewing procedures, data analysis, and steps for ensuring trustworthiness.

Participants
Participants (n = 10) all identified as African American and/or Black, heterosexual, Christian females, ranged in age from 22 to 44 (M = 30.50,SD = 6.74), and made the decision to attend individual counseling with a licensed professional counselor (LPC) or LPC-intern in the last three years.More information about participants is provided in Table 1.

Procedures
After obtaining Institutional Review Board approval, we recruited a purposive sample of participants through flyers and networking in a major metropolitan area in the Southwest USA.We asked LPCs to share information about the study with current and former clients, and we recruited participants through personal contacts, Facebook networking, National Pan-Hellenic Association organizations, and diverse professional and religious groups that served the African American community.Individuals interested in the study completed an online questionnaire that included questions about dates and length of service, age, gender, ethnic/racial identification, sexual orientation, religious/spiritual affiliation, ability status, and counselor characteristics.Twenty-eight individuals completed the demographic survey and a followup telephone call, and we selected 10 individuals to participate in interviews.
In efforts to access participants' perceptions and insights, we developed a semistructured interview protocol based on recommendations by Moustakas (1994).The grand tour question was "Please tell me about your experience deciding to seek counseling, in as much detail as you feel comfortable sharing."The interview protocol included seven open-ended questions with optional follow-up prompts focusing on life context, considerations involved in the decision, role of loved ones in the decision, and beliefs about counseling.The lead author piloted the interview with volunteers prior to conducting interviews face-to-face in a confidential counseling office (n = 6) or via distance technology (n = 4).Interviews were assigned a pseudonym, transcribed verbatim, and triple-checked for accuracy.

Data Analysis
A coding team analyzed data using an inductive-deductive approach based on an adaptation of classic data analysis (Miles et al., 2014).Coding team members included the primary investigator (an African American female doctoral candidate) and two additional doctoral students (one African American female completing her third year and one White male completing his first year) who had completed advanced study of multicultural counseling and counseling research.The supervising researcher identified as a multiethnic female and was experienced in teaching 1 3 Journal of African American Studies (2023) 27:251-267  (Smith & Luke, 2021).Data analysis included epoche, initial coding, and final coding (Miles & Huberman, 1964;Moustakas, 1994).We demonstrated epoche (i.e., identifying our own personal assumptions and bias) through journaling and discussion of assumptions prior to engaging in the coding process and again during each meeting (Moustakas, 1994).We began analysis with a subset of four interviews on which we completed the following steps: taking notes, summarizing notes, playing with words, and making comparisons (Miles et al., 2014).We independently applied preliminary codes to the subset, discussed discrepancies and points of agreement, adjusted preliminary codes, and reapplied to the data subset.We finalized the coding manual when we reached mean agreement of 90%.Next, two team members independently coded each interview using the final coding manual, reaching mean agreement of 97.2%.Finally, the lead researcher performed member checks with nine of 10 participants; all reported the coding manual fit their overall help-seeking experience.One participant reported she did not have a preference regarding her counselors' cultural characteristics; two participants reported they did not experience stigma regarding seeking services.

Trustworthiness
Credibility, transferability, dependability, and confirmability are essential for demonstrating trustworthiness and rigor in qualitative research (Williams, 2021).Credibility was established through the use of research partners in debriefing, reflexivity, and participant checks.We worked toward transferability by being transparent in providing information about researchers, research context, participants, and researcher-participant relationships.We also attended to dependability and transferability through an audit trail.Confirmability was demonstrated through triangulation, the use of multiple methods of verifying data sources, participant checks, use of a supervising researcher, and team consensus.

Results
Phenomenological analysis led to six major themes and 13 sub-themes displayed in Fig. 1.

Theme 1: Feelings Prior to Attending Counseling
All participants described feelings they experienced prior to engaging in counseling.However, participants differed in frequency, strength, and duration of these feelings.In referring to concerns about her marriage, one participant shared: 1 3 Journal of African American Studies (2023) 27:251-267 I felt overwhelmed because-I think the biggest struggle for me internally was I didn't actually believe in divorce, and I knew that...that was where we were headed.(Venus) Another participant reflected the stress that occurred after the ending of her relationship: I was just feeling really ... I just felt really depressed.I think I, I just starting to have a feeling of, like hopelessness, you know, that my situation wasn't going to improve.I mean, it went on for about a year that I was kind of in this situation and things kind of spiraled down.(Kasey) Although these appeared to be emotions most people feel on a regular basis, it seemed as if participants knew they needed something more.For example, Jay discussed feeling "crazy" and hoped a counselor could help her sort through her feelings: Fig. 1 Themes and sub-themes And I just thought, "You know what?I need to maybe see a counselor about this 'cause maybe they can help me not only work through the issues I have about the miscarriage itself, but the issues I'm having, like, relating to people and, like, just feeling like I'm crazy all the time."(Jay) As participants reflected on their emotional experiences, they shared ways they tried to work through feelings or alleviate stress.

Theme 2: Coping Mechanisms Used Prior to Counseling
All participants utilized strategies to manage concerns prior to attending counseling, and these included three sub-themes: self-care strategies, support from others, and unsuccessful strategies.Eight of ten participants engaged in activities such as journaling, prayer, and exercise in attempts to care for themselves.
I also was, like, reading my Bible, trying to pray, trying to, like, work through it in that way.(Jay) I love the gym.It doesn't look like it but I actually-that is like one of my best stress-relievers.(Mildred) Eight participants reported processing feelings, stress, or life events with others in hope of finding encouragement.Connections participants felt with these individuals continued to be a theme when participants decided to seek services.
My line sisters and my best friends have been like a saving grace.And then, of course, my parents.(Mildred) My close-knit circle, uh, process and talk with them and had actually talked to them about knowing that I needed to make a different decision about my life and about our, my, about my relationship.(Venus) Support from others was important, and some participants shared it was this support that confirmed their initial desire to seek counseling services due to worry about burdening friends, family members, and significant others.Some participants simply wanted someone objective with whom to discuss concerns.I would use friends but sometimes you just get tired of, and I, you know, I felt like they were getting tired of hearing me talk or just seeing me cry.(Tiana) My mom and my boyfriend, but I wouldn't tell him everything because I expected he would be very scared if I was talking about my suicide ideations.(Kerry) Six of ten participants reported engaging in strategies that did not alleviate their concerns.These participants reported internalizing their experiences, and three experienced suicidal ideation or attempts.
So I would internalize everything and I had no way, I didn't know how to deal with anything at all…Um ... strategies ... they weren't good.Like I said, I tried to commit suicide.I assumed that was a way to deal with it.Um, I was bulimic 1 3 Journal of African American Studies (2023) 27:251-267 in high school, um, not because I had a weight issue, per se, um, I was a runner.(Jem) And, at one point ... I don't ... I was not the type to open up to my mother very much, but um, one day I told her, you know, I was suicidal, and she just, kind of like, stared at me.And was like, "Okay, so what does that mean?" And, um, after that, I never talked about it again with her, of course.(Olivia) Although some participants had self-care strategies or were able to gain support from others, there was a sense that participants needed additional support.Unfortunately, some participants had some obstacles to overcome during their decision making to seek services.

Theme 3: Barriers to Treatment
When asked to discuss how they chose to attend counseling, participants first expressed obstacles that limited their likelihood of engaging in counseling.Participants also reflected on obstacles they believed prevented African Americans from seeking mental health counseling services.Repeatedly, stigma and ambiguity about the counseling process came up as barriers to help-seeking.
All but one participant discussed stigma as a potential barrier to her own treatment and/or to treatment for African Americans in general.Participants expressed a variety of stigmas including that from spiritual institutions, significant others, culture, society, and self.I was also scared, I guess, of, briefly, of how I'd be perceived.Um, because, you know, the Black community, they don't put much stock in psychological help.You know, "Let's pray on it."And, you know, I did pray on it.(Olivia) I think it's such a stigma in our community 'cause we think if someone goes to counseling that they're crazy.(laughs) And that's not the case.You can be a perfectly normal person without any extremes, it's just sometimes you are, your emotions can play a lot into it.Um, you can easily get down.Anything can trigger those factors.I also think one, one thing I mentioned before is that in the Black community we always feel we can pray everything away.(Tiana) Jem and Jay shared perceptions they heard from others that counseling was a resource that was only utilized by dominant populations: Um, my mom always said that that was for White people and Black people didn't get counseling.And that basically, I mean, to suck it up, there was nothing wrong.(Jem) Mildred and Kasey reflected on ideas about how to decrease stigma in the African American community: I think there's-it has to be more education.It just has to be more education and I think it really needs to start in the church because as black people, that's been our cornerstone.(Mildred) I would want any, anything that I think that maybe African Americans might be held up on is, is some of the things that you've heard about counseling and people's bad experiences.You know, you may just need to find a different counselor.Sometimes, you may need to go to more than one before finding the right person.(Kasey) Notably, not all participants experienced stigma regarding seeking help.Aria, Venus, Isis, Kerry, and Mildred shared how counseling was utilized in their families: Man.I feel like I've always known about counseling I think I come from a really educated family on both sides and my mom sides, medically and then my dad's side everything.(Aria) All the women over 18 have at least one degree, so it was more education and more exposure, and then also because of my mom and anything that she could do to make sure that I was well rounded and healthy and happy, she did, so it wasn't odd for me to be exposed to that, because I saw my first counselor when I was 8-7, so it wasn't foreign to me, and my mom never talked about the stigma.(Kerry) Although it was not a central part of the experience for most participants, two participants reported uncertainty related to aspects of help-seeking they believed limited their likelihood of engaging in counseling.Jem and Joy were unaware of resources and did not know anyone who had sought counseling.I wasn't sure what it really was to go to real counseling.I didn't know if it meant to, like, if it was like they were gonna be sitting there writing down stuff about you.Um, you know, you get these movie ideas...Yeah, I didn't think that you just went there to just talk, like, about whatever.(Jay) Some participants expressed the ambiguity of the cost related to engaging in mental health counseling services: Well, I was scared of the cost, most definitely.Oh, when I was told that the clinic worked with a sliding scale that was a huge, huge source of relief.I did feel guilt about it, or, I guess, shame.I was embarrassed that I had to pay a reduced amount.(Olivia) Because I couldn't afford to go see, you know, I guess what you'd call a real counselor.But the counselors at the church are real counselors.(Jem) Kasey discussed concern and ambiguity regarding the cultural competence of counselors as an unclear factor related to engaging in professional counseling services: I was a little bit concerned about being African American and going to counseling.I, I knew that I couldn't, or at least I didn't think that I could, necessarily request an African American counselor.(Kasey) Despite multiple stigmas and ambiguity of the counseling process, participants still decided to seek out mental health counseling services.

Theme 4: Motivation to Attend Counseling
The research team identified three sub-themes within the major theme of driving force to attend counseling: positive reinforcement, last resort, and open to new perspectives.All participants reported there were factors that strengthened their comfort with seeking counseling.Encouragement from others played a big part in seeking services.
And when she was just encouraging me and speaking of it so highly, I was just like, "Okay, well, you know, maybe I should go ahead and do that."And then, of course, like I said, um, talking to my mom about it, I, I ran it by her, and I'm just like, "Well, I'm thinking about maybe going to get some counseling, but what do you think?"And she's just like, "No, I think that'd be good, I think."So I was kinda getting the encouragement from family and friends.(Jay) Knowing someone who was familiar with counseling or being familiar with counseling themselves helped participants feel more confident about their decision to seek services.
So, that's why I feel like, you know-so being in healthcare helped a lot with me understanding that talking to somebody is probably the first step.(Mildred) Well, I knew that it was an option because I am a counselor.But I also knew it was an option because I had been taught that if there is something that you need you know to process or deal with you should.(Isis) All but one participant reported seeking counseling as a "last resort" for coping with life stressors.Participants' coping mechanisms were no longer effective in relieving distress, and their concerns affected daily activities.
So when my family, you know, those things start changing, in 2012, I had a miscarriage.And then right before I decided to go to counseling, is with the incident where we had this whole big blow-out at a brother's birthday party.My sisters jumped on me, tried to fight-I lost a patch of hair so just a whole bunch of stuff that happened that I just felt like I needed to talk to somebody before I went postal on somebody.(Mildred) I noticed that two weeks came and went, and I was still bad.A month came and went, and I was still pretty bad.She (mom) just called me on Tuesday and said she's coming on Thursday, and I just broke down on the phone and I had no idea where that came from, and that's when I knew it was really bad then.(Kerry) After accepting counseling as a last resort, half of participants reported openness to new perspectives as a driving force to attend counseling.Participants shared selfdetermination, desire to push past stigma, and being open or neutral to counseling.I'm pretty open.And I ... Like I said, I believe ... That no man is an island that, that you don't have evr-all the answers and everything together and that you should pursue and seek ... Other people's help ...Sometime or, or just to get another ... Perspective or a vantage point... (Venus) I've always thought counseling was warranted and necessary and I think everyone can benefit from processing through and understanding who they are and why they do the things that they do.(Aria)

Theme 5: Characteristics of Counselor
All participants shared characteristics they believed to be significant qualities of their counselors and critical to their initial help-seeking experience.Some participants expressed characteristics related to the culture, while other participants identified characteristics related to the counselor's style.
Most, not all, participants preferred to have a counselor who shared some of their cultural characteristics, and these elements varied among participants.
I wanted to see a Christian counselor, but I wanted to see a Christian counselor that was more real and down to earth, and not just telling me, "oh, you just got to pray harder."(Jem) So it was good and I want to say that somebody that looked like me…African American, female was my preference, and that's what I got.(Mildred) All participants expressed qualities related to their counselor's style they were looking for or experienced within the relationship.
Um, straightforward, honest, personable, you know, a good listener.And somebody that was gonna get-give me what I felt was honest feedback.I didn't go to be pacified.(Mildred) So to be immediate, to be respectful, to be curious, too, because only one of my counselors comes from the same culture as me.(Kerry) All participants reflected on characteristics that affected their counseling experience.There was a sense that the core conditions helped them to feel safe in their therapeutic relationships, which helped them grow in various ways.

Theme 6: Post Counseling Experiences
All participants shared reflections on their help-seeking process and discussed changes they experienced as a result of counseling.Subthemes include personal growth, unexpected insight, and desire to share meaningful experience.Participants reported improvement in their quality of life because of engaging in mental health counseling services.
Just ... it also helped me learn to be more, more verbal, more vocal.To be able to express myself in words as opposed to in actions.(Jem) To me, it's helped me became more secure in my own voice and trusting my own decisions.Um ... I think that's probably the biggest thing.(Venus) Some participants (n = 4) shared unforeseen experiences that arose within their therapeutic relationships.

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Journal of African American Studies (2023) 27:251-267 I'm just very pleasantly surprised with how it's all gone.And, you know, it wasn't an immediate thing.I've, I've been through a few counselors.I initially had three.(Olivia) All participants reflected on their willingness to disclose the value of their own counseling journey for the betterment of others.Although engaging in counseling may be viewed as taboo, participants in this study appeared to be comfortable and willing to share their counseling experiences, and this willingness reflects a changing attitude about seeking professional counseling services.

Discussion
Literature exists about stigma and barriers to African Americans participating in mental health services; however, empirical research is lacking about how African Americans transcend barriers and choose to attend counseling.Consistent with prior literature, participants looked to self-reliance, spirituality, and/or nuclear and extended family members prior to seeking mental health counseling services (Abrams et al., 2019;Burkett, 2017;Monterrosa, 2019;Nelson et al., 2020;Spates et al., 2020;Vaterlaus et al., 2015;Watson-Singleton et al., 2017).Although stigma is a major theme in previous literature, participants in this study seemed to be aware of stigma within the African American community, but not all experienced or internalized messages that deterred help-seeking (Kam et al., 2019;Nelson et al., 2020).
Participants in this study expressed a preference for counselors who created a comfortable environment and appreciated that their counselors were personable, unbiased, affirming, patient, competent, and experienced.Directness and indirectness, as characteristics of the counselor's style, was a valuable part of many relationships.Some participants valued directness from their counselor, while other participants appreciated how their counselors were able to give constructive feedback in gentle and more indirect ways.These preferences align with recommendations by Kawaii-Bogue et al. (2017) for a strengths-based approach as culturally competent and appropriate for working with African Americans.
Participants varied in their desire to work with counselors who shared their cultural characteristics (e.g., Christian, female, African American), and preferences that may have varied depending on the concerns they wanted to discuss.This finding is similar to literature, which suggests mixed results regarding client preferences for counselor characteristics (Jones & Pritchett-Johnson, 2018;Kawaii-Bogue et al., 2017).Participants also discussed cultural competence as part of the therapeutic relationship.Among participants who found their counselors to be culturally competent, there seemed to be a sense of acceptance and connection with their counselor.
Participants' experiences aligned with suggestions that counselors fine-tune skills but still give space for participants' perspectives (Day-Vines et al., 2021).

Limitations
Strengths of this study included overall rigor of design and responsiveness to participant needs.It is possible that use of a single, flexible interview format (including variation in face-to-face and videoconference interviews) limited depth of responding.Despite plans to recruit a sample that was diverse in terms of age, gender, sexual orientation, religious/spiritual orientation, and education, all ten participants identified as heterosexual, Christian women.Six of the ten women were working toward or had completed a Master's degree.Those who responded to invitations to participate mirror those most open to help-seeking in qualitative studies in terms of level of education and family norms (Nelson et al., 2020), and they expressed desires to use their stories to benefit their community (Ullman & Lorenz, 2020).
Qualitative research is not intended to be generalizable, and it is quite possible that the women who chose to give voice to their experiences had different cultural values than African Americans who identified as men, had lower socioeconomic status, had lower degrees of educational attainment, or who did not attend counseling voluntarily.These individuals may have been reluctant to participate due to cultural mistrust, institutional racism, or lack of understanding about the research process (Ullman & Lorenz, 2020).In hopes of securing a more diverse pool of participants, we continued recruitment beyond initial saturation at eight interviews; however, these efforts did not influence study participation.Finally, experiences of those who have experienced less stigma or those comfortable with sharing their experience in counseling may be different than the experiences of those for whom counseling was taboo.It is possible individuals in the latter group did not present for the study.

Implications
This study can serve as exploration regarding why African American women seek counseling; however, future research is needed to examine the impact of help-seeking with African American individuals who are mandated to attend professional counseling services, men, and a more diverse group of women, including those with lower levels of SES and education.Additionally, researchers could examine how expectations about counseling predict relationships and outcomes within this population.Other research could be conducted to explore relationships between stigma and cultural identity in attempts to understand how experiences, expectations, and beliefs impact participation in professional counseling services.
Knowing someone who had sought counseling or being familiar with the counseling profession had a meaningful impact on participants' decision to seeking counseling services.Clinicians can use this information to provide outreach and education in communities about counseling in general as well as different types of support that can be obtained from a professional counselor.Clinicians may network within 1 3 Journal of African American Studies (2023) 27:251-267 churches and spiritual institutions to advertise services to non-dominant groups.For example, counselors could provide congregations with a short informational in which they explain how counseling can help with a wide range of life concerns while also honoring faith practices.This may be more impactful if the counselor is able to have members of the congregation speak to their experiences in counseling.
Regarding counselor education and supervision, students need to be exposed to cultural experiences and values of African American individuals that impact experiences of mental health and help-seeking practice.It is equally important that students understand that not all of the cultural values identified in the literature review of this study will "fit" their clients.Counselor educators need to help students understand complexities related to ethnic, gender, and religious identification; education and socioeconomic experiences; and individual uniqueness relates to cultural values.Educators and supervisors can assist students and supervisees in skills related to understanding how elements of clients' experiences are connected to their worldview and counseling needs.Counselor educators can help students gain awareness and understanding about cultural complexities through the use of panel discussions.Counselor educators can then facilitate course discussions regarding ways in which individuals with similar identification may still have different beliefs and ways they carry out values in day-to-day life.

Conclusion
The African American women who participated in this study provided intimate and detailed accounts of their concerns and difficult moments in their lives, and how they benefitted from using professional counseling.Personal growth, unexpected insight, and a desire to share their experience with others came up repeatedly as the women shared their takeaways from counseling.It is our hope that this study is the beginning of a movement to increase awareness about the utilization of mental health counseling services as a resource for all people.
Funding Open access funding provided by SCELC, Statewide California Electronic Library Consortium.

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actually do, um, when people say certain things that kind of trigger something in me, or if I feel a certain way, I, I always recommend counseling.(Jem) I'm pretty open about sharing my experience just, you know, 'cause I don't, know, I figure it could help somebody.(Jay)